Greetings. This is Thomas Bird. I'm honored to be part of this EASHA AOSSM program. My topic is abduction malfunction. You can find my disclosures on either website. Arthroscopic techniques of the hip have evolved into endoscopic methods for extra-articular disorders around the hip. This provides a less invasive approach for disorders previously addressed with conventional and open techniques, but we've also defined new disorders and redefined existing disorders amenable to an endoscopic approach. We credit Brian Kelly with teaching us about the peritrochanteric space. It's just the space between the greater trochanter and the iliotibial band and is analogous to the subacromial space in the shoulder. You'll hear talk of the pelvic deltoid, which is the tensor fasciae latae, the gluteus maximus and the iliotibial band. It's what you can see and feel around the hip, and this term was actually coined by Henry many years ago. We know that there are four facets on the greater trochanter. Three of these are insertion sites for tendons. The gluteus medius mostly inserts on the lateral facet, and it covers the insertion of the gluteus minimus on the anterior facet. Many of you may not be familiar with Joe Davies' work. He recently retired, but he classified abductor injuries and had some eloquent techniques for restoring the gluteus medius regardless of how bad the damage may be. Trochanteric bursitis has always been one of the banes of orthopedics. They're painful. They limp. They respond poorly to conservative treatment, but a lot of that recalcitrant trochanteric bursitis isn't bursitis at all, and that led to the term greater trochanteric pain syndrome, which, although less specific, is more accurate for the constellation of things that can present as laterally based hip pain. Abductor tendinopathy or tendinosis is a common cause of recalcitrant laterally based pain that fails to respond to conservative treatment. With regards to abductor lesions, I used to run the other way from these because I thought they were old people, they were miserable, and they were hard to sort out. Well, over time, I realized that only two of those three things were true. They were a more elderly population. They were severely disabled, but not necessarily that difficult to sort out. Two other things that are true are that MRI evidence of abductor tendinopathy is often a normal, inconsequential change with age, but also symptomatic abductor lesions often masquerade as a recalcitrant trochanteric bursitis. This is just the first case I ever did, a 68-year-old gal sent to me by an orthopedic surgeon that I'd operated on, and he sort of shamed me into operating on her. He said, you'll operate on me. Why won't you operate on my patient with this abductor tendon damage? So this is the very first case I ever did. She had an avulsion of the gluteus medius. We just used the techniques we knew for the shoulder with double row technique, proximal row, and distal row, but the bottom line is it worked, and she was a very happy patient, and that sort of brought me kicking and screaming into the world of treating abductor tendon lesions. As far as clinically relevant findings, of course, it's laterally based hip pain. They have pain and may have weakness with resisted abduction, but this can fool you in the office. We're on manual testing. They may seem like they have pretty good strength, but they fatigue and break down easily. Stairs are very difficult for them. This is laterally based pain exacerbated with external rotation because that's stressing the anterior fibers of the gluteus medius. This is not typical impingement-type pain. It's not difficult to differentiate this from back or SI symptoms, although these difficulties may coexist in the same patient. We know about the positive Trendelenburg sign, and we know about the positive Trendelenburg gait. MRIs are pretty reliable at showing abductor pathology, but again, it may be the normal consequence of aging, and it's your history and exam that establishes the clinical relevance. Ultrasound guided injections can have both therapeutic and diagnostic value, and I would say that ultrasound really has an essential role because many of the patients that come to you, the greater trochanter is seemingly an easy target for those who may not be very dialed in on the nuances of abductor pathology, and a lot of these people have had various injections which may cloud the issue. Also, with ultrasound, you can see the structural damage about as well as you can by MRI. The injections help in establishing the clinical relevance, but keep in mind that these are often older patients. They may have coexistent intra-articular pathology, and differential injections helps you to differentiate is it a joint problem, an abductor problem, or possibly a combination of both. We talk about the rotator cuff tear of the hip. This is addressed through the paratrochanteric space. I prefer an IT band sparing approach, which starts with two anteriorly based portals to develop the paratrochanteric space. Just a brief sort of accelerated video, we come in over the vastus ridge. That keeps you from going too deeply and inadvertently perforating the insertion of the medius. We'll put the scope distally. We'll establish a working portal. You can see some angry trochanteric bursitis that will clear out. Now we're seeing the structures, the vastus ridge, and the insertion of the gluteus medius. This is just an illustrative example of a 45-year-old lady where two lumbar spine procedures had failed to solve her laterally based hip pain. Working from the paratrochanteric space, we establish a viewing portal just posterior to the vastus ridge and a working portal distal to the ridge. This vertically oriented tear, we freshen up the lateral facet. We'll place a couple of triple-loaded longitudinally oriented anchors, placing the suture limbs through the posterior and anterior leaf, and once we've passed them all, replacing our more distal anchor. Got all the sutures in place, and then we'll just sequentially tie the sutures and inspect the integrity of the repair site, which will influence the rehab process afterwards. Just another example, and this is a 63-year-old gal who's had several laterally based injections. She's got a sleeve avulsion of the gluteus medius. Well-suited for double row technique, we'll use two or three transversely oriented double-loaded anchors, pass all the suture limbs and tie these down, then take one suture limb from each of the proximal anchors and match it with our distal row fixation, and here's the finished product. Now when we looked at our results with minimum two-year follow-up, several important observations. This is a vastly female population. Compared to our FAI results, these patients were more than 20 years older. They had more than 20 points worse baseline preoperative scores. They were severely disabled, but their amount of improvement doubled that which we reported with the FAI. Now this isn't entirely an old person's disease. This is a 22-year-old female cross-country runner from one of our local universities. Abductor pathology failed, two corticosteroid and two PRP injections. A partial thickness tear will incise the intact superficial surface of the tendon, expose the lateral facet, freshen it up, place a couple of double-loaded longitudinally oriented anchors and repair it with a successful outcome. She's very happy. She went on. She's been married, had children. Again, a successful result in one of the rare young people that we address. Just a few final comments. Most symptomatic abductor tendon tears that have failed conservative treatment are amenable to an endoscopic approach, but it doesn't matter if it's open or endoscopic. It's the rehab that's onerous. It ain't the surgery. It's the rehabilitation. It's hard for me to envision a role for an acute repair because most of these occur in older people, and regardless of the suddenness of the onset of symptoms, this is still a chronic process. What about an acute tear at a young person? That might be the case, but I've never seen an acute avulsion of the tendon from the greater trochanter. In young people, the injury tends to occur at the myotendinous junction, and those injuries heal uneventfully without surgery. The results of endoscopic abductor repairs are excellent. It dispels two commonly held myths about hip arthroscopy, that older patients are poor candidates and poor preoperative scores an indicator of poor results. That's not the case with these at all, but just because our results are excellent doesn't mean that we can't strive to do better. Keep in mind that not all tears are amenable to an endoscopic approach, and not all lesions necessitate a surgical repair. We'll see all kinds of MRI findings in people who are not having abductor symptoms. With regards to open repairs, this is very acceptable. It's preferred by some surgeons. It is quicker. There's less of a fiddle factor. There's more versatility for repairs that may not be amenable to endoscopic techniques, large retracted tears with fatty infiltration. The cons are that it's harder to perform as an outpatient. You're not able to assess and address coexistent intra-articular pathology, which commonly occurs with these patients. The complication rate is similar to that with endoscopic approach, but the complications tend to be more serious with the open approach. What about grafts? Well, usually it's not necessary with most endoscopic repairs. Keep in mind that the graft is not a substitute for a secure repair. You don't want to just slap a graft on it if you're not confident in your repair. This is probably more applicable for large open repairs and reconstructions. But it's the symptomatic partial thickness tears that are the large unsolved problem, because there's a big gap between failure of conventional conservative care and successful surgical repair. And again, it's not the surgery, it's the owner's post-operative rehabilitation that you're obligating them to. So how do we bridge that gap? Well, PRP is one way of bridging this gap. I'm not a big proponent of PRP, but it works quite well for some of these abductor tears. There's some expense. We try to keep it affordable. If they have significant associated joint pathology, it just doesn't tend to be quite as effective. So we've been pleased with our results, and the published data by John O'Donnell and his folks from Australia supports that PRP can provide a more durable response than conventional corticosteroids. There are non-repair surgical techniques that give you more latitude as far as more progressive recovery. These include, there's a radiofrequency micro-debridement that's been described. Ultrasound guided percutaneous tenotomy was popularized and has been championed by Champ Baker, who unfortunately we lost Champ this last spring. The one I've been most familiar with is this bioinductive scaffold. It's been described for use of partial thickness rotator cuff tears. And when people like Jeff Abrams and Buddy Savoie and Rick Ryu, friends of mine, tell me that this thing works, that really struck my attention for trying to use it. This is a picture when they were my guests here in Nashville a few years back. Just an example of a partial thickness tear. The superior tendon's intact. Here comes the scaffold. We unfold it, secure it with absorbable tendon anchors. And again, this is just in fast forward. We'll get it secured. We'll remove the inserter, finish the fixation, and simply placing the patch on the superficial surface, which potentiates healing of the partial tear. So in closing, have doctor tendon lesions represent a spectrum of pathology and requires a spectrum of skills and technology, both for diagnosis and for treatment. Greetings from Nashville and thank you very much.

abductor malfunction

hip treatment

arthroscopic techniques

abductor tendinopathy diagnosis

endoscopic repair