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Treating Abductor Deficiency: a Transference Technique

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Treating Abductor Deficiency: a Transference Technique ■ Hip Arthroplasty: Avoiding Pitfalls & Managing Problems Treating Abductor Defi ciency: A Transference Technique LEO A. WHITESIDE, MD abstract Full article available online at OrthoSuperSite.com. Search: 20110714-34 Loss of abduction power is a common problem after total hip arthroplasty (THA) and may lead to severe limp and instability. A surgical reconstruction technique using a gluteus maximus fl ap transfer was developed to repair defi cient abductor muscles and capsule. The gluteus maximus muscle was split as in a posterior approach to the hip, and the anterior portion of the muscle was elevated as a fl ap, separating it from the fas- cia lata and fashioning a triangular distal fascial end. The lateral surface of the greater trochanter was decorticated, and the anterior half of the gluteus maximus was sutured to the greater trochanter with multiple nonabsorbable sutures through drill holes in the bone. The distal fascial end was sutured beneath the vastus lateralis muscle with heavy absorbable sutures. The posterior portion of the gluteus maximus (approximately one- sixth of the muscle body and half the length) was passed beneath the primary fl ap to substitute for the gluteus minimus and capsule. The tensioning of the fl ap was done with the hip in 15Њ to 20Њ abduction to ensure adequate tension in the transferred muscle. The lower half of the gluteus maximus muscle and fascia lata were also closed Figure: The upper third of the gluteus maximus muscle is elevated as the anterior fl ap. over the greater trochanter and transferred muscle fl ap with the hip abducted and then closed proximally, leaving the anterior edge of the gluteus maximus fl ap unsutured so that the transferred muscle would be allowed to pull directly on the greater trochanter. Gradual rehabilitation included 2-handed support for 8 weeks and careful gradual abduction exercises beginning 4 weeks postoperatively. Dr Whiteside is from Missouri Bone and Joint Center, St Louis, Missouri. Dr Whiteside has no relevant fi nancial 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 protected]). doi: 10.3928/01477447-20110714-34 e470 ORTHOPEDICS | ORTHOSuperSite.com ■ Hip Arthroplasty: Avoiding Pitfalls & Managing Problems oss of abduction power due to chronic avulsion or infl ammatory Ldestruction of the abductor por- tions of the gluteus medius and gluteus minimus muscles can predispose patients to dislocation and severe limp after total hip arthroplasty (THA).1-4 The gluteus maximus muscle, if healthy and robust, can be used to fashion a fl ap transfer that can substitute for the defi cient abductor muscles.4,5 This article describes a recon- structive surgical technique for gluteus maximus fl ap transfer in THA. SURGICAL TECHNIQUE A posterior approach is used to expose 1 2 the hip, splitting the gluteus maximus Figure 1: The upper third of the gluteus maximus muscle is elevated as the anterior fl ap (A). The posterior muscle in line with its fi bers along ap- fl ap is demarcated (B). Figure 2: The repair is done in 15Њ abduction. The anterior fl ap (A) is sutured into proximately half the length of the muscle. a trough in the greater trochanter and sutured under the vastus lateralis. The posterior fl ap (B) is passed The incision in the muscle is extended dis- over the femoral neck and sutured into the anterior capsule and greater trochanter. The lower half of the tally, splitting the fascia lata in line with gluteus maximus and fascia lata are closed tightly over these fl aps. its fi bers and extending well below the greater trochanter. After the procedure on the hip joint fascia lata is elevated sharply and dis- are drilled in the cortical edges of the bone. itself is completed, reconstruction of the sected proximally approximately one-half The vastus lateralis is split in line with its fi - abductor mechanism is begun. The an- the length of the muscle to fashion a tri- bers (2 cm) and detached from its proximal terior portion of the gluteus maximus is angular fl ap that is wider proximally than attachment into the femur 15 mm anteriorly exposed by deep subcutaneous dissection, distally. The sciatic nerve is nearby and and posteriorly. Then the hip is abducted and the fascia lata anterior to the gluteus must be guarded carefully throughout the 15Њ and the muscle fl ap is sutured under maximus is split in line with its fi bers from procedure. A heavy nonabsorbable suture moderate tension into the greater trochanter the upper portion of the muscle to a point (#5 Ethibond; Ethicon, Somerville, New with multiple heavy sutures (#5 Ethibond), approximately 4 cm distal to the upper at- Jersey) is passed through the anterior cap- angled so as to pull the fl ap distally. tachment of the gluteus maximus muscle sular structures of the hip, then the suture The triangular fascial tongue of the into the fascia. This incision connects is passed through the tip of the posterior gluteus maximus fl ap is placed under the with the fascial incision made during ex- fl ap in a fi gure-eight and out through the vastus lateralis and held in place with posure, leaving a substantial distal fascial anterior capsule of the hip. The posterior multiple heavy absorbable sutures (#3 fl ap to allow its attachment to bone under fl ap is pulled across the top of the femoral Vicryl). The vastus lateralis is reattached the vastus lateralis muscle. The anterior neck and the suture is tied to secure the to its original site with the same suture. In half of the gluteus maximus is elevated posterior fl ap to the anterior edge of the cases where the greater trochanter is miss- with blunt and sharp dissection to form a greater trochanter and anterior capsule of ing, the distal fascial tongue is fashioned triangular proximally-based fl ap (Figure the hip. This construct is reinforced with long enough to attach to the lateral femo- 1). The anterior fascial edge of this fl ap additional absorbable sutures (#3 Vicryl; ral cortex distally. A single cable passed is transected down to muscle tissue to al- Ethicon) passed through the anterior edge around the femur allows the fascial tongue low the muscle fi bers to be tensioned cor- of the greater trochanter and through the to be passed under, folded back, and su- rectly. Defi ciency of the posterior capsule anterior hip capsule (Figure 2). tured to itself for attachment to bone. The and short external rotators is addressed Next, a sharp osteotome is used to re- vastus lateralis covers this attachment and with an additional posterior gluteus maxi- move the lateral cortex of the greater tro- is sutured down proximally. mus fl ap. Approximately 15 mm of the chanter over an area of approximately 2ϫ3 Additional abductor muscle mass can distal attachment of the posterior portion cm to allow attachment of the anterior mus- be recruited by using the tensor fascia of the gluteus maximus muscle into the cle fl ap directly to the femur. Multiple holes lata. After the gluteus maximus fl ap is at- SEPTEMBER 2011 | Volume 34 • Number 9 e471 ■ Hip Arthroplasty: Avoiding Pitfalls & Managing Problems tached, the fascia lata is cut transversely at the posterior fl ap underneath. This com- CONCLUSION the distal attachment of the tensor fascia pleted muscle and fascial closure applies Complete loss of abduction is a com- lata, then the anterior edge of the tensor the upper half of the gluteus maximus to mon and challenging problem after THA is dissected from its fascial attachments the greater trochanter to maximize its ef- and can cause severe limp, dislocation, and elevated with sharp and blunt dissec- fectiveness for abducting the femur. and pain. A fl ap transfer using the anterior tion. The posterior edge of the tensor is re- portion of the gluteus maximus muscle re- leased sharply from it fascial attachments CLINICAL REVIEW stores abductor function in a majority of one-half to two-thirds the length of the Eleven patients (11 hips) had gluteus cases. This procedure can be done during muscle, and the distal end of the muscle maximus fl ap transfer for abductor defi cit the primary THA or later as a secondary is attached to the gluteus maximus fl ap at- after THA. Postoperative care included procedure. tachment with heavy absorbable sutures early partial weight bearing of 50 lbs with (#3 Vicryl). This tensor fascia lata trans- 2-handed support, use of an abduction pil- REFERENCES fer is done before the vastus lateralis is low for 3 days while in bed, and avoidance 1. Alberton GM, High WA, Morrey BF. Dis- closed, and its distal attachment includes of abduction exercises for 6 weeks postop- location after revision total hip arthro- plasty: an analysis of risk factors and treat- suturing under the vastus lateralis fl aps. eratively. Patients then began gradual ab- ment options. J Bone Joint Surg Am. 2002; Closure is done with the hip in 15Њ ab- duction strengthening exercise and gradu- 84(10):1788-1792. duction. The posterior edge of the anterior ally increased weight bearing for another 2. Coventry MB. Late dislocations in patients fl ap is sutured snugly to the top of the pos- 6 weeks. All patients were encouraged to with Charnley total hip arthroplasty.
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