Endoscopic Abductor Repairs of the Hip Simplified: Double-Pulley Suture-Passage Free Technique

Abstract

Greater trochanteric pain syndrome is a prevalent cause of lateral-sided hip pain. In this Technical Note, we propose an endoscopic double-pulley technique that demonstrates gluteus medius and minimus repair via a double-row tape-bridge configuration. Our approach facilitates abductor repair in a consistent and reproducible manner using 3 to 4 peritrochanteric portals while avoiding the difficulties of antegrade or retrograde suture passage. This surgical technique is useful for high-grade partial tears, minimally retracted full-thickness tears, or refractory greater trochanteric pain syndrome with gluteal tendinopathy.

Fig 1

Patient positioned supine, a left hip shown here. Green: proximal anterolateral portal; blue: distal anterolateral portal; yellow: mid-anterior portal; red: posterior portal. To establish the proximal anterolateral portal, which is our primary viewing portal, we aim a spinal needle at the vastus ridge, which allows a broader proximal view. The distal anterolateral portal is primarily used as a working portal for suture management, bringing out sutures to the lateral row, and for tendon stapling. The posterior portal or the mid-anterior portal is best for percutaneous anchor insertion into the greater trochanteric attachment sites. The posterior portal tends to have a better and more perpendicular trajectory to the trochanter and is therefore our preferred portal for tendon stapling and final double-row compression. (Used with permission; Pascual-Garriod C, Schwabe MT, Chahla J, Haneda M. Surgical treatment of gluteus medius tears augmented with allograft human dermis. Arthrosc Tech 2019;8:e1379-e1387.)

Fig 2

(A) Needle localization with fluoroscopy guidance on a left hip (used with permission license CC BY-NC-ND 4.0; Laskovski J, Urcheck R. Endoscopic gluteus medius and minimus repair with allograft augmentation using acellular huma dermis. Arthroscopy Tech 2018;7:e225-e230). (B) Further mapping with both arthroscopy and fluoroscopy on a right hip, through a PALA viewing portal. Fluoroscopy is used to pinpoint the vastus ridge, after which one should map out greater trochanter major landmarks with palpation of the 3 facets using the tip of an ablator or probe. For correct arthroscopic orientation, the bursectomy is started at the vastus ridge and then moved proximally toward the lateral facet of the greater trochanter. One should ensure to identify the vastus lateralis muscular insertion, which can be termed the “lighthouse” of the peripheral compartment of the hip. (C) Proximal, or medial row, tendon stapling via a mid-posterior portal, viewing from PALA. (D) Distal, or lateral row, anchor fixation via a DALA, viewing from PALA. This distal row is aimed around the vastus ridge. (E) Illustration of the greater trochanter facets (used with permission; Robertson WJ, Gardner MJ, Barker JU, et al. Anatomy and dimensions of the gluteus medius tendon insertion. Arthroscopy 2008;24:130-136). (DALA, distal anterolateral portal; PALA, proximal anterolateral portal.)

Fig 3

(A) Patient is positioned supine and viewing from the proximal anterolateral portal on a right hip. The blunt tip of the shaver/radiofrequency device from the distal anterolateral portal can be used as a probe to enter the tear and palpate the trochanter under x-ray. (B) Once the borders and thickness of the tendon tear are defined, one further decides on gluteus medius and/or minimus involvement as well as anticipates the number of medial row anchors required. A combination of shaver and radiofrequency ablation is used to prepare the footprint.

Fig 4

(A) Patient is positioned supine and viewing from the proximal anterolateral portal on a right hip. On average, 2 medial row anchors are required. This involves advancing 2 self-tapping double-loaded anchors (ICONIX SPEED; Stryker), with 2.3-mm suture tapes onto the tear in a stapling-type fashion using the pointed ends of the anchor to reduce the tear (at the muscle-tendon junction) to bone with distal advancement. These act as the medial row of anchors. This provides 4 limbs from the anterior anchor and 4 limbs from the posterior anchor. Tendon stapling is facilitated through the mid-posterior portal or mid-anterior portal, whichever provides the most perpendicular entry onto the trochanter. (B) Extracorporeal view with the patient positioned supine with a left hip as an example; the matching colors from each anchor are tied outside the cannula in a double-barrel knot fashion. The tails of these sutures are then cut short. One then pulls on the respective untied limbs and then retrieves them out of a separate proximal portal or through the cannula in the distal anterolateral portal portal, which effectively uses the anchors as a double-pulley system. We prefer to use a cannula in the distal anterolateral portal portal for suture management. (C) Medial row anchors now viewed from proximal anterolateral portal with the double-barrel knots nicely seated onto the gluteus medius muscle/tendon junction, on a right hip demonstrated here.

Fig 5

Right hip viewed from the anterolateral portal, and the remaining 2 pairs of tapes (now a total of 4 limbs) are secured onto a lateral row with a single 4.75-mm Omega self-punching anchor. For this, we prefer the limbs are shuttled back out the posterior portal as there is a more perpendicular trajectory for the lateral row anchor. This produces a double-row tape-bridge construct in an inverted triangle-type configuration.