Dr Whiteside is from Missouri Bone and Joint Center, St Louis, Missouri.
Dr Whiteside has no relevant financial relationships to disclose.
This study was conducted at Missouri Bone and Joint Center and Missouri Bone and Joint Research Foundation.
Presented at Current Concepts in Joint Replacement 2010 Winter Meeting; December 8–11, 2010; Orlando, Florida.
The author thanks Diane Morton, MS, for editorial assistance with the manuscript.
Correspondence should be addressed to: Leo A. Whiteside, MD, Missouri Bone and Joint Research Foundation, 1000 Des Peres Rd,
Ste 150, St Louis, MO 63131 (email@example.com).
Loss of abduction power due to chronic avulsion or inflammatory destruction of the abductor portions of the gluteus medius
and gluteus minimus muscles can predispose patients to dislocation and severe limp after total hip arthroplasty (THA).
The gluteus maximus muscle, if healthy and robust, can be used to fashion a flap transfer that can substitute for the deficient
This article describes a reconstructive surgical technique for gluteus maximus flap transfer in THA.
A posterior approach is used to expose the hip, splitting the gluteus maximus muscle in line with its fibers along approximately
half the length of the muscle. The incision in the muscle is extended distally, splitting the fascia lata in line with its
fibers and extending well below the greater trochanter.
After the procedure on the hip joint itself is completed, reconstruction of the abductor mechanism is begun. The anterior
portion of the gluteus maximus is exposed by deep subcutaneous dissection, and the fascia lata anterior to the gluteus maximus
is split in line with its fibers from the upper portion of the muscle to a point approximately 4 cm distal to the upper attachment
of the gluteus maximus muscle into the fascia. This incision connects with the fascial incision made during exposure, leaving
a substantial distal fascial flap to allow its attachment to bone under the vastus lateralis muscle. The anterior half of
the gluteus maximus is elevated with blunt and sharp dissection to form a triangular proximally-based flap (Figure
1). The anterior fascial edge of this flap is transected down to muscle tissue to allow the muscle fibers to be tensioned correctly.
Deficiency of the posterior capsule and short external rotators is addressed with an additional posterior gluteus maximus
flap. Approximately 15 mm of the distal attachment of the posterior portion of the gluteus maximus muscle into the fascia
lata is elevated sharply and dissected proximally approximately one-half the length of the muscle to fashion a triangular
flap that is wider proximally than distally. The sciatic nerve is nearby and must be guarded carefully throughout the procedure.
A heavy nonabsorbable suture (#5 Ethibond; Ethicon, Somerville, New Jersey) is passed through the anterior capsular structures
of the hip, then the suture is passed through the tip of the posterior flap in a figure-eight and out through the anterior
capsule of the hip. The posterior flap is pulled across the top of the femoral neck and the suture is tied to secure the posterior
flap to the anterior edge of the greater trochanter and anterior capsule of the hip. This construct is reinforced with additional
absorbable sutures (#3 Vicryl; Ethicon) passed through the anterior edge of the greater trochanter and through the anterior
hip capsule (Figure
Figure 1: The upper third of the gluteus maximus muscle is elevated as the anterior flap (A). The posterior flap is demarcated (B).
Figure 2: The repair is done in 15° abduction. The anterior flap (A) is sutured into a trough in the greater trochanter and sutured
under the vastus lateralis. The posterior flap (B) is passed over the femoral neck and sutured into the anterior capsule and
greater trochanter. The lower half of the gluteus maximus and fascia lata are closed tightly over these flaps.
Next, a sharp osteotome is used to remove the lateral cortex of the greater trochanter over an area of approximately 2×3 cm
to allow attachment of the anterior muscle flap directly to the femur. Multiple holes are drilled in the cortical edges of
the bone. The vastus lateralis is split in line with its fibers (2 cm) and detached from its proximal attachment into the
femur 15 mm anteriorly and posteriorly. Then the hip is abducted 15° and the muscle flap is sutured under moderate tension
into the greater trochanter with multiple heavy sutures (#5 Ethibond), angled so as to pull the flap distally.
The triangular fascial tongue of the gluteus maximus flap is placed under the vastus lateralis and held in place with multiple
heavy absorbable sutures (#3 Vicryl). The vastus lateralis is reattached to its original site with the same suture. In cases
where the greater trochanter is missing, the distal fascial tongue is fashioned long enough to attach to the lateral femoral
cortex distally. A single cable passed around the femur allows the fascial tongue to be passed under, folded back, and sutured
to itself for attachment to bone. The vastus lateralis covers this attachment and is sutured down proximally.
Additional abductor muscle mass can be recruited by using the tensor fascia lata. After the gluteus maximus flap is attached,
the fascia lata is cut transversely at the distal attachment of the tensor fascia lata, then the anterior edge of the tensor
is dissected from its fascial attachments and elevated with sharp and blunt dissection. The posterior edge of the tensor is
released sharply from it fascial attachments one-half to two-thirds the length of the muscle, and the distal end of the muscle
is attached to the gluteus maximus flap attachment with heavy absorbable sutures (#3 Vicryl). This tensor fascia lata transfer
is done before the vastus lateralis is closed, and its distal attachment includes suturing under the vastus lateralis flaps.
Closure is done with the hip in 15° abduction. The posterior edge of the anterior flap is sutured snugly to the top of the
posterior flap. Next, the anterior and posterior portions of the fascia lata are brought together over the top of the transferred
flaps, suturing them snugly, extending proximally to form a Y shape. The anterior edge of the anterior flap is not closed
so that the muscle pull is exerted directly on the greater trochanter. The upper edge of the lower half of the gluteus maximus
is sutured to the posterior edge of the anterior flap, closing the posterior flap underneath. This completed muscle and fascial
closure applies the upper half of the gluteus maximus to the greater trochanter to maximize its effectiveness for abducting
Eleven patients (11 hips) had gluteus maximus flap transfer for abductor deficit after THA. Postoperative care included early
partial weight bearing of 50 lbs with 2-handed support, use of an abduction pillow for 3 days while in bed, and avoidance
of abduction exercises for 6 weeks postoperatively. Patients then began gradual abduction strengthening exercise and gradually
increased weight bearing for another 6 weeks. All patients were encouraged to use a cane for 6 months.
Nine patients regained strong abduction against gravity with a mean follow-up of 33 months (range, 16–42 months). One patient
had weak abduction with moderate limp. One patient with multiple health issues had weak abduction with a severe limp even
after 6 months of physical therapy, refused additional treatment, and was lost to follow-up.
Complete loss of abduction is a common and challenging problem after THA and can cause severe limp, dislocation, and pain.
A flap transfer using the anterior portion of the gluteus maximus muscle restores abductor function in a majority of cases.
This procedure can be done during the primary THA or later as a secondary procedure.
- Alberton GM, High WA, Morrey BF. Dislocation after revision total hip arthroplasty: an analysis of risk factors and treatment options.
J Bone Joint Surg Am. 2002; 84(10):1788–1792.
- Coventry MB. Late dislocations in patients with Charnley total hip arthroplasty.
J Bone Joint Surg Am. 1985; 67(6):832–841.
- Whiteside LA. Major femoral bone loss in revision total hip arthroplasty treated with tapered, porous-coated stems.
Clin Orthop Relat Res. 2004; (429):222–226. doi: 10.1097/01.blo.0000150129.65400.78
- Whiteside LA, Nayfeh TA, Katerberg BJ. Gluteus maximus flap transfer for greater trochanter reconstruction in revision THA.
Clin Orthop Relat Res. 2006; (453):203–210. doi: 10.1097/01.blo.0000246538.75123.db
- Gray H.
Gray’s Anatomy. 1901 ed. Philadelphia, PA: Running Press; 1974.