Download Treating Abductor Deficiency: A Transference Technique

■ Hip Arthroplasty: Avoiding Pitfalls & Managing Problems
Treating Abductor Deficiency: 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 flap transfer was developed to repair deficient 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 flap, separating it from the fascia 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 onesixth of the muscle body and half the length) was passed beneath the primary flap to
substitute for the gluteus minimus and capsule. The tensioning of the flap was done
with the hip in 15⬚ to 20⬚ abduction to ensure adequate tension in the transferred
muscle. The lower half of the gluteus maximus muscle and fascia lata were also closed
over the greater trochanter and transferred muscle flap with the hip abducted and then
closed proximally, leaving the anterior edge of the gluteus maximus flap 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.
Figure: The upper third of the gluteus maximus
muscle is elevated as the anterior flap.
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 protected]).
doi: 10.3928/01477447-20110714-34
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■ Hip Arthroplasty: Avoiding Pitfalls & Managing Problems
L
oss 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).1-4 The gluteus
maximus muscle, if healthy and robust,
can be used to fashion a flap transfer that
can substitute for the deficient abductor
muscles.4,5 This article describes a reconstructive surgical technique for gluteus
maximus flap transfer in THA.
SURGICAL TECHNIQUE
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
SEPTEMBER 2011 | Volume 34 • Number 9
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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.
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 2).
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 at-
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■ Hip Arthroplasty: Avoiding Pitfalls & Managing Problems
tached, 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
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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 the femur.
CLINICAL REVIEW
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.
CONCLUSION
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.
REFERENCES
1. 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.
2. Coventry MB. Late dislocations in patients
with Charnley total hip arthroplasty. J Bone
Joint Surg Am. 1985; 67(6):832-841.
3. 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.
4. 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.
5. Gray H. Gray’s Anatomy. 1901 ed. Philadelphia, PA: Running Press; 1974.
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