Thanks a lot, and Johan, thanks, that was an interesting talk that you just gave. I'm going to, these are my disclosures, none of which are relevant to this talk. So, you know, the etiology of gluteus minimus and medius teres, it hasn't really been popular for a long time. Probably one of the earlier studies that described it wasn't until the late 90s, particularly in the native hip. It's been described after total hips, particularly after lateral approach, and I would agree they are a lot like rotator cuff tears. In fact, when we first published on this in 2007, which I looked at your, had you graduated high school yet by 2007? Yeah, I was a little precocious, was that they are very similar. We did call them sort of the rotator cuff tears of the hip. I think the most important thing, whether you do it open or arthroscopic, is to understand the anatomy of the insertional footprint. And there's four facets on the greater trochanter, the anterior, the lateral, the posterior and the posterior superior. And three of the four facets actually have attachment sites. So here you see the anterior facet with the gluteus minimus attaching. This is the lateral facet with the middle and anterior portions of the gluteus medius insert. And then you have this strong tendon of the posterior superior facet. And the posterior facet itself is devoid of any tendinous insertion and is really the most common location of bursitis of the big bursal sac. We first published on the technique in 2007, it's one of the earlier reports on it, talking about the accessibility of the peritrochanteric space arthroscopically. And I think the anatomy is actually very well visualized. You can see it extraordinarily well. And for small tears, I think you still can do a very good repair and have good results with them. This was the first published outcome studies in 2009 by one of our fellows at the time, James Voos, who's now in Cleveland. And it was a small series of patients, but we had good outcomes with 94 points and HIP outcome scores 93 points at final follow up. So I think you can successfully do this. But as I started seeing more and more of these abductor repairs and the tears got bigger and bigger and we started to see some fatty infiltration, I started to question the ability to adequately repair these tendons. And these are two studies that were published relatively recently, one in 2022 and one in 2021. We looked at clinical outcomes of HIP abductor tendon repairs with minimum two-year follow up and a slightly larger group of patients. And we showed that it is a safe and effective procedure, even when the tears get larger. And the technique that we use for those with fatty infiltration is with gluteus max transfer We also looked at defining what the minimum clinical important difference after open HIP abductor repairs and likewise showed that there was significant improvement with the open repairs regardless of the size of the tear. So here are the types that I think you should do open. These are large tears with significant retraction and more significantly those where you start to get fatty infiltration of the muscle belly. Because once you have fatty infiltration, re-approximating or repairing that tendon back down the trochanter may look good anatomically, but functionally it's not going to provide any lateral support. This is the technique that we use. It's a straight laterally based incision. We split the IT band. It's a very easy dissection. You can clearly see where the retracted tendon is. Similar to what Michael said with the open hamstring repairs, I think you can get more rigid fixation. You can put double rows. You can put as many anchors as you want. You can clearly visualize the greater trochanter and get a good primary repair. In those where there's fatty infiltration, we dissect posteriorly and mobilize the gluteus maximus tendon and we will try to do a primary repair of the tendon if we can mobilize it and bring it down. But frequently there's such retraction and fatty infiltration, it doesn't help that much. We'll try to get the retracted tendon down as far as we can with mobilization. And then we'll bring the anterior fibers of the gluteus maximus where it inserts onto the IT band posteriorly all the way anterior to the lateral facet. And we'll use the same sutures that we held down the medius with to tenodes the gluteus maximus to the greater trochanter and it forms a lateral buttress for the deficient abductor. The biggest challenge with any tendon transfer though, it changes the vector and the biomechanics of that gluteus maximus from a primary extensor so that it's functioning more as a lateral abductor. And so there is some neuromuscular training that needs to occur afterwards, but I think it's the best solution for those with significant atrophy of the muscle. We did look at the comparison of open and endoscopic repairs at a minimum of two years and really we're looking at outcomes, differences, and interoperative duration for surgery of each technique. So between over a two-year period we had 1,200 patients that we looked at, 15, 18 were total hips, some were bilateral. And we identified 51 patients that had undergone either an open or an endoscopic abductor repair. They had to have a minimum of two-year follow-up. The size of the tear was less than four centimeters to try to keep the cohort similar. And we excluded those for the revision surgery and we didn't include our gluteus maximus tendon transfers. The endoscopic technique I think you showed very nicely. I think you do get great visualization. You can actually go all the way down and visualize the sciatic nerve like was shown by Carlos. With the open technique, I showed this, you can get very, very strong repairs regardless of the size of the tendon retraction and always have the option to do the maximus transfer if there's significant fatty infiltration. We obtained preoperative, one, two, and three-year postoperative patient-reported outcomes scores and we looked at the surgical time of the patients. We had nine in the open repair, 21 hips, 18 patients in the endoscopic repair. The average age of the endoscopic repair was slightly younger and male-to-female ratio was a predominantly female problem which is consistent with what we've seen in the literature. So you'll see for the open obviously there was no interarticular procedures for the endoscopic. And some patients do come in with interarticular pathology, anterior medial groin pain and lateral pain with the tendon tear. And I think that's probably my primary indication for an endoscopic repair. We have to access the joint and want to take care of interarticular pathology simultaneously. But if you really just have an isolated large abductor tear and you're not doing anything in the joint, I think the straight open one is an easier surgery for patients to recover from and you can be more confident in the fixation. Surgical, the clinical outcomes, there was no difference in score improvements between the groups. So we saw significant improvements in both the endoscopic and the open and we saw a slightly increased but not statistically significant improvements with the open versus the endoscopic. Similar findings for the HIP outcomes scores. We had one complication, we had one poor clinical outcome that required no further treatment and this was persistent pain and limp which with these larger tears can sometimes be a problem. And we had two patients in the endoscopic group that required revision, abductor repairs at 5 and 24 months. I haven't ever had to do a revision for an open. I've had a handful of revisions for the endoscopics. The surgical time was significantly better, faster for the open in this study at least. And if you look at the total abductor repairs during this time period, there were 107 but we excluded those with the gluteus maximus transfers. We had 41% that we did a scope on, 59% that we did open and 14% where we had to do the augmentation with the maximus transfer. This is the, these were my practice patterns during the study period. When we initially started, I was doing them all endoscopic. As I said, as we started to see significantly worse tears, higher, more retraction, more fatty infiltration, started doing more open. What I found was that the open repairs, the recovery was easier for them than the endoscopic. You could be more aggressive about weight bearing, you didn't have to worry about your fixation so much. There was no, significantly less swelling, you had a lot of endoscopic fluid extravasation in the soft tissue, a lot of oozing from the wounds. So I've moved toward doing most of my abductor repairs open as long as there's no interarticulate pathology that needs to be addressed. So there are limitations from this study. We didn't randomize them. We don't have non-op control group. There were small group sizes. It's also, you know, patient reported outcomes are subjective. We don't have great objective documentation of abductor strength and healing. And the tear sizes, although we said were all less than four centimeters, it's difficult to accurately measure those because of the complex anatomy. And the interarticulate pathology was only addressed in the endoscopic group. So for me, my conclusions are that I think that open gluteus medius tendon repair is something that we should know, even though we're arthroscopic surgeons, I think we're actually surgeons as well. We should be able to do an open technique. Doing these as part of your practice, if you're doing abductor repairs, it's going to be important because sometimes you do have to convert to an open repair and you want to be able to know how to do that safely. For me, the surgical time, these are extremely straightforward cases. If you're, they're also, you know, it's much better visualization. So in terms of teaching the anatomy, when you have a fellow in the room, it's much more, it's important to be able to see the open anatomy so you can start to look at those facets. And then if you want to progress to endoscopic, you know what you're looking at a little better. So I would recommend that in large tears, those with fatty infiltration are good indications for the open repair. If there is no, and if there's no interarticulate pathology for the smaller tears or those tears where there's interarticulate pathology, I think the endoscopic technique is a good technique. Thank you very much.

gluteus tears

repair techniques

open repair

endoscopic repair

study findings