ePoster #114 - ISHA Annual Scientific Meeting 2016

Endoscopic Gluteus Medius Repair With Allograft Augmentation For Recurrent Abductor Tear-A Case Report And Novel Technique

Jovan R. Laskovski, MD, Akron, OH UNITED STATES

Crystal Clinic Orthopedic Center, Akron, Ohio, UNITED STATES

FDA Status Cleared

Summary: Endoscopic technique for the repair of a recurrent abductor tear with allograft augmentation following Total Hip Arthroplasty

Abstract:
We present the case of a 39 year old female who underwent a total hip arthroplasty, developed a severe Trendelenberg Gait, and underwent 2 years of non-operative care with no improvement. The patient was then referred to the senior author's clinic for evaluation. History and physical exam confirmed abductor insufficiency. The patient underwent a musculoskeletal ultrasound, which confirmed a post operative gluteus medius and minimus tear. All options were discussed, and the patient decided to undergo endoscopic gluteus medius repair.
The patient remained touchdown weight bearing for 6 weeks post operatively and regained full abduction strength at 18 weeks post operatively. Nine months post-operatively, the patient sustained a fall and presented at the senior author's clinic. The patient had severe lateral pain and a pronounced Trendelenberg Gait with 3/5 abductor strength. Ultrasound evaluation noted massive re-tear of the abductors with retraction. Conservative care with 8 weeks of physical therapy was attempted with no gain in strength, function, or pain relief.
After extensive pre-operative consultation, the patient was consented for revision endoscopic gluteus medius repair with possible allograft augmentation. The patient understood all risks, benefits and alternatives and wished to proceed.
For the surgical technique, the patient was placed in the supine position on a standard hip arthroscopy table with no traction applied. The leg was placed in extension with internal rotation. Three portals were utilized for the repair- Proximal Anterolateral Portal (PALA), Distal Anterolateral Portal (DALA), and a Mid Anterior portal (MA). We began superficial to the Iliotibial Band (ITB) and performed a diamond shaped resection of the ITB. The trochanteric bursa and underlying scar tissue was removed to gain visualization of the gluteus medius (GMed), gluteus minimus (GMin), vastus lateralis (VL), and the insertion of the gluteus maximus (GMax). We then identified the tear, which was massive and retracted proximally from the tip of the greater trochanter approximately 3 cm. Soft tissue releases were utilized to mobilize the GMed and GMin tendons. The tendons were then repaired proximal to their insertion sites on the greater trochanter using 2 triple loaded suture anchors. At that point, a 3 centimeter by 3 centimeter defect was measured on the greater trochanter, and an allograft patch of acellular dermis was prepped on the back table. Six sutures were placed circumferentially around the allograft with stick knots and shuttle sutures were placed through the repair sites of the GMed and GMin. The graft was then shuttled into place, and the proximal four sutures were sewn into the surrounding abductor tendons. The inferior 2 sutures were then placed into a knotless anchor which was placed at the level of the vastus lateralis tubercle.
The patient was placed in a brace post-operative for 6 weeks and was touchdown weight bearing for 6 weeks. The patient discontinued her ambulatory assistive devices at 12 weeks and regained 5/5 strength at 18 weeks post-operative. The patient had significant increases in pre and post-operative mHHS and HOS-ADL.