Intermediate repair for dummies. Greater trochanteric pain syndrome has clearly evolved in its understanding, and we are not today where we were even five or ten years ago. Today we understand that a lot of GTPS involves an underlying pathology of the abductor mechanism. So in addressing GTPS, Dr. Lal from our group created this algorithm discussing the possible diagnoses and the treatment steps. So we can consider bursitis, external snapping, and gluteal tears, both partial and full thickness, as possible underlying diagnoses. In almost all events, the initial treatments are conservative with physical therapy and NSAIDs, then progressing to injections, whether cortisone or biologics, and then finally, when those have failed, we may consider either endoscopic or open surgery. The anatomy of the greater trochanter was described in our article back in 2010 and others before it, involving four facets and two tendon insertions. The main insertion that we're talking about today is the lateral insertion, where the tears most commonly begin. Clinical presentation can occur at a variety of stages, whether at the stage of chronic tendinosis, at the stage of a partial thickness tear, or at the stage of a full thickness tear, and we can do our best to distinguish amongst these using MRI. But I will tell you, based on my experience, that MRI is imperfect in predicting which of these you're going to encounter surgically. Excluding full thickness gluteus medius tears, which might, in some cases, be an indication for surgery, we generally begin with physical therapy and NSAIDs, in some cases, extracorporeal shockwave treatment. And then, as far as injections, there is pretty good evidence today that PRP is a better option than cortisone for this indication, and we found it particularly useful for the partial thickness gluteus medius entity. So when encountering the tear that has failed all of those conservative measures, we may consider endoscopic gluteus medius repair techniques, and in some cases, open techniques. The endoscopic techniques I'll discuss today are for partial thickness tears, including transtendinous repair and suture staple technique, and for full thickness tears, the double row suture bridge technique. So here's the suture staple technique. This is for a tear that's less than 50% thickness, and you get a sense of that by palpating with the probe. So what we'll do here is a marrow stimulation technique, very much like a microfracture. You'll see a little bit of blood come out of the bone marrow there, so we're affecting the biology, hopefully, in a favorable way. And then we'll stabilize the tendon using this suture staple technique, which is basically pairs of anchors where A is linked to B, and B is linked to A, and typically, we use knotless suture anchors for this that are a linkable technology. So we create this suture staple, as you see in the diagram on the right, and this can be done with one pair of anchors or with two pairs of anchors, where you create two suture staples, as in the diagram on the right. It's a very quick technique. It's very efficient and has been very effective in our practice. So what about if we have a partial thickness tear that's more than 50% thickness? This is a technique for transtendinous repair, which we proposed all the way back in 2010, where we make a longitudinal incision in line with the fibers, and through that window, we can access the deep fibers, which are torn. We can decorticate the lateral facet, and then we can place our anchors through this window, as you see here, and ultimately create side-to-side mattress configurations to close the longitudinal incision over top of that decorticated lateral facet. And there's the completed repair. The third technique is for a full thickness tear, and this is the completed technique. I won't belabor every step of it, but this is essentially the same as a rotator cuff repair using a double row suture bridge construct, and you see this web here. This is two anchors proximal and two distal, with knots tied proximally, taken two anchors distally, and we get very nice approximation of the tendon to the lateral facet. It's confluent with the vastus lateralis at the vastus ridge, and we have good compression of a broad surface area of the tendon against a broad surface area of decorticated greater trochanter for healing. We looked at our initial series of 32 patients published in JBJS and found very favorable outcomes. This overall has been one of the happiest groups of patients that I treat, is gluteus medius tears, gluteus medius repairs, and we have since looked at the minimum five-year outcomes in a slightly smaller group and found that these favorable outcomes are sustained at a minimum of five-year follow-up. So what about open repair? If we have a big tear like this, in some cases with retraction, perhaps some atrophy, this is a large U-shaped tear where it's affected not just the lateral facet, but the entirety of the gluteus medius and minimus. In this case, an open repair may be a useful technique, and here this is treated with a margin convergence technique and a very large many-anchored repair. Lastly, what about gluteus maximus transfer? The indications for me today include an irreparable gluteus medius, severe atrophy, or in some cases after revision THR where there's a devascularized greater trochanter. In this case, we make a flap of the anterior third of the gluteus maximus and may incorporate some of the TFL as well. We repair whatever we can of the gluteus medius, diminutive gluteus medius that's been repaired, and I've left these sutures here for subsequent repair of the gluteus maximus. So we've now taken the gluteus maximus anterior third and repaired it to substitute for or augment the deficient gluteus medius. GTPs and gluteal tears are clearly a common cause of lateral or perhaps even a spectrum of pathologies from trochanteric bursitis to external snapping hip to gluteus medius tendinopathy to gluteus medius tears. Non-operative management is almost always the initial treatment involving physical therapy, NSAIDs, shockwave therapy, and injections including PRP and cortisone, and surgical management when needed can be highly successful. It can be done endoscopically in a lot of cases. An open technique is very useful in some of the retracted cases or scarred cases and gluteus maximus transfer is useful to have in your armamentarium for salvage when repair cannot be accomplished. Thank you very much. Thank you.

greater trochanteric pain syndrome

GTPS

abductor mechanism

conservative treatment

surgical techniques