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Editorial Commentary: An Optimal Classification System to Guide Prognosis and Treatment in Greater Trochanteric Pain Syndrome: Now We’re Speaking the Same Language

      Abstract

      The optimal classification system in arthroscopic and related surgery research and clinical practice should be clinically relevant, descriptive, reproducible, simple, inexpensive, safe, and widely applicable. For the hip, classification systems that characterize intra-articular disorders like femoroacetabular impingement (FAI) syndrome, dysplasia, labral tears, and articular cartilage disease predominate the literature. Recently, awareness of peritrochanteric and other extra-articular disorders has increasingly led to greater recognition, diagnosis, and treatment of what has been historically known as “just bursitis”. These disorders are far more complex and include greater trochanteric pain syndrome, the spectrum of gluteal tendon pathology, greater trochanteric bursitis, snapping iliotibial band (external coxa saltans), and greater trochanteric-ischial impingement. The utility of an intraoperative greater trochanteric pain syndrome classification system has now been proven using prospectively collected data, assimilating a decade-long eligibility period following open or endoscopic treatment of peritrochanteric disorders with a minimum two-year follow-up using validated patient-reported outcome scores. This classification guides prognosis and treatment, exactly as an optimal orthopedic classification system should do.
      Classification systems are ubiquitous in arthroscopic and related surgery research. The optimal classification system should be clinically relevant, descriptive, reproducible, simple, inexpensive, safe, and widely applicable.
      • Kaeding C.C.
      • Miller T.
      The comprehensive description of stress fractures: a new classification system.
      In order to be considered clinically relevant, the system must significantly correlate with prognosis and must affect treatment decision-making. This is why “Intraoperative Classification System Yields Favorable Outcomes for Patients Treated Surgically for Greater Trochanteric Pain Syndrome” by Annin, Lall, Meghpara, Maldonado, Shapira, Rosinsky, Ankem, and Domb, is so useful.
      • Annin S.
      • Lall A.C.
      • Meghpara M.B.
      • et al.
      Intraoperative classification system yields favorable outcomes for patients treated surgically for greater trochanteric pain syndrome.
      Historically known as “just bursitis”, greater trochanteric pain syndrome (GTPS) is now increasingly being recognized, as awareness of the wide spectrum of gluteal tendon problems improves. This is a follow-up investigation that incorporates the entire spectrum of bursal and tendon pathology after the authors’ seminal publication that first reported the classification.
      • Lall A.C.
      • Schwarzman G.R.
      • Battaglia M.R.
      • Chen S.L.
      • Maldonado D.R.
      • Domb B.G.
      Greater trochanteric pain syndrome: An intraoperative endoscopic classification system with pearls to surgical techniques and rehabilitation protocols.
      The introduction of the classification system, named the Lall GTPS Classification System, did not in itself equate to guidance on prognosis or treatment. The new article—a level 3 prognostic evidence retrospective comparative analysis of prospectively collected data assimilating a decade-long eligibility period following open or endoscopic treatment of 324 patients with peritrochanteric disorders at two-year minimum follow-up with validated patient-reported outcome scores—does just that: 1) guides prognosis, and 2) guides treatment.
      • Annin S.
      • Lall A.C.
      • Meghpara M.B.
      • et al.
      Intraoperative classification system yields favorable outcomes for patients treated surgically for greater trochanteric pain syndrome.
      The cornerstone of the GTPS classification system (proposed and used) is endoscopically based management recommendations. The classification is intuitive, with each of the five described types correlating to specific intraoperative findings, physical examination, and preoperative imaging findings. It recommends surgical techniques and corresponding postoperative rehabilitation programs. The classification is based on a large number of subjects in each of the types reported, with even seven subjects in the gluteus maximus / tensor fascia lata transfer group. The number of subjects analyzed is important, especially considering the exemplary transparency in data reported in Tables 3-6 and Figs. 1-7. This quantity and quality of data are only possible with obligatory prospective data collection in a registry or clinical trial database. The optimistic “glass half-full” sees the situation as hip preservation because surgeons are increasingly collecting outcomes, but the pessimistic “glass half-empty” sees the situation as we’re all collecting different scores, at different times, for different conditions without appropriate classifications.
      • Klavas D.
      • Duplantier N.
      • Gerrie B.
      • et al.
      Patient-reported outcome score utilisation in arthroscopic hip preservation: we are all doing it differently, if at all.
      ,
      • Kollmorgen R.
      Editorial commentary: Patient-reported outcomes measurement information system (PROMIS) has decreased disease-specific responsiveness more than legacy outcome measures, but PROMIS and legacy measures do correlate: you can't have your cake and eat it too.
      Unfortunately, the latter is based on central and peripheral compartment hip arthroscopy for femoroacetabular impingement (FAI) syndrome and chondrolabral pathology, a much more common surgically treated entity than extra-articular disorders surgically treated with peritrochanteric endoscopy. Given the complexity and diversity of evaluation and management of bursitis and gluteal tendon pathology, a clinically relevant, generalizable, reproducible, and easily applicable classification, the Lall GTPS Classification System, is a perfect place to start.
      It is well known that the path to diagnosis of FAI Syndrome can be fraught with complexity. On average, patients with an FAI syndrome diagnosis see 4.0 health care providers (range 2–15), with symptoms for 32 mo (range 0.3–360 mo), had 3.4 diagnostic imaging tests, and attempted 3.1 treatments prior to diagnosis.
      • Kahlenberg C.A.
      • Han B.
      • Patel R.M.
      • Deshmane P.P.
      • Terry M.A.
      Time and cost of diagnosis for symptomatic femoroacetabular impingement.
      Before the FAI syndrome diagnosis was even made, the average cost of each health care provider visit was $315.05 per patient per visit (maximum $1,245.80; year 2012 Medicare numbers), the average cost of imaging was $837.01 per patient (maximum $4,001.10; year 2012 Medicare price), and the average cost of attempted treatments was $1,375.44 (maximum $19,938.09; year 2012 prices). The overall average cost of health care per patient was $2,456.97 prior to diagnosis. Similarly, the path to diagnosis of dysplasia is an arduous challenge. On average, patients with symptomatic acetabular dysplasia see 3.3 health care providers (range 1-11) and endure symptoms for 61.5 mo (range 5 mo to 29 yr). Most patients have tried several treatments even before a correct diagnosis is rendered: rest (75%), oral nonsteroidal medications (57%), physical therapy (43%), activity modification (42%), surgery (18%), and opioids (8%).
      • Nunley R.M.
      • Prather H.
      • Hunt D.
      • Schoenecker P.L.
      • Clohisy J.C.
      Clinical presentation of symptomatic acetabular dysplasia in skeletally mature patients.
      A separate study of patients with symptomatic dysplasia reported a duration of symptoms greater than 1 yr in 71% of patients, greater than 3 yr in 30%, and greater than 5 yr in 17%.
      • Sankar W.N.
      • Duncan S.T.
      • Baca G.R.
      • et al.
      Descriptive epidemiology of Aacetabular dysplasia: the academic network of conservational hip outcomes research (ANCHOR) periacetabular osteotomy.
      Now apply these concepts from FAI syndrome and dysplasia to that of peritrochanteric pain and gluteal tendon pathology. Anecdotally, we have all seen patients that have received many injections (The highest documented number of injections in my practice on the same hip is 21. Unsurprisingly, that hip had a full-thickness abductor tear, with significant retraction, severe atrophy, and complete fatty degeneration.). These injections were performed using a variety of imaging guidance techniques [e.g., none or “landmark-based”, ultrasound, fluoroscopy, even computed tomography (CT)], in a variety of locations (e.g., subgluteus maximus bursa, trochanteric bursa, subgluteus medius bursa, intratendinous gluteus medius/minimus), with a variety of substances [e.g., corticosteroid, platelet-rich plasma (PRP), bone marrow aspirate concentrate, “stem cells”, amniotic membrane solutions/suspensions, prolotherapy, and saline]. Further, the etiology of GTPS is incompletely understood—aging,
      • Chi A.S.
      • Long S.S.
      • Zoga A.C.
      • et al.
      Prevalence and pattern of gluteus medius and minimus tendon pathology and muscle atrophy in older individuals using MRI.
      mechanical (e.g., greater trochanteric-ischial impingement, iliotibial band),
      • Kivlan B.R.
      • Martin R.L.
      • Martin H.D.
      Defining the greater trochanter-ischial space: a potential source of extra-articular impingement in the posterior hip region.
      ,
      • Hatem M.
      • Martin H.D.
      • Safran M.R.
      Snapping of the sciatic nerve and sciatica provoked by impingement between the greater trochanter and ischium: a case report.
      or iatrogenic (e.g., intratendinous corticosteroid injection, surgical retractors during open hip surgery, including total hip arthroplasty, and fluoroquinolone medications).
      • Goyal H.
      • Dennehy J.
      • Barker J.
      • Singla U.
      Achilles is not alone!!! Ciprofloxacin induced tendinopathy of gluteal tendons.
      ,
      • Shimatsu K.
      • Subramaniam S.
      • Sim H.
      • Aronowitz P.
      Ciprofloxacin-induced tendinopathy of the gluteal tendons.
      Thus, clearly, we need to “speak the same language” in managing patients with peritrochanteric pain and gluteal tendon pathology.
      Once we all agree upon clarity, transparency, and utility in the Lall GTPS Classification System, the economics cannot be overlooked. If we draw the analogy between central/peripheral compartment hip arthroscopy and peritrochanteric endoscopy for GTPS, the impact on society may be huge. In an economic and decision analysis trial in patients with FAI syndrome, calculation of direct and indirect (primarily lost wages and decreased workplace productivity) costs and comparison of surgical and nonsurgical treatments, there was a significant increase in productivity of $8,968 after surgery (driven by 20% improvement in probability of being employed).
      • Mather 3rd, R.C.
      • Nho S.J.
      • Federer A.
      • et al.
      Effects of arthroscopy for femoroacetabular impingement syndrome on quality of life and economic outcomes.
      Cost-effective analysis showed mean cumulative total 10-year societal savings of $67,418 per patient from hip arthroscopy versus nonoperative treatment. Hip arthroscopy also conferred a gain of 2.03 quality-adjusted life years over this period. Mean cost of hip arthroscopy was $23,120, and the mean cost of nonsurgical treatment was $91,602. In 99% of trials, hip arthroscopy was recognized as the preferred cost-effective strategy. If we assume a high-volume hip arthroscopy surgeon performs 300 hip arthroscopy procedures per year, that surgeon generates nearly a $20 million annual societal savings by appropriately diagnosing and treating FAI syndrome with arthroscopic labral repair and FAI correction. Although the above calculations assume 10 yr of durability of hip arthroscopy, break-even analysis finds that the direct costs of hip arthroscopy are paid for by indirect cost benefits less than 2 yr after surgery. When evaluating return to work in isolation, nearly 100% return, and two-thirds do so within 5 wk after surgery. While peritrochanteric endoscopy volume is estimated to be significantly less than that of central/peripheral compartment hip arthroscopy, the economic impact is still considerable.

      Supplementary Data

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