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Hip and Knee Surgeon 
                              North Wales

Mr. Muthu Ganapathi  MBBS, MS(Ortho), FRCS, MSc (Ortho Eng), FRCS (Orth)

Spire Abergele Consulting Rooms
Ground Floor, Priory House
North Wales Business Park
Abergele, LL22 8LJ

Tel:  01745 828900  

Fax: 07145 828908  (find us)

Felinheli Surgery

Rowen

Y Felinhelli, Gwynedd

LL56 4RX

Tel:  01248 670423

Fax: 01248 670966    (find us)

 

 

Private Consultations:

 NHS Work:

      Ysbyty Gwynedd, Bangor

  

 Private Surgery:

      Spire Yale Hospital, Wrexham

© Mr. Ganapathi 2010
Web design by Mr.Ganapathi

“Anglesey Bonesetters”

(An historical article)
 

Computer Guided Surgery (video demonstration)

Hip Replacement in Young Adults (special considerations)
 

Hip Impingement
(recently recognised condition)

Hip Arthroscopy

(an emerging field)

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Private Physiotherapy

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Useful Contacts

The Anglesey Bonesetters And Modern Orthopaedics
Computer guided surgery videos
Hip Replacement in Young Adults
What is Hip Impingement
Hip Arthroscopy Introduction
Contacts
Private Physio links

Optimising yourself for hip/knee surgery

Outcome Scores

(downloadable forms)

Optimising Before Surgery
Validated Outcome Scores

Knee  Arthroscopy

(key hole surgery)

Knee Arthroscopy
Menai

Personalised Knee Replacements (is it the future?)

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Enquiries
Personalised Knee Replacements

Pain over the lateral aspect of the hip (outer aspect) is quite a common clinical problem. It could be due to a number of reasons, including pain from the lower back as well as hip arthritis. One of the common causes is trochanteric bursitis and is usually treated by pain killers and local steroid injections.

It is now being recognised that in a small proportion of the cases, the pain may be due to tear in the abductor muscles of the hip (gluteus minimus/gluteus medius - the muscle which hold the pelvis level during single-leg stance) at their insertion into the greater trochanter. This is now considered to be similar to the “rotator cuff tear” of the shoulder and occurs due to chronic attrition. While the shoulder rotator cuff problems have been well recognised for a long time and the treatment is well evolved, the diagnosis and management of the “hip abductor problem” is still evolving.

 

 

 

 

 

 

 

The clinical diagnosis is based on the location of pain, temporary response to steroid injection, weakness of abductors, positive Trendelenberg test, pain during passive abduction etc., although not all signs may be present.

When a clinical diagnosis is suspected, further investigation is required to evaluate the problem. Either ultrasound or MRI scan can be done. MRI scan is probably better as the ultrasound interpretation is dependant on the person who does the ultrasound.

The management depends on the symptoms and the MRI findings. Although the long term results of repairing such an abductor tear is not known (as the condition is being recognised as a cause of hip pain only recently and the awareness about this condition among health professionals including orthopaedic surgeons is still scarce), recent studies have shown favourable short term results following surgical repair of the abductor tear. However, if there is significant fatty degenerative changes and wasting of the muscles, the results are likely to be less than optimal. Hence it is important to understand that the results may not be always successful.

The surgical treatment involves a open repair procedure although with advances in key hole surgery it is also possible to do the repair through key hole procedure. After the surgery, the repair should be protected with partial weight bearing with crutches for about 6 weeks.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scientific Literature

 

The following are some relevant selected scientific references:

 

1. Surgical repair of chronic tears of the hip abductor mechanism.

Hip Int. 2009 Oct-Dec;19(4):372-6.

Davies H, Zhaeentan S, Tavakkolizadeh A, Janes G.

Avon Orthopaedic Centre, Bristol, UK.

Lateral sided hip pain frequently presents to the orthopaedic clinic. The most common cause of this pain is trochanteric bursitis. This usually improves with conservative treatment. In a few cases it doesn't settle and warrants further investigation and treatment. We present a series of 28 patients who underwent MRI scanning for such pain, 16 were found to have a tear of their abductors. All 16 underwent surgical repair using multiple soft tissue anchors inserted into the greater trochanter of the hip to reattach the abductors. There were 15 females and 1 male. All patients completed a self-administered questionnaire pre-operatively and 1 year post-operatively. Data collected included: A visual analogue score for hip pain, Charnley modification of the Merle D'Aubigne and Postel hip score, Oxford hip score, Kuhfuss score of Trendelenburg and SF36 scores.Of the 16 patients who underwent surgery 5 had a failure of surgical treatment. There were 4 re ruptures, 3 of which were revised and 1 deep infection which required debridement. In the remaining 11 patients there were statistically significant improvements in hip symptoms. The mean change in visual analogue score was 5 out of 10 (p=0.0024) The mean change of Oxford hip score was 20.5 (p=0.00085). The mean improvement in SF-36 PCS was 8.5 (P=0.0020) and MCS 13.7 (P=0.134). 6 patients who had a Trendelenburg gait pre-surgery had normal gait 1 year following surgery.We conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric pain that should be further investigated with MRI scanning. Surgical repair is a successful operation for reduction of pain and improvement of function. However there is a relatively high failure rate.

 

 

2. Advanced techniques in hip arthroscopy.

Instr Course Lect. 2009;58:423-36.

Larson CM, Guanche CA, Kelly BT, Clohisy JC, Ranawat AS.

Twin Cities Orthopaedics, Minneapolis, Minnesota, USA.

The indications for hip arthroscopy are expanding as the understanding of hip disease increases. Improved instrumentation and technical skills also have facilitated the ability to treat some hip disorders arthroscopically. Femoroacetabular impingement (FAI) is increasingly recognized as a disorder that can lead to progressive intra-articular chondral and labral injury. Although FAI is usually treated through an open approach, limited-open and all-arthroscopic approaches have been described. Various arthroscopic techniques allow treatment of labral and acetabular rim pathology as well as peripheral compartment femoral head-neck abnormalities. Early outcomes of limited-open and all-arthroscopic treatment of FAI are only beginning to be reported but appear to compare favorably with those of open dislocation procedures. Although labral tears traditionally have been treated with simple débridement, concerns have been raised about the consequences of removing the labrum. Modified portal placement and hip-specific suture anchors are now being used in an effort to repair some labral tears. Snapping hip disorders typically are treated nonsurgically. For persistent symptoms, arthroscopic release is successful, compared with open release, and allows additional evaluation of the hip joint during surgery. Diagnosis and management of traumatic and atraumatic hip instability continue to be challenging. Hip arthroscopy has been shown to be effective in the treatment of hip instability in some patients. The extra-articular peritrochanteric space is receiving increased attention. The arthroscopic anatomy has been well defined, but the treatment of greater trochanteric pain syndrome and arthroscopic repair of abductor tendon tears are only beginning to be reported. Improved techniques and longer-term outcomes studies will further define the optimal role of hip arthroscopy.

 

3. Endoscopic repair of gluteus medius tendon tears of the hip.

Am J Sports Med. 2009 Apr;37(4):743-7.

Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT.

Hospital for Special Surgery, New York, NY 10021, USA.

BACKGROUND: Tears of the gluteus medius tendon at the greater trochanter have been termed "rotator cuff tears of the hip." Previous reports have described the open repair of these lesions. HYPOTHESIS: Endoscopic repair of gluteus medius tears results in successful clinical outcomes in the short term. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Of 482 consecutive hip arthroscopies performed by the senior author, 10 patients with gluteus medius tears repaired endoscopically were evaluated prospectively. Perioperative data were analyzed on this cohort of patients. There were 8 women and 2 men, with an average age of 50.4 years (range, 33-66 years). Patients had persistent lateral hip pain and abductor weakness despite extensive conservative measures. Diagnosis was made by physical examination and magnetic resonance imaging and was confirmed at the time of endoscopy in all cases. At the most recent follow-up, patients completed the Modified Harris Hip Score and Hip Outcomes Score surveys. RESULTS: At an average follow-up of 25 months (range, 19-38 months), all 10 patients had complete resolution of pain; 10 of 10 regained 5 of 5 motor strength in the hip abductors. Modified Harris Hip Scores at 1 year averaged 94 points (range, 84-100), and Hip Outcomes Scores averaged 93 points (range, 85-100). There were no adverse complications after abductor repairs. Seven of 10 patients said their hip was normal, and 3 said their hip was nearly normal. CONCLUSION: With short-term follow-up, endoscopic repair of gluteus medius tendon tears of the hip appears to provide pain relief and return of strength in select patients who have failed conservative measures. Further long-term follow-up is warranted to confirm the clinical effectiveness of this procedure.

 

4. Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip.

Arthroscopy. 2007 Nov;23(11):1246.e1-5.

Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT.

Hospital for Special Surgery, New York, New York 10021, USA.

Disorders of the lateral or peritrochanteric space (often grouped into the greater trochanteric pain syndrome), such as recalcitrant trochanteric bursitis, external snapping iliotibial band, and gluteus medius and minimus tears, are now being treated endoscopically. We outline the endoscopic anatomy of the peritrochanteric space of the hip and describe surgical techniques for the treatment of these entities. Proper portal placement is key in understanding the peritrochanteric space and should be first oriented at the gluteus maximus insertion into the linea aspera, as well as the vastus lateralis. When tears of the gluteus medius and minimus are encountered, suture anchors can be placed into the footprint of the abductor tendons in a standard arthroscopic fashion. Our initial experience indicates that recalcitrant trochanteric bursitis, external coxa saltans, and focal, isolated tears of the gluteus medius and minimus tendon may be successfully treated with arthroscopic bursectomy, iliotibial band release, and decompression of the peritrochanteric space and suture anchor tendon repair to the greater trochanter, respectively.

 

 

 

 

 

MRI scan showing trochanteric bursitis and 
partial tear of the abductors in left hip
The following video shows Mr.Ganapathi performing an arthroscopic assessment of
an abductor tear and mini-open repair of the abductor tear using suture anchors
Hip Arthroscopy Introduction
CAM Impingement Hip Arthroscopy
Snapping Hip
Abductor Tear
(please click the pictures or topics to go the relevant pages)
Click play for video

ABDUCTOR TEAR OF THE HIP