Download TRANSPOSITION OF GLUTEUS MAXIMUS, TENSOR FASCIAE

TRANSPOSITION
OF
ILIO-TIBIAL
BAND
GLUTEUS
FOR
IN
MAXIMUS,
PARALYSIS
The
assessment
was
active
unit
and
the
was
gluteus
other
was
and
Report
AXER,
Aviv,
Department,
twenty-four
patients
In order
three-quarters
twofold
deep fibres
of
the
,4ssaf
Harofe
“
its
muscle-that
The pelvic
as
is, all
gap
tensor,
piece
between
tract
of Henry-Between
“
of the fascia
a special
“
the
deltoid
part
and
lata
of tract-the
the maximus
maximus)
tract)
proximal
and tensor
as figuring
“
and
for
the gluteus
half-gain
the
musculo-tendinous
maximus
insertion
its superficial
fibres
fasciae
latae
and
ilio-tibial
muscles
after
when the muscle
: only
into
and
one-fourth
the femur;
the
tract
(Gray’s
Anatomy
is a tensor
of the fascia
expanse
muscles.
which
“
latae
abdominal
obtained
motor
is situated
a pelvic
It is the
pelvic
deltoid
of Henry
1954, as the motor
for the musculo-tendinous
fasciae
the lateral
results
were
the tensor
(ilio-tibial
MUSCLES
Sarafand
tensor
insertion
of
of its caudal
cranial
the pelvic
Hospital,
powerful
half-are
inserted
into the ilio-tibial
Henry
1945).
The gluteus
maximus
in other
words
to being
an extensor
and lateral
rotator
of the hip.
of
ABDOMINAL
AND
ISRAEL
in whom
a more
of the
taken
maximus-the
TEL
for strengthening
revealed
that better
to obtain
LATAE
POLIOMYELITIS
A Preliminary
Orthopaedic
FASCIAE
LATERAL
AFTER
performed
Axer 1956)
strong.
advantage
the
of
the
of
band
transposition
poliomyelitis
(Clark
OF
CHILDREN
ANATOL
From
TENSOR
deep
1946,
lata
and the gluteus
was
described
fibres
Last
1954,
in addition
maximus
by Henry
(1945)
which
hides gluteus
medius,
and occupies
Indeed
we may regard
these three
(the
deltoid
has
unit,
. .
(Fig.
.“
2).
in this
been
used
with
gratifying
operation,
results.
since
August
OPERATION
The
fasciae
the
The
operation
latae
for
addition
patient
is carried
paralysis
of the
is placed
out
of the
proximal
part
on the operation
upon
uppermost.
The
appropriate
manipulation
greatest
of the
the
its
iliac
crest,
facilitate
thigh
to
wide
strip
curves
the
exposure
end
at the
of
the
in much
lateral
in
of
level
ilio-tibial
of the
table
possible
table.
proximal
the
band
same
knee
correction
The skin
as the
transposition
(Clark
and
maximus,
1).
in the
and
The
of the
Axer
1956),
tensor
except
for
the musculo-tendinous
unit.
with the side to be operated
of lumbar
scoliosis
is secured
by
incision
starts
below
the anterior
part
behind
the greater
trochanter
in order
slightly
(Fig.
begins
way
muscles
gluteus
maximus
to
in the lateral
posture,
part
gluteus
of the
the
abdominal
continues
dissection
region
of the
along
the
of the
three
lateral
outer
to
aspect
five
femoral
of
an
of
to
the
centimetres
condyle
and
is
continued
towards
the greater
trochanter.
When
the gluteus
maximus
is reached
its cranial
half (or third)
is separated
from the rest of the muscle
and mobilised,
but left attached
to the
ilio-tibial
band.
This division
of the gluteus
maximus
is carried
out through
its whole thickness
far enough
posteriorly
to allow for the unobstructed
redirection
of the cranial
part of the muscle
obliquely
and upwards
towards
the ribs together
with the ilio-tibial
band (Figs. 2 and 3). Care
is taken
not to injure
the nerve to the muscle:
the gluteus
maximus
is supplied
by the inferior
gluteal
nerve, which enters the deep surface
of the muscle
nearer
to its origin
than to its insertion
(Last
In
muscle
644
1954).
none
so far
of the
posteriorly
eight
cases
reported
as to endanger
here
its
nerve
was
it necessary
to
the
carry
division
of the
supply.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
PARALYSIS
dissection
unit
of
ready
the
Figure
Freeing
of
consisting
chosen
rib.
distance
for
(the
cranial
tensor
by a few
catgut
sutures
free
of
ilio-tibial
being
of
is measured
fasciae
the
through
the
incision
with
latae.
These
If
that
stabilisation
of
because
the
(tensor
fasciae
are
dissected
the
thoraco-pelvic
transplant
latae)
of the
Axer
part
of the
and
the
with the
extension
rib.
greatest
exercises
contractions
synchronised
and
with
the
relationship
tension
both
and
the
3).
rib
The
after
proximal
end
is followed
and
are
the
and the
of the
by
of the scoliosis.
added
to abduction
pelvis
all
and
tensor
on
active
practically
(gluteus
the
to
approximated
wounds
of the
latae
in
extension
latae
are
maximus
elevation
fasciae
is achieved
during
the
correction
hip are
same
transposition
joining
of
gluteus
active
tensor
the
is created
(Fig.
to the chosen
tunnel,
the
fasciae
for
maximus
Closure
of
in
with
is done
at that stage
with each contraction
gluteus
possible
of the
are approximated
A musculo-tendinous
tensor
ready
the outline
musculo-tendinous
is completed
bulky
motor
unit
moderate
tension
subcutaneous
over
latae
1956).
the
is raised
one
under
prepared
maximus
is under
latae
and
maximus,
Henry)
situated
later
gluteus
fasciae
(Clark
11).
proximal
to elicit
the
tensor
645
POLIOMYELITIS
Fio. 3
of Henry with
“
3-The
both
muscles
separately
of the ilio-tibial
band
moves
spica,
in order
movements
both
deltoid
of
previously
of a double
hip
Post-operative
treatment-Active
side.
Figure
gluteus
of
and
application
movements
the
and in that manner
band
is attached
thigh
flexion
of
of the
(Table
the
latae
pulled
the
AFTER
pelvic
“
transposition.
and
deltoid”
stimulation
the free end
which
for
transplantation
part
“pelvic
particular
The
end
band
latae
Electrical
muscle
IN CHILDREN
FiG. 2
Figure 2-The
incisions.
unit
ilio-tibial
fasciae
of the
band
1-Skin
MU5CLE5
to the rib. The gluteus
maximus
and tensor
fasciae
catgut sutures
to form one motor
unit.
the
as in tensor
ilio-tibial
ABDOMINAL
musculo-tendinous
for transposition
manner
unit
LATERAL
FIG. 1
of operation.
Technique
of
OF
a
fasciae
the
phases
maximus)
same
continuous
of
and
gait,
fiexion
hip.
DISCUSSION
I the indications
for and
children
had poliomyelitis
during
their
onset
being one year and two months.
In
VOL.
Table
40 B,
NO.
4,
NOVEMBER
1958
results
first
of
or
the
second
operation
year
are
of
life,
presented.
the
average
All
the
age
eight
at
the
646
A. AXER
-J
0
z
0
z
<0
0
Z
0
I..
U
0
z
THE JOURNAL
OF
BONE
AND
JOINT SURGERY
PARALYSIS
OF
LATERAL
ABDOMINAL
MUSCLES
IN
CHILDREN
AFTER
POLIOMYELITIS
‘‘
FIG.
Boy
aged
Photographs
paralytic
six
with
paralysis
5-Same
40 B, NO. 4,
VOL.
C
NOVEMBER
lateral
4
abdominal
muscles
on
the
left
side.
show
the boy before
operation.
Note
the uncompensated
scoliosis,
with marked
shift of the upper trunk to the right.
FIG.
Figure
of the
child
after
1958
5
operation.
Improved
posture.
operation,
sitting.
Figure
Fio. 6
6-Same
child
after
647
648
A.
AXER
TABLE
RESULTS
C
Pre-operative
ase
num
r
OF MUSCLES
grading*
Tensor
maximus
fasciae
extension)
BEFORE
Excursion
Gluteus
(hip
*
TO GRADING
RELATED
II
OPERATION
AND
on electrical
at operation
ELECTRICAL
stimulation
Gluteus
maximus
Tensor
fasciae
1
2
1
3
0
2
4-
4+
2
1
3
4
4
2
4
3
1+
5
3-
6
AT
OPERATION
Post-operative
grading
of
gluteus
maximus
(centimetres)t
latae
RESPONSES
latae
(hip
Result
extension)
3-
Active
4-
Active
3
3+
Active
1
0
3
4-
2’S
0
3
Active
3+
3+
3’S
2
3+
Active
7
2
1
1
0
2-
Active
8
3+
3+
2
0
3+
Active
According
-
-
to international
grading:
from
t The distance
(in centimetres)
through
(faradic)
stimulation
ofthe motor(muscle)
The
oldest
two
years
and
The
five
shortest
interval
years,
the average
In
became
all eight
in
A follow-up
the
drawn
years
at the
and
operation
two
present
at the
six months
was
three
operation
time
was
of the
of age,
the
years
and
one
year,
operation
and in five it remained
unchanged
years
and two months
to three
years
all
to
boy
on
boy
before
the
right
the
due
is shown
the left
in a very
side and
is shown
sitting.
transplantation
to
decompensated
similar
resulted
was eliminated
in six cases
extremities
was corrected
improved
in
beneficial,
as indicated
the
Case 2-A
boy, who
difficulty,
circumducting
the
is shown
trunk
Pelvic obliquity
length
of the lower
of
was
lateral
children,
in the
for
and
following
in
two
(weak)
(weak)
on direct electrical
unit was completed.
youngest
ten months.
the
: in one
after
is too
case
reports.
CASE
REPORTS
maximus.
paralytic
scoliosis
stance
fifteen
in a definite
and improved
in all patients.
instances
of gluteus
the
months
after
improvement
longest
child
operation
deformity
1956 (not
A marked
is obvious
the
in
operation
posture.
in two.
The discrepancy
in the
Thoraco-pelvic
stability
was.
improvement
was
exceptionally
three
years after the onset of poliomyelitis
could walk only with great
the right lower limb widely and falling frequently
because
of a pronounced
abdominal
muscles
and
quadratus
lumborum
on the
right
side,
was
at the age of four (three years after the onset of paralysis),
and he is now able to run.
Case 6-The
boy in this case could not walk or stand for five years after the onset of paralysis,
operated
upon
because
his right
lateral
abdominal
muscles
and
quadratus
lumborum
were
so weak
that
mainly
a considerable
pelvic tilt deVeloped,
causing
a discrepancy
of three centimetres
in the length of the lower extremities.
and a scoliosis.
With the gluteus
maximus
and tensor fasciae latae transplantation
performed
at the
age of seven years and six months
the deformities
were corrected
and enough
thoraco-pelvic
stability
was restored
to allow the boy to walk with the help of apparatus.
THE
it
the operation.
short
to allow
on
report)
upper
In Figure
5 the same
which
was
performed
In Figure
6 the same
weakness
scoliosis
from
seven
age
the onset of paralysis
and
two years and seven months.
it improved,
two
was
average
moved
ofthe
the durability
of the apparently
beneficial
effect of this
scoliosis.
Nevertheless,
it seems that in most cases the progress
of the
or retarded.
In Figure
4 a boy aged six at the operation
in December
be
in this
of
operation
Active
-
to 5 (normal).
which the free end of the ilio-tibial
band
with a bipolarelectrode,
after the dissection
The
between
being
ranging
to
on paralytic
was checked
included
at the
months.
children
worse,
conclusions
shift
child
two
0 (paralysed)
#{149}
JOURNAL
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AND
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PARALYSIS
OF
LATERAL
ABDOMINAL
MUSCLES
IN
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AFTER
649
POLIOMYELITIS
4
FIG.
7
FIG.
8
FIG. 9
Case 1-Effect of a strong motor unit. Figure 7-Before
operation.
Considerable
pelvic tilt in relaxed suspension.
Figure 8-After
operation.
Pelvic tilt corrected
in relaxed suspension.
Figure 9-On
active hip extension
pelvic
tilt is over-corrected
by action
of the musculo-tendinous
unit consisting
of gluteus
maximus
and ilio-tibial
band transferred
to the ninth rib. On electrical
stimulation
of the motor during the operation
the tensor fasciae
latae was found to be completely
paralysed,
but the gluteus
maximus
contracted
vigorously
and moved the free
end of the ilio-tibial
With
an
active,
synchronising
or with
operated
upon
bulging
under
contributing
transplant
movement
fiexion-abduction,
Figures
10 and
In
the
strong
that
on
the
the
skin
with
girl
With
a transplant
in walking
during
sitting;
that
the
is only
the pelvis
high
during
walking
stability
extension
gravity
of the
knee
is able
of the hip
the
phase
However,
this
manner.
lift
against
walking.
strength
and
of weight
transplant
the
pelvis
helps
to allow
13 and
(Fig.
transplant,
against
maximus)
gravity
(Figs.
by
7 to 9),
efficiency
to balance
of the
transplant
even
the
the left leg (Fig. 1 1),
the gait.
In Figure
12
thorax
over
the pelvis.
the
“weak,”
patient
a comfortable
“swing-through”
but the musculo-tendinous
15).
In that
insufficient
but
on
facilitating
or
for
14),
is concerned,
bearing
and
strong
the excursion
of the free end of the ilio-tibial
band
operation
(Table
II), but also to the “vigorousness”
objective
to
(by the gluteus
stability
moderately
enough
(Figs.
improve
the thoraco-pelvic
weak
“hamstrings-into-patella”
of the knee during
The ultimate
child
ofthoraco-pelvic
is shown
be able to raise
lower
extremity
the
extension
of three centimetres.
if the tensor
fasciae
latae is active.
1 1 a girl of twenty
(not included
in this report)
is shown
who was
left side in July 1957.
A strong
gluteus
maximus
transplant
can be seen
to improvement
same
band for a distance
respect
its
so far
as the
strong
enough
is not
on faradic
of
only
action
for
effective
directly
not
of the
unit
recalls
carrying
may
would
that
of
of
a full
out
a
stabilisation
proportional
stimulation
of its motor
the contraction
of the
to
during
muscle.
factor
was omitted
from the Table
because
it could
hardly
be presented
in an
On the whole,
those
transplants
were
ultimately
strong
in which
the
contractions
of both
muscles
or of the gluteus
maximus
alone
caused
the free end of the
ilio-tibial
band to move
for a distance
of not less than three centimetres.*
In all eight
to be emphasised
*
For
each
applied
t in the
and Axer
VOL.
operation
to different
40B,
previously
instances
the transplant
that in five of the eight
the
same
electrical
published
series
NO.
4,
NOVEMBER
1958
stimulator
found
“active”
the tensor
fasciae
after
latae
the
was
operation.t
It has
found
at operation
was used and the same strength
of faradic
current
was
excursion
of the free end of the ilio-tibial
band was noted.
of twenty-four
cases of transplantation
of the tensor
fasciae
latae (Clark
unit was found to be “passive”
in seven instances.
areas of the muscle.
1956) the musculo-tendinous
was
cases
The longest
A.
650
FIG.
10
Figure
10-A
strong
left
transplant
is seen bulging
AXER
1-10.
gluteus
under
maximus
the skin
In Figure
II
transplant
demonstrated
and contributing
to the
12 the same girl is shown
in a girl
improvement
sitting.
FIG.
12
of twenty.
In Figure
11 the
of thoraco-pelvic
stability.
.:1F
FIG.
Case
relaxed
5-Effect
suspension.
13
FIG.
of transposition
Figure
14-After
of a moderately
operation.
strong
Slight
14
FIG.
muscle.
pelvic
tilt
Figure
still
13-Before
present
operation.
in relaxed
suspension.
15
Pelvic
Figure
tilt in
15-
On active hip extension
pelvic tilt is corrected
but not over-corrected.
The musculo-tendinous
unit consisting
of gluteus maximus
and ilio-tibial
band can be seen in action bulging
under the skin.
On electrical
stimulation
of the motor during the operation
the tensor fasciae latae was found to be completely
paralysed,
but contractions
of the gluteus
maximus
were of moderate
strength
and moved
the free end of the ilio-tibial
band
for a distance
of 25 centimetres.
THE
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651
POLIOMYELITIS
to be completely
paralysed,
as it did not react at all to the direct
faradic
stimulation
with a
bipolar
electrode
(Table
II).
However,
in none
of these
five cases
was the tensor
fasciae
graded
0
before
the operation
; in Cases 5 and 8 it was even charted
4 and 3 respectively.
“
That
“
proves
children
that
the
be
very
may
clinical
estimation
misleading
of the
and
strength
therefore
of the
cannot
be
tensor
relied
fasciae
upon.
latae
The
in small
pre-operative
grading
of the gluteus
maximus,
on the other
hand,
was found
to correspond
with
the
observations
made
at operation.
The
advantage
of using
the gluteus
maximus
for the
transplantation
in conjunction
with the tensor
fasciae
latae,
or alone
if the latter
muscle
is
paralysed,
is obvious.
It was further
observed
that the pre-operative
grading
of hip extension
remained
practically
unchanged
in all cases
after
the operation,
although
one would
expect
a weakening
of hip
extension
after removal
of half of the gluteus
the gluteus
maximus,
already
referred
to, may
the deep fibres of the caudal
half of the muscle
maximus
from
its insertion.
The anatomy
of
contain
the explanation
for that phenomenon:
are the only ones that gain insertion
directly
into
inserted
probability
the
femur,
all the rest of the muscle
being
fibres may be regarded
with reasonable
muscle
They
on
remain
undisturbed
a larger
series
after
this
operation.
into the fascia
lata.
Those
as the primary
extensors
However,
this observation
requires
particular
of the hip.
confirmation
of cases.
SUMMARY
1.
An
operation
poliomyelitis
maximus,
to
a chosen
2.
3.
The
results
of
and
A
weak
“
motor
“
tendinous
this
operation
unit
Those
helps
eight
abdominal
muscles
in
of the proximal
band
(“
the pelvic
invariably
(gluteus
move
in
children
after
part of the gluteus
deltoid
of Henry)
“
stimulation
with
free
a bipolar
to lift the
so efficiently.
restoring
the
of
paralytic
pelvis
against
However,
scoliosis,
pelvic
“
whereas
with
weak
musculo-
stability,
a
“
just
as
a
weak
knee.
or
without
ilio-tibial
band
electrode
gravity,
even a
thoraco-pelvic
the
with
of the
end
cases
assessed.
stabilises
maximus
the
consecutive
are
transplant
and
faradic
in
motor
allows
the child
the child is unable
to do
motors
vigorously
most
lateral
of transposition
the ilio-tibial
instability
“hamstring-into-patella”
4.
the
It consists
latae
and
thoraco-pelvic
strong
“
strengthening
rib.
obliquity
“
for
is described.
the tensor
fasciae
during
the
tensor
fasciae
for at least
operation
latae)
three
that
centimetres
become
contract
on direct
ultimately
strong
and
efficient.
5.
The
and
the
unreliability
of the
advantage
of using
clinical
the
test
gluteus
of tensor
fasciae
as the
maximus
latae
motor
in small
for
the
children
is discussed,
musculo-tendinous
unit
is emphasised.
6.
Using
abdominal
the
proximal
muscles
phenomenon
not
(or
seem
be explained
may
of that
insertion
half
does
less)
to
with
of
gluteus
the
affect
maximus
appreciably
reasonable
the
probability
for
strengthening
strength
by
of
the
hip
existence
the
extension.
of
lateral
This
a twofold
muscle.
I wish to acknowledge
the financial
help given to the Orthopaedic
Department
of Assaf Harofe
Hospital
for the rehabilitation of handicapped
children by the Henrietta Rinaldo Scheider Foundation
Inc. The donation
was made available
through
the courtesy
of Dr I. S. Wechsler
and Dr Leo Mayer of New York, and the expenses
connected
with preparation
of this paper were covered
in part by that fund.
REFERENCES
J. M. P., and
Transposition
for Paralysis of the Lateral
Abdominal
in Poliomyelitis.
Journal
of Bone and Joint Surgery,
38-B, 475.
GRAY’S
Anatomy
(1946):
Twenty-ninth
edition by T. B. Johnston
and J. Whillis, p. 652. London,
New York,
Toronto:
Longmans,
Green and Co.
HENRY,
A. K. (1945): Extensile
Exposure
Applied
to Limb Surgery,
p. 86. Edinburgh:
E. & S. Livingstone
Ltd.
LAST,
R. J. (1954):
Anatomy
Regional
and Applied,
p. 160. London:
J. & A. Churchill
Ltd.
CLARK,
AXER,
A. (1956):
Muscles
VOL.
40 B,
NO.
4,
NOVEMBER
1958
A Muscle-Tendon