Repair of Symptomatic Partial Gluteus Medius Tear During Total Hip Arthroplasty Through the Direct Anterior Approach

Abstract

Gluteus medius (GM) tears are a well-established source of pain and disability. Considering previous studies, which have reported rates of incidental GM tears in 20% of patients undergoing primary total hip arthroplasty (THA) and a 3-fold greater rate in elderly female patients, additional focus should be placed on identifying treatment options. The direct anterior approach (DAA) for primary THA has gained popularity within the past few years. However, there has been a paucity in the literature on how to address symptomatic and partial GM tears through this approach. The purpose of this Technical Note is to describe a method to repair partial GM tears during primary THA using the DAA.

Technique Video

Video 1

The video documents the repair of a gluteus medius tear in a right hip using the direct anterior approach for a total hip arthroplasty. The patient is in the supine position in a traction table. By using the anterior superior iliac spine as an anatomic landmark, a longitudinal and slightly oblique incision is marked 3 cm distal and 3 cm lateral from this point. The fascia of the tensor fascia lata is exposed and incised in line with the skin incision. The interval between the tensor fascia lata and the rectus femoris muscle is developed. The gluteus medius tendon is identified, and the tear pattern and tissue condition assessed. To improve visualization, trochanteric bursa and/or nonviable tissue are debrided. Attention is taken to achieve as much tendon mobilization as possible by releasing any surrounding scar tissue. The greater trochanter lateral facet is decorticated to create a bleeding bed of bone for healing. One double-loaded 5.5-mm PEEK Corkscrew Suture Anchor (Arthrex, Naples, FL) is selected in this case and is placed onto the footprint. All the sutures are passed through gluteus medius tendon. Next, both sets of sutures are then tied in a horizontal mattress fashion. Complete approximation of the tendon over the bone is achieved.

Total hip arthroplasty (THA) for end-stage osteoarthritis is one of the most successful orthopaedic procedures, with excellent long-term outcomes in the literature. The gluteus medius (GM) and minimus muscle–tendon complex is critical for gait and hip joint stability, and tears involving these muscles are currently a well-established source of pain and disability. Incidental GM tears have been reported in 20% of patients undergoing primary THA, with a 3-fold greater rate in elderly female patients. The posterior approach is the most popular approach in THA. Because of the excellent exposure and visualization, regardless of the size of the GM tear, this approach is an ideal alternative when both pathologies need to be addressed.

Nonetheless, the direct anterior approach (DAA) has gained popularity in recent years for THA^1,2; however, it has been questioned whether an efficacious GM tear repair is reproducible using the DAA.³ There are several patterns of GM tearing.⁴ Although the DAA is perhaps not the best option for large and retracted full-thickness GM tears, it can be used effectively for partial-thickness GM tears, preserving the DAA advantages in primary THA surgery.^5,6 We present a description on how to address partial GM tears through the DAA with the traction table,² using the suture-staple and transtendinous techniques.^7,8 Potential indications and contraindications are listed in Table 1. Furthermore, advantages and disadvantages are presented in Table 2.

Table 1.

Surgical Indications and Contraindications for Partial GM Tear Through DAA in THA

Indications	Contraindications
•Symptomatic partial and small full-thickness GM tear.	•Large full-thickness and retracted GM tear.
	•Irreparable GM tear when procedure like gluteus maximus transfer is needed.
	•BMI >40

BMI, body mass index; DAA, direct anterior approach; GM, gluteus medius; THA, total hip arthroplasty.

Table 2.

Advantages and Disadvantages

Advantages	Disadvantages
•Same surgical approach.	•Exposure and visualization can be difficult in large patients.
•Inherent benefits of DAA in primary THA.	•A traction table required (author’s preference).
	•Additional OR staff for traction table management during surgery.

DAA, direct anterior approach; OR, operative room; THA, total hip arthroplasty.

This study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki. This study was carried out in accordance with relevant regulations of the US Health Insurance Portability and Accountability Act (HIPAA). Details that might disclose the identity of the subjects under study have been omitted.

Surgical Technique (With Video Illustration)

Patient Positioning

It is the authors’ preference to use general anesthesia. The patient is placed in the supine position on the Hana table (Mizuho OSI, Union City, CA). The patient is then slid down against a padded perineal post. Both legs are placed in neutral rotation.

Direct Anterior Approach

There is no modification to the DAA when a partial GM tear is part of the surgical plan. By using the anterior superior iliac spine as an anatomic landmark, a longitudinal and slightly oblique incision is marked 3 cm distal and 3 cm lateral from this point (Fig 1). Once the skin and subcutaneous tissue is incised, the fascia of the tensor fascia lata (TFL) is exposed and incised in line with the skin incision. The interval between the TFL and the rectus femoris muscle is developed, and the circumflex vessels are identified and coagulated. The deep fascia is opened, and the femoral neck and anterior capsule are identified (Video 1). Although the authors performed the THA before the partial GM tear repair, the GM evaluation is done beforehand for a final status (partial tear) confirmation (Fig 2).

Fig 1.

The patient is in the supine position and the right hip is shown in preparation for a right total hip arthroplasty and gluteus medius repair using the direct anterior approach. The incision and the inguinal crease are marked by the white and black arrows, respectively. The white asterisk is at the level of the anterior superior iliac spine.

Fig 2.

The patient is in the supine position at the right hip is shown. The gluteus medius tendon (∗) is exposed and probed. A small full-thickness tear is found in this patient right hip. The border of the gluteus medius tear is marked by the dot-line. To achieve this view, the operative leg is brought to 30° of abduction and 20 to 25° of internal rotation.

Gluteus Medius Tendon Exposure

When using DAA with the Hana table, the following maneuvers/steps are required to achieve a proper GM exposure (Fig 2 and Table 3):

• 1.All retractors for femoral neck and anterior capsule need to be removed.
• 2.The operative leg is brought to 30° of abduction.
• 3.Twenty to 25° of internal rotation is also applied.
• 4.Final visualization can be obtained with hibbs retractors.

Table 3.

Pearls and Pitfalls

Pearls	Pitfalls
•Abduction of 30-40° in the operative leg.	•Minimal experience in DAA can result in a nonreproducible procedure.
•Internal rotation of 20-30° in the operative leg.	•Iatrogenic GM damage during femoral capsular release stage.
•Aim the punch before anchor insertion, away from the femoral stem.	•Perform micropuncture after anchor placement can compromise anchor fixation.

DAA, direct anterior approach; GM, gluteus medius.

Once appropriate exposure is obtained, the surgeon must probe the tendon and determine the type of tear involved based on macroscopic findings/intraoperative evaluation and consequently, decide on a repair technique.⁴ Based on Lall et al., we classified the partial GM tears as follows: partial-thickness tear <25% (type IIIA) and partial-thickness tear >25% (type IIIB).

We use the GM tear repair algorithm for the endoscopic alternative to determine the appropriate type of repair. In cases of type IIIA, the suture-staple option would be chosen; for type IIIB, the transtendinous surgical technique would be used.^4,7,8

Repair Technique

Suture-Staple Technique

After trochanteric bursectomy (if required), the GM insertion is probed and confirmation of partial destabilization from its undersurface on the lateral facet is made. To enhance biologic response, a microfracture awl (Arthrex, Naples, FL) is used to create multiple holes within the lateral facet to obtain bone marrow material.⁹ The microfracture awl aims for a depth of 3 to 5 mm. In general, 5 to 8 holes are required in the destabilized area. The PEEK 3.0-mm Knotless SutureTak anchors (Arthrex) are used, and the number of anchors (at least 2) depends on the surface area that needs to be compressed. With the corresponding metal punch, one anchor is placed anteriorly and one is placed posteriorly in the lateral facet of the greater trochanter at the level of the partial tear. It is vital that the metal punch is properly oriented to avoid hitting the femoral stem; an angle between 30° and 45° is required for this task. The repair suture from each anchor is shuttled through the adjacent anchor looped shuttle stitch (A to B and B to A) and a horizontal mattress suture staple configuration is created. If more tendon compression is required, a second row can be added distally using the same technique.

Transtendinous Technique

As mentioned previously, this alternative is preferred for partial type IIIB GM tears. Once the tear is identified and assessed, a longitudinal incision within the mid-substance of the GM tendon is made until the bone (footprint) is reached. This technique also can be used for small full-thickness GM tears (Fig 2). The underlying damage and nonviable tendon tissue are excised. With the use of a motorized burr or curette, the tendon footprint on the lateral facet is decorticated until a bleeding bed of bone is obtained (Fig 3). The “window concept” is applied: First, a small 90° Hohmann retractor is placed on the posterior border of the greater trochanter to expose the most posterior area of the lateral facet. Second, the same steps are used for the anterior counterpart. Considering the appropriate direction of anchor insertion to avoid the femoral stem, 1 or 2 double-loaded 5.5-mm PEEK Corkscrew suture anchors (Arthrex) are placed through the tendon split onto the footprint (Fig 4). Then, one limb of each suture is passed through the anterior and posterior tendon leaflets (Fig 5). Finally, both sets of sutures are tied in a horizontal mattress fashion; an arthroscopic knot pusher may be used for this step. This process is repeated until complete closure of the tendon over the bone is achieved (Fig 6 and Video 1).

Fig 3.

The patient is in the supine position at the right hip is shown. The gluteus medius tendon has been retracted posteriorly. The tendon footprint on the lateral facet (white arrow) is decorticated.

Fig 4.

The patient is in the supine position at the right hip is shown. In this case a single double-loaded 5.5-mm PEEK Corkscrew suture-anchor (Arthrex, Naples, FL) is selected for the repair. The sequence of suture-anchor insertion is shown. A. The corresponding suture-anchor punch (white arrow) is used at the footprint. B. The suture-anchor is (white arrow) placed in the selected location. C. Sutures can be seen after suture-anchor placement (white arrow).

Fig 5.

The sutures (white arrows) have been passed in a mattress fashion through the gluteus medius tendon (asterisk). The border of the gluteus medius tear is marked by the dotted line.

Fig 6.

The gluteus medius tendon has been repaired and final constructed is shown.

Postoperative Rehabilitation Protocol

While patients who undergo a suture-staple GM repair are not required to wear a brace following surgery, they are instructed to use crutches or a walker with weight-bearing as tolerated. Patients who undergo a transtendinous repair are instructed to practice partial weight-bearing (20 lbs) while wearing a low-profile abduction brace (DJO Global, Vista, CA) for 6 weeks in addition to using crutches or a walker. All patients are counseled to complete home physical therapy and home nursing care according to standard protocol. After 1 to 2 weeks of home care, patients participate in another 6 to 8 weeks of outpatient physical therapy to increase range of motion and strength. Patients also follow-up at the 2-week, 3-month, and annual time points for clinical and radiographic assessment.

Discussion

The purpose of this technique is to address the partial GM tear through a DAA in the setting of primary THA. Currently, the posterior approach is often advocated for as the ideal approach since it allows for excellent exposure during the THA procedure as well as the GM repair.^3,10 Further, it has been previously stated that GM tear cannot be fixed using the DAA.³ The authors must mention that the posterior approach is more suitable for full-thickness GM tears, particularly if a salvage procedure such a gluteus maximus transfer with or without TFL is a surgical possibility.11, 12, 13, 14 Nevertheless, repair of partial GM tears is feasible using the DAA. The authors acknowledge the demanding nature of this procedure, especially at the beginning of the DAA learning curve (Tables 3 and 4).15, 16, 17 Moreover, although the use of a traction table is not mandatory for primary DAA THA,¹⁸ the contemporary surgical technique has been implemented by the authors while using an specialized traction table.

Table 4.

Risks

Risks
•Related to the DAA with traction table: pudendal nerve injury, femoral fracture.

DAA, direct anterior approach.

Signs of GM tears such as lateral hip pain, abductor weakness, and unstable gait should be closely assessed by the clinician to identify tears in the setting of hip osteoarthritis.19, 20, 21 Tools to confirm GM tears include diagnostic injections, preferably under ultrasound, in addition to magnetic resonance imaging.22, 23, 24, 25, 26, 27, 28, 29 Intraoperatively, it is vital for surgeons to develop the ability to recognize the different patterns of partial GM tearing. In addition, partial-thickness GM tears require unique techniques to address the limited access to the deep side of the GM tendon and usually involve suture anchors with or without knotless technology.^7,8

With the proper indications, partial tears can be evaluated and treated through the DAA in a reproducible manner by applying previously described arthroscopic techniques in an open setting.

Supplementary Data

Video 1

The video documents the repair of a gluteus medius tear in a right hip using the direct anterior approach for a total hip arthroplasty. The patient is in the supine position in a traction table. By using the anterior superior iliac spine as an anatomic landmark, a longitudinal and slightly oblique incision is marked 3 cm distal and 3 cm lateral from this point. The fascia of the tensor fascia lata is exposed and incised in line with the skin incision. The interval between the tensor fascia lata and the rectus femoris muscle is developed. The gluteus medius tendon is identified, and the tear pattern and tissue condition assessed. To improve visualization, trochanteric bursa and/or nonviable tissue are debrided. Attention is taken to achieve as much tendon mobilization as possible by releasing any surrounding scar tissue. The greater trochanter lateral facet is decorticated to create a bleeding bed of bone for healing. One double-loaded 5.5-mm PEEK Corkscrew Suture Anchor (Arthrex, Naples, FL) is selected in this case and is placed onto the footprint. All the sutures are passed through gluteus medius tendon. Next, both sets of sutures are then tied in a horizontal mattress fashion. Complete approximation of the tendon over the bone is achieved.