Rotator Cuff Tear of the Hip: Pro: Fix the Gluteal Tear It Is a Real - - PowerPoint PPT Presentation

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%

• f 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

 Older THA women?

5% ?

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%

• f 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%

• f hip art hroplast ies in women (0.6%
• f 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

• u won’ t really help someone wit h referred back

pain

 Y

• u may cause t endon degenerat ion

 Y

• u’ 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.