Late Repair of Abductor Avulsion After the Transgluteal Approach for Hip Arthroplasty

The abductor release sometimes does not heal after a transgluteal approach for hip arthroplasty. Factors influencing the success of subsequent repair are unclear. We used magnetic resonance imaging (MRI) to compare the condition of the gluteus medius with clinical outcome after late repair of abductor dehiscence in 12 total hip patients. Evaluation included a pain rating, gait evaluation, Trendelenburg test, strength grading, and Harris Hip Score. Most had both prerepair and postrepair MRI studies to assess the repair and to grade abductor muscle fatty degeneration. Two repairs without MRI were explored surgically. Although average pain, limp, and strength scores improved significantly, rerupture occurred in 4 subjects and fatty degeneration in the gluteus medius did not improve, even with intact repair. Nine patients were satisfied; 7 of these had an intact repair. Magnetic resonance imaging and operative observations suggest that chronic degeneration in the abductor mechanism is the major impediment to successful repair.     

Abductor tendon tears of the hip: evaluation and management

The gluteus medius and minimus muscle-tendon complex is crucial for gait and stability in the hip joint. There are three clinical presentations of abductor tendon tears. Degenerative or traumatic tears of the hip abductor tendons, so-called rotator cuff tears of the hip, are seen in older patients with intractable lateral hip pain and weakness but without arthritis of the hip joint. The second type of tear may be relatively asymptomatic. It is often seen in patients undergoing arthroplasty for femoral neck fracture or elective total hip arthroplasty (THA) for osteoarthritis. The third type of abductor tendon dysfunction occurs with avulsion or failure of repair following THA performed through the anterolateral approach. Abductor tendon tear should be confirmed on MRI. When nonsurgical management is unsuccessful, open repair of the tendons with transosseous sutures is recommended. Good pain relief has been reported following endoscopic repair. Abductor tendon repair has had inconsistent results in persons with avulsion following THA. Reconstruction with a gluteus maximus muscle flap or Achilles tendon allograft has provided promising short-term results in small series.     

Arthroscopic Anatomy and Surgical Techniques for Peritrochanteric Space Disorders in the Hip

Disorders of the lateral or peritrochanteric space (often grouped into the greater trochanteric pain syndrome), such as recalcitrant trochanteric bursitis, external snapping iliotibial band, and gluteus medius and minimus tears, are now being treated endoscopically. We outline the endoscopic anatomy of the peritrochanteric space of the hip and describe surgical techniques for the treatment of these entities. Proper portal placement is key in understanding the peritrochanteric space and should be first oriented at the gluteus maximus insertion into the linea aspera, as well as the vastus lateralis. When tears of the gluteus medius and minimus are encountered, suture anchors can be placed into the footprint of the abductor tendons in a standard arthroscopic fashion. Our initial experience indicates that recalcitrant trochanteric bursitis, external coxa saltans, and focal, isolated tears of the gluteus medius and minimus tendon may be successfully treated with arthroscopic bursectomy, iliotibial band release, and decompression of the peritrochanteric space and suture anchor tendon repair to the greater trochanter, respectively.     

Muscle atrophy and metal-on-metal hip implants

Background and purpose — Muscle atrophy is seen in patients with metal-on-metal (MOM) hip implants, probably because of inflammatory destruction of the musculo-tendon junction. However, like pseudotumors, it is unclear when atrophy occurs and whether it progresses with time. Our objective was to determine whether muscle atrophy associated with MOM hip implants progresses with time.

Patients and methods — We retrospectively reviewed 74 hips in 56 patients (32 of them women) using serial MRI. Median age was 59 (23–83) years. The median time post-implantation was 83 (35–142) months, and the median interval between scans was 11 months. Hip muscles were scored using the Pfirrmann system. The mean scores for muscle atrophy were compared between the first and second MRI scans. Blood cobalt and chromium concentrations were determined.

Results — The median blood cobalt was 6.84 (0.24–90) ppb and median chromium level was 4.42 (0.20–45) ppb. The median Oxford hip score was 34 (5–48). The change in the gluteus minimus mean atrophy score between first and second MRI was 0.12 (p = 0.002). Mean change in the gluteus medius posterior portion (unaffected by surgical approach) was 0.08 (p = 0.01) and mean change in the inferior portion was 0.10 (p = 0.05). Mean pseudotumor grade increased by 0.18 (p = 0.02).

Interpretation — Worsening muscle atrophy and worsening pseudotumor grade occur over a 1-year period in a substantial proportion of patients with MOM hip implants. Serial MRI helps to identify those patients who are at risk of developing worsening soft-tissue pathology. These patients should be considered for revision surgery before irreversible muscle destruction occurs.     

Functional evaluation of hip abductor muscles with use of magnetic resonance imaging

The hip abductor muscles are considered important for gait and biomechanics of the hip joint; however, their specific function has not been defined precisely. The intensity of magnetic resonance imaging signals in skeletal muscle has been reported to increase immediately after exercise. Making use of this phenomenon, we evaluated the hip abductor muscles. Magnetic resonance imaging was performed after isometric exercise of the hip abductor in three positions (20° of abduction, neutral, and 20° of adduction). The abduction force of the hip was measured with a dynamometer, and electromyographic measurements were made simultaneously for the same hip positions. Additionally, magnetic resonance imaging was performed after one-legged stance. As the hip was more adducted, the signal intensity increased on the scans. The values for muscle force, as evaluated with the dynamometer and integratedoelectromyography, also supported the results. The increase in signal intensity of the gluteus minimus at 20° of abduction and after one-legged stance was significantly greater than that of the gluteus medius (p <0.0001 and p <0.0001, respectively). The results of this study indicate that the gluteus minimus muscle, along with the gluteus medius, plays an important role in hip abduction, gait, and stabilization of the pelvis.     

Asymptomatic Gluteal Tendinopathies Negatively Impact Outcomes of Total Hip Arthroplasty: A Propensity Score-Matched Study

BackgroundThe purpose of this study is to compare outcomes after total hip arthroplasty (THA) in patients with preoperative asymptomatic gluteus medius and minimus (GMM) pathology to a control group with no GMM pathology.MethodsPatients undergoing THA for osteoarthritis between August 2012 and March 2018 were retrospectively reviewed. Asymptomatic GMM pathology was considered as the presence of gluteal tendinopathy diagnosed by magnetic resonance imaging (MRI) without the following clinical symptoms: Trendelenburg gait or test, abductor weakness, and lateral thigh tenderness. Patients with asymptomatic GMM pathology were matched (1:1) to patients without GMM pathology on MRI. Two-year data were collected on patient-reported outcomes including Harris Hip Score, Forgotten Joint Score, pain, and satisfaction. Postoperative clinical examination, radiographic measures, complications, and revisions for both groups were reviewed.ResultsFifty cases of asymptomatic GMM pathology were successfully matched to 50 hips without GMM pathology on MRI. Patients with asymptomatic GMM pathology demonstrated significantly worse outcomes regarding 2-year Harris Hip Score (86.24 vs 92.39, P = .04), VAS for pain (1.82 vs 0.98, P = .05), and patient satisfaction (7.69 vs 9.16, P = .002). The study group exhibited significantly higher rates of lateral hip pain postoperatively. Two cases (4%) in the control group underwent a revision THA and 4 cases (8%) in the study group underwent revision THA.ConclusionIn patients undergoing THA for osteoarthritis, those with asymptomatic GMM pathology experience inferior 2-year postoperative patient-reported outcomes compared to a matched group. This finding should raise awareness surrounding this important pathology’s negative impact on surgical outcomes, thus warranting increased vigilance, and possibly justifying concomitant treatment, even in cases of asymptomatic GMM tears.Level of EvidenceLevel III - Retrospective comparative prognostic study.     

Assessment of hip abductors by MRI after total hip arthroplasty and effect of fatty atrophy on functional outcome

Objectives

The aim of this study was to evaluate how fatty atrophy (FA) of the hip abductors in operated and non-operated hips affected the functional outcome following arthroplasty.

An anterolateral approach to the hip joint

I describe an anterolateral approach to the hip joint. The intermuscular plane is between the gluteus me-dius and tensor fascia lata. The anterior one third of gluteus medius and the insertion of gluteus minimus are stripped from the anterior aspect of the greater trochanter to raise a flap in a way that facilitates reattachment. The vastus lateralis muscle is left undisturbed. This simple and relatively quick approach provides sufficient anatomic orientation and exposure to allow the surgeon to perform total hip arthroplasty, with minimal dissection and without excessive retraction. There is no danger of injury to the superior gluteal nerve or its branches. This has been used in 178 patients for primary total hip replacement. The strength of the hip abductor muscles was unimpaired and there were no complications attributable to the approach in 128 patients reviewed after at least 6 months.     

Soft-tissue changes in hip abductor muscles and tendons after total hip replacement: comparison between the direct anterior and the transgluteal approaches

The direct anterior approach in total hip replacement anatomically offers the chance to minimise soft-tissue trauma because an intermuscular and internervous plane is explored. This motivated us to abandon our previously used transgluteal approach and to adopt the direct anterior approach for total hip replacement. Using MRI, we performed a retrospective comparative study of the direct anterior approach with the transgluteal approach. There were 25 patients in each group. At one year post-operatively all the patients underwent MRI of their replaced hips. A radiologist graded the changes in the soft-tissue signals in the abductor muscles. The groups were similar in terms of age, gender, body mass index, complexity of the reconstruction and absence of symptoms. Detachment of the abductor insertion, partial tears and tendonitis of gluteus medius and minimus, the presence of peri-trochanteric bursal fluid and fatty atrophy of gluteus medius and minimus were significantly less pronounced and less frequent when the direct anterior approach was used. There was no significant difference in the findings regarding tensor fascia lata between the two approaches. We conclude that use of the direct anterior approach results in a better soft-tissue response as assessed by MRI after total hip replacement. However, the impact on outcome needs to be evaluated further.     

Iliotibial band Z-lengthening for refractory trochanteric bursitis (greater trochanteric pain syndrome)

BACKGROUND: Trochanteric bursitis or greater trochanter pain syndrome (GTPS) is a frequent cause of lateral hip pain. This article reports our experience with a new method of Z-lengthening of the iliotibial band for refractory GTPS. METHODS: Fifteen patients (17 hips) were diagnosed with GTPS unresponsive to conservative treatment including steroid injection. Fourteen patients were women. The average age was 60 years and average duration of symptoms was 4.7 years. RESULTS: At the mean follow up of 47 months following Z-lengthening, eight patients reported excellent results with complete resolution of symptoms, eight had good results with symptoms improved and one had a poor result. One patient required secondary repair of a tear in the tendon of gluteus minimus, with a subsequent excellent result. The mean Harris Hip Score improved from 46 to 82. CONCLUSION: We recommend this technique in patients with refractory GTPS. Associated tears of gluteus medius or minimus should be identified and repaired at the time of surgery.     

Magnitude of impact and healthcare use for musculoskeletal disorders in the paediaric: a population-based study

Background

The gluteus medius muscle is essential for gait and hip stability. Changes that occur in the gluteus medius muscles in patients with developmental dysplasia of the hip (DDH) are not well understood. A better understanding of DDH related changes will have positive repercussions toward hip soft tissue reconstruction.

Methods

19 adult patients with unilateral DDH scheduled for total hip arthroplasty were assessed for: cross-sectional area (CSA), radiological density (RD) and the length of gluteus medius using computed tomograhpy(CT) (scanned before THA). Hip abductor moment arm and gluteus medius activation angle were also measured via hip anteroposterior radiographs.

Results

Both CSA and RD of gluteus medius muscle were significantly reduced (p?<?0.05) in the affected hip compared to the control. In the affected hip, the length of the gluteus medius muscle was reduced by 8-11?% (p?<?0.05) while the gluteus medius activation angle was significantly increased (p?<?0.05) and the hip abductor moment arm was decreased (p?<?0.05).

Conclusions

The gluteus medius showed substantial loss of CSA, RD as well as decreased length in patients with DDH in the affected hip. These changes should be considered in both hip reconstruction and postoperative rehabilitation training in patients with DDH.     

Partial anterior trochanteric osteotomy in total hip arthroplasty: surgical technique and preliminary results of 127 cases

The authors describe a new approach to the hip joint arthroplasty performed in 127 cases of total hip arthroplasty without major complication. A small anterior fragment of greater trochanter, maintaining the insertions of the gluteus minimus and vastus lateralis muscles, is detached. The whole insertion of the gluteus medius is preserved intact, providing good prosthetic stability and rapid recovery of abductor power and gait. Three months after surgery, 74% of patients had recovered good abductor strength with a Merle d'Aubigné and Postel score of 17 points. This surgical approach is technically easy to perform and provides good exposure of the hip. The osteotomized fragment is easily reattached using 2 cerclage wires, and upward displacement after operation was rarely seen.     

Surgical repair of hip abductors. A new technique using Graft Jacket? allograft acellular human dermal matrix

Purpose

Avulsion of the abductors from the hip can be an infrequent but debilitating complication after total hip arthroplasty performed through a trans-gluteal approach. This can result in intractable pain, limp, Trendelenberg lurch and instability of the hip. There have been various methods described for repairing or reconstruction of this abductor muscle complex including direct trans-osseous repair, muscle transfers, muscle and tendon sling, bone tendon allograft reconstruction and endoscopic repair techniques.

Methods

In a prospective study at our institution we evaluated the results of a surgical technique in 12 patients using a trans-osseous repair of gluteus medius and minimus insertions augmented by a Graft Jacket? allograft acellular human dermal matrix (Graft Jacket?; Wright Medical Technology, Arlington, TN) over the anterior and anterolateral aspects of the greater trochanter. Diagnosis of hip abductor avulsions was made by evaluation of the history of presenting complaint, clinical examination and confirmed by ultrasound or MRI scans.

Results

Evaluation of results included pain scoring, gait evaluation, Trendelenberg test, and the Harris hip score. There was a significant improvement in pain (VAS mean values 8.25 to 2.33; p value?<?0.0001), limp and gait along with abductor strength. The Trendelenberg test became negative in all but one. At the mean follow up of 22?months Harris hip scores improved from 34.05 to 81.26 (p value <0.0001).

Conclusion

Overall this procedure appears to be safe and associated with high patient satisfaction, without the morbidity of any tendon or muscle transfers.     

Surgical Technique: Transfer of the Anterior Portion of the Gluteus Maximus Muscle for Abductor Deficiency of the Hip

Background  

Loss of the abductor portions of the gluteus medius and gluteus minimus muscles due to THA causes severe limp and often instability.     

Reattachment of the migrated ununited greater trochanter after revision hip arthroplasty: the abductor slide technique. A review of four cases

BACKGROUND: Proximal migration of the ununited greater trochanter following total hip arthroplasty may produce pain and substantial functional disability. Successful reattachment of the migrated fragment is difficult following multiple hip procedures. The purpose of this report is to describe four patients in whom a severely migrated trochanteric fragment was reattached successfully with a modified Charnley-Harris wiring technique after subperiosteal advancement of the abductor muscles from their origin on the iliac wing. METHODS: This series consisted of one man and three women with an average age of sixty years (range, fifty-one to sixty-eight years) at the time of the index procedure. The patients were followed for an average of eighty-one months (range, fifty-five to ninety-six months). All patients had undergone mobilization of the abductor muscles based on the superior gluteal neurovascular pedicle to aid with trochanteric reattachment, and all had undergone prior hip operations (average, two). Advancement of the abductor muscles was achieved through a separate transverse curvilinear incision over the iliac crest, and subperiosteal releases of the entire origins of the gluteus minimus, medius, and maximus muscles from the ilium were performed. RESULTS: Roentgenographic union of the trochanteric fragment occurred in all four patients. There were three excellent functional outcomes (Harris hip scores of 90, 94, and 96 points) and one fair functional outcome (76 points). The average improvement in the Harris hip score was 47.5 points (range, 35 to 58 points). Two patients continued to have a mild or moderate Trendelenburg gait postoperatively. Two patients had heterotopic bone formation of no clinical importance. CONCLUSIONS: Use of this technique resulted in union of the greater trochanter, pain relief, and decreased functional disability without major complications in these four patients. More widespread use of this technique may be indicated for the treatment of symptomatic non-union of the greater trochanter when the fragment cannot be reattached to its anatomical location with the hip in less than approximately 20 degrees of abduction.     

Hip abduction force measured by a new method and its relation to EMG activity

I measured hip abduction force using a new device of my own design and evaluated the correlation between hip abduction force and electromyographic (EMG) activity of the gluteus medius, gluteus maximus, rectus femoris and adductor longus in 20 normal adults. Hip abduction force showed a maximum value on starting and decreased during abduction of the hip joint. Durability, on the other hand, showed an increase. The attenuation curve was approximated to the exponential function A.e-Kt; A and l/k indicating maximum hip abduction force and durability, respectively. Maximum hip abduction force was about 20 kg and durability was about 160 seconds on starting hip abduction. The regression coefficient between hip abduction force and EMG activity of the gluteus medius, gluteus maximus, rectus femoris and adductor longus was 1.5, 06, 0.6 and 0.2 respectively. From these results, I concluded that although the gluteus medius plays the major role in hip abduction, the rectus femoris and gluteus maximus may act as stabilizers for maintaining the position of hip abduction.     

Treating abductor deficiency: a transference technique

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 one-sixth 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.     

Evaluation of muscle activity just after straight leg raising exercise by using 18FDG-PET

Background

Exercise therapy is one of the recognized treatment methods for knee osteoarthritis (KOA). One such exercise technique, straight leg raising (SLR), is widely known as a home exercise method for strengthening the quadriceps femoris muscle. However, whether this exercise truly strengthens the quadriceps is not known. The objective of the present study was to investigate which lower limb muscle is stimulated and shows increased activity with SLR.

The relationship between gluteus medius and minimus muscle volumes and hip development in developmental dysplasia of the hip

BackgroundSeveral studies in adult hips have revealed the role of the gluteus medius (Gmed) and gluteus minimus (Gmin) muscles in maintaining the stability and centripetal force of the hip joint. Hip centripetality in developmental dysplasia of the hip (DDH) patients contributes to subsequent healthy hip development later in life. The purpose of this study is to investigate the relationship between Gmed and Gmin volume and centripetality of the hip in infant DDH patients.MethodsWe retrospectively enrolled 41 unilateral DDH patients (4 males, 37 females) who were treated by closed reduction from 2006 to 2016 and underwent magnetic resonance imaging at around 2 years old.Gmed, and Gmin volume was measured in magnetic resonance imaging. We defined both Gmin and Gmed together as hip abductor gluteus muscles (GMs; Gmed + Gmin). The muscle volume ratio of the affected side was calculated by dividing the GMs volume of the affected side by the contralateral side. Relationships between center-head distance discrepancy (CHDD) at 2 years old, and at 4–6 years old and GMs volume ratio were investigated by Pearson's correlation coefficient within the same patients.ResultsMean age of closed reduction was 0.8 years old and mean age at MRI was 2.2 years old with a mean follow-up period of 3.7 years. Mean GMs volume in the affected side, contralateral side, and muscle volume ratio were 25.3 cm³, 27.0 cm³, and 0.94, respectively. GMs volumes were significantly higher in the contralateral side (p < 0.001). GMs volume ratio at 2 years old significantly correlated with CHDD at 4–6 years old (p < 0.05).ConclusionGMs volume at 2 years old was found to be associated with later hip afferents. Promoting the healthy development of GMs by properly maintaining the infant's natural hip movement is important for the healthy hip development.Level of EvidenceLevel III.