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Case Reports Medical Education Research Forum 2019

5-2019 Gluteus Maximus Transfer for Trendelenburg Following Total Hip Arthroplasty Karen Nelson Henry Ford Health System

Melissa Martinez Henry Ford Health System

Fremont Scott Henry Ford Health System

JJ Goldman

K Chaiyasate

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Recommended Citation Nelson, Karen; Martinez, Melissa; Scott, Fremont; Goldman, JJ; and Chaiyasate, K, "Gluteus Maximus Transfer for Trendelenburg Gait Following Total Hip Arthroplasty" (2019). Case Reports. 93. https://scholarlycommons.henryford.com/merf2019caserpt/93

This Poster is brought to you for free and open access by the Medical Education Research Forum 2019 at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Case Reports by an authorized administrator of Henry Ford Health System Scholarly Commons. For more information, please contact [email protected]. Gluteus Maximus Transfer for Trendelenburg Gait Following Total Hip Arthroplasty MM Martinez, KE Nelson DO, JJ Goldman MD, FL Scott DO, K Chaiyasate MD Henry Ford Health System, Clinton Township, Michigan

Abstract Post Operative Follow Up

Introduction: Lateral approach total hip arthroplasty (THA) accounts for 12% of the total hip reconstructions performed annually. Approximately 4.4% of these patients experience postoperative rupture of the (routinely taken down and repaired during the surgery), resulting in loss of abduction and a contralateral hip drop (Trendelenburg gait). While functional muscle transfer has been proposed for use at the time of implant revision surgery, to our knowledge, no report exists of dynamic repair in patients with a functioning implant and early muscle rupture. Case: A 47-year-old female presented to clinic with MRI proven rupture of the gluteus medius and failed secondary repair. The patient noted significant discomfort with activities of daily living. A review of the literature was performed, and joint decision-making was utilized to consent for a superior gluteus maximus transfer. An interdisciplinary team (plastic and orthopedic) performed the surgery with modifications to a technique previously described. Figure 1. Pictured on the left are preoperative radiographs of the left hip Results: Surgery was performed in 2 hours and 49 minutes. Postoperative course was uneventful. At 4 demonstrating severe degenerative osteoarthritis. Pictured on the right are immediate months post-op, the patient has a significant increase in abduction strength. The patient is able to stand without hip drop and continues extensive for balance and gait given the 2 years of atrophy post operative radiographs following left total hip arthroplasty. and maladaptation. The patient reports improvement in quality of life, and physical therapy notes indicate improvement across all gait, stance, and strength studies. Conclusion: The superior gluteus maximus muscle transfer for gluteus medius rupture is a viable option in patients with Trendelenburg gait, warranting further clinical study. Figure 2. Pictured on the left is an MRI of the Left hip demonstrating complete rupture Introduction of the gluteus medius. Figure 6. 4 month followup image without a hip drop.

Abductor deficiency can be secondary to repair failure following total hip arthroplasty or from severe metallosis, damage to the superior gluteal nerve, or attritional rupture of the abductor complex1. The Hardinge Direct Lateral approach or modified Watson Jones Anterolateral approach to total hip arthroplasty (THA) accounts for 12% of the total hip reconstructions performed annually3. Through this Conclusion & Discussion approach the gluteus medius and minimus tendons are taken down and repaired. Approximately 4.4% of these patients experience postoperative rupture of the gluteus medius, resulting in loss of abduction and a contralateral hip drop (Trendelenburg gait). Other complications include pain, feeling Lateral approach to total hip arthroplasty is a commonly used approach for joint replacement. of instability, weakness in abduction, and possible increased rate of dislocation7. While functional However, some patients may have abductor deficiency with continued lateral hip pain with the muscle transfer has been proposed for use at the time of implant revision surgery, to our knowledge, most serious complication being hip instability. This complication increases with each hip no report exists of dynamic repair in patients with a functioning implant and early muscle rupture. ! surgery. Injury to the superior gluteal nerve must be evaluated before proceeding with any Figure 3. Pictured on the right is an surgical intervention. There are several repair techniques described in the literature, but when Intraoperative image demonstrating those options have been exhausted, there are very few procedures to address trendelenburg Case Report gait. There were two techniques specifically reviewed prior to this case. The first was rupture of the gluteus medius and described by Fehm et al5, in which an achilles tendon allograft was used to repair the abductor minimus. mechanism. The second option was originally described by Whiteside7 for a gluteus maximus A 47 year old female patient underwent left total hip arthroplasty for primary osteoarthritis muscle transfer where the anterior fibers of the gluteus maximus are transferred to the greater through an anterolateral approach. Her past medical history does include systemic arterial trochanter to recreate the gluteus medius and minims complex. In our technique we chose to hypertension, hypercholesterolemia, and stroke without residual deficits. Five months after her transfer the anterior fibers of the gluteus maximus with a sleeve of the ilitobial band and initial surgery, and completion of her 12 weeks of routine physical therapy, she had persistent anchoring the tissue into the greater trochanter. Whiteside described a second flap to stabilize weakness and abnormal gait. She underwent MRI which revealed rupture of the gluteus medius the posterior joint capsule and short external rotators. This was not necessary because our and minimus. She then underwent Left gluteus medius repair with all-suture bone anchors. She patient had intact posterior complex. There are several limitations to the study. This is a single again continued to have weakness in hip abduction with a trendelenburg gait even after case report with short follow up. There is also no comparative group. However, despite all the completing 8 sessions of physical therapy. She was sent to another orthopedic surgeon for a limitations, we feel that this is a viable technique for patients with a trendelenburg gait second opinion and it was recommended that she undergo a functional muscle transfer versus a following total hip arthroplasty that affects their quality of life. tendon allograft reconstruction. At that time she had an EMG which revealed normal neurologic ! function. A review of the literature was performed, and joint decision-making was utilized to Conclusion: consent for a superior gluteus maximus transfer. An interdisciplinary team (plastic and orthopedic The superior gluteus maximus muscle transfer for gluteus medius rupture is a viable option in surgery) performed the surgery with a modified technique previously described by Whiteside for patients with Trendelenburg gait, warranting further clinical study. use at the time of hip revision. ! The patient was placed in a lateral decubitus position and an incsion was carried out through the Figure 4. Intraoperative image demonstrating the triangular shaped anterior gluteus prior incision and extended superiorly in a curvilinear fashion towards the PSIS. The gluteus maximus muscle flap. The image on the right is the final position of the tendon over maximus muscle and tensor fascia lata with the iliotibial band were exposed. Approximately half References of the gluteus maximus muscle was split in line with it’s fibers and carried down to the fascia lata the greater trochanter. which was split in line with its fibers. The gluteus maximus flap was elevated to produce a triangular shaped flap. It was noted at this time that there was no deficiency of the posterior 1. Davies H, Zhaeetan S, Tavakkolizadeh A, Janes G. Surgical repair of chronic tears of the hip abductor mechanism. Hip Int. 2009;19:372–376. ! short external rotators or capsule and the second limb of the flap was not dissected. The greater ! trochanter was prepped with a rasp down to bleeding bone utilizing the proximal 4cm of the 2. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical greater trochanter. Next the proximal vastus laterals was dissected in a T shape, subperiosteally examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44:2138–2145. ! down to bone. 8 bone tunnels were drilled into the greater trochanter. The flap was laid into the ! groove and a heavy non absorbable suture was used to anchor the flap to bone. This was 3. Baker AS, Bitounis VC. Abductor function after total hip replacement. An electromyographic and clinical review. J Bone tensioned with the hip in 15 degrees of abduction. The very distal end of the flap was sewn into Joint Surg Br. 1989;71:47–50. ! ! the vastus laterals and the limbs were oversewn. A drain was left in place for 1 week. 4. Daly PJ, Morrey BF. Operative correction of an unstable total hip arthroplasty. J Bone Joint Surg Am. 1992;74:1334– ! 1343. ! Surgery was performed in 2 hours and 49 minutes. Postoperative course was uneventful. Post ! operatively the patient was placed in a hip abduction orthosis. She was toe touch weight bearing 5. Fehm MN, Huddleston JI, Burke DW, Geller JA, Malchau H. Repair of a deficient abductor mechanism with Achilles for 6 weeks with progressive weight bearing since then. She was made full weight bearing at 3 tendon allograft after total hip replacement. J Bone Joint Surg Am. 2010;92:2305–2311. ! months without the abduction orthosis. She has continued physical therapy for strengthening. At 4 ! 6. Kohl S, Evangelopoulos DS, Siebenrock KA, Beck M. Hip abductor defect repair by means of a vastus lateralis muscle months post-op, the patient has a significant increase in abduction strength (0-1 to 2-3). The shift. J Arthroplasty. 2012;27:625–629. ! patient is able to stand without hip drop but continues to require extensive physical therapy for ! balance and gait given the 2 years of atrophy and mal-adaptation. She continues to ambulate Figure 5. Intraoperative image demonstrating the final suture into the greater 7. Whiteside LA. Surgical technique: Transfer of the anterior portion of the gluteus maximus muscle for abductor with a cane. The patient reports improvement in quality of life, and physical therapy notes trochanter with closure of the muscle. deficiency of the hip. Clin Orthop Relat Res. 2012;470:503–510. ! indicate improvement across all gait, stance, and strength studies. ! 8. Whiteside LA. Surgical technique: Gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip. Clin Orthop Relat Res. 2014;472:645–653.