Surgical Reconstruction of Gluteal Tendon Tears

All patients will undergo gluteal tendon reconstruction, augmented with a synthetic ligament, as outlined in detail below. This is the preferred operative technique of the orthopaedic surgeon involved in this research, and this surgical intervention is being undertaken regardless of whether patients choose to participate in the prospective clinical follow-up or not. As part of this prospective follow-up, patients will be evaluated pre-surgery and at 3, 6, 12 and 24 months post-surgery. The surgical procedure is performed using general anesthesia, prophylactic antibiotics and an indwelling urinary catheter. In the lateral decubitus position, a 10cm longitudinal incision is made over the lateral aspect of the greater trochanter. The tensor fascia lata (TFL) is divided longitudinally, the same length as the skin incision. A 1-2 cm V-Y lengthening of the TFL investing fascia is performed. The thickened trochanteric bursa is excised to expose the insertion of the gluteus medius tendon into the lateral facet of the anterior greater trochanter. Subsequent evaluation of the tendon is performed for the extent of the tear and the presence or otherwise of an associated enthesiophyte. The involved portions of the tendon is elevated from the anterior greater trochanter. Any intact, generally posterior, fibres of the gluteus medius are not dissected from bone. The underlying bone on the footprint of the tendon insertion is decorticated with an osteotome to remove sclerotic reactive bone and enthesiophytes, exposing a bleeding bone surface ready to receive the prepared tendon. Tendinopathic tissue is excised from the tendon end. Any de-laminations of the tendons are then repaired. The repair in all cases is augmented with a LARS (ACTOR 10, Corin Group, Cirencester, UK) ligament which is cut longitudinally along the seam allowing the tube to fan. The flattened portion is sutured onto the under-surface of medius, or reflected minimus. Stay sutures in the reflected tendon ends aided retraction during LARS attachment. The LARS ligament is secured using 2-Ethibond sutures (Ethicon Inc., Johnson and Johnson, USA). A 4.5 mm bone tunnel is drilled from the foot-print of gluteus minimus on the anterior facet of the greater trochanter, which exits postero-distal to the lateral prominence of the greater trochanter. A flexible looped wire passed through the bone tunnel permits passing of the draw-string on the free end of the LARS ligament through from antero-medial (deep) to lateral (superficial), and the deep surface of the tendon is drawn onto the footprint. A 5.2 mm interference screw (Corin, Cirencester, UK) is placed into the bone tunnel to secure the tension in the ligament/bone interface. The excess tail of the LARS ligament is trimmed. Subsequently, formal repair of the gluteal tendons to the anterior greater trochanter is performed with interosseous suture and bone anchors as indicated. The wound is closed in layers excluding the proximal fascia lata decompression. Patients are discharged from hospital 3-5 days after surgery, and two weeks of subcutaneous DVT prophylaxis is administered in all patients.