Deficiency of the abductor mechanism of the hip may cause a noticeable limp and is often accompanied by severe pain. The impaired function of the abductor muscles can have various causes, such as traumatic avulsion, surgical approach, or an idiopathic tear.1–3 Osteolytic destruction of the proximal femoral bone stock in association with failed total hip arthroplasty (THA) or destruction of the abductor muscles by the inflammatory process sometimes associated with metal-on-metal THA are also described as important causes of abductor deficiency.4–10 Other well-known causes are failure of the repair of the abductor muscles and injury of superior gluteal nerve during hip replacement surgery.11
The incidence of gluteus medius and minimus deficiency after THA has been reported to be between 0.1% and 22%12 and is higher in women and the elderly.13–15 During Hardinge's approach to the hip, the abductor muscles are often damaged.16 Surgeons cannot always reattach the abductors to the femur, leading to a denuded trochanter with residual pain and a Trendelenburg limp.
Restoring the abductor function by re-fixation with or without bone anchors has been reported with a high failure rate.2,17,18 Especially tears with fatty degeneration and large retraction may not be repairable. These tears may require an augmentation as described by Whiteside.19,20 In an attempt to restore the abductor function, Whiteside19,20 developed a reconstruction technique using the gluteus maximus muscle. The muscle is split and the anterior portion is elevated as a flap, separating it from the tensor fascia lata and thereby fashioning a triangular distal fascial end that can cover the denuded trochanter.21 Gluteus maximus transfer was found to be reproducible and effective for improving pain and abductor function at short-term follow-up.19–21 However, minimum 1-year follow-up studies supported by magnetic resonance imaging (MRI) evaluation have not yet been published.
The authors present the short- and intermediate-term results of the gluteus maximus augmentation technique in patients with severe deficiencies of the abductors of the hip. The aim of this study was primarily to evaluate improvement of pain, disability, and quality of life. Secondarily, the integrity and functionality of the reconstruction were assessed by post-operative clinical examination and MRI evaluation.
Materials and Methods
This study was approved by the ethics committee of the hospital ZOL Genk. Informed consent was obtained from all patients. Sixteen gluteus maximus augmentation procedures were performed in 5 male and 11 female patients between January 2014 and April 2016. All procedures were performed by the same surgeon (K.C.) using the technique described by White-side.19,20 The mean patient age was 62 years (range, 46–74 years). All patients had severe abductor lurch during walking and a positive Trendelenburg sign. A discriminative Trendelenburg test was used with the foot in neutral rotation, internal rotation, and external rotation to test the middle, posterior, and anterior bundle of the gluteus medius. Nine patients had a primary THA conducted through a direct lateral approach. Two patients had an abductor deficiency following a revision THA, and 5 patients were treated for idiopathic, severe disruption of the gluteus medius muscle (Table 1).
Eight patients had a preoperative MRI that showed a complete rupture of the anterior part of the gluteus medius with retraction and fatty degeneration of the muscle. Two patients refused preoperative MRI assessment. The gluteus maximus muscle was intact in all patients. Indications for surgery where severe lateral hip pain refractory to nonoperative management and severe abductor lurch.
The procedure was conducted in the lateral decubitus position, and a straight lateral incision was used. A Gibson approach was used, and the interval between the tensor fascia lata and the gluteus maximus was created. The gluteus maximus was divided from the subdermal fat to allow for maximal mobilization of the anterior flap. The greater trochanter and the intact vastus lateralis were identified. The insertion of the gluteus maximus tendon was identified. The trochanter was completely denuded in all cases, with severe retraction of the gluteus medius and minimus by more than 2 cm and 50% or more of fatty degeneration. The abductors were gradually and carefully divided from the tensor fascia lata and gluteus maximus. The tear was debrided until more healthy tissue was identified. The denuded trochanter was freed of scar tissue, and the insertion of the vastus lateralis was opened in a T-shaped way to allow the gluteus maximus flap to be sutured to the vastus lateralis at the end of the augmentation (Figure 1).
Posterocranial view of the left hip. The denuded greater trochanter (GT) and anterior pillar (AP) and posterior pillar (PP) of the ruptured gluteus medius (GM) are indicated.
A rectangular sleeve 1 cm wide and 5 to 8 mm deep was created over the total length of the greater trochanter, including the vastus ridge. Care was taken to have sufficient strong cortical bone at the edges of the sleeve to have a strong fixation of the transosseous sutures. Typically, the abductor tear consists of an anterior pillar bridging over the superior side toward the posterior pillar. Drill holes are created through the anterior cortex, and Ti-Cron 5 (Covidien; Metronic, Minneapolis, Minnesota) braided polyester sutures are put through the first drill hole, the viable muscle border, and then back through the second drill hole. This transosseous suturing is started anteriorly, going superiorly and then in the posterior direction (Figure 2).
Posterocranial views of the left hip. Vastus lateralis (VL) T-shaped incision and trochanter sleeve (TS) created in the greater trochanter (GT). The posterior pillar of the gluteus medius (GM) is visible. The T-shaped split of the VL is important to suture the flap at the end of the procedure. This prevents retraction of the flap (A). Drilling transosseous sutures through the anterior trochanter cortex (ATC). It is important to put the tunnel deep enough to prevent pulling out of the Ti-Cron 5 (Covidien; Metronic, Minneapolis, Minnesota) suture. The suture starts through a tunnel in the ATC, captures the anterior pillar (AP) of the GM, and goes back through another tunnel in the ATC (B).
The sutures are not tight yet. However, prior to fixing the posterior sutures through the medius muscle, the gluteus maximus flap is created as described by Whiteside.19,20 The flap is created starting from the anterior half of the tendon and then splitting the muscle carefully in the posterosuperior direction (Figure 3). Once the flap is mobile enough to cover the greater trochanter and the proximal femur distal to the vastus ridge, the split of the muscle is sufficient. Once the flap is created, the posterior sutures are put through the drill holes in the bone, through the posterior part of the gluteus medius muscle, and through the maximus flap that is already pulled under tension over the greater trochanter (Figure 4). Because the flap is still mobile, the suture is put back through the flap, the gluteus medius, and then the second drill hole. The sutures are not tight yet until all drill holes are filled with sutures. The most posterior sutures are then tight first so that the flap along with the gluteus medius remnant is pulled toward the greater trochanter (Figure 5A). In this way, the posterior pillar of the gluteus medius is augmented first.
Posterocranial views of the left hip. Preparation of the anterior flap of the gluteus maximus (Glut Max) starting at the insertion site. The anterior portion of the gluteus tendon is released and then pulled with a Kocher to keep it under tension, which makes the split easier. The gluteus medius (GM) is also shown (A). The Glut Max flap is held under tension when the muscle is split (B). Sufficient cover of the greater trochanter (GT) is tested during the splitting of the Glut Max (C). The leg is held in neutral rotation and the flap is pulled over the GT and under the vastus lateralis (VL), which was already T-split (left). This ensures that the flap can be sutured to the VL, which will prevent superior retraction of the flap (D).
Posterocranial view of the left hip. Transosseous fixation of the gluteus maximus flap (Glut Max) to the posterior trochanter cortex and the posterior pillar (PP) of the gluteus medius (GM). The tip of the right forceps pulls the gluteus maximus. The tip of the left forceps pulls the PP of the GM. Sutures through the anterior pillar (AP) of the GM are already in place.
Posterocranial views of the left hip. All sutures through the anterior pillar (AP) and posterior pillar (PP) of the gluteus medius (GM) are put through the greater trochanter sleeve and the gluteus maximus flap (A). Final coverage of the abductor defect and the denuded trochanter by the gluteus maximus flap is evaluated by pulling the flap over the greater trochanter (B).
Next, the superior and then anterior sutures are tight, with the sutures also pulled through the gluteus maximus flap (Figure 5B). The flap is augmenting the gluteus medius defect, which is tight against the flap and toward the bone. The distal part of the flap is then sutured underneath the T-shaped vastus lateralis, which in turn fixes the flap distally and prevents cranial retraction of the flap. Finally, the tensor fascia lata is sutured back over the gluteus maximus flap (Figure 6). A deep drain is left for 2 to 3 days for prevention of postoperative seroma. Patients are restricted from weight bearing for 6 weeks, followed by 50% weight bearing for another 6 weeks. Gait rehabilitation and protected cycling is allowed after 12 weeks.
The gluteus maximus flap (Glut Max) is fixed to the bone and underneath the vastus lateralis (VL). A gap between the tensor fascia lata (TFL) remains present, leaving the anterior part of the gluteus medius (AP) proud (A). This gap is closed and the TFL and Glut Max are pulled toward each other (B).
Patients were evaluated preoperatively and followed at 6 weeks, 3 and 6 months, and a minimum of 1 year after surgery. All patients were clinically evaluated for the discriminative Trendelenburg sign preoperatively and at a minimum of 1 year postoperatively. A postoperative MRI was obtained for 10 patients to evaluate the healing of the tear and to compare with the preoperative findings. Six patients were not suitable for MRI assessment due to contraindications such as the presence of a pacemaker or a stent. The flap was considered fully ingrown in case there was no interruption of the bony femoral interface and the medial layer of the flap. The presence of fluid between the flap and the bone was considered a sign of incomplete ingrowth. In addition, retraction of the flap with the presence of fluid between the bony interface and the flap was considered as a failure of the procedure.
The following patient-reported outcomes were collected: Harris Hip Score (HHS), Short Form Health Survey 36 (SF-36), Hip Disability and Osteoarthritis Outcome Score (HOOS), Physical Activity Scale for Individuals With Physical Disability (PASIPD) score, and visual analog scale (VAS) score. Patients were also asked about the level of satisfaction with the result of the procedure.
The Wilcoxon signed rank test was used for statistical analysis. For the analysis of the Trendelenburg sign, the authors used the McNemar test. The analysis was performed with SPSS 24 (IBM, Armonk, New York). Significance was set at P<.05 for every analysis.
All patients were available for follow-up at a mean of 20 months (range, 12–36 months). There were 2 patients with a seroma that resulted in lateral sagging of subdermal fat on the lateral side of the thigh. In both patients, the postoperative drain was unintentionally removed on postoperative day 1, whereas in all other patients the drain was removed after a minimum of 3 days.
Patient-reported outcomes improved in 14 patients but deteriorated in 2 patients. All patients reported improved outcomes postoperatively but not to a statistically significant level, except for the HHS (Table 2). Social and emotional status as indicated on the SF-36 improved significantly.
Descriptive Statistics With Wilcoxon Signed Rank Test Results
Pain and Satisfaction
In 12 of 16 patients, VAS scores and SF-36 and HOOS subscores for pain improved postoperatively. Two patients reported that pain was worse after surgery. Overall, VAS score and SF-36 and HOOS subscores for pain improved significantly (Table 2). When asked about procedure satisfaction, 11 patients answered affirmatively to have the procedure redone, 3 were in doubt, and 2 patients were not happy with the result and did not want to undergo the same surgery again. Both patients had some improvement in postoperative outcomes but did not feel that the postoperative functional and pain improvement was sufficient considering the difficult postoperative rehabilitation protocol. One of these patients had signs of severe failure of the flap on MRI.
MRI Findings and Function
Integrity and functionality of the reconstruction was assessed by postoperative clinical examination and MRI evaluation at a minimum of 1 year postoperatively. Seven (44%) patients regained active abduction of the hip against gravity in lateral decubitus, had a negative Trendelenburg sign in neutral rotation, and walked without a limp. Eight (50%) patients had a negative Trendelenburg sign with the foot in external rotation, activating the anterior portion of the gluteus medius. This is considered an indication of full functional recovery of the anterior abductor function (Table 3). Seven of 10 reconstructions that were evaluated on MRI showed a perfect ingrowth at the level of the greater trochanter without any signs of retear (Figure 7). One patient had a severe failure and rerupture on MRI with moderate improvement of pain symptoms. Two reconstructions showed some fluid around the posterior portion of the greater trochanter, but with an intact insertion at the level of the anterior portion of the trochanter. These patients were considered as having an incomplete ingrowth of the flap on MRI but still had a significant improvement of their outcomes and were clinically satisfied.
Discriminative Trendelenburg Sign (McNemar Test)
A significant rupture of the gluteus medius and minimus preoperatively (A). One year postoperatively, the gluteus maximus flap has been integrated into the gluteus medius and the greater trochanter (B).
Loss of the abductor mechanism can cause severe gait dysfunction and pain. The described treatments for this condition are inconsistently successful.2,3,6,13,17,18 Transfer of the anterior portion of the gluteus maximus, as described by Whiteside,19–21 could substitute for the deficient abductor muscles. The current authors used the gluteus maximus flap as an augmentation for the repair of the deficient gluteus medius and minimus. The primary goal for the procedure was pain relief, followed by recovery of abductor function.
Most patients in the current study reported significant pain relief, improved function based on clinical evaluation, and good ingrowth in 70% of the cases. To the best of the authors' knowledge, they have presented the largest series reported in the literature of gluteus maximus transfer, including functional, clinical, and MRI evaluations. Whiteside19–21 reported the outcomes of 5 patients with abductor tendon avulsion. Four patients reported improved pain relief, function, and gait. However, Whiteside did not report any patient-reported outcome measurements. Kohl et al22 reported the results of 11 patients who underwent vastus lateralis transfer. Two patients had a resection of the proximal femur, and 9 had multiple revision THA procedures. They reported a significant improvement in pain scores. Chandrasekaran et al23 described a series of 3 patients with primary abductor avulsion who were treated with gluteus maximus transfer. They reported improved patient-reported outcome measures and VAS pain scores. In line with previous studies, the current authors conclude that the gluteus maximus augmentation technique can significantly improve patients' postoperative pain level, allowing them to also show marked improvements in social and emotional status.
The gluteus maximus muscle is effective for covering soft tissue defects about the pelvis.10,24,25 Because the gluteus muscle is active in abduction and extension of the hip, it is capable of actively abducting the hip if attached directly to the greater trochanter. In most patients, this abductor strength is sufficient to stabilize the pelvis and eliminate the abductor lurch during walking.17 The current authors found that the function of the abductor mechanism during stance and gait improved markedly in 44% of patients with these severe defects. This was also confirmed with MRI, where 7 of 10 reconstructions showed an excellent integration of the muscle flap with the trochanter bone. These findings suggest that gluteus maximus transfer as an augmentation of the deficient gluteus medius is successful in most patients for pain relief and in some for abductor function restoration.
From a technical point of view, the authors found no differences in terms of level of difficulty between patients following a primary or revision procedure. Augmentation of the abductor mechanism could reproducibly be conducted. However, in 2 cases, the trochanter bone was osteopenic due to stress shielding, leaving the anchoring of the flap more difficult with some pullouts of the Ti-Cron 5 wires. Therefore, in those cases, the bony tunnels for the sutures should be made as deep as possible in the bone (ie, as close as possible to the stem) so that a sufficient bone bridge is left, minimizing the risk of pullout. Finally, the authors suggest conducting preoperative MRI to evaluate the gluteus maximus muscle tissue for any possible fatty degeneration, which could be a relative contraindication. Although the authors did not encounter this in their series, it could potentially be a problem for the quality of the flap.
Both the small sample and the heterogenic group of patients were limitations of this study. However, complete loss of abduction function is uncommon, and therefore the indications are limited. The follow-up was relatively short, and there was no comparative cohort of patients treated with alternative methods. Not all patients had pre- or postoperative MRI, mainly because of contraindications for MRI, such as the presence of a pacemaker. Finally, quantifying the abductor strength by means of example a Cybex isokinetic test (Humacnorm, Stoughton, Massachusetts) could have been a more appropriate method for abductor function assessment. However, with THA, the authors doubt the safety of this.
The results of this study showed that transfer of the anterior portion of the gluteus maximus can be effective in pain relief and even in improving function and gait in patients with complete loss of the abductor mechanism. It appears to be an effective reconstruction technique that can improve quality of life in patients with severe abductor defects. It allows for a coverage of the denuded trochanter, thereby relieving pain.
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|Age, mean (range), y||62 (46–74)|
|Trendelenburg sign, No.||16|
|Idiopathic rupture, No.||5|
|Total hip arthroplasty, No.||9|
|Revision total hip arthroplasty, No.||2|
Descriptive Statistics With Wilcoxon Signed Rank Test Results
|Patient-Reported Outcome Measure||No. of Patients||Mean Score||z Score||P|
Discriminative Trendelenburg Sign (McNemar Test)
|Position of the Foot||No.||P|