These are my best tips and tricks for endoscopic gluteus medius and minimus repair. Disclosures are available on the Academy website. When we look at abductor tendon tears, why should we repair these endoscopically? The answer is quite simple. Essentially, the equivalent outcomes with far fewer overall complications. When we look at the rotator cuff literature, the shift has been towards arthroscopic repair versus this, which is a large open repair. And we know that complication rates are lower with an equivalent outcome. When we look at the history of these, these are typically atraumatic. It's very similar to the rotator cuff tear population, other than it's 10 to 1 females to males, often over 60 years old. Injections are important to understand. If they have a corticosteroid injection and they only have relief for a couple days, that's a much higher probability of having a gluteal tendon tear. They're unable to sleep on that side as well. That will wake them up from the middle of their sleep. On physical examination, start with palpation. Posterior trochanteric pain, usually is bursal, where mid-troch and anterior troch are mead and men. Abduction strength, this is absolutely critical. Beware of passive external rotation with abduction. That denotes a large tear. And also be aware of a large L4-5 disc. One of the pearls that you can ask your patient is ambulating up and down the stairs. They'll often require holding a banister and will almost pull themselves up. And at the end of the exam, I typically ask them to ambulate down the hallway and I have a set of stairs at the end of my office that can also allow you to assess them to see how well they can go up and down stairs. The history of this, we are, as orthopedic surgeons, relatively neophytes. It was T.D. Bunker in 1997 that first described this. And in the last nearly 30 years, the literature has relatively exploded. When we look at people with, quote-unquote, chronic lateral hip pain or chronic bursitis, almost half of these, both proven on MRI and ultrasound, had tears within those tendons. What this means for you is there is a large multitude of people, particularly the baby boomer generation, that have these tears and that are relatively disabled by them. This is a great assessment by ISHA on greater trochanteric pain syndrome and what our recommendations are for that. Radiographically, it's oftentimes that you'll see enthesphytic change present with these and you can look and you notice on the hip on the right, these enthesphytes that are present on the greater trochanter. What happens with these is as that tendon is failing and pulling away from bone, Wolf's Law dictates that that stress of the tendon pulling away from bone calls hypertrophy, that causes bone remodeling, and that's why we see those enthesphytes present. On MRI, Ben Dome wrote a wonderful article on this. You can see that bright T2 fluid signal deep to that tendon on coronals. And on your axials, you can see here's a great example of a minimish partial tear fluid deep to it, as well as intrasubstance tearing within that minimus tear. Full thickness tears will be easily identified both by radiology. I would urge you to assess on T1s the muscle quality for large full thickness retracted tears. MSK ultrasound is an excellent tool for the assessment of the painful total hip. You can see here, this is our workhorse, you can see the ruptured tendon versus the intact tendon on the examples to the left and to the right. The repair setup, this is absolutely crucial. I've changed the portals. What I learned from Dr. Bird and Dr. Kelly, those portals simply didn't make sense to me. They've used an IT band sparing approach with a 70-degree arthroscope. These portals made the repair far more difficult. I tend to put several portals in, a proximal interlateral portal, almost a 50-yard line view, and then a dollop portal. And these are made under fluoroscopy, and the reason for this is to facilitate easier repair. So I want you to imagine in your mind's eye that the Apollo portal, that's going to be your 30-degree arthroscope, and you really want that 50-yard line view, you want the needle for the dollop to just slide gently under that lateral facet so that you can facilitate anterior passing of your sutures. We start by evaluating the tear pattern. Here we can see a full thickness tear of the minimus with partial thickness tearing of the medius. And what I'm trying to see in my mind's eye is, okay, what are the lines of stress and tension on this tear? Where am I going to place my anchors? What is my suture pattern going to be? And it'll allow you to better estimate what you need to do to repair this anatomically. You want to prep the footprint. This is a great example of a full thickness tear. You can see one of the real principles of these tears is the tissue tends to be very, very attenuated. And you can see we're removing those intestines, we're prepping that bleeding bed of bone, the tissue is rather thin in this case. For anchors, I tend to favor triple loaded anchors. I use peak anchors, not biocomposite or metal or all suture as this bone tends to be extremely soft and anchor pullout can be an issue. For minimus and the anterior portion of the medius we use retrograde suture passing. This is a little bit outside the box. This is a labral repair device. We're using that to pass our sutures through that full thickness tear and it's important to establish that that mid-anterior portal while you're in the peritrapeutic spaces allow for a more efficient way of passing your sutures. Antegrate suture passing, this works quite well overall as long as you plan that dollar portal in line with the lateral facet. This will allow you to be very facile and very fast with your suture passing. You can see this is one of my residents that is using an integrated suture passer and is able to be able to pass these sutures in a relatively expeditious fashion. Once this is complete you can go single row or double row. I tend to be a single row guy because I tend to augment these quite a bit. We tie those sutures down utilizing SMC followed by reverse altering half hitches on altering posts. Here we can assess our completed primary repair single row. We want to make sure that that gap is closed down. Is this indeed a you know anatomic repair? Do we need to add any sutures, add any more fixation? And really this brings me to re-ruptures. What I've noticed over the past 12 years of practice is re-ruptures are very evident and they're very very common in literature particularly radiology literature somewhere between 16 to 35 percent and I honestly became tired of seeing this. This is a great example. Five anchors all triple loaded. You can see the knot stack is still tied but the entirety of our gluteus medius and minimus pair is pulled away and that's where we came up with the concept of augmentation for these through the scope. This is an example of an acellular dermal patch. We published this way back in 2018. So the shuttle technique is very simple. We call this a simplified shuttle technique. Two sutures in two only in a railroad pattern. This will allow you to glide that that down the cannula and allow it to fixate to the proximal aspect of your tendon repair. What this allows is also insight to tensioning the graft. What this does is allow you to get a really nice compressive almost biologic double row aspect to your augmentation. Once the augmentation is complete, we can do a stress test of those graft and tendons. I want to see is this anatomically reduced to the footprint? Is this compressing the underlying tissue and will this allow us to be able to rehab the patient perhaps a little bit quicker? And we'd like to stress this in internal experimentation, abduction, adduction, and ensure that we have a overall solid repair. Our options for augmentation are vast in this day and age. You can see acellular dermis on your left. This is type 1 bovine collagen on the central screen. And then on the right we can see this is a combination of PLLA in a mesh configuration along with bovine type 1 collagen. You can see these do indeed heal. This is a one-year revision of an acellular dermal graft along with primary gluteal tendon repair, and we revised this for iliotibial band snapping. We can see excellent bioincorporation of the graft. We can see neovascularity in and around that graft, and overall an excellent repair, again revised for IT band snapping. Re-tears after augmentation do indeed happen. What I've noticed, particularly with dermal graft, is it can be a stress riser. So we can see the medias on the inferior aspect of the screen along with the minimus. We can see a macerated re-tear, and the graft almost acted like a stress riser here. We didn't have full fixation minimus as it wasn't torn, and you can see here that it did tear after that augmentation medias. We revised this utilizing three triple-loaded anchors. We used a Mason-Allen configuration here. And you can see the primary revision repair with those sutures tied down. And we did choose to augment this with a larger acellular dermal graft covering that anterior facet as well as the lateral facet. So, in conclusion, gluteal tendon tears are the predominant pathology. Hopefully this video allowed you to better hone your skill set and be able to address these through the scope. Thank you.

endoscopic repair

gluteus medius tendon

surgical techniques

triple-loaded anchors

acellular dermal patches