Peritrochanteric Space: Disorders and Treatment

AANA Specialty Day

Friday, February 19th, 2011

Bryan T. Kelly, MDCo-DirectorCenter for Hip Pain and Preservation

Bryan T. Kelly, MD

Hospital for Special Surgery

Disclosure: I DO NOT have a financial interest in any commercial products or service presented in this lecture AND

DO NOT INTEND to discuss off label or investigational use of products or

services.

Types of financial relationships and the companies with whom I have relationships are as follows:

Pivot Medical, Inc.: Consultant

Smith & Nephew: Educational Consultant

A2 Surgical: Consultant

The Peritrochanteric Space

• Space between the Greater Trochanter and Iliotibial Band

• Analogous to the subacromial space in the shoulder

Greater Trochanter Iliotibial Band

Peritrochanteric Space Pathology

•External Snapping Hip•Greater Trochanteric Pain Syndrome

– Recalcitrant Trochanteric Bursitis

– Gluteus Medius Tears

– Gluteus Minimus Tears

External Snapping Hip

• External coxa saltans results from a thickened band of the posterior iliotibial band or anterior gluteus maximus tendon sliding over the greater trochanter.

• Any irritation or injury to the underlying bursa results in inflammation and the addition of pain with the snapping.

External Snapping Hip

• Although conservative treatment is usually successful, small numbers of patients remain symptomatic.

• Open treatment– Excision of an ellipsoid-shaped

portion of the iliotibial band overlying the greater trochanter and removal of the trochanteric bursa.

• Zoltan et al.

• Arthroscopic ITB release can be relatively easily accomplished via the lateral compartment.

External Snapping Hip• The thickened posterior third of the ITB can be palpated with

a flexible probe.• The band can be released directly across from the area of

irritation on the lateral prominence of the greater trochanter.

Peritrochanteric Space Pathology

•External Snapping Hip• Greater Trochanteric Pain Syndrome

– Recalcitrant Trochanteric Bursitis

– Gluteus Medius Tears

– Gluteus Minimus Tears

Greater Trochanteric Pain Syndrome (GTPS)

•Lateral sided hip pain and tenderness•Common clinical syndrome peaking between the 4th and 6th decades of life. 4♀:1♂

•Previously known as “Trochanteric Bursitis”– Bursal distention is actually uncommon

– Kingzett-Taylor et al, 1999– Bird et al, 2001

– The initial pathology usually occurs in the tendons attached to the greater trochanter. The adjacent bursae are secondarily involved.

– Gordon EJ, 1961

GTPS (cont.)

• Vast majority respond to conservative mgt.

• Recalcitrant cases are often due to gluteus medius or minimus tendon tears.

• Prospective MRI evaluation of 24 middle aged women with intractable GTPS

• 45.8% had gluteus medius tendon tears» Bird et al, 2001

• Prospective US evaluation of 75 pts with GTPS• 53/75 had gluteus medius tendinopathy• 25 of these 53 had full or partial g. medius tears

» Connell et al, 2002

Rotator Cuff Tears of the Hip

• Bunker et al, 1997• 22% of patients with femoral neck

fractures had gluteus medius tears

• Kagan A, 1999• Seven pts with recalcitrant GTPS

ranging from 2mos – 10yrs• Open repair through bone tunnels &

or side-to–side after debride• F/u at 45 mos, all were free of pain

• Howell et al, 2001• 20% of women undergoing THA for

OA had abductor tears

Footprint Anatomy• Most gluteus medius tears occur anteriorly, at the

junction with the minimus.

Gluteus Medius Gluteus Minimus

Dwek J. et al MR imaging of the hip abductors: normal anatomy and commonly encountered pathology at the greater trochanter. Magnetic Resonance Imaging Clinics of North America. 13(4):691-704, vii, 2005 Nov

•4 facets, 3 have distinct insertions

Anterior Facet

• 2 parts to Gluteus minimus– tendon attachment lateral to joint capsule

– Muscular attachment to superior joint capsule

Lateral Facet

• Middle and Anterior portions of the medius attach to the lateral facet

• Also continues anteriorly to cover insertion of minimus

Superoposterior Facet

• Main insertion point for the posterior portion of the medius.

Posterior Facet

• No muscle attachments• Trochanteric bursa

Clinical Presentation: Recalcitrant GTPS – Abductor Tear

• Sometimes a history of a “pop” or sudden injury.

• Age group late 50’s to 60’s• Females > Males.• Failure of corticosteroid

injections.• Refractory lateral sided hip

pain.• Abductor weakness.• MRI confirmation.• In some (many ?) cases,

refractory trochanteric bursitis may be overlooked tears of the gluteus medius and minimus.

Arthroscopic Management

An arthroscopic approach through the peritrochanteric space is now possible for the repair of focal gluteus medius and minimus tendon tears.

Gluteus Medius Tears

Repair

Abductor Repair - Preparation• In some cases trochanteric spurs may be present that can be

burred down to created a better surface area for tendon healing.

Case TG: Senior Triathlete

• 65 y/o male

• Developed left hip pain associated with training

• Lateral Based

• No groin pain

• Treated for trochanteric bursitis with multiple injections / PT with no improvement in symptoms over 6 month period

ResultsArthroscopic Abductor Repair

•Results of 10 patients with minimum of 2 year f/u:

– All patients had complete resolution of pain in the lateral hip.

– 9 out of 10 (90%) had 5 out of 5 abductor muscle strength and one patient had 4 out of 5 strength.

– All patients maintained full hip range of motion.

ResultsArthroscopic Abductor Repair

•Modified Harris Hip Scores at one year averaged 92.2 points (range 72-100) and Hip Outcomes Score 93.1 points (range 85-100).

•7 out of 10 patients said their hip was normal and 3 said their hip was nearly normal.

ConclusionAbductor Repair

• Endoscopic repair of the gluteus medius tendons to the greater trochanter can be performed in a predictable manner.

• In the short term, resolution of pain and return to activity is predictable.

• Long term follow-up and a larger number of patients in prospective trials will provide further insight into the treatment of abductor repairs.

Thank You