Open surgical repair of hip abductor tendon tears.

INTRODUCTION: Tendinopathy and tendon tears of the gluteus medius and/or minimus (GMM) insertion at the greater trochanter are increasingly recognised internationally as a cause of recalcitrant lateral hip pain (LHP). The purpose of this study was to report the first Danish results of open surgical repair of GMM tears in female patients. METHODS: In this retrospective observational study, we included 67 women (68 hips) with a mean (95% confidence interval (CI)) age of 59 (56-61) years who underwent open GMM repair between September 2018 and June 2022. All cases had magnetic resonance imaging before surgery. Pre-, three- and 12-month post-operative testing included LHP (numerical rating scale 0-10), Copenhagen Hip and Groin Outcome Score (HAGOS), Oxford Hip Score (OHS), the EuroQol-Visual Analogue Scale (EQ-VAS) and the Global Rating of Change score (GROC). Responses on GROC were considered successful if patients scored "moderately better" to "very much better". Function of the lower limbs was assessed by the 30-second Chair-Stand-Test (CST). RESULTS: From pre-testing to 12-month follow-up, LHP at rest and during activity decreased significantly, all HAGOS subgroups improved by 27-35 points, the OHS improved from 22 to 35 points, the EQ-VAS improved from 52 to 72 points and the mean (95% CI) number of repetitions in the CST improved by 2.4 (1.4-3.3). Success on the GROC was reported by 79% of the patients. CONCLUSION: Open surgical repair of GMM tendon tears in women produced statistically significant improvements in patient-reported outcomes at one-year follow-up. FUNDING: None. TRIAL REGISTRATION: Not relevant.

Exercise compared to a control condition or other conservative treatment options in patients with Greater Trochanteric Pain Syndrome: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: To estimate the effectiveness of exercise at end of treatment and long-term follow-up compared to a control condition or other conservative treatments in patients with Greater Trochanteric Pain Syndrome (GTPS). METHODS: Databases were searched September 2021 and updated September 2023. Randomized controlled trials (RCT) comparing exercise interventions for patients with GTPS, to a control condition; corticosteroid injection; shock wave therapy; or other types of exercise programs were included. Risk of bias was assessed using the ROB2 tool. Meta-analyses were performed using a random-effects model. The certainty of the evidence was rated by the GRADE approach. RESULTS: Six RCTs including a total of 733 patients with GTPS were included. Three trials compared exercise to sham exercise or wait-and-see control groups, two trials compared exercise to corticosteroid injection, two trials compared exercise to shockwave therapy, and one trial compared exercise to another type of exercise. Meta-analyses showed that in the long term, exercise slightly reduces hip pain and disease severity, while slightly improving patient-reported physical function and global rating of change compared to a control condition. No serious adverse events were reported. Compared to corticosteroid injection, exercise improves long-term global rating of change. CONCLUSION: The current evidence supports a strong recommendation for exercise as first line treatment in patients clinically diagnosed with GTPS. Compared to corticosteroid injection, exercise is superior in increasing the likelihood that a patient experiences a meaningful global improvement. These results are based on few trials and a moderate number of patients. REGISTRATION: This review was prospectively registered in the PROSPERO database of systematic reviews (ID: CRD42021261380). CONTRIBUTION OF PAPER.

Effects of blood-flow restricted exercise versus conventional resistance training in musculoskeletal disorders-a systematic review and meta-analysis.

OBJECTIVE: To compare the effect of low-load blood flow restricted resistance training (BFR-RT) versus high-load resistance training (HL-RT) on muscle strength, muscle mass, physical function, patient-reported outcomes, and adherence to training in clinical musculoskeletal populations. DATA SOURCES: Web of Science, Cochrane Central, Medline, Embase, SportDiscus was searched on the 30th May 2022. REVIEW METHODS: This study was conducted as a systematic review and meta-analysis. Randomized Controlled Trials (RCTs) were included if they (i) included patients, (ii) comprised of a BFR-RT intervention protocol and a group who performed HL-RT (≥ 70%1RM) for at least eight exercise sessions, and (iii) involved at least 1 exercise that targeted the lower limbs. The Cochrane Risk of Bias tool was used to evaluate the risk of bias. The meta-analyses were performed using a random effects model with an adjustment to the confidence interval. RESULTS: Seven RCTs comprising 303 participants (BFR-RT: n = 151; HL-RT: n = 152) were identified. HL-RT and BFR-RT showed similar gains in dynamic (1-10RM) knee extensor strength and leg press strength, quadriceps cross sectional area, sit-to-stand performance, and patient reported pain and function. There was a moderate effect favoring BFR-RT for increasing maximal isometric knee extensor strength. The grading of certainty in evidence was low-to-very low for all outcome variables. CONCLUSION: This systematic review and meta-analysis extends our current knowledge about BFR-RT and HL-RT as equally effective exercise methods for inducing gains in maximal muscle strength in healthy populations, by now also comprising patients suffering from various clinical musculoskeletal conditions. The certainty in the estimates was low-to-very low, prompting the inclusion of future higher-quality trials. TRIAL REGISTRATION: PROSPERO ID (CRD42022337173). Registered June 18th 2022.

Effects of Resistance Training Prior to Total Hip or Knee Replacement on Post-operative Recovery in Functional Performance: A Systematic Review and Meta-Analysis.

Objective: To evaluate the effectiveness of pre-operative resistance training in patients allocated to TJR surgery on selected post-operative outcomes, via a meta-analysis of studies using exercise modalities and loading intensities objectively known to promote gains in muscle size and strength in adults of young-to-old age. Design: A systematic review and meta-analysis. Literature Search: Cochrane Central, MEDLINE, EMBASE, and PEDro were searched on August 4th 2021. Study Selection: Randomized Controlled Trials (RCTs) were included if (i) they compared pre-operative lower-limb-exercises before elective TJR with standard care, (ii) explicitly reported the exercise intensity, and (iii) reported data on functional performance. Data Synthesis: This systematic review and meta-analysis is reported in accordance with the PRISMA reporting guidelines. A random effects model with an adjustment to the confidence interval was performed for pooling the data. Results: One thousand studies were identified. After applying exclusion criteria, five RCTs were located including 256 participants (mean age ranged from 61 to 72 years, 54% women). Moderate-to-large improvements in functional performance and maximal knee extensor strength were observed at 3 months after surgery along with small-to-moderate effects 12 months post-operatively. For patient-reported outcomes, small-to-moderate improvements were observed at 3 months post-operatively with no-to-small improvements at 12 months. Conclusion: Prehabilitation efforts involving progressive resistance training provides an effective means to improve post-operative outcomes related to functional performance, knee extensor strength and patient-reported outcome in patients undergoing TJR. Due to large methodological diversity between studies, an optimal loading intensity remains unknown. Systematic Review Registration: Prospero ID: CRD42021264796.

[Traumatic rupture of the gluteus minimus tendon].

An acute isolated tear of the gluteus minimus tendon after a traumatic event is very uncommon, and only a few cases have been reported worldwide. We present a case report of a 43-year-old woman with lateral hip pain after a scooter accident. Prior to the accident, she had no hip pain. Magnetic resonance imaging showed rupture of the gluteus minimus tendon attachment to the trochanter major. The patient underwent operative repair after non-surgical treatment had been attempted. The surgery was successful, and the patient fully recovered without any hip pain.

Low prevalence of trochanteric bursitis in patients with refractory lateral hip pain.

INTRODUCTION: Bursitis at the greater trochanter has historically been identified as a major pain generator in patients with lateral hip pain (LHP). We believe that hip abductor tendon pathology (HATP) plays an important and overlooked role in LHP. The purpose of this study was to evaluate the presence of isolated trochanteric bursitis on MRI in patients with refractory LHP. METHODS: The MRIs of 120 patients with LHP (94% women, median age 54 years) performed at our orthopaedic outpatient clinic between 2017 and 2020 were evaluated by two raters for trochanter-related pathologies, including HATP and bursitis. RESULTS: Two (2%) patients were registered with greater trochanteric bursitis with no relevant HATP, 30 (25%) patients had elements of inflammation (high-intensity signals) in the greater trochanteric bursa with relevant HATP. Five (4%) patients had relevant HATP with bursitis in the sub-gluteus minimus bursa with no bursitis in the greater trochanteric bursa. The remaining 83 (69%) patients had no sign of trochanter-related bursitis. CONCLUSION: Isolated trochanteric bursitis as the cause of refractory LHP appears to be rare. We believe that the presence of HATP in LHP has been severely underestimated and a shift in focus towards treatment of these structures is necessary. FUNDING: none. TRIAL REGISTRATION: According to current national legislation, no formal ethical approval was required for this study. The National Data Protection Agency approved the study (1-16-02-124-19).

Exercise With Low-Loads and Concurrent Partial Blood Flow Restriction Combined With Patient Education in Females Suffering From Gluteal Tendinopathy: A Feasibility Study.

Introduction: To date, there exists no gold standard conservative treatment for lateral hip pain due to tendinopathy of the gluteus medius and/or minimus tendon (GT), a condition often complicated by pain and disability. Higher loads during everyday activities and exercise seems to be contraindicated with GT. The purpose of this study was to evaluate the feasibility of exercise with low-loads concurrent partial blood flow restriction (LL-BFR) and patient education for patients present GT. Methods: Recruitment took place at three hospitals in the Central Denmark Region. The intervention consisted of daily sessions for 8 weeks with one weekly supervised session. From week three patients exercised with applied partial blood flow restriction by means of a pneumatic cuff around the proximal thigh of the affected leg. Throughout the intervention patients received patient education on their hip condition. Sociodemographic and clinical variables were collected at baseline. The feasibility of LL-BFR was conducted by adherence to the exercise protocol and drop-out rate. Patient reported outcome measures (The Victorian Institute of Sport Assessment-Gluteal Questionnaire, EuroQol - 5 Dimensions-Visual Analogue Scale, Oxford Hip Score, Copenhagen Hip and Groin Outcome Score), maximal voluntary isometric hip abduction-, hip extension, and knee extension strength (Nm/kg) measured using a handheld dynamometer, and functional capacity tests (30 second chair-stand test and a stair-climb test) was conducted as secondary outcomes. Results: Sixteen women with a median (IQR) age of 51 (46-60) years were included. Median (IQR) Body Mass Index was 26.69 (23.59-30.46) kg/m2. Adherence to the total number of training sessions and the LL-BFR was 96.4 and 94.4%, respectively. Two patients dropped out due to (i) illness before initiation of LL-BFR and (ii) pain in the affected leg related to the LL-BFR-exercise. At follow-up both pain levels and patient-reported outcome measures improved. Isometric hip abduction-, hip extension-, and knee extension strength on both legs and functional performance increased. Conclusion: LL-BFR-exercise seems feasible for treatment of GT. At follow-up, a high adherence and low drop-out rate were observed. Further, patients reported clinically relevant reductions in pain, and showed significant increases in isometric hip and knee strength.

Gluteal-related lateral hip pain.

INTRODUCTION: Lateral hip pain (LHP) due to tendon pathologies of insertion of the M. gluteus medius and minimus at the greater trochanter are often misdiagnosed and may lead to unrecognised disability. The purpose of this study was to evaluate pain and patient-reported outcomes in patients presenting with LHP in the context of a publicly financed healthcare system. METHODS: Data were collected from September 2017 to November 2020 at a regional teaching hospital. Inclusion criteria were clinical and MRI-verified hip abductor tendon pathology. Baseline testing included pain scoring (numerical rating scale, NRS), and the following patient-reported outcome scores: Copenhagen Hip and Groin Outcome Score (HAGOS), Oxford Hip Score (OHS) and EuroQol-Visual Analogue Scale (EQ-VAS). RESULTS: A total of 151 patients (94% women) with a median age of 55 years were included. The mean LHP (NRS 0-10) at rest, during activity and worst pain at any given time was 4, 7 and 9, respectively. The mean patient-reported outcome scores were HAGOS: pain 42.9, symptoms 49.8, activities of daily living 42.2, sport/recreation 28.1, participation in physical activities 25, quality of life 27.8; OHS 24; EQ-VAS 59.6. CONCLUSIONS: We found that patients with hip abductor tendon pathology display poor patient-reported outcomes comparable to those of patients suffering from severe hip osteoarthrosis. Further research into this patient group is warranted. The results are based on a heterogeneous study population in terms of variety of hip abductor tendon pathology and comorbidities and need to be interpreted as such. FUNDING: none. TRIAL REGISTRATION: According to current Danish law, no formal ethical approval was required for this study. The National Data Protection Agency approved the study (1-16-02-125-19).

Efficacy of low-load blood flow restricted resistance EXercise in patients with Knee osteoarthritis scheduled for total knee replacement (EXKnee): protocol for a multicentre randomised controlled trial.

INTRODUCTION: Up to 20% of patients undergoing total knee replacement (TKR) surgery report no or suboptimal pain relief after TKR. Moreover, despite chances of recovering to preoperative functional levels, patients receiving TKR have demonstrated persistent deficits in quadriceps strength and functional performance compared with healthy age-matched adults. We intend to examine if low-load blood flow restricted exercise (BFRE) is an effective preoperative method to increase functional capacity, lower limb muscle strength and self-reported outcomes after TKR. In addition, the study aims to investigate to which extent preoperative BFRE will protect against surgery-related atrophy 3 months after TKR. METHODS: In this multicentre, randomised controlled and assessor blinded trial, 84 patients scheduled for TKR will be randomised to receive usual care and 8 weeks of preoperative BFRE or to follow usual care-only. Data will be collected before randomisation, 3-4 days prior to TKR, 6 weeks, 3 months and 12 months after TKR. Primary outcome will be the change in 30 s chair stand test from baseline to 3-month follow-up. Key secondary outcomes will be timed up and go, 40 me fast-paced walk test, isometric knee extensor and flexor strength, patient-reported outcome and selected myofiber properties.Intention-to-treat principle and per-protocol analyses will be conducted. A one-way analysis of variance model will be used to analyse between group mean changes. Preintervention-to-postintervention comparisons will be analysed using a mixed linear model. Also, paired Student's t-test will be performed to gain insight into the potential pretraining-to-post-training differences within the respective training or control groups and regression analysis will be used for analysation of associations between selected outcomes. ETHICAL APPROVAL: The trial has been accepted by the Central Denmark Region Committee on Biomedical Research Ethics (Journal No 10-72-19-19) and the Danish Data Protection Agency (Journal No 652164). All results will be published in international peer-reviewed scientific journals regardless of positive, negative or inconclusive results. TRIAL REGISTRATION NUMBER: NCT04081493.

[Abductor-related lateral hip pain in patients older than 30 years].

Lateral hip pain is a complex entity, and recent focus has been brought to pathological changes in relation to the hip abductors as a cause of lateral hip pain. A short overview of anatomy, physiology, diagnostics and treatments of hip abductor pathologies is given in this review.

Three-dimensional kinematic and kinetic analysis of knee rotational stability in ACL-deficient patients during walking, running and pivoting.

BACKGROUND: Anterior cruciate ligament (ACL) deficiency leads to altered stability of the knee. The purpose of this study was to compare the dynamic, rotational stability of the knee, expressed as rotational stiffness, between anterior cruciate ligament-deficient (ACLD) knees, their contralateral intact knees (ACLI) and a knee healthy control group during walking, running and 90° pivoting. We hypothesized a larger tibial internal rotation, a smaller knee joint external moment and a lower rotational stiffness in the ACLD group compared to the ACLI and the control group. METHODS: Kinematic and kinetic data were collected from both legs of 44 ACLD patients and 16 healthy controls during walking, running and a pivoting maneuver (descending a staircase and immediately pivoting 90° on the landing leg). Motion data were captured using 8 high-speed cameras and a force-plate. Reflective markers were attached to bony landmarks of the lower limb and rigid clusters on the shank and thigh (CASH model). Maximum internal tibial rotation and the corresponding rotational moment were identified for all tasks and groups and used to calculate rotational stiffness (= Δmoment /Δrotation) of the knee. RESULTS: The tibial internal rotation of the ACLD knee was not significantly different from the ACLI knee during all three tasks. During walking and running, the tibial rotation of the control group was significantly different from both legs of the ACL-injured patient. For pivoting, no difference in tibial rotation between knees of the ACLD, ACLI and the control group was found. Knee joint external moments were not significantly different between the three groups during walking and pivoting. During running, the moments of the ACLI group were significantly higher than both the knees of the ACLD and the control group. Rotational stiffness did not differ significantly between groups in any of the three tasks. CONCLUSION: A high-intensity activity combining stair descent and pivoting produces similar angular rotations, knee joint external moments and rotational stiffness in ACLD knees compared to ACLI knees and the control group. During running, the ACLI knee displayed a higher external moment than the ACLD and the healthy control group. This could indicate some type of protective strategy or muscular adaptation in the ACL-injured patients.

Rotational laxity after anatomical ACL reconstruction measured by 3-D motion analysis: a prospective randomized clinical trial comparing anatomic and nonanatomic ACL reconstruction techniques.

PURPOSE: To compare the ability of three different anterior cruciate ligament (ACL) reconstruction techniques to normalize rotational knee stability 1 year after ACL reconstruction. Two of these techniques are so-called anatomic techniques. METHODS: Three different ACL reconstruction techniques were tested for their ability to normalize rotational knee stability in a prospective randomized study. Forty-seven ACL-deficient (ACLD) patients were randomized to transtibial single-bundle (SB), anatomic SB, and double-bundle ACL reconstruction. Three-dimensional motion analysis was performed preoperatively and at 1-year follow-up to evaluate tibial rotation and rotational stiffness. Motion data were captured using an eight-camera motion analysis system. Tibial rotation was determined during walking, running, and a pivoting task. Other outcome parameters were KT-1000 knee laxity measurements and the subjective outcome scores KOOS and IKDC. RESULTS: Three-dimensional motion analysis demonstrated that the tibial internal rotation and the rotational stiffness did not differ between the ACL reconstruction techniques during walking, running, and pivoting at 1-year follow-up. Objective knee stability and subjective outcome scores did not differ between the reconstruction groups. CONCLUSION: No significant difference in rotational stability walking, running, and pivoting was seen between anatomic and nonanatomic ACL reconstruction techniques at 1-year follow-up. LEVEL OF EVIDENCE: Therapeutic study, Level I.