Abstract
Objectives:
The majority of patients undergoing surgical management for gluteus medius and/or minimus tears do not complete formal pre-operative physical therapy. Prehabilitation consisting of gait training with a walker while maintaining a level pelvis, building upper body strength in the arms in preparation for post-operative ambulatory aids, and strengthening the dampening muscles of the hip (e.g., lower abdominal core, lower back, quadriceps, gluteal muscles, iliotibial band) is crucial for optimizing post-operative recovery. Furthermore, previously published rehabilitation protocols for gluteus medius and/or minimus patients fail to consider the risks of surgical repair site disruption from early hip abduction and strengthening exercises in the intermediate post-operative period. Thus, to improve long-term outcomes for patients undergoing endoscopic gluteus medius and/or minimus repair, the purpose of the present study was to (1) provide a comprehensive prehabilitation and rehabilitation protocol and (2) demonstrate the efficacy of this protocol by reporting mid-term patient-reported outcome measures (PROMs).
Methods:
This was a prospective study of patients ≥ 18 years old with minimum 2-year follow-up who underwent endoscopic repair for symptomatic full-thickness gluteus medius and/or minimus tendon tears. Tears were classified intra-operatively as either full-thickness (tear involving > two-thirds the width of the tendon) or partial-thickness (tear involving ≤ two-thirds the width of the tendon). All patients followed a standard 6-phase prehabilitation/rehabilitation protocol that consisted of: (1) Prehabilitation [3 months pre-operatively]; (2) Immediate Post-operative Recovery [0-6 weeks post-operatively]; (3) Endurance and Strength [6-12 weeks post-operatively]; (4) Balance, Coordination, and ROM [3-6 months post-operatively]; (5) Home Exercise/physical therapy [6-12 months post-operatively]; and (6) Gradual Return to Sport/Recreational Activity [12-24 months post-operatively]. The Gluteus-Score-7 (GS7) was calculated to estimate a patient’s risk of post-operative clinical failure. Outcomes were assessed pre-operatively and at 3-, 6-, 12-, 24-, and 60-month post-operative timepoints; they included hip abduction strength, Trendelenburg gait, retear rate, and the following PROMs: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score (HOS)–Activities of Daily Living (HOS-ADL), HOS–Sports Specific Subscale (HOS-SSS), 33-item International Hip Outcome Tool (iHOT-33), and Visual Analog Scale (VAS) pain score.
Results:
Overall, 26 patients (age, 67.5 ± 7.2 (range: 48-81); BMI, 28.8 ± 4.1; 76.9% female) met inclusion criteria (Table 1). All patients had full-thickness tears, of which 46.1% (n=12) were retracted more than 2 cm. Patients had an average GS7 score of 4.8 ± 1.2, indicating a high risk of post-operative failure. At baseline, patients had the following mean ± SD PROMs: mHHS (55.6 ± 16.6), HOS-ADL (50.4 ± 15.9), HOS-SSS (23.1 ± 24.1), NAHS (55.7 ± 13.0), iHOT-12 (35.6 ± 15.5), and VAS (5.8 ± 2.8). After undergoing endoscopic repair and following the patient-guided rehabilitation protocol, patients achieved significant improvements in all PROMs besides HOS-SSS at 3-, 6-, 12-, 24-, and 60-month follow-up (Figure 1 and Table 2). By 2-year follow-up, 100% (n = 26%) of patients achieved 5/5 hip abduction strength, only 1 patient (3.8%) re-developed a Trendelenburg gait, and no patients experienced a tendon re-tear. Despite having a high overall GS7 score, patients achieved high rates of 2-year MCID by the end of Phase 6 of the 2-year rehabilitation protocol (Table 3).
Conclusions:
Patients who underwent a 6-phase prehabilitation/rehabilitation protocol for endoscopic repair of full-thickness gluteus medius and/or minimus tears achieved significant improvements in functional outcomes despite their high risk of post-operative failure. PROM improvements began as early as 3 months post-operatively and were sustained at long-term follow-up with excellent 5-year outcomes. These findings highlight the value of implementing formal prehabilitation and a conservative, patient-guided rehabilitation protocol that avoids early hip abduction and strengthening exercises in the intermediate post-operative period.
