Thank you very much for the opportunity to present today. I was tasked to talk about superior gluteal reconstruction. I'm Jorge Chala, and I'm an assistant professor of orthopedic surgery at Rush University Medical Center in Chicago, Illinois. And as we know, the trochanteric space is an analogous space to the subacromial space in the shoulder. The etiology of the pain can sometimes be challenging, and the estimated prevalence of injuries within the lateral side of the hip is up to 25%. And one of the most important pathologies that we have on the lateral side of the hip are the gluteus medius and gluteus minimus, the abductor's tears of the hip. And when we're thinking about the algorithm and how to treat these injuries, there are four things that we need to consider. One is which tendon or which tendons are involved. If it's a partial or full thickness tear, the retraction of the tear, and the muscle atrophy. Which tendon? We know that there's a bald spot in between the insertion of the gluteus medius posteriorly and the gluteus minimus anteriorly, and therefore, it's critical to understand the anatomy not only for the open cases, but also for the arthroscopic cases where we might see that there might be an area from the trochanter that is denuded from any insertions, and that's not abnormal. It's completely normal, and it's how the anatomy should be. When we think about partial versus full thickness, this can allow us to think if we want to repair this in an arthroscopic or in an open fashion, depending on how comfortable do you feel with your arthroscopic skills on the lateral side of the hip. In regards to retraction, we commonly say that the more retraction there is, the less chances you will have to do this in an arthroscopic way, just because the possibility of freeing up the tissues to improve the excursion of the tendon might not be as good as it can be on the shoulder, and therefore, sometimes, if extrusion is significant, an open procedure might be indicated. And finally, atrophy, this classification described by my partner, Shay Ngo, where he basically looked at an analogy between the muscle fatty atrophy that we have in the shoulder to what we have in the gluteus medius in the hip. So when taking everything into consideration, we know that if we have just the gluteus medius there that can be repaired in the partial or full thickness, we can do this arthroscopically or open, but if we have fatty atrophy or we have significant retraction, a superior gluteal reconstruction might be indicated. This is a case of mine, 70 years old, with a significant calcification of the tendon. Very nice 65-year-old lady that has been dealing with significant trendelium brigade, as well as significant pain on the lateral side for many, many years. This is our preferred approach. It's a vertical longitudinal approach on top of the trochanter and centered over the tip of the trochanter. We like to do this in a layered fashion and with the use of a cobell retract or a hip, we can actually get pretty good access to the side of the repair. You can see here, this is the calcification that we saw in the MRI and after you remove this, there's going to be significant retraction of the tendon that will not allow us to put it safely and with no significant tension back to the footprint. For this reason, we decided to place some traction stitches that will allow us to mobilize the tendon very well and then prepare the bony bed with the use of a burr and multiple holes to try to create a healing environment for this tendon to sit in. As you can see here, although the mobilization of the tendon aided into better footprint coverage, it was not without a significant tension. For those reasons, we elected to proceed with a superior gluteal reconstruction. For this, multiple double-loaded anchors are placed in the proximal aspect of the greater trochanter and these sutures will be placed through the tendon but also through the graft. Multiple grafts can be used at this point including Achilles tendon that can be folded to improve the thickness of the tendon as well as a dermal allograft. There are no significant differences between the outcomes between those two. And after we tied all our knots proximally, then we go distally for a second row to try to dunk all the sutures into a more distal row. As you can see here, there's a pretty good sitting of the graft with the tendon that moves equally with external and internal rotation. The rehabilitation for this surgery is a little bit slower when we just do a gluteus medius repair. We don't allow full weight-bearing for six to eight weeks. We treat this like a rotator cuff, hip orthosis and write an A-reduction splint for six weeks and just passive range of motion and circumduction can be performed at this point. In the phase two, we progress to gait training, progress off of crutches and walker to a cane, core trunk and proximal motor control, a closed chain, lower limb strength. In conclusion, this is a reliable technique for retracted tears. The anatomy is key for an accurate repair and understanding where the gluteus medius and the minimus should sit on the greater trochanter. There are multiple graft options and there's no significant evidence to suggest that one graft should or is better or should be used in comparison to others and there's promising outcomes although there's short-term follow-up and that's why we encourage further research in this area. Thank you very much.

Jorge Chala

superior gluteal reconstruction

gluteus medius

gluteus minimus

hip anatomy