OS ET 2017 Bellagio Las Vegas Rotator Cuff Tear of the Hip: Pro: Fix the Gluteal Tear It Is a Real Problem No THA Required! Thomas Gross 2:29 PM 23
No current conflict s
My Position S ympt omat ic glut eal t ears should be repaired By themselves if the hip is not arthritic In conj unction with THR if the hip is arthritic No evidence t hat sympt omat ic t ears will lead t o hip OA A THR t reat s pain from cart ilage loss not from a glut eal t ear Disclosure: a minimal evidence based t alk
What we don’ t know How sensitive are MRI at finding abductor tears? Beware of scanners <1.5 Tesla How reliably do MRI abductor abnormalities predict symptomatic tears? I have explored 1 case with a complete “ tear” and found normal tendons Can a small or partial tear be improved by surgery? I don’ t operate on these but suggest consultation with an arthroscopic surgeon Does Bursectomy help patients? I have never done this and am highly skeptical
Incidence of isolated abductor tears? 2/ 3482 (0.06% ) patients presenting with surgical hip pain Incidence of finding a tear with THR? 1.6% Cates 2010 22% Bunker 1997 20% Howell 2001 2% Gross 2017 I rarely operate on older women Incidence of symptomatic tear after lateral approach? 4.9% lateral pain Iorio 2006
How often are abductor tears missed at S x? I diagnosed my first one 4/ 2009 (8 years) I now see a tear in 1-2% (2.4% in women & 0.6% in men) 80% of tears are in women Mean age HRA =52 years, tear=63 years Most tears are in older women
Incidence of tears Rare as an isolat ed present at ion 0.06% Uncommon in younger hip 0.6% men art hroplast y pat ient s 2.4% women Older THA women?
Incidence of tears Rare as an isolat ed present at ion 0.06% Uncommon in younger hip 0.6% men art hroplast y pat ient s 2.4% women 5% ? Older THA women?
Approach Lat eral: always see t hem and repair t hem but you creat e more wit h t he approach Ant erior: Difficult t o see t hem Post erior: Can find t hem if you always make a point t o look I missed t hem all before 2009
How to find a tear? Awareness of the problem Maybe a preop MRI Irregularity of the lateral trochanter on preop XR A few are obvious if you are not going too fast S uspicious findings: A thick bursa resect it and look carefully A rough gritty feel to the trochanter If you are suspicious carefully detach the anterior ¼ of the G. medius and look at the minimus tendon. The G minimus is usually the problem
Dissatisfaction with THR Anakwe JOA 2011 7% Mancuso JOA 1997 11% How many of t hese are due t o unrecognized unt reat ed abduct or t ears?
Repairing Tears during THR Most with 2 #2 fiberwire Krackow stiches in minimus into a bone trough and #2 Quill absorbable medius repair S maller partial tears with suture anchors Extra slow program 10% WB 6 weeks 50% WB 4 weeks 100% 4 weeks Cane as needed thereafter Formal PT at 6 months. More residual pain and limp for 1 year Most have a no/ slight limp and 5-/ 5 strength at I year.
Fink JOA 2017 Open repairs with collagen patch 30 tears with severe limp and without OA followed mean 4 years 28 women / 2 men, mean age 77 Pain 11 none 17 mild occasional Residual limp 11 none 14 mild 5 severe Poor outcome if 75% of the muscle was fatty by MRI
Miozarri JOA 2010 12 repairs aft er lat eral approach THR 9 sat isfied, 4 limped Fat t y muscle degenerat ion did not improve on post op MRI
Perets,Domb Arthroscopy 2017 16 cases art hroscopic abduct or repair wit h labral t reat ment 13 women/ 1 man mean age 57 Favorable out come
Makridis Orthopaedics and traumatology 2014 67 open repairs isolat ed t ears Avg f/ u 4.6 years 85% improved Trendelenberg decreased from34% t o 3% 16% failures
Chandrasekaran Review 2015 Open Repair 3 st udies 127 pat ient s Art hroscopic repair 4 st udies 40 pat ient s S imilar scores at 1-2 years More complicat ions in open group
My series 43 cases in 8 years (2009-2017) 3480 hip art hroplast ies 2.4% of hip art hroplast ies in women (0.6% of men) Mean age 62 Locat ion: minimus 63% 86% medius 23% bot h 14%
Results HHS 59 94 UCLA 6 + 1.8 VAS pain (1-10) 0.3 + 0.7 Limp none 24% slight 73% severe 3% S trength testing 5/ 5 75% 5-/ 5 7% 4/ 5 10%
S ummary Most pat ient s are improved by repair Large t ears probably do bet t er open S maller t ears probably do bet t er art hroscopically Most occur in conj unct ion wit h an art hrit ic hip Many are missed during THR possibly leading t o residual pain and weakness Most occur in older women
S ummary Warn pat ient s wit h a repair t hat t hey will have a longer recovery Limit WB for several mont hs MARS MRI may discover t hem in a painful THR Unclear if a failed abduct or form a lat eral approach can be improved wit h surgery
S ummary Have a High index of suspicion: Older women Incidental preop MRI Irregular lateral trochanter on XR Thick trochanteric bursa Gritty texture on lateral trochanter If you miss these and don’ t repair them you will have more dissatisfied limping THR patients
My Opinion Isolat ed t ears are rare…order a hip MRI for lat eral pain ,limp, and abduct or weakness Don’ t j ust repeat edly inj ect bursit is Y ou won’ t really help someone wit h referred back pain Y ou may cause t endon degenerat ion Y ou’ ll miss someone who can be fixed Therapy does not heal complet e t ears Repair complet e t ears…but set expect at ions correct ly don’ t replace t he hip unless it is bad.
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