View Article PDF

Hip abductor tendon tears are a common cause of greater trochanteric pain syndrome, affecting up to 20% of those over the age of 50 (Figure 1).1–5 Patients with abductor tendon tears often present in three distinctive groups. The first group presents prior to arthroplasty with primary tendinopathy and tear of the gluteus medius and minimus tendons, the second group have tears found incidentally at the time of arthroplasty.6 The third group presents following hip arthroplasty, this can be a consequence of the surgical approach (Hardinge approach) in conjunction with existing tendon degeneration, or due to complications such as metalosis and infection.7

Patients often complain of pain over the greater trochanter which worsens on weight bearing; many have the classic ‘Trendelenburg gait’ where the pelvis sags away from the planted leg while walking.6 Abductor tendon tears can be debilitating and render patients immobile. This has important implications for independence and confidence in the elderly population.8

While effective surgical treatments are available for other lower limb tendon tears, hip abductor tears are difficult problems to manage.9 Conservative treatments are of little benefit for symptomatic patients with significant tears. While both open and arthroscopic surgical repair has been attempted, they are often limited by the failure of the repaired tissue to heal.6,10 This survey seeks to establish the level of recognition of this problem among New Zealand orthopaedic surgeons, and identify the challenges the surgeons face in treating abductor tendon tears. With the emergence of novel biomaterials and biologics to improve tendon repair, there are new opportunities to improve the outcome of surgical repair.

Figure 1: Diagram of hip abductor tendon including gluteus medius and minimus tendons (left), T2 MRI scan showing complete tears of gluteus medius and minimus (centre), and intraoperative findings showing an undersurface tear of gluteus medius (right).

Methods

With the assistance and permission of the New Zealand Orthopaedic Association, an online survey was sent to 215 consultant orthopaedic surgeons in New Zealand with a registered interest in hip surgery. Following the initial email and link to online survey, two further reminder emails were sent. The survey was administered through surveygizmo and consisted of five questions, including whether the surgeon performed hip arthroplasty (Q1), how often they diagnose a patient with a hip abductor tendon tear (Q2), whether they perform surgery for hip abductor tendon tears (Q3a and Q3b), the contraindications for surgery (Q4) and the innovations they need to improve the management of patients with hip abductor tendon tears (Q5) (Table 1). The option of adding comments as free text after each question was made available. Demographic data collected included subspecialty and whether hip arthroplasty was performed as part of routine practice. The survey was designed and thoroughly tested by the authors. Further assessment of the survey was performed by two additional hip surgeons (HB and AC). The survey was anonymised with a response window of three months.

Table 1: Items in hip abductor tendon tear survey.

Results

Eleven surgeons contacted the author with their apologies stating they did not complete the survey as they no longer perform any hip surgery. Eighty-six surgeons completed the survey, giving a response rate of 42.2%. The majority of respondents (81%) performed hip arthroplasty as part of their routine practice and the remainder did not despite registering an interest in hip surgery. Table 2 lists a summary of the following results.

Table 2: Summary of survey results.

Q1. Frequency of diagnosing patients with hip abductor tendon tears

The majority of surgeons chose to enter free text for this section. Ninety percent of respondents have diagnosed this problem, 54% diagnose the condition up to once per month and 36% diagnose it frequently, defined as more than once per month. Ten percent have never diagnosed a hip abductor tendon tear.

Q2. Proportion of surgeons performing surgery for gluteus medius and minimus tears

Over half of respondents (59%) have performed repairs on either the gluteus medius or minimus tendon. The majority (57%) have performed repair of the gluteus medius tendon in the last 12 months and a significant number (36%) performed gluteus minimus repairs in the last 12 months.

Of the surgeons performing repairs, 67% were able to provide the numbers of procedures performed per year. The average number of cases per year was 3.22. Of the surgeons performing repairs, 12% performed more than five repairs per year, while 29% performed one or less repair per year.

Q3a. Indications for surgical management

In the 51 surgeons who performed surgical repairs, many gave more than one answer for this question. The responses were counted cumulatively. Twenty surgeons (39%) stated that they performed repairs both pre- and post-hip arthroplasty, four (8%) stated that they performed repairs for incidental tears. The rest (53%) did not provide clarification on their practice as related to tear classification.

Pain was the most common indication for repair (35%), followed by function loss/weakness (29%), MRI evidence of tear with preserved muscle bulk (16%), failed conservative therapy (13%), incidental findings at the time of the primary or revision arthroplasty (6%) and bursitis (1%) as an indication for debridement and direct repair.

Q3b. Surgical technique

In the 51 surgeons who performed surgery for either medius or minimus tears, seven surgical methods were reported. Transosseous repair through drill holes in the greater trochanter was the most common technique (41%), followed by using suture anchors to approximate tendon back to bone (37%). These were by far the most popular responses. The remaining surgical techniques described direct side to side repair of the tendon only (6%), Z lengthenings of the iliotibial band (6%), augmenting the repair using Lars ligament and an Achilles bone block (6%), endoscopic repair (4%, with these surgeons also performing open repair via suture anchors), and direct repair of the gluteus medius with minimus release (2%).

Q4. Reasons for not performing surgery

There were six reasons for not performing hip abductor tendon repair and these responses included surgeons that had never performed repair. The most common reason (33%) was concern regarding the poor quality of tissue resulting in a repair that would not heal. Following that, 24% of surgeons did not see hip abductor tendon tears as a significant surgical problem. The remaining reasons in descending order; believing that conservative treatment had similar outcomes (16%), concern whether surgery is beneficial given an imperfectly defined clinical problem (15%), difficulties with post-operative care limiting surgical success (6%) and preferred referral of patients to colleagues (5%).

Q5. What is needed for better management of patients with hip abductor tendon tears

There were 81 responses for this question. Out of the positive responses, 26% stated that better tendon augments and fixation methods would be useful, 23% advocated for the advancement of biologicals to improve tendon regeneration and 11% believed that improved understanding of the problems (ie, classification of tears and selection of patients for surgery) was critical to improving management. Four percent believed improved immobilisation following surgery was required while 2% advocated for the wider use of botox following repair to “rest” the muscles involved. Approximately one third of surgeons (33%) did not know what would improve management.

Discussion

A nationwide survey on hip abductor tendon tears was performed to ascertain the level of recognition of this problem among New Zealand orthopaedic surgeons. To the authors’ knowledge this is the first survey of hip abductor tendon tear diagnosis and management among orthopaedic surgeons. The response rate of 42.4% lies within the broad range of expected response rates for surveys administered to orthopaedic surgeons.11,12

Hip abductor tendon tears are increasingly recognised as a cause of lateral hip pain, gait instability and prosthetic joint dislocations.5,6,13,14 While traditionally managed conservatively, surgical repair has been well reported in the literature since the 1990s.1,15 A recent randomised control trial in Australia examined different conservative management options; load management education plus exercise, single corticosteroid injection and no treatment on a series of 204 patients with hip abductor tendon tears.16 The study excluded patients with total hip arthroplasty and hip osteoarthritis which make up a significant group of patients with hip abductor tendon tears. They did report an improvement in patient reported outcomes at eight and 52 weeks in the education and exercise group compared to both steroid injections and the control group.

Operative management may be necessary in patients who do not achieve adequate improvement with conservative management or those with tears present at the time of total hip arthroplasty.10 In this survey, 59% of surgeons have performed surgical repair of hip abductor tendon tears. However, the number of surgeries performed per year is small with only 12% of surgeons surveyed performing more than five repairs per year.

The reluctance to perform repair centred on two main concerns. Firstly, achieving a strong repair in degenerative tendon is difficult. Approximately one third of the surgeons had concerns regarding the lack of healing in suboptimal tissues. To overcome this, the surveyed surgeons used transosseous and suture-anchor based repair techniques. This reflects the most commonly reported techniques in the literature.17–20 A small number of surgeons reported using LARS ligament augmentations, while none used tissue patches or biologics to supplement their repair. This is perhaps not surprising, as the use of biologics in the literature consist of small case series only.21 Half of all surgeons surveyed stated that novel materials and biologics are needed to improve the quality of healing and clinical outcomes. As such, further research in this area is required to identify such products and conduct high-quality trials to prove efficacy.

Secondly, the clinical problem and indications for treatment are unclear. The most common indication for surgery in this survey was pain, followed by functional disability and MRI evidence of tears without muscle atrophy. These indications are similar to those proposed in the literature.17,22 However, the heterogeneity in which tendons are repaired reflect the uncertainties around the clinical problem. The majority of surgeons reported repairing the gluteus medius and not the minimus, with one advocating for the release of gluteus minimus. Previous cadaveric and imaging studies have varied in their report of tear locations and morphologies, with a number reporting greater incidence of gluteus minimus tears.23–26 A better understanding of how tears originate and progress is required to guide surgical classification and management.

Finally, the optimal surgical approach to these patients is unclear. Seven different repair methods were reported by the surgeons in this survey. Only 2% of surgeons reported endoscopic repairs, despite increases in the incidence of arthroscopic surgery. Endoscopic repair may offer advantages in repair with similar post-operative patient-reported outcomes and less complications compared with open repair.10

Hip abductor tendon tears were identified as a pertinent clinical problem in this survey. An improvement in the fundamental pathological understanding of disease is required. Tissue engineering solutions such as tissue augments and biologics hold promise; however, high quality studies are required to validate their efficacy and applicability.

Summary

Abstract

Aim

Hip abductor tendon tears are a common cause of chronic hip pain and a difficult problem to manage. The aim of this survey is to establish the level of recognition by New Zealand orthopaedic surgeons and identify the challenges in treating abductor tendon repairs.

Method

An online survey was sent to 215 consultant orthopaedic surgeons in New Zealand with a registered interest in hip surgery. The survey consisted of five questions regarding the diagnosis, management and clinical challenges related to hip abductor tendon tears.

Results

Eighty-six of 204 eligible surgeons (42.2%) completed the survey. Almost all (90%) of respondents have diagnosed abductor tendon tears and over half (59%) have performed hip abductor tendon tears in their practice. The most common indication for repair was pain (35%), followed by functional weakness (29%), and the most common repair technique involved transosseous repair through the greater trochanter (41%), closely followed by suture anchors (37%). The majority of surgeons identified a need for novel biologics and tissue augments for improving repair.

Conclusion

Hip abductor tendon tears were identified as a pertinent clinical problem in this survey. An improvement in the fundamental pathological understanding of disease and greater availability of proven biologics and tissue augments are required.

Author Information

Mark F Zhu, Orthopaedic Registrar, The Bone and Joint Laboratory, The University of Auckland, Auckland; Auckland City Hospital, Department of Orthopaedic Surgery, Auckland; David S Musson, AMRF Fellow, The Bone and Joint Laboratory, The University of Auckland, Auckland; Jacob T Munro, Orthopaedic Consultant, Senior Lecturer, The Bone and Joint Laboratory, The University of Auckland, Auckland; Auckland City Hospital, Department of Orthopaedic Surgery, Auckland.

Acknowledgements

The authors would like to acknowledge Mr Hugh Blackley and Mr Andrew Campbell for their assessment of the final survey, and Prue Elwood from the New Zealand Orthopaedic Association for assistance with approval and dissemination of the survey. The authors would like to acknowledge the New Zealand Orthopaedic Association (Grant number 371455) and the Health Research Council of New Zealand (Grant number 3714609) for funding this study.

Correspondence

Mark Zhu, University of Auckland, 85 Park Road, Grafton 1023.

Correspondence Email

mzhu031@aucklanduni.ac.nz

Competing Interests

Nil.

1. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br. 1997; 79:618–620.

2. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty. 2001; 16:121–123.

3. Hendry J, Biant LC, Breusch SJ. Abductor mechanism tears in primary total hip arthroplasty. Arch Orthop Trauma Surg. 2012; 132:1619–1623.

4. Board TN, Hughes SJ, Freemont AJ. Trochanteric bursitis: The last great misnomer. Hip Int. 2014; 24:610–615.

5. Albers IS, Zwerver J, Diercks RL, Dekker JH, Van den Akker-Scheek I. Incidence and prevalence of lower extremity tendinopathy in a dutch general practice population: A cross sectional study. BMC Musculoskelet Disord. 2016; 17:16.

6. Berry DJ, Sierra RJ, Hanssen AD, et al. AAHKS symposium: State-of-the-art management of tough and unsolved problems in hip and knee arthroplasty. The Journal of Arthroplasty. 2016; 31:7–15.

7. Lachiewicz PF. Abductor tendon tears of the hip: Evaluation and management. J Am Acad Orthop Surg. 2011; 19:385–391.

8. Fearon AM, Cook JL, Scarvell JM, et al. Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: A case control study. J Arthroplasty. 2014; 29:383–386.

9. Ebert JR, Bucher TA, Ball SV, Janes GC. A review of surgical repair methods and patient outcomes for gluteal tendon tears. Hip Int. 2015; 25:15–23.

10. Chandrasekaran S, Lodhia P, Gui C, et al. Outcomes of open versus endoscopic repair of abductor muscle tears of the hip: A systematic review. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2015; 31:2057–2067.e2.

11. Sprague S, Quigley L, Bhandari M. Survey design in orthopaedic surgery: Getting surgeons to respond. Journal of Bone & Joint Surgery. 2009; 91:27–34.

12. Raneses E, Secrist ES, Freedman KB, et al. Opioid prescribing practices of orthopaedic surgeons: Results of a national survey. Journal of the American Academy of Orthopaedic Surgeons. 2019; 27:e166.

13. Fearon AM, Scarvell JM, Cook JL, Smith PN. Does ultrasound correlate with surgical or histologic findings in greater trochanteric pain syndrome? A pilot study. Clin Orthop Relat Res. 2010; 468:1838–1844.

14. Redmond J, Chen A, Domb B. Greater trochanteric pain syndrome. Journal of the American Academy of Orthopaedic Surgeons. 2016; 24:231–240.

15. Kagan A. Rotator cuff tears of the hip. Clin Orthop Relat Res. 1999:135–140.

16. Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial. BMJ. 2018; 361:k1662.

17. Walsh MJ, Walton JR, Walsh NA. Surgical repair of the gluteal tendons: A report of 72 cases. The Journal of Arthroplasty. 2011; 26:1514–1519.

18. Domb BG, Botser I, Giordano BD. Outcomes of endoscopic gluteus medius repair with minimum 2-year follow-up. Am J Sports Med. 2013; 41:988–997.

19. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endoscopic repair of gluteus medius tendon tears of the hip. Am J Sports Med. 2009; 37:743–747.

20. Ebert JR, Bucher TA, Mullan CJ, Janes GC. Clinical and functional outcomes after augmented hip abductor tendon repair. Hip Int. 2017.

21. Rao BM, Kamal TT, Vafaye J, Taylor L. Surgical repair of hip abductors. A new technique using graft jacket® allograft acellular human dermal matrix. International Orthopaedics. 2012; 36:2049.

22. Grimaldi A, Mellor R, Hodges P, et al. Gluteal tendinopathy: A review of mechanisms, assessment and management. Sports Med. 2015; 45:1107–1119.

23. Hoffman DF, Smith J. Sonoanatomy and pathology of the posterior band of the gluteus medius tendon. Journal of Ultrasound in Medicine. 2017; 36:389–399.

24. Connell D, Bass C, Sykes C, Young D, Edwards E. Sonographic evaluation of gluteus medius and minimus tendinopathy. Eur Radiol. 2003; 13:1339–1347.

25. Capogna BM, Shenoy K, Youm T, Stuchin SA. Tendon disorders after total hip arthroplasty: Evaluation and management. The Journal of Arthroplasty. 2017.

26. Garcia FL, Picado CHF, Nogueira-Barbosa MH. Sonographic evaluation of the abductor mechanism after total hip arthroplasty. Journal of Ultrasound in Medicine. 2010; 29:465–471.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

Hip abductor tendon tears are a common cause of greater trochanteric pain syndrome, affecting up to 20% of those over the age of 50 (Figure 1).1–5 Patients with abductor tendon tears often present in three distinctive groups. The first group presents prior to arthroplasty with primary tendinopathy and tear of the gluteus medius and minimus tendons, the second group have tears found incidentally at the time of arthroplasty.6 The third group presents following hip arthroplasty, this can be a consequence of the surgical approach (Hardinge approach) in conjunction with existing tendon degeneration, or due to complications such as metalosis and infection.7

Patients often complain of pain over the greater trochanter which worsens on weight bearing; many have the classic ‘Trendelenburg gait’ where the pelvis sags away from the planted leg while walking.6 Abductor tendon tears can be debilitating and render patients immobile. This has important implications for independence and confidence in the elderly population.8

While effective surgical treatments are available for other lower limb tendon tears, hip abductor tears are difficult problems to manage.9 Conservative treatments are of little benefit for symptomatic patients with significant tears. While both open and arthroscopic surgical repair has been attempted, they are often limited by the failure of the repaired tissue to heal.6,10 This survey seeks to establish the level of recognition of this problem among New Zealand orthopaedic surgeons, and identify the challenges the surgeons face in treating abductor tendon tears. With the emergence of novel biomaterials and biologics to improve tendon repair, there are new opportunities to improve the outcome of surgical repair.

Figure 1: Diagram of hip abductor tendon including gluteus medius and minimus tendons (left), T2 MRI scan showing complete tears of gluteus medius and minimus (centre), and intraoperative findings showing an undersurface tear of gluteus medius (right).

Methods

With the assistance and permission of the New Zealand Orthopaedic Association, an online survey was sent to 215 consultant orthopaedic surgeons in New Zealand with a registered interest in hip surgery. Following the initial email and link to online survey, two further reminder emails were sent. The survey was administered through surveygizmo and consisted of five questions, including whether the surgeon performed hip arthroplasty (Q1), how often they diagnose a patient with a hip abductor tendon tear (Q2), whether they perform surgery for hip abductor tendon tears (Q3a and Q3b), the contraindications for surgery (Q4) and the innovations they need to improve the management of patients with hip abductor tendon tears (Q5) (Table 1). The option of adding comments as free text after each question was made available. Demographic data collected included subspecialty and whether hip arthroplasty was performed as part of routine practice. The survey was designed and thoroughly tested by the authors. Further assessment of the survey was performed by two additional hip surgeons (HB and AC). The survey was anonymised with a response window of three months.

Table 1: Items in hip abductor tendon tear survey.

Results

Eleven surgeons contacted the author with their apologies stating they did not complete the survey as they no longer perform any hip surgery. Eighty-six surgeons completed the survey, giving a response rate of 42.2%. The majority of respondents (81%) performed hip arthroplasty as part of their routine practice and the remainder did not despite registering an interest in hip surgery. Table 2 lists a summary of the following results.

Table 2: Summary of survey results.

Q1. Frequency of diagnosing patients with hip abductor tendon tears

The majority of surgeons chose to enter free text for this section. Ninety percent of respondents have diagnosed this problem, 54% diagnose the condition up to once per month and 36% diagnose it frequently, defined as more than once per month. Ten percent have never diagnosed a hip abductor tendon tear.

Q2. Proportion of surgeons performing surgery for gluteus medius and minimus tears

Over half of respondents (59%) have performed repairs on either the gluteus medius or minimus tendon. The majority (57%) have performed repair of the gluteus medius tendon in the last 12 months and a significant number (36%) performed gluteus minimus repairs in the last 12 months.

Of the surgeons performing repairs, 67% were able to provide the numbers of procedures performed per year. The average number of cases per year was 3.22. Of the surgeons performing repairs, 12% performed more than five repairs per year, while 29% performed one or less repair per year.

Q3a. Indications for surgical management

In the 51 surgeons who performed surgical repairs, many gave more than one answer for this question. The responses were counted cumulatively. Twenty surgeons (39%) stated that they performed repairs both pre- and post-hip arthroplasty, four (8%) stated that they performed repairs for incidental tears. The rest (53%) did not provide clarification on their practice as related to tear classification.

Pain was the most common indication for repair (35%), followed by function loss/weakness (29%), MRI evidence of tear with preserved muscle bulk (16%), failed conservative therapy (13%), incidental findings at the time of the primary or revision arthroplasty (6%) and bursitis (1%) as an indication for debridement and direct repair.

Q3b. Surgical technique

In the 51 surgeons who performed surgery for either medius or minimus tears, seven surgical methods were reported. Transosseous repair through drill holes in the greater trochanter was the most common technique (41%), followed by using suture anchors to approximate tendon back to bone (37%). These were by far the most popular responses. The remaining surgical techniques described direct side to side repair of the tendon only (6%), Z lengthenings of the iliotibial band (6%), augmenting the repair using Lars ligament and an Achilles bone block (6%), endoscopic repair (4%, with these surgeons also performing open repair via suture anchors), and direct repair of the gluteus medius with minimus release (2%).

Q4. Reasons for not performing surgery

There were six reasons for not performing hip abductor tendon repair and these responses included surgeons that had never performed repair. The most common reason (33%) was concern regarding the poor quality of tissue resulting in a repair that would not heal. Following that, 24% of surgeons did not see hip abductor tendon tears as a significant surgical problem. The remaining reasons in descending order; believing that conservative treatment had similar outcomes (16%), concern whether surgery is beneficial given an imperfectly defined clinical problem (15%), difficulties with post-operative care limiting surgical success (6%) and preferred referral of patients to colleagues (5%).

Q5. What is needed for better management of patients with hip abductor tendon tears

There were 81 responses for this question. Out of the positive responses, 26% stated that better tendon augments and fixation methods would be useful, 23% advocated for the advancement of biologicals to improve tendon regeneration and 11% believed that improved understanding of the problems (ie, classification of tears and selection of patients for surgery) was critical to improving management. Four percent believed improved immobilisation following surgery was required while 2% advocated for the wider use of botox following repair to “rest” the muscles involved. Approximately one third of surgeons (33%) did not know what would improve management.

Discussion

A nationwide survey on hip abductor tendon tears was performed to ascertain the level of recognition of this problem among New Zealand orthopaedic surgeons. To the authors’ knowledge this is the first survey of hip abductor tendon tear diagnosis and management among orthopaedic surgeons. The response rate of 42.4% lies within the broad range of expected response rates for surveys administered to orthopaedic surgeons.11,12

Hip abductor tendon tears are increasingly recognised as a cause of lateral hip pain, gait instability and prosthetic joint dislocations.5,6,13,14 While traditionally managed conservatively, surgical repair has been well reported in the literature since the 1990s.1,15 A recent randomised control trial in Australia examined different conservative management options; load management education plus exercise, single corticosteroid injection and no treatment on a series of 204 patients with hip abductor tendon tears.16 The study excluded patients with total hip arthroplasty and hip osteoarthritis which make up a significant group of patients with hip abductor tendon tears. They did report an improvement in patient reported outcomes at eight and 52 weeks in the education and exercise group compared to both steroid injections and the control group.

Operative management may be necessary in patients who do not achieve adequate improvement with conservative management or those with tears present at the time of total hip arthroplasty.10 In this survey, 59% of surgeons have performed surgical repair of hip abductor tendon tears. However, the number of surgeries performed per year is small with only 12% of surgeons surveyed performing more than five repairs per year.

The reluctance to perform repair centred on two main concerns. Firstly, achieving a strong repair in degenerative tendon is difficult. Approximately one third of the surgeons had concerns regarding the lack of healing in suboptimal tissues. To overcome this, the surveyed surgeons used transosseous and suture-anchor based repair techniques. This reflects the most commonly reported techniques in the literature.17–20 A small number of surgeons reported using LARS ligament augmentations, while none used tissue patches or biologics to supplement their repair. This is perhaps not surprising, as the use of biologics in the literature consist of small case series only.21 Half of all surgeons surveyed stated that novel materials and biologics are needed to improve the quality of healing and clinical outcomes. As such, further research in this area is required to identify such products and conduct high-quality trials to prove efficacy.

Secondly, the clinical problem and indications for treatment are unclear. The most common indication for surgery in this survey was pain, followed by functional disability and MRI evidence of tears without muscle atrophy. These indications are similar to those proposed in the literature.17,22 However, the heterogeneity in which tendons are repaired reflect the uncertainties around the clinical problem. The majority of surgeons reported repairing the gluteus medius and not the minimus, with one advocating for the release of gluteus minimus. Previous cadaveric and imaging studies have varied in their report of tear locations and morphologies, with a number reporting greater incidence of gluteus minimus tears.23–26 A better understanding of how tears originate and progress is required to guide surgical classification and management.

Finally, the optimal surgical approach to these patients is unclear. Seven different repair methods were reported by the surgeons in this survey. Only 2% of surgeons reported endoscopic repairs, despite increases in the incidence of arthroscopic surgery. Endoscopic repair may offer advantages in repair with similar post-operative patient-reported outcomes and less complications compared with open repair.10

Hip abductor tendon tears were identified as a pertinent clinical problem in this survey. An improvement in the fundamental pathological understanding of disease is required. Tissue engineering solutions such as tissue augments and biologics hold promise; however, high quality studies are required to validate their efficacy and applicability.

Summary

Abstract

Aim

Hip abductor tendon tears are a common cause of chronic hip pain and a difficult problem to manage. The aim of this survey is to establish the level of recognition by New Zealand orthopaedic surgeons and identify the challenges in treating abductor tendon repairs.

Method

An online survey was sent to 215 consultant orthopaedic surgeons in New Zealand with a registered interest in hip surgery. The survey consisted of five questions regarding the diagnosis, management and clinical challenges related to hip abductor tendon tears.

Results

Eighty-six of 204 eligible surgeons (42.2%) completed the survey. Almost all (90%) of respondents have diagnosed abductor tendon tears and over half (59%) have performed hip abductor tendon tears in their practice. The most common indication for repair was pain (35%), followed by functional weakness (29%), and the most common repair technique involved transosseous repair through the greater trochanter (41%), closely followed by suture anchors (37%). The majority of surgeons identified a need for novel biologics and tissue augments for improving repair.

Conclusion

Hip abductor tendon tears were identified as a pertinent clinical problem in this survey. An improvement in the fundamental pathological understanding of disease and greater availability of proven biologics and tissue augments are required.

Author Information

Mark F Zhu, Orthopaedic Registrar, The Bone and Joint Laboratory, The University of Auckland, Auckland; Auckland City Hospital, Department of Orthopaedic Surgery, Auckland; David S Musson, AMRF Fellow, The Bone and Joint Laboratory, The University of Auckland, Auckland; Jacob T Munro, Orthopaedic Consultant, Senior Lecturer, The Bone and Joint Laboratory, The University of Auckland, Auckland; Auckland City Hospital, Department of Orthopaedic Surgery, Auckland.

Acknowledgements

The authors would like to acknowledge Mr Hugh Blackley and Mr Andrew Campbell for their assessment of the final survey, and Prue Elwood from the New Zealand Orthopaedic Association for assistance with approval and dissemination of the survey. The authors would like to acknowledge the New Zealand Orthopaedic Association (Grant number 371455) and the Health Research Council of New Zealand (Grant number 3714609) for funding this study.

Correspondence

Mark Zhu, University of Auckland, 85 Park Road, Grafton 1023.

Correspondence Email

mzhu031@aucklanduni.ac.nz

Competing Interests

Nil.

1. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br. 1997; 79:618–620.

2. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty. 2001; 16:121–123.

3. Hendry J, Biant LC, Breusch SJ. Abductor mechanism tears in primary total hip arthroplasty. Arch Orthop Trauma Surg. 2012; 132:1619–1623.

4. Board TN, Hughes SJ, Freemont AJ. Trochanteric bursitis: The last great misnomer. Hip Int. 2014; 24:610–615.

5. Albers IS, Zwerver J, Diercks RL, Dekker JH, Van den Akker-Scheek I. Incidence and prevalence of lower extremity tendinopathy in a dutch general practice population: A cross sectional study. BMC Musculoskelet Disord. 2016; 17:16.

6. Berry DJ, Sierra RJ, Hanssen AD, et al. AAHKS symposium: State-of-the-art management of tough and unsolved problems in hip and knee arthroplasty. The Journal of Arthroplasty. 2016; 31:7–15.

7. Lachiewicz PF. Abductor tendon tears of the hip: Evaluation and management. J Am Acad Orthop Surg. 2011; 19:385–391.

8. Fearon AM, Cook JL, Scarvell JM, et al. Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: A case control study. J Arthroplasty. 2014; 29:383–386.

9. Ebert JR, Bucher TA, Ball SV, Janes GC. A review of surgical repair methods and patient outcomes for gluteal tendon tears. Hip Int. 2015; 25:15–23.

10. Chandrasekaran S, Lodhia P, Gui C, et al. Outcomes of open versus endoscopic repair of abductor muscle tears of the hip: A systematic review. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2015; 31:2057–2067.e2.

11. Sprague S, Quigley L, Bhandari M. Survey design in orthopaedic surgery: Getting surgeons to respond. Journal of Bone & Joint Surgery. 2009; 91:27–34.

12. Raneses E, Secrist ES, Freedman KB, et al. Opioid prescribing practices of orthopaedic surgeons: Results of a national survey. Journal of the American Academy of Orthopaedic Surgeons. 2019; 27:e166.

13. Fearon AM, Scarvell JM, Cook JL, Smith PN. Does ultrasound correlate with surgical or histologic findings in greater trochanteric pain syndrome? A pilot study. Clin Orthop Relat Res. 2010; 468:1838–1844.

14. Redmond J, Chen A, Domb B. Greater trochanteric pain syndrome. Journal of the American Academy of Orthopaedic Surgeons. 2016; 24:231–240.

15. Kagan A. Rotator cuff tears of the hip. Clin Orthop Relat Res. 1999:135–140.

16. Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial. BMJ. 2018; 361:k1662.

17. Walsh MJ, Walton JR, Walsh NA. Surgical repair of the gluteal tendons: A report of 72 cases. The Journal of Arthroplasty. 2011; 26:1514–1519.

18. Domb BG, Botser I, Giordano BD. Outcomes of endoscopic gluteus medius repair with minimum 2-year follow-up. Am J Sports Med. 2013; 41:988–997.

19. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endoscopic repair of gluteus medius tendon tears of the hip. Am J Sports Med. 2009; 37:743–747.

20. Ebert JR, Bucher TA, Mullan CJ, Janes GC. Clinical and functional outcomes after augmented hip abductor tendon repair. Hip Int. 2017.

21. Rao BM, Kamal TT, Vafaye J, Taylor L. Surgical repair of hip abductors. A new technique using graft jacket® allograft acellular human dermal matrix. International Orthopaedics. 2012; 36:2049.

22. Grimaldi A, Mellor R, Hodges P, et al. Gluteal tendinopathy: A review of mechanisms, assessment and management. Sports Med. 2015; 45:1107–1119.

23. Hoffman DF, Smith J. Sonoanatomy and pathology of the posterior band of the gluteus medius tendon. Journal of Ultrasound in Medicine. 2017; 36:389–399.

24. Connell D, Bass C, Sykes C, Young D, Edwards E. Sonographic evaluation of gluteus medius and minimus tendinopathy. Eur Radiol. 2003; 13:1339–1347.

25. Capogna BM, Shenoy K, Youm T, Stuchin SA. Tendon disorders after total hip arthroplasty: Evaluation and management. The Journal of Arthroplasty. 2017.

26. Garcia FL, Picado CHF, Nogueira-Barbosa MH. Sonographic evaluation of the abductor mechanism after total hip arthroplasty. Journal of Ultrasound in Medicine. 2010; 29:465–471.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

Hip abductor tendon tears are a common cause of greater trochanteric pain syndrome, affecting up to 20% of those over the age of 50 (Figure 1).1–5 Patients with abductor tendon tears often present in three distinctive groups. The first group presents prior to arthroplasty with primary tendinopathy and tear of the gluteus medius and minimus tendons, the second group have tears found incidentally at the time of arthroplasty.6 The third group presents following hip arthroplasty, this can be a consequence of the surgical approach (Hardinge approach) in conjunction with existing tendon degeneration, or due to complications such as metalosis and infection.7

Patients often complain of pain over the greater trochanter which worsens on weight bearing; many have the classic ‘Trendelenburg gait’ where the pelvis sags away from the planted leg while walking.6 Abductor tendon tears can be debilitating and render patients immobile. This has important implications for independence and confidence in the elderly population.8

While effective surgical treatments are available for other lower limb tendon tears, hip abductor tears are difficult problems to manage.9 Conservative treatments are of little benefit for symptomatic patients with significant tears. While both open and arthroscopic surgical repair has been attempted, they are often limited by the failure of the repaired tissue to heal.6,10 This survey seeks to establish the level of recognition of this problem among New Zealand orthopaedic surgeons, and identify the challenges the surgeons face in treating abductor tendon tears. With the emergence of novel biomaterials and biologics to improve tendon repair, there are new opportunities to improve the outcome of surgical repair.

Figure 1: Diagram of hip abductor tendon including gluteus medius and minimus tendons (left), T2 MRI scan showing complete tears of gluteus medius and minimus (centre), and intraoperative findings showing an undersurface tear of gluteus medius (right).

Methods

With the assistance and permission of the New Zealand Orthopaedic Association, an online survey was sent to 215 consultant orthopaedic surgeons in New Zealand with a registered interest in hip surgery. Following the initial email and link to online survey, two further reminder emails were sent. The survey was administered through surveygizmo and consisted of five questions, including whether the surgeon performed hip arthroplasty (Q1), how often they diagnose a patient with a hip abductor tendon tear (Q2), whether they perform surgery for hip abductor tendon tears (Q3a and Q3b), the contraindications for surgery (Q4) and the innovations they need to improve the management of patients with hip abductor tendon tears (Q5) (Table 1). The option of adding comments as free text after each question was made available. Demographic data collected included subspecialty and whether hip arthroplasty was performed as part of routine practice. The survey was designed and thoroughly tested by the authors. Further assessment of the survey was performed by two additional hip surgeons (HB and AC). The survey was anonymised with a response window of three months.

Table 1: Items in hip abductor tendon tear survey.

Results

Eleven surgeons contacted the author with their apologies stating they did not complete the survey as they no longer perform any hip surgery. Eighty-six surgeons completed the survey, giving a response rate of 42.2%. The majority of respondents (81%) performed hip arthroplasty as part of their routine practice and the remainder did not despite registering an interest in hip surgery. Table 2 lists a summary of the following results.

Table 2: Summary of survey results.

Q1. Frequency of diagnosing patients with hip abductor tendon tears

The majority of surgeons chose to enter free text for this section. Ninety percent of respondents have diagnosed this problem, 54% diagnose the condition up to once per month and 36% diagnose it frequently, defined as more than once per month. Ten percent have never diagnosed a hip abductor tendon tear.

Q2. Proportion of surgeons performing surgery for gluteus medius and minimus tears

Over half of respondents (59%) have performed repairs on either the gluteus medius or minimus tendon. The majority (57%) have performed repair of the gluteus medius tendon in the last 12 months and a significant number (36%) performed gluteus minimus repairs in the last 12 months.

Of the surgeons performing repairs, 67% were able to provide the numbers of procedures performed per year. The average number of cases per year was 3.22. Of the surgeons performing repairs, 12% performed more than five repairs per year, while 29% performed one or less repair per year.

Q3a. Indications for surgical management

In the 51 surgeons who performed surgical repairs, many gave more than one answer for this question. The responses were counted cumulatively. Twenty surgeons (39%) stated that they performed repairs both pre- and post-hip arthroplasty, four (8%) stated that they performed repairs for incidental tears. The rest (53%) did not provide clarification on their practice as related to tear classification.

Pain was the most common indication for repair (35%), followed by function loss/weakness (29%), MRI evidence of tear with preserved muscle bulk (16%), failed conservative therapy (13%), incidental findings at the time of the primary or revision arthroplasty (6%) and bursitis (1%) as an indication for debridement and direct repair.

Q3b. Surgical technique

In the 51 surgeons who performed surgery for either medius or minimus tears, seven surgical methods were reported. Transosseous repair through drill holes in the greater trochanter was the most common technique (41%), followed by using suture anchors to approximate tendon back to bone (37%). These were by far the most popular responses. The remaining surgical techniques described direct side to side repair of the tendon only (6%), Z lengthenings of the iliotibial band (6%), augmenting the repair using Lars ligament and an Achilles bone block (6%), endoscopic repair (4%, with these surgeons also performing open repair via suture anchors), and direct repair of the gluteus medius with minimus release (2%).

Q4. Reasons for not performing surgery

There were six reasons for not performing hip abductor tendon repair and these responses included surgeons that had never performed repair. The most common reason (33%) was concern regarding the poor quality of tissue resulting in a repair that would not heal. Following that, 24% of surgeons did not see hip abductor tendon tears as a significant surgical problem. The remaining reasons in descending order; believing that conservative treatment had similar outcomes (16%), concern whether surgery is beneficial given an imperfectly defined clinical problem (15%), difficulties with post-operative care limiting surgical success (6%) and preferred referral of patients to colleagues (5%).

Q5. What is needed for better management of patients with hip abductor tendon tears

There were 81 responses for this question. Out of the positive responses, 26% stated that better tendon augments and fixation methods would be useful, 23% advocated for the advancement of biologicals to improve tendon regeneration and 11% believed that improved understanding of the problems (ie, classification of tears and selection of patients for surgery) was critical to improving management. Four percent believed improved immobilisation following surgery was required while 2% advocated for the wider use of botox following repair to “rest” the muscles involved. Approximately one third of surgeons (33%) did not know what would improve management.

Discussion

A nationwide survey on hip abductor tendon tears was performed to ascertain the level of recognition of this problem among New Zealand orthopaedic surgeons. To the authors’ knowledge this is the first survey of hip abductor tendon tear diagnosis and management among orthopaedic surgeons. The response rate of 42.4% lies within the broad range of expected response rates for surveys administered to orthopaedic surgeons.11,12

Hip abductor tendon tears are increasingly recognised as a cause of lateral hip pain, gait instability and prosthetic joint dislocations.5,6,13,14 While traditionally managed conservatively, surgical repair has been well reported in the literature since the 1990s.1,15 A recent randomised control trial in Australia examined different conservative management options; load management education plus exercise, single corticosteroid injection and no treatment on a series of 204 patients with hip abductor tendon tears.16 The study excluded patients with total hip arthroplasty and hip osteoarthritis which make up a significant group of patients with hip abductor tendon tears. They did report an improvement in patient reported outcomes at eight and 52 weeks in the education and exercise group compared to both steroid injections and the control group.

Operative management may be necessary in patients who do not achieve adequate improvement with conservative management or those with tears present at the time of total hip arthroplasty.10 In this survey, 59% of surgeons have performed surgical repair of hip abductor tendon tears. However, the number of surgeries performed per year is small with only 12% of surgeons surveyed performing more than five repairs per year.

The reluctance to perform repair centred on two main concerns. Firstly, achieving a strong repair in degenerative tendon is difficult. Approximately one third of the surgeons had concerns regarding the lack of healing in suboptimal tissues. To overcome this, the surveyed surgeons used transosseous and suture-anchor based repair techniques. This reflects the most commonly reported techniques in the literature.17–20 A small number of surgeons reported using LARS ligament augmentations, while none used tissue patches or biologics to supplement their repair. This is perhaps not surprising, as the use of biologics in the literature consist of small case series only.21 Half of all surgeons surveyed stated that novel materials and biologics are needed to improve the quality of healing and clinical outcomes. As such, further research in this area is required to identify such products and conduct high-quality trials to prove efficacy.

Secondly, the clinical problem and indications for treatment are unclear. The most common indication for surgery in this survey was pain, followed by functional disability and MRI evidence of tears without muscle atrophy. These indications are similar to those proposed in the literature.17,22 However, the heterogeneity in which tendons are repaired reflect the uncertainties around the clinical problem. The majority of surgeons reported repairing the gluteus medius and not the minimus, with one advocating for the release of gluteus minimus. Previous cadaveric and imaging studies have varied in their report of tear locations and morphologies, with a number reporting greater incidence of gluteus minimus tears.23–26 A better understanding of how tears originate and progress is required to guide surgical classification and management.

Finally, the optimal surgical approach to these patients is unclear. Seven different repair methods were reported by the surgeons in this survey. Only 2% of surgeons reported endoscopic repairs, despite increases in the incidence of arthroscopic surgery. Endoscopic repair may offer advantages in repair with similar post-operative patient-reported outcomes and less complications compared with open repair.10

Hip abductor tendon tears were identified as a pertinent clinical problem in this survey. An improvement in the fundamental pathological understanding of disease is required. Tissue engineering solutions such as tissue augments and biologics hold promise; however, high quality studies are required to validate their efficacy and applicability.

Summary

Abstract

Aim

Hip abductor tendon tears are a common cause of chronic hip pain and a difficult problem to manage. The aim of this survey is to establish the level of recognition by New Zealand orthopaedic surgeons and identify the challenges in treating abductor tendon repairs.

Method

An online survey was sent to 215 consultant orthopaedic surgeons in New Zealand with a registered interest in hip surgery. The survey consisted of five questions regarding the diagnosis, management and clinical challenges related to hip abductor tendon tears.

Results

Eighty-six of 204 eligible surgeons (42.2%) completed the survey. Almost all (90%) of respondents have diagnosed abductor tendon tears and over half (59%) have performed hip abductor tendon tears in their practice. The most common indication for repair was pain (35%), followed by functional weakness (29%), and the most common repair technique involved transosseous repair through the greater trochanter (41%), closely followed by suture anchors (37%). The majority of surgeons identified a need for novel biologics and tissue augments for improving repair.

Conclusion

Hip abductor tendon tears were identified as a pertinent clinical problem in this survey. An improvement in the fundamental pathological understanding of disease and greater availability of proven biologics and tissue augments are required.

Author Information

Mark F Zhu, Orthopaedic Registrar, The Bone and Joint Laboratory, The University of Auckland, Auckland; Auckland City Hospital, Department of Orthopaedic Surgery, Auckland; David S Musson, AMRF Fellow, The Bone and Joint Laboratory, The University of Auckland, Auckland; Jacob T Munro, Orthopaedic Consultant, Senior Lecturer, The Bone and Joint Laboratory, The University of Auckland, Auckland; Auckland City Hospital, Department of Orthopaedic Surgery, Auckland.

Acknowledgements

The authors would like to acknowledge Mr Hugh Blackley and Mr Andrew Campbell for their assessment of the final survey, and Prue Elwood from the New Zealand Orthopaedic Association for assistance with approval and dissemination of the survey. The authors would like to acknowledge the New Zealand Orthopaedic Association (Grant number 371455) and the Health Research Council of New Zealand (Grant number 3714609) for funding this study.

Correspondence

Mark Zhu, University of Auckland, 85 Park Road, Grafton 1023.

Correspondence Email

mzhu031@aucklanduni.ac.nz

Competing Interests

Nil.

1. Bunker TD, Esler CN, Leach WJ. Rotator-cuff tear of the hip. J Bone Joint Surg Br. 1997; 79:618–620.

2. Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty. 2001; 16:121–123.

3. Hendry J, Biant LC, Breusch SJ. Abductor mechanism tears in primary total hip arthroplasty. Arch Orthop Trauma Surg. 2012; 132:1619–1623.

4. Board TN, Hughes SJ, Freemont AJ. Trochanteric bursitis: The last great misnomer. Hip Int. 2014; 24:610–615.

5. Albers IS, Zwerver J, Diercks RL, Dekker JH, Van den Akker-Scheek I. Incidence and prevalence of lower extremity tendinopathy in a dutch general practice population: A cross sectional study. BMC Musculoskelet Disord. 2016; 17:16.

6. Berry DJ, Sierra RJ, Hanssen AD, et al. AAHKS symposium: State-of-the-art management of tough and unsolved problems in hip and knee arthroplasty. The Journal of Arthroplasty. 2016; 31:7–15.

7. Lachiewicz PF. Abductor tendon tears of the hip: Evaluation and management. J Am Acad Orthop Surg. 2011; 19:385–391.

8. Fearon AM, Cook JL, Scarvell JM, et al. Greater trochanteric pain syndrome negatively affects work, physical activity and quality of life: A case control study. J Arthroplasty. 2014; 29:383–386.

9. Ebert JR, Bucher TA, Ball SV, Janes GC. A review of surgical repair methods and patient outcomes for gluteal tendon tears. Hip Int. 2015; 25:15–23.

10. Chandrasekaran S, Lodhia P, Gui C, et al. Outcomes of open versus endoscopic repair of abductor muscle tears of the hip: A systematic review. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2015; 31:2057–2067.e2.

11. Sprague S, Quigley L, Bhandari M. Survey design in orthopaedic surgery: Getting surgeons to respond. Journal of Bone & Joint Surgery. 2009; 91:27–34.

12. Raneses E, Secrist ES, Freedman KB, et al. Opioid prescribing practices of orthopaedic surgeons: Results of a national survey. Journal of the American Academy of Orthopaedic Surgeons. 2019; 27:e166.

13. Fearon AM, Scarvell JM, Cook JL, Smith PN. Does ultrasound correlate with surgical or histologic findings in greater trochanteric pain syndrome? A pilot study. Clin Orthop Relat Res. 2010; 468:1838–1844.

14. Redmond J, Chen A, Domb B. Greater trochanteric pain syndrome. Journal of the American Academy of Orthopaedic Surgeons. 2016; 24:231–240.

15. Kagan A. Rotator cuff tears of the hip. Clin Orthop Relat Res. 1999:135–140.

16. Mellor R, Bennell K, Grimaldi A, et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial. BMJ. 2018; 361:k1662.

17. Walsh MJ, Walton JR, Walsh NA. Surgical repair of the gluteal tendons: A report of 72 cases. The Journal of Arthroplasty. 2011; 26:1514–1519.

18. Domb BG, Botser I, Giordano BD. Outcomes of endoscopic gluteus medius repair with minimum 2-year follow-up. Am J Sports Med. 2013; 41:988–997.

19. Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT. Endoscopic repair of gluteus medius tendon tears of the hip. Am J Sports Med. 2009; 37:743–747.

20. Ebert JR, Bucher TA, Mullan CJ, Janes GC. Clinical and functional outcomes after augmented hip abductor tendon repair. Hip Int. 2017.

21. Rao BM, Kamal TT, Vafaye J, Taylor L. Surgical repair of hip abductors. A new technique using graft jacket® allograft acellular human dermal matrix. International Orthopaedics. 2012; 36:2049.

22. Grimaldi A, Mellor R, Hodges P, et al. Gluteal tendinopathy: A review of mechanisms, assessment and management. Sports Med. 2015; 45:1107–1119.

23. Hoffman DF, Smith J. Sonoanatomy and pathology of the posterior band of the gluteus medius tendon. Journal of Ultrasound in Medicine. 2017; 36:389–399.

24. Connell D, Bass C, Sykes C, Young D, Edwards E. Sonographic evaluation of gluteus medius and minimus tendinopathy. Eur Radiol. 2003; 13:1339–1347.

25. Capogna BM, Shenoy K, Youm T, Stuchin SA. Tendon disorders after total hip arthroplasty: Evaluation and management. The Journal of Arthroplasty. 2017.

26. Garcia FL, Picado CHF, Nogueira-Barbosa MH. Sonographic evaluation of the abductor mechanism after total hip arthroplasty. Journal of Ultrasound in Medicine. 2010; 29:465–471.

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.

LOGINSUBSCRIBE