I want to start by thanking Dr. Noah for having me on what should be a very interesting and spirited virtual debate on gluteal tendon repair. My disclosures are available on the Academy website, and they shouldn't have any bearing on this talk. So, we're going to talk about the outline. What is the rationale behind endoscopic versus open gluteal tendon repair? We're going to talk about management of the IT band and its effect on outcomes. And we're going to talk about the endoscopic technique and new portals, and these portals are absolutely critical in decreasing the amount of time spent in the OR, and we're going to talk about allograft augmentation utilizing acellular dermis. I want to point out that my fellow debater, Shane Ngo, does this exact procedure, but does it open. I tend to think that Shane is very, very smart, and I think that there is a lot of value in adding a graft to these very thin, attenuated tendons. So why should we repair endoscopically? I will pose this question to everybody in the audience. Who in the audience does their rotator cuff repairs open? And hopefully it's none of you, because we know in the rotator cuff world that the arthroscopic approach to repairing that tendon leads to excellent overall outcomes. We also know in the hip world that a systematic review showed excellent outcomes comparable to open with fewer overall complications. This means less patient morbidity, less blood loss, less pain post-op, and we can send these folks home as a same-day procedure. So I'm not going to belabor a history physical exam, but I will tell you three pearls. One is just like a rotator cuff tear, these folks cannot sleep through the night, so if they come in and tell you they cannot get a full night's sleep, that should be a click in the box that they probably have an abductor tear. Another pearl is they will tell you that they cannot ambulate up and down stairs without using a banister, and I want you to ask them about injections. The shorter the duration of pain relief with the corticosteroid injections should tell you there's an increased probability of having a gluteal tendon tear. We know that there are a lot of folks out there, and these two studies show that patients that have recalcitrant lateral hip pain have nearly a 50% probability of having a tear in the tendons. What this should tell you is there are a lot of people that are walking around in their more senior years that have gluteal tendon tears that are missed by other practitioners. So the endoscopic repair setups, we're going to talk about portals. So these were the portals that we described. These are portals that are in line with the femur, utilizing a proximal anterior and distal anterior lateral portal in line with the femur. When we look back to what Dr. Byrd and Dr. Kelly had taught us, I started out using these portals and they just simply didn't make sense. They were awkward. They made the repair more difficult, and I found I was spending a lot of time in the operating room trying to do these endoscopically. So the portals that we described are best seen in this fluoroscopic image. I want you to imagine the polyportal, the proximal anterior lateral portal. This is our 50-yard line view. We use a 30-degree arthroscope akin to what we do with a lateral viewing portal in the rotator cuff repair work. And we look at our dollop portal, and it's critical that the dollop portal is parallel to the lateral facet of the femur because that will essentially make our integrated suture passer work in a much more efficient manner for us. So we start with an IT band split. Why is this important? So this will make the repair far easier for you, and it has implications in terms of outcome. All we do is a simple incision in line with the fibers of the IT band from essentially the lateral aspect of the vastus lateralis ridge to the tip of the greater trochanter. This will allow for better visualization, and it has an implication in terms of outcomes. So I converted Robbie Westerman to my portals, and we asked ourselves a question. Is there any proof out there that splitting the IT band may actually help the patient? So we did a systematic review with meta-analysis, and we saw and found that splitting the IT band may be associated with greater improvements in modified Harris-Hicks scores and may have lower surgical failure rates. And this is important because not only does it help you in surgery visualizing, but it also may have implications in terms of outcomes. So next we're going to evaluate the tear pattern. So what I'm looking at here is we've got a full thickness tear of the minimus with partial thickness tearing of the medius, and I want to see where am I going to place my sutures? Where am I going to place my anchors? What is my overall surgical plan? Am I going to go single row here? Am I going to go double row here? And what that'll do is help you assess, okay, where are vector forces and lines of tension in this tear, and how do we get it repaired anatomically? Next we'll prepare the footprint. I tend to use a reciprocating shaver that's non-tooth. The reason for this is those of you in the audience who prepare these either endoscopically or open know that this bone can be extremely, extremely soft, and we can have anchor pull-outs. So I want to address enthesophytes. I want to remove those enthesophytes and get a good bleeding bed of bone, but I don't want to over decorticate this area and make this bone weaker than it needs to be. What about anchors? So I tend to favor all suture anchors for this. I like to have a lot of fixation per square centimeter of bone here, and so you can see what we're doing is placing our anchor into the lateral facet here. We're going to deploy that anchor, and this lets me better assess if the first anchor fails and pulls out due to very osteopenic or osteoporotic bone. We can go to a more traditional threaded anchor with peak or biocomposite if you wish. This is a critical portion of the procedure. We make our mid-interior portal parallel to the lateral and interior facets. The reason for this is we're going to go a little bit outside the box. We're going to use a labor repair device to pass sutures in a very efficient manner, utilize our assistant to be able to help us. Here we can see we're coming in with a labor repair device here, a so-called stab-and-grab retrograde suture passer, and you can see I'm going to simply deploy. My assistant will pass that suture to me, and what this will allow you to do is repair these in a very efficient and a very time-saving manner. Here we can see we're going to shovel this through, and we'll head right back in until we pass all these sutures through the tendon. Then we're going to let the residents have at this, and the fellows have at this. We're using an integrated suture passer. These are all my residents that are passing here. They're going to grab a good bite of that tendon. They're going to pass it to me, and we pass these from anterior to posterior. This will allow you to pass a lot of sutures in a very efficient manner, and it'll also allow you to have better suture management skills so that you don't get entanglement of those sutures. We'll then tie these down. I tend to use an SMC followed by reverse alternating half hitches on alternating posts, and I want to make sure that we have adequate fixation in this tendon so that we minimize the chance of a re-rupture. Here we can see our completed primary repair in a single row fashion. We're stressing those tendons, and I want to see do I need to add perhaps a trans-tendon repair, or do I need to augment this? How stable is this construct? What about re-ruptures? If you delve into the literature, the re-rupture rate is going to be somewhere between 16% to 35%, possibly even higher. That led us to thinking about, okay, why do these tendons re-tear? Why the high failure rate? This is an example of a case that I did just last week. You can see this is the gluteus medius tendon. It's an extremely fragile, frail tendon, and you can see as we're utilizing our electric Kari wand here to look at this tendon, this is a tendon that is very, very probable to re-tear. If you look, there was a great study out of Japan in JVGIS last year looking at cadaveric specimens and basically proving that some of these tendon tears are less than a millimeter in their thickness. I got tired of looking at this. This is one of my patients who came from out of state who had a massive tear of the medius minimus. Here, you can see we put in five triple-loaded anchors, and you can see a massive re-tear of the tendon. We came up with this idea of adding tissue to the tendon, and this is acellular dermis. This can be done efficiently. This can be done in a non-time-consuming way, and we can do this exactly like Shane does his open repairs. So, allograft preparation in the shuttle. The shuttle, we basically designed this to be a railroad track. Two single-loaded anchors, we used labor repair anchors, and we basically slide this down in the most simplified fashion as possible. We'll then tie these down and get our proximal fixation with the graft. We'll then use in-situ tensioning. The beauty of this technique is in-situ tensioning will allow me to look at the graft, be able to tension this, and get a true biologic double row. Once I pull that graft and I like the tension, I know that that's where I can place my anchor and pass my suture to get ideal tension. Once we're done, I want to make sure, is that graft married to the tendon? Do I need to add additional free sutures, suture tapes? Do I need to add additional anchors? Once I have my construct, I want to stress test this, and when we stress test this, I want to make sure that we have a construct that moves as one unit. The gluteal tendon is repaired underneath, and the graft acting as that biologic double row to compress it. Here's a great example of a patient who had a massive tear of the abductors, both medius and minimus. We put in four triple-loaded anchors, got a nice primary repair, but again, I learned from my mistakes. I know that this is at high risk for failure, so we added a graft on top of this. I went through a journey with this. I actually went through a phase where I closed the IT band, and what I found was I had about 20 patients or so that had an IT band closure, and that IT band closure unfortunately caused iatrogenic external snapping hip syndrome. Here we can see we went in for an IT band resection, and you can see the graft did indeed biologically incorporate. It is a strong construct. It is now married to those underlying abductor tendons, and we think that this will lower the retear rate in the long term, so the graft does indeed bioincorporate. So, is this bulletproof? It is absolutely not bulletproof. Again, because it acts as a biologic double row, here we can see a rupture of the minimus after we've done an allograft augmentation. The posterior aspect of the medius had healed. That anterior junction between medius and minimus had failed, unfortunately, so understand that just like a double-row cuff repair, this is a stress riser to those tendons, so we've gone bigger with the allograft augmentation in order to try and prevent this. Here we can see our revision repair. We placed three triple-loaded anchors. We're using a Mason-Allen configuration of sutures here, and basically tying these down, again, using that SMC followed by reverse alternating half hitches on alternating posts. Here we can see the completed primary repair. A nice overall fixation of those tendons. Again, because of the size of that tear, I did back. And we used an allograft revision augmentation for this, and I covered the entirety of the trochanter, both the anterior facet and lateral facet. This was approximately a four centimeter by three centimeter construct. So in conclusion, why endoscopic? It's lower morbidity with equivalent outcomes. Why did we split the IT band? We've shown that there are lower retail rates and improved PROs. Why the endoscopic technique, the new portals? It is just as fast as open, if not faster. And we'll demonstrate that with a live demonstration later on this weekend. And why allograft augmentation? It addresses the retail rates. We've seen this proven in the rotator cuff world. And it addresses the thin attenuated tendon. And I will say further that Shane believes in this enough that he does this in an open fashion. Thank you, those are my kids. Best part of my life.

gluteal tendon repair

endoscopic repair

open repair techniques

IT band splitting

allograft augmentation