Repair of a deficient abductor mechanism with Achilles tendon allograft after total hip replacement

[Modified gluteus maximus transfer for hip abductor deficiency]

OBJECTIVE

Transfer of the gluteus maximus with refixation at the greater trochanter for treatment of abductor deficiency.

INDICATIONS

Symptomatic abductor deficiency with atrophy and fatty degeneration of the gluteal muscles > 50% (grade 3 by quartile) with good strength of the gluteus maximus.

CONTRAINDICATIONS

Low atrophy or fatty degeneration of less than 50% of the gluteal muscles, limited strength of the gluteus maximus, infection.

SURGICAL TECHNIQUE

First, the fascia lata is incised dorsally to the tensor fascia latae muscle, with the incision extending approximately 1.5 cm proximal to the iliac crest. A second incision divides the gluteus maximus muscle longitudinally along the muscle fibers and continues towards the fascia lata distal to the greater trochanter. These incisions result in a triangular muscle flap, which is elevated and divided into anterior and posterior portions. The posterior flap is positioned ventrally over the femoral neck and fixed to the anterior capsule and the anterior edge of the greater trochanter. The anterior flap is placed directly on the proximal femur. For this purpose, a groove is prepared in the area of the proximal femur using a spherical burr to freshen up the future footprint. The anterior flap is positioned from the tip of the greater trochanter towards the insertion of the vastus lateralis muscle. Subsequently, the anterior flap is fixed to the created groove with transosseous sutures and positioned under the elevated vastus lateralis muscle in 15° abduction of the leg. To provide additional stabilization to the tendinous part of the anterior flap, a screw is inserted distally to the greater trochanter. The vastus lateralis muscle is attached to the distal tip of the anterior flap, and the remaining gluteus maximus muscle is sutured to the fascia lata to cover the anterior flap. Additionally, a flap of the tensor fascia latae muscle can be mobilized and adapted to the reconstruction. Layered wound closure is performed.

RESULTS

The technique of a gluteus maximus transfer represents a method for the treatment of chronic abductor deficiencies and improves abduction function as well as the gait pattern in short-term follow-ups. Fifteen patients (mean age at time of surgery 62 years) had after a mean follow-up of 2.5 years. The modified Harris Hip Score (mHHS) improved from 48 points preoperatively to 60 points at follow-up. Preoperatively, 100% had a positive Trendelenburg sign; at follow-up, this was about 50%.

Gluteus Maximus Transfer for Irreparable Hip Abductor Deficiency: A Systematic Review and Meta-Analysis

BACKGROUND

Gluteus maximus tendon transfer has recently been described as a treatment option for irreparable abductor tendon tears. The purpose of this study was to systematically review outcomes following gluteus maximus tendon transfer for hip abductor deficiency.

METHODS

The published literature was queried for outcomes following gluteus maximus transfer in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcomes of interest included preoperative and postoperative functional scores, resolution of pain and gait abnormalities, postoperative rehabilitation protocols, surgical complications, reoperation rates, and postoperative magnetic resonance imaging. In total, 10 studies with a total of 125 patients (76% women) with a mean age of 67 years (range, 30 to 87) were identified for inclusion.

RESULTS

Modified Harris Hip Score (+30.1 ± 6.6 [95% confidence interval: +15.5 to +46.5]) and Visual Analog Scale for pain (-4.1 ± 1.1 [95% confidence interval: -7.1 to -1.0]) were improved following gluteus maximus transfer, compared to preoperative levels. No significant improvement was noted in abduction strength and 33% of patients demonstrated a residual Trendelenburg gait postoperatively. The overall complication rate was 5.6% (7 of 125), with a reoperation rate of 1.6% (2 of 125).

CONCLUSIONS

Gluteus maximus tendon transfer for abductor insufficiency has demonstrated reliable outcomes at 3 years, with improvement in hip function and pain. However, patients demonstrate modest improvements in abduction strength, and a significant subset will continue to demonstrate a Trendelenburg gait postoperatively.

Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) or trochanteric bursitis is described as pain on the lateral side of the hip that does not involve the hip joint and can be elicited clinically by palpation over the greater trochanter. To date, there remains no consensus on clinical guidelines for either diagnosis or management of GTPS.

METHODS

To understand the practice patterns, beliefs, and attitudes relating to the management of GTPS after total hip arthroplasty, a survey was developed and completed by Canadian arthroplasty surgeons. The final survey consisted of 23 questions divided into three sections: 1) screening questions; 2) demographic information; and 3) practice patterns, attitudes, and beliefs.

RESULTS

Most surgeons use physical examination alone for diagnosis. A detailed analysis indicates that surgeons primarily treat GTPS with oral anti-inflammatories (57.1%), structured physiotherapy (52.4%), and steroid injections (45.2%). Management options are typically nonsurgical and comprise a combination of either unstructured or targeted physiotherapy, corticosteroid injections, or platelet-rich plasma.

DISCUSSION

There remains an absence of clinical consensus for the diagnosis and management of GTPS after total hip arthroplasty. Physical examination is most often relied on, regardless of the availability of imaging aids. While common treatments of GTPS were identified, up to one-third of patients fail initial therapy.

Gluteus maximus transfer for wound closure and treatment of abductor deficiency: a single-plastic surgeon series

INTRODUCTION

Due to the increasing number of total hip arthroplasties (THA), the number and complexity of revision procedures are also on the rise. For complex cases such as periprosthetic joint infections with soft tissue compromise or for abductor muscle deficiencies, one of the treatment options is a gluteus maximus flap (GMF) that covers dead space and can help restore the failed abductor mechanism. The purpose of this study is to investigate the outcomes of a single-plastic surgeon's series of GMF procedures.

MATERIALS AND METHODS

This retrospective review reports on 57 patients (mean follow-up 39.2 months) undergoing GMF transfers for abductor insufficiency on native hip (N = 16), for abductor insufficiency in aseptic revision THA (rTHA) (N = 16), for soft tissue defects in aseptic rTHA (N = 8) and for soft tissue defects in septic rTHA (N = 17) by a single plastic surgeon over a 10-year period. Revision-free survival and complication rates were assessed and risk factors were analyzed with Cox-regression analysis.

RESULTS

The reoperation-free survival rate of GMF for abductor insufficiency in native hips was 100%. GMF procedures for soft tissue defects in septic rTHA had the lowest cumulative revision-free survival (34.3%) and highest reinfection rates (53.9%). More than three prior surgeries (HR = 2.9, p = 0.020), presence of infection (HR = 3.2, p = 0.010) and resistant organisms (HR = 3.1, p = 0.022) significantly increased the risk of revision.

CONCLUSIONS

GMF is a viable option for addressing abductor insufficiency in native hip joints. However, high revision and complication rates are reported for GMF in septic rTHA. This study highlights the need to clarify the circumstances for which the flap reconstruction will be indicated.

Short-term outcomes following open gluteus maximus transfer for the management of hip abductor tears

Tears of the gluteus medius and minimus are an important cause of recalcitrant greater trochanteric pain syndrome. Although endoscopic and open abductor repairs have demonstrated promising outcomes, the success of these techniques is dependent on the size of the tear and the quality of the tissue. In patients presenting with abductor insufficiency and evidence of previous repair failure, large retracted tears, muscle atrophy and/or fatty infiltration, reconstruction/augmentation techniques should be considered. In the present study, we present a retrospective cohort study assessing patient outcomes following open gluteus maximus transfer for irreparable or severely retracted gluteus medius tears. Patients were included in the present study if they underwent open gluteus maximus transfer to address hip abductor tears that a senior surgeon deemed irreparable or at high risk for failure following isolated repair secondary to the following tear characteristics: large tears with >2 cm of retraction, the presence of extensive fatty infiltration (Goutallier Grade 3 or greater) and/or patients requiring revision abductor repair due to primary repair failure with associated pain and a Trendelenburg gait. Patients undergoing a concomitant, or those with a previous history of hip arthroplasty, were excluded from the study. All participants were prospectively enrolled in the study, and both pre- and post-operative patient-reported outcomes were collected at 6 months and 1 year including the modified Hip Harris Score, Visual Analog Score, Hip Outcomes Score of Activities Daily Living, Hip Outcomes Score for Sports-Related Activities and Overall Satisfaction with Hip. Pre-operative scores were compared with post-operative assessments using Student's t-test with a significance level of P < 0.05. Twenty-one patients and 22 hips were included. The average age was 69 (SD ±9.2) and 17 (81%) were females. The average body mass index was 30.0 (±6.2). The outcome scores at both 6 months and 1 year demonstrated significant improvements compared with pre-operative functional assessment. This article reports the utility of gluteus medius/minimus repair augmentation or reconstruction via gluteus maximus transfer demonstrating improvement in patient-reported outcomes at short-term follow-up.

Chronic abductor lesion after total hip arthroplasty in a sitting proud stem: direct repair by osteotomy of the greater trochanter

A woman in her late 70s with bilateral total hip arthroplasty (THA) presented with left hip pain arising immediately after the last THA procedure, progressively worsening. Clinically, a severe abductor insufficiency with Trendelenburg limp was observed. Moreover, symptomatic leg length discrepancy required a contralateral heel lift of 0.5 cm. She was previously managed conservatively without any clinical benefit. Radiographs showed a well-fixed uncemented straight, sitting proud stem. MRI showed a large abductor tear. A minimally invasive proximal advancement of the greater trochanter was planned to allow direct surgical repair of the abductor lesion. The patient made a good recovery, and 12 months after surgery, wire removal was performed. The patient gained significant improvements in hip function (Harris Hip Score from 52 to 89), full limp recovery and complete pain relief at 13 months follow-up from primary surgery.

Impact of fatty degeneration on the functional outcomes of 38 patients undergoing surgical repair of gluteal tendon tears

BACKGROUND

Gluteal tendon tears (GTT) can cause pain and weakness of the hip. We analyze the impact of gluteal muscle fatty degeneration, atrophy and tear morphology on clinical outcomes of surgical repair.

METHODS

All sequential patients receiving surgical repair of GTTs via anchor sutures between 1/2015 and 11/2018 were retrospectively identified. MRIs were reviewed by a radiologist for tendon retraction, muscle atrophy and tear size. The Goutallier-Fuchs Classification (GFC) was used to quantify fatty degeneration as < 2° or ≥ 2°. Demographic and clinical variables were abstracted from the electronic records. The surveys HHS Section 1 and HOOS Jr. were obtained at last follow-up. The Pearson correlation and one-way ANOVA tests served for statistical analysis of clinical variance.

RESULTS

38 patients were identified, 29 (76.3%) were female. The average age was 67. Of the 11 (28.9%) patients with a prior hip arthroplasty 87.5% of primary THAs had a direct lateral approach. 29 (76.3%) patients were treated open and 9 (23.7%) arthroscopically. At an average follow-up of 20.9 months, patients reported a significant improvement in pain (97%), analgesic use (85.7%), limp (52.6%) and abduction strength (54.2%) (all: P ≤ 0.01). GFC ≥ 2° were associated with significantly worse outcomes in terms of limp (0.19/3 vs. 1.2/3, P = 0.05), HHS-S1 (58.19 vs. 71.68, P = 0.04) and complication rates (37.5% vs. 0%, P = 0.02). There was a strong correlation between tear retraction (P = 0.005), tear size (P = 0.009) and muscle atrophy (P = 0.001) with GFC ≥ 2° but not with clinical outcomes. GFC ≥ 2° was strongly related to lateral THA exposures (P < 0.001). Surgical approach had no impact on clinical outcomes.

CONCLUSION

While fatty degeneration can negatively impact functional outcomes, pain relief is reliably achieved. Tear morphology and muscle atrophy did not correlate with outcomes in this patient cohort. Patients should be counseled to expect a residual limp after surgery if they have GFC ≥ 2° on MRI.

Gluteus Medius Repair using a Gluteus Maximus Flap Augmented with Synthetic Polyethylene Mesh: Surgical Technique and Case Series

Introduction

Gluteus medius tendon tears may not be feasible for direct repair when significant retraction or fatty degeneration is present. Several augmentation techniques have been reported for challenging cases. We describe a novel technique using a transfer of the anterior portion of the gluteus maximus combined with synthetic mesh to reinforce the direct suture of the gluteus medius. The goal of this study was to assess the functional and pain outcomes in three patients treated with this reconstruction technique.

Case presentation

A retrospective study was performed including 3 patients with complete and retracted ruptures of the abductor mechanism. When conservative management failed, surgical treatment was attempted. After a minimum follow-up of 12 months (mean follow-up of 18 months), all of the patients showed clinical improvement.The mean Harris Hip Score improved from 31.8 to 75.6, with an average postoperative abduction strength of 3 in the Medical Research Council muscle strength grading system, and no residual limp was noticed. The mean Visual Analogue Scale pain score decreased from 8.3 preoperatively to 1.6 postoperatively. No complications were reported.

Conclusion

In conclusion, this technique demonstrates efficacy in terms of improving clinical symptoms and functional status and is a reproducible way to augment irreparable gluteus medius tears.

Diagnosis and Treatment of Musculotendinous Deficiencies of the Hip

Musculotendinous deficiencies related to iliopsoas tendinitis and abductor mechanism disruption following total hip arthroplasty (THA) are frequently under diagnosed and can be frustrating to surgeons and devastating to patients with painful THAs with normal appearing radiographs. Current peer-reviewed evidence is presented for diagnosis and treatment options for these two musculotendinous deficiencies. While these musculotendinous deficiencies are treatable, prevention during the primary THA is ideal, and special attention should be taken into consideration for optimized acetabular cup size and position, optimized hip biomechanics, and preservation and protection of the abductor tendon insertion to the greater trochanter.

Diagnosis and Treatment Options of Abductor Insufficiency After Total Hip Replacement

Abductor insufficiency can cause abnormal gait, lateral hip pain, and abduction weakness in both native and prosthetic hips. In the setting of total hip arthroplasty (THA), abductor insufficiency may occur secondary to iatrogenic injury to the superior gluteal nerve or gluteus medius muscle, adverse local tissue reactions owing to metal-associated prosthetics, and osteolysis owing to bearing wear or infection. Surgical reconstruction of the abductor complex is indicated for patients with chronic tears who have pain, weakness, limp, and/or instability. This article reviews the pearls and pitfalls of surgical reconstruction options for abductor insufficiency following THA.

Gluteus Maximus Transfer following Total Hip Arthroplasty Does Not Improve Abductor Moment: A Case-Control Gait Analysis Study of 15 Patients with Gluteus Medius Disruption

Gluteus maximus flap transfer (GMT) is a surgical technique used to improve gait kinematics and kinetics, as well as to reduce and ameliorate the functional outcome in patients with hip abductor deficiency following total hip arthroplasty (THA). The purpose of this observational study was to evaluate the gait pre- and postoperatively and examine whether GMT increases the abduction moment. Materials and Methods: A gait analysis based on reflective markers and force plates was performed in 15 patients who underwent GMT and were examined using an optical tracking system before and at a minimum of 13 months after the operation. The median follow-up time was 24 (13−60) months. The primary outcome was hip abduction moment (Nm/kg) during gait. The control group consisted of 15 female subjects without any gait pathology. Results: The mean adduction moment was significantly higher compared with controls before the operation (p = 0.02), but this did not apply to the abduction moment (p = 0.60). At the group level, the abduction moment did not improve postoperatively (p = 0.30). Only six of fifteen patients slightly improved their hip abduction moment postoperatively. However, speed (0.74 to 0.80 m/s) and cadence (94 to 105 steps/min) were improved (p < 0.03). Discussion: The results of this study showed no improvement in the hip abduction moment after GMT surgery. In our experience, abduction deficiency following primary THA is still a difficult and unsolved problem.

Gluteus maximus tendon transfer for chronic abductor insufficiency: the Geneva technique

INTRODUCTION

The treatment options of chronic abductor insufficiency in the setting of muscle degeneration, are limited and technically demanding. We present the outcomes of a salvage technique for unreconstructable, chronic abductor tears performed by a single surgeon.

METHODS

We retrospectively evaluated 38 patients who were surgically managed for chronic abductor insufficiency. Patients without hip implants and patients following primary or revision total hip arthroplasty (THA) were involved. All patients had a Trendelenburg gait, impaired muscle strength of abduction (⩽M4) and fatty degeneration of muscles (Goutallier ⩾3). They underwent transfer of a flap of the anterior third of gluteus maximus to the greater trochanter that was sutured under the slightly mobilised vastus lateralis. The level of pain, functional scores, muscle strength and Trendelenburg gait were re-evaluated at 12 postoperative months.

RESULTS

The mean age of patients was 70.2 years. 10 patients received the tendon transfer on a native hip, 6 following primary THA and 22 after revision THA. The mean pain level (3.2 vs. 7, p < 0.001) and Harris Hip Score (80.2 vs. 41.6, p < 0.001) and the median abductor strength (4 vs. 3, p < 0.001) was significantly improved compared to the preoperative scores. 26 patients demonstrated negative and 12 positive Trendelenburg sign at 12 postoperative months. No serious complications were reported.

CONCLUSIONS

This salvage technique improved the strength of abduction and functional results and reduced the level of pain in 80% of patients with chronic abductor tears. The short-term outcomes of the procedure were favourable; however, further evaluation is needed.

Superior Gluteal Reconstruction Results in Promising Outcomes for Massive Abductor Tendon Tears

Purpose

To evaluate the 1-year outcomes of a small patient series following open gluteus medius/minimus repair with human dermal allograft incorporated into the repair construct using a double-row repair.

Methods

Data from consecutive patients undergoing a superior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy by a single fellowship trained surgeon from January 2018 to May 2019 were collected and analyzed. Baseline demographic data and magnetic resonance imaging were collected preoperatively. Clinical outcomes including Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris hip score (mHHS), international Hip Outcome Score-12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were recorded at 1-year postoperatively.

Results

A total of 8 patients underwent open superior gluteal reconstruction for severe hip abductor deficiency. The mean age and body mass index were 62.6 ± 7.3 years and 29.6 ± 5.3 kg/m², respectively. The majority of patients were female (N = 7, 87.5%). Three (37.5%) patients had undergone previous endoscopic gluteus medius repair and presented for revision surgery. All patients had full-thickness tears with gluteus medius and gluteus minimus involvement. Patients were evaluated at an average of 11.5 ± 1.7 months from the initial surgical intervention and reported a mean HOS-ADL of 82.9 ± 24.3, HOS-SS of 73.2 ± 37.3, mHHS of 83.6 ± 17.1, iHOT-12 of 63.9 ± 27.4, VAS Pain of 30.0 ± 23.1, and VAS Satisfaction of 87.1 ± 17.0. There was no evidence of retears in this patient cohort as defined by physical examination findings and/or corroborating magnetic resonance imaging.

Conclusions

Superior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy is a technique that demonstrates promising 1-year postoperative outcomes in both primary and revision patients.

Level of Evidence

Level IV, therapeutic case series.

Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology

Greater trochanteric pain syndrome is a common cause of lateral hip pain, encompassing a spectrum of disorders, including trochanteric bursitis, abductor tendon pathology, and external coxa saltans. Greater trochanteric pain syndrome is primarily a clinical diagnosis, and careful clinical examination is essential for accurate diagnosis and treatment. A thorough history and physical exam may be used to help differentiate greater trochanteric pain syndrome from other common causes of hip pain, including osteoarthritis, femoroacetabular impingement, and lumbar stenosis. Although not required for diagnosis, plain radiographs and magnetic resonance imaging may be useful to exclude alternative pathologies or guide treatment of greater trochanteric pain syndrome. The majority of patients with greater trochanteric pain syndrome respond well to conservative management, including physical therapy, non-steroidal anti-inflammatory drugs, and corticosteroid injections. Operative management is typically indicated in patients with chronic symptoms refractory to conservative therapy. A wide range of surgical options, both open and endoscopic, are available and should be guided by the specific etiology of pain. The purpose of this review is to highlight pertinent clinical and radiographic features used in the diagnosis and management of greater trochanteric pain syndrome. In addition, treatment indications, techniques, and outcomes are described.

A roadmap to develop clinical guidelines for open surgery of acute and chronic tears of hip abductor tendons

PURPOSE

Abductor tendon tears are increasingly recognised as a common cause of lateral hip pain. Surgical treatment of these tears has been recommended, but the indications and types of open surgery have not been precisely elucidated yet. This manuscript aimed to critically review the literature concerning all open treatment options for this condition while identifying knowledge gaps and introducing a treatment algorithm.

METHODS

Literature search was conducted, including PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE from 2000 to May 2020. Inclusion criteria were set as: (i) clinical studies reporting outcomes following open surgical treatment of acute or chronic hip abductor tendon tears, (ii) studies reporting an open direct or augmented suturing or muscle transfer procedure, (iii) acute or chronic tears found in native or prosthetic hips.

RESULTS

A total of 34 studies published between 2004 and 2020 were included. The vast majority of studies were uncontrolled case series of a single treatment method. A total of 970 patients (76% women) with an age range between 48 and 76 years were involved. Women between 60 and 75 years old were most commonly treated. Preoperative evaluation of patients and reporting of open surgical technique and outcomes are inconsistent. All studies reported variable improvement of pain, functional outcomes and gait of patients. Overall, complication rates ranged from 0 to 31.2%.

CONCLUSION

The current literature on this topic is highly heterogeneous, and the overall level of the available evidence is low. A roadmap to develop practical guidelines for open surgery of acute and chronic tears of abductor tendons is provided. The anatomy and chronicity of the lesion, the extent of fatty infiltration and neurologic integrity of hip abductor muscles may influence both treatment choice and outcome. Further high-quality studies with standardisation of preoperative evaluation of patients and reporting of outcomes will help delineate best treatments.

LEVEL OF EVIDENCE

IV.

Transfer of the anterior gluteus maximus to address abductor deficiency following soft tissue tumour excision

Hip abductor deficiency is most commonly encountered in the context of degeneration of the hip, and techniques for reconstruction pioneered by arthroplasty surgeons. We adopted a local muscle transfer technique utilizing the anterior half of the gluteus maximus for abductor reconstruction following soft tissue tumour excision in a young female patient. The patient of concern had a solitary fibrous tumour located between the right gluteus medius and minimus detected as an incidental finding. Marginal excision of the mass resulted in removal of the gluteus medius. The anterior half of the gluteus maximus was transferred and attached to the decorticated lateral greater trochanter by means of suture anchors and transosseous sutures. The patient initially demonstrated a Trendelenburg gait and limited abduction against gravity. By 1-year post-operation, there was return of normal gait and recovery of hip abductor power. This is the first report of anterior gluteus maximus transfer being successfully applied for soft tissue reconstruction around the hip subsequent to tumour excision.

Lesions of the abductors in the hip

Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral thigh pain. Gluteal tendon pathology is more prevalent in women and frequency increases with age.

Chronic atraumatic tears result in altered lower limb biomechanics. The chief complaint is lateral thigh pain. Clinical examination should include evaluation of muscle strength, lumbar spine, hip and fascia lata pathology. The hip lag sign and 30-second single leg stance tests are useful in diagnosing abductor insufficiency.

Magnetic resonance imaging (MRI) is the gold-standard investigation to identify abductor tendon tears and evaluate the extent of muscle fatty infiltration that has predictive value on the outcome of abductor repair.

Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich protein, physical and radial shockwave therapy. The limited number of available high-quality studies on treatment outcomes and limited evidence between tendinosis and partial ruptures make it difficult to provide definite conclusions regarding the best management of gluteal tendinopathy.

Surgical management is indicated in complete and partial gluteal tendon tears that are unresponsive to conservative treatment.

There are various open and arthroscopic surgical procedures for direct repair of abductor tendon tears. There is limited evidence concerning surgical management outcomes. Prerequisites for effective tendon suturing are neurologic integrity and limited muscle fatty infiltration. Chronic irreparable tears with limited muscle atrophy and limited fatty infiltration can be augmented with grafts. Gluteus maximus or/vastus lateralis muscle transfers are salvage reconstruction procedures for the management of chronic end-stage abductor tears with significant tendon insufficiency or gluteal atrophy.

Cite this article: EFORT Open Rev 2020;5:464-476. DOI: 10.1302/2058-5241.5.190094

Hip abductor tendon tears: where are we now?

Hip abductor tendon tear is a difficult problem to manage. The hip abductor mechanism is made up of the gluteus medius and minimus muscles, both of which contribute to stabilising the pelvis through the gait cycle. Tears of these tendons are likely due to iatrogenic injury during arthroplasty and chronic degenerative tendinopathy. Ultrasound and magnetic resonance imaging have provided limited clues regarding the pattern of disease and further work is required to clarify both the macro and microscopic pattern of disease. While surgery has been attempted over the last 2 decades, the outcomes are variable and the lack of high-quality studies have limited the uptake of surgical repair. Hip abductor tendon tears share many features with rotator cuff tears, hence, innovations in surgical techniques, materials and biologics may apply to both pathologies.

Surgical repair for abductor lesion after revision total hip arthroplasty: a systematic review

BACKGROUND

Abductor mechanism lesions represent a severe complication after revision total hip arthroplasty (rTHA). The resulting abductor insufficiency can cause limping, pain, instability, and a higher rate of failure, thus requiring further revision surgery. In case of severe degeneration and retraction of the abductor mechanism, several different surgical treatments are needed.

AIM

To systematically review all studies reporting on surgical treatment of severe abductor lesion after rTHA, focusing on surgical techniques, and clinical and functional results.

METHOD

Scientific databases were accessed in December 2018 to identify studies addressing the surgical management of severe abductor disruption after rTHA. The PRISMA guidelines were followed. Data were extracted from the identified articles and summarised. Only data about patients with symptoms of abductor insufficiency after rTHA were included in the database.

RESULTS

9 retrospective studies were included, all being retrospective case series reporting on a total of 92 patients. Several surgical strategies have been described and performed: a repair using a synthetic mesh was reported in 1 study; 2 studies reported on local muscle transfer (gluteus maximus transfer or advancement); vastus lateralis advancement was described in 4 studies while in 2 studies the injury was repaired with the use of an allograft. Overall positive results have been reported in terms of pain reduction, while poor to mild functional scores with persistent limping have often been observed in the postoperative period.

CONCLUSIONS

The short follow-up time of the reviewed studies is inadequate to uncover any late dislocation, implant failure or different complications related to abductor mechanism reconstruction.

Surgical Treatment of Gluteus Medius Tears Augmented With Allograft Human Dermis

Greater trochanteric pain syndrome can be caused by gluteus medius and minimus tendinopathy/tears and chronic trochanteric bursitis. Specifically, moderate-to-severe abductor tendon tears can cause severe lateral hip pain, limp, and abnormal gait. A variety of open and endoscopic techniques to treat glut abductors hip tears have been described. The use of scaffolds, such as acellular human dermal allograft, to augment tendon repair, already has been successfully reported in rotator cuff repairs of the shoulder. Still, the use of acellular human dermal allograft in the hip has been limited. However, there are some clinical scenarios in which augmentation of abductors hip tendon repair with scaffold is indicated. Chronic or massive gluteus tears or revision cases may benefit from augmentation with a scaffold. The purpose of this technical note and accompanying video is to describe our indications, pearls, and pitfalls of repair of moderate to severe gluteus tears via a minimally invasive technique augmented with acellular human dermal allograft.

Superior Gluteal Reconstruction for Severe Hip Abductor Deficiency

Abductor tendon tears are one of the common causes of recalcitrant laterally based hip pain and dysfunction. In most cases, abductor tendon tears are associated with chronic nontraumatic tearing of the gluteus medius tendon. Restoring abductor function of the hip by primary repair of the gluteus medius tendon has been reported to have good and excellent outcomes. However, primary repair might not be as effective for chronic detachment of the gluteus medius tendon with a wide separation from the femoral footprint or severe tendon loss. The lack of tendinous foot for repair and the intrinsically degenerative condition of the tendon may create high tension at the repair site thereby predisposing to surgical failure. We believe that the use of soft-tissue allograft from the Achilles tendon or human dermal allograft may help strengthen the surgical site. We describe a superior gluteal reconstruction technique that is suitable for cases with abductor tendon tear with severe tendon loss.

[Surgical repair of gluteus medius muscle in hip replacement surgery]

Injury of gluteus medius muscle is a serious often complication after hip replacement surgery followed by pain, claudication and significant deterioration of the quality of life. Prevention of intraoperative injury of this muscle is especially relevant in young patients. Normal function of this muscle provides rapid rehabilitation and early postoperative recovery. However, hip replacement surgery through Hardinge's direct lateral approach is accompanied by fatty degeneration of gluteus medius muscle in 12-20% of cases. Moreover, two or more redo procedures lead to fatty degeneration of almost 70% of anterior and 40% of central muscular segment. Currently, there are many methods of surgical treatment of this complication including transosseous muscle fixation, endoscopic procedures, repair using Achilles tendon, gluteus maximus muscle, lateral head of quadriceps muscle and allografts. However, various publications devoted to this problem have certain disadvantages including short follow-up period, small sample size and often unsatisfactory outcomes. Therefore, the question of surgical repair of hip abductor function remains open.

High risk of positive Trendelenburg test after using the direct lateral approach to the hip compared with the anterolateral approach: a single-centre, randomized trial in patients with femoral neck fracture

Aims

The aim of this randomized trial was to compare the functional outcome of two different surgical approaches to the hip in patients with a femoral neck fracture treated with a hemiarthroplasty.

Patients and Methods

A total of 150 patients who were treated between February 2014 and July 2017 were included. Patients were allocated to undergo hemiarthroplasty using either an anterolateral or a direct lateral approach, and were followed for 12 months. The mean age of the patients was 81 years (69 to 90), and 109 were women (73%). Functional outcome measures, assessed by a physiotherapist blinded to allocation, and patient-reported outcome measures (PROMs) were collected postoperatively at three and 12 months.

Results

A total of 11 patients in the direct lateral group had a positive Trendelenburg test at one year compared with one patient in the anterolateral group (11/55 (20%) vs 1/55 (1.8%), relative risk (RR) 11.1; p = 0.004). Patients with a positive Trendelenburg test reported significantly worse Hip Disability Osteoarthritis Outcome Scores (HOOS) compared with patients with a negative Trendelenburg test. Further outcome measures showed few statistically significant differences between the groups.

Conclusion

The direct lateral approach in patients with a femoral neck fracture appears to be associated with more positive Trendelenburg tests than the anterolateral approach, indicating a poor clinical outcome.

Cite this article: Bone Joint J 2019;101-B:793–799.

Incidence and treatment of abductor deficiency during total hip arthroplasty using the posterior approach: repair with direct suture technique and gluteus maximus flap transfer

AIMS

The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus.

PATIENTS AND METHODS

A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter.

RESULTS

Abductor strength was maintained in the normal hips, but lateral hip pain progressed significantly, five years postoperatively (p < 0.0001). In the 54 patients with mild abductor tendon damage treated with simple repair, lateral hip pain also increased significantly during follow-up (p = 0.002). In the 35 patients with severe avulsion but good muscle repaired using a gluteus maximus flap transfer, abductor function was restored. The six patients with complete avulsion and poor muscle did not regain strong abductor power, but lateral hip pain decreased.

CONCLUSION

The posterior approach offered excellent exposure and preservation of the abductor mechanism during primary THA. Augmentation of the repair with a gluteus maximus flap provided stable reconstruction of the abductor muscles and seemed to restore function in the hips with functioning muscles. Cite this article: Bone Joint J 2019;101-B(6 Supple B):116-122.

Outcomes of gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip

PURPOSE

This study aims to present 3 patients' results after undergoing gluteus maximus and tensor fascia lata (TFL) transfer for chronic abductor tears unable to be repaired primarily.

METHODS

3 patients were identified intraoperatively as having an abductor tear unable to be repaired primarily. The anterior 1/3 of the gluteus maximus and the posterior 1/3 of the TFL were mobilised and transferred to the greater trochanter in order to reproduce the normal force vector of the gluteus medius and minimus. Data was prospectively collected for changes in gait, abductor strength, and the following patient reported outcomes (PROs): modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), visual analogue scale (VAS), and satisfaction.

RESULTS

The patients were female, 63-75 years old, with BMIs of 23-28. All patients had follow-up at mean 2.1 years (1.25-2.5) with positive Trendelenburg signs preoperatively; 2 patients normalised postoperatively. For 2 patients, abductor strength improved by 2 grades postoperatively; the other patient maintained grade four. 2 patients' PROs all improved; the other patient's PROs all improved except mHHS. Postoperative VAS scores were 0, 0, 1. 2 patients reported maximum satisfaction.

CONCLUSIONS

This case series suggests that gluteus maximus and TFL transfer for irreparable abductor deficiency may be effective for pain relief, improving abductor strength, and reconstructing abductor function. Although this is a small series, it is to our knowledge the first report of clinical outcomes of this procedure.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management

BACKGROUND

Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized.

METHODS

We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy.

RESULTS

We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary.

CONCLUSION

Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

Gluteus Maximus Advancement Flap Procedure for Reconstruction of Posterior Soft Tissue Deficiency in Revision Total Hip Arthroplasty

The current study describes the surgical technique and early outcomes of a gluteus maximus advancement flap procedure for the treatment of posterior soft tissue insufficiency among patients with complex revision total hip arthroplasty. This retrospective case series was conducted with a prospective, single-institution arthroplasty registry. Patients who underwent a gluteus maximus advancement flap procedure in the setting of revision total hip arthroplasty between January 2012 and January 2016 were eligible for inclusion (N=7). Primary indications for the gluteus maximus flap procedure included periprosthetic infection with persistent wound breakdown (n=4), persistent symptomatic aseptic pseudotumor in the setting of adverse local tissue reaction after unsuccessful operative debridement (n=2), and abductor insufficiency with recurrent hip instability after unsuccessful placement of a constrained liner (n=1). All patients who underwent a gluteus maximus advancement flap procedure for chronic periprosthetic infection or adverse local tissue reaction had healing of the wound and were infection-free at the last follow-up. In the early postoperative period, 2 patients had recurrent wound infection that required flap elevation. The patients remained infection-free after the subsequent procedure. No patient had repeat instability, and no complications of flap necrosis or nerve palsy occurred. The gluteus maximus advancement flap procedure provides a diverse range of soft tissue coverage options for patients with recalcitrant periprosthetic joint infection, adverse local tissue reaction with pseudotumor, or recurrent instability. [Orthopedics. 2017; 40(3):e495-e500.].

Abductor Reconstruction with Gluteus Maximus Transfer in Primary Abductor Deficiency during Total Hip Arthroplasty

Abductor deficiency in native hip joint may cause severe limping and pain. It is more serious situation in case of arthroplasty due to instability and recurrent dislocation. Well-known causes of abductor deficiency are repeated surgery, chronic trochanteric bursitis, superior gluteal nerve injury, failure of repair of abductor tendon insertion to the greater trochanter. Author had experienced primary abductor deficiency during total hip replacement and treated successfully with the transfer of gluteus maximus. We'd like to introduce the operation technique with the review of literature.

AAHKS Symposium: State-of-the-Art Management of Tough and Unsolved Problems in Hip and Knee Arthroplasty

BACKGROUND

Incompletely solved problems in hip and knee arthroplasty present ongoing practice challenges.

METHODS

Content experts summarized treatment options and preferred treatment methods for 4 incompletely solved problems in hip and knee arthroplasty.

RESULTS

The problems chosen for discussion in this symposium included 2 soft tissue problems: chronic extensor mechanism deficiency after total knee arthroplasty and abductor deficiency after total hip arthroplasty (THA), recurrent infection after a 2-stage procedure for infected THA or total knee arthroplasties, and pelvic discontinuity after THA.

CONCLUSION

The approaches outlined may provide guidance on management of these different problems. For surgeons and others in the orthopedic community interested in innovation, these challenges also present ripe opportunities to improve the care of patients with unmet needs.

Lesion of the hip abductor mechanism

Introduction: The disruption of the abductor muscles of the hip after hip revision surgery often causes limping, pain, and instability of the implant. The purpose of our paper is to describe a mesh technique to repair hip abductor mechanism injuries after hip revision.

Patients and methods: Forty-six patients with hip abductor damage after prosthetic revision were treated. Inclusion criteria were: patients presenting with prosthetic loosening, complaint of pain, and with a positive Trendelenburg sign due to deficient abductor muscle mechanisms. Thirty-one were women (67.39%) with an average age of 64 years (34–82 years). The number of previous revision surgeries was three (two to seven). The Merle d’Aubigné score and variants before and after treatment were also reported.

Results: In the postoperative follow-up after hip revision with the mesh technique, the Merle d’Aubigné score improved and the Trendelenburg sign was negative in 78.3% of the patients (p < 0.001). Also, the Trendelenburg test with the knee flexed was negative in 60.9% (p < 0.001) and the stair-climbing test was negative in 60.9% of cases (p < 0.001). The gluteus medius test in the lateral position was negative in 52.2% of patients, and in the lateral position with the knee flexed it was negative in 47.8% of patients (p < 0.001).

Discussion: Repair of the abductor mechanism with the mesh technique has proven effective for both partial and total lesions.

Greater Trochanteric Pain Syndrome

Patients who have lateral hip pain historically have been diagnosed with trochanteric bursitis and treated with nonsteroidal anti-inflammatory medications, corticosteroid injections, and physical therapy. Although this strategy is effective for most patients, a substantial number of patients continue to have pain and functional limitations. Over the past decade, our understanding of disorders occurring in the peritrochanteric space has increased dramatically. Greater trochanteric pain syndrome encompasses trochanteric bursitis, external coxa saltans (ie, snapping hip), and abductor tendinopathy. A thorough understanding of the anatomy, examination findings, and imaging characteristics aids the clinician in treating these patients. Open and endoscopic treatment options are available for use when nonsurgical treatment is unsuccessful.

Modified anterolateral approach in minimally invasive total hip arthroplasty

PURPOSE OF THE STUDY

Minimally invasive procedures for total hip arthroplasty (THA) provide less surgery related trauma, and perhaps a fast recovery and satisfaction. Using modified instruments, we reported clinical follow-up data for a modified anterolateral approach.

BASIC PROCEDURES

Using specialised retractors to expose the acetabulum and femur, this single-incision technique preserved more gluteus medius tendon and provided access for soft tissue repair. The demographic data for 1003 patients undergoing THA with this technique are presented, including operative variables, complications, Harris Hip Score for clinical evaluation and cup inclination angle for radiographic evaluation. Average follow-up was 59 months (range 24-121).

MAIN FINDINGS

In 1077 primary THAs performed in 1003 patients, the median wound length was 6 cm (range 4.8-9.2), median operation time was 68 minutes (range 45-112). The mean perioperative blood loss was 422 mls (range 56-990). The median cup inclination angle was 44 degrees (range 33-54), median acetabular version angle was 17° (range 12-24) median length of hospitalisation was 4 days (range 3-8). A total of 22 (2.0%) complications were noted including 5 cases of stem subsidence, 4 cup loosening, 5 greater trochanter fractures, 4 infections, 2 intraoperative proximal femur fractures and 2 iliopsoas impingement. In total, 13 (1.2%) received additional surgery. No neurovascular injury or dislocation was noted. For the clinical results, Harris Hip Score improved from 53 (range 33-67) preoperatively to 94 postoperatively (range 87-100).

PRINCIPAL CONCLUSIONS

Minimally invasive surgery via this modified anterolateral approach is a safe and reliable method.

Conversion of a failed hip resurfacing arthroplasty to total hip arthroplasty: pearls and pitfalls

Surface replacement arthroplasty (SRA) remains a viable alternative to total hip arthroplasty (THA) in appropriately selected, active adults with degenerative hip disease. However, orthopedic surgeons are facing a number of scenarios where revision of one or both components of an SRA is indicated. Indications for revision vary and impact the potential outcomes of conversion of a SRA to THA. While clinical outcomes are generally favorable, a growing body of data illustrates patients who undergo conversion of a SRA to THA to be at increased risk of requiring a repeat revision surgery and experiencing functional outcomes inferior to that of a primary THA. The results of patients undergoing conversion of a SRA to THA highlight the need for careful patient selection, thorough preoperative counseling, and technical precision when performing a SRA. Furthermore, a systematic approach to the failed SRA is necessary to ensure optimal clinical results.

Reconstruction of chronic abductor deficiency after revision hip arthroplasty using an extensor mechanism allograft

This study reports the clinical outcome of reconstruction of deficient abductor muscles following revision total hip arthroplasty (THA), using a fresh-frozen allograft of the extensor mechanism of the knee. A retrospective analysis was conducted of 11 consecutive patients with a severe limp because of abductor deficiency which was confirmed on MRI scans. The mean age of the patients (three men and eight women) was 66.7 years (52 to 84), with a mean follow-up of 33 months (24 to 41). Following surgery, two patients had no limp, seven had a mild limp, and two had a persistent severe limp (p = 0.004). The mean power of the abductors improved on the Medical Research Council scale from 2.15 to 3.8 (p < 0.001). Pre-operatively, all patients required a stick or walking frame; post-operatively, four patients were able to walk without an aid. Overall, nine patients had severe or moderate pain pre-operatively; ten patients had no or mild pain post-operatively. At final review, the Harris hip score was good in five patients, fair in two and poor in four. We conclude that using an extensor mechanism allograft is relatively effective in the treatment of chronic abductor deficiency of the hip after THA when techniques such as local tissue transfer are not possible. Longer-term follow-up is necessary before the technique can be broadly applied.

Vastus lateralis transfer for severe hip abductor deficiency: a salvage procedure

INTRODUCTION

Abductor muscle deficiency can be a debilitating problem following hip arthroplasty surgery. We report outcomes of a novel method of abductor muscle function reconstruction surgery in patients with chronic, irreparable gluteus medius and minimus defects.

PATIENTS AND METHODS

Four consecutive patients who underwent our method of abductor reconstruction surgery were retrospectively reviewed. All patients had severe pain and positive Trendelenberg gait before surgery.

TECHNIQUE

the vastus lateralis (VL) muscle was raised on its neurovascular pedicle and transferred 12-14 centimetres by proximal translation. The proximal portion of VL was reattached via bony anchors to the external surface of the iliac wing just below the iliac crest. The distal portion of VL reattached to the lateral femoral shaft, lateral intermuscular septum, and the fascia of vastus intermedius.

RESULTS

Average follow-up was 10 months (range 7-15 months). Three of the four patients report dramatic improvement in pain as measured by the visual analogue pain scale. The same three patients report being "extremely satisfied" with the pain relief achieved and "extremely satisfied" with the operation overall. Two patients reported being "extremely satisfied" with improvements in walking. Hip abduction power improved in all patients but to varying degrees.

CONCLUSION

The results show that our method of VL transfer may be a viable option for patients with severe abductor deficiency. Modest but clinically relevant early results are seen.

Surgical Technique for the Repair of Tears to the Gluteus Medius and Minimus Tendons of the Hip

Introduction

We describe the surgical treatment of tears to the abductor tendons of the hip, which are typically progressive and can lead to recalcitrant pain and progressive weakness, leading to considerable difficulties with walking.

Step 1 Perform the Exposure and Identify the Tear

Place the patient in the lateral decubitus position, expose the lateral peritrochanteric space, and then identify the extent of the tear.

Step 2 Mobilize the Tendons

Mobilize the typically scarred-in tendons from the surrounding tissue to allow the tendon to be brought back down to the trochanter.

Step 3 Prepare the Tendon and Greater Trochanter

Debride the tendon, and lightly burr the greater trochanter to maximize the healing of the tendon to the bone.

Step 4 Locate the Insertional Site of the Tendons and Place the Suture Anchors or Drill Holes Into This Site

Identify the area of the footprint for each of the tendons; all suture anchors should be placed in the footprint, and the transosseous drill holes should straddle the near and far edges of the footprint.

Step 5 Reattach the Tendons

After all of the sutures are placed, tie them down, starting with the pull sutures first, to bring the tendon back to bone; then secure the tendon down with the simple sutures.

Step 6 Reinforce Larger Tears

Reinforce larger tears to protect them and aid in their healing.

Step 7 Postoperative Protocol

The postoperative protocol period consists of partial weight-bearing for specific periods of time, followed by vigorous physical therapy for strengthening and gait retraining.

Results

Surgical repair can improve function and reliably decreases pain in patients with a hip abductor tear.IndicationsContraindicationsPitfalls & Challenges.

Acetabular cup revision combined with tensor facia lata reconstruction for management of massive abductor avulsion after failed total hip arthroplasty

We report on 17 patients with massive abductor avulsions after total hip arthroplasty (THA) treated with medialization of the acetabular component and tensor fascia lata (TFL) reconstruction. All patients had severe limp, positive Trendelenburg sign, and avulsion of the abductor insertion confirmed on MRI. Mean age was 69 years (range, 50-83 years), and mean follow-up period was 36 months (range, 18-78 months). After surgery, 9 patients had no limp (47%), 8 patients had a mild limp, and abductor power improved from mean 2.5/5 to mean 3.8 (P < 0.0001). At latest follow-up, the Harris Hip Score was excellent in 6 hips (37%), good in 7 (43%) hips, and fair or poor in 3 (23%). Two patients with mild limp were not satisfied with their procedure.

Surgical technique: Gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip

BACKGROUND

Avulsion of the abductor muscles of the hip may cause severe limp and pain. Limited literature is available on treatment approaches for this problem, and each has shortcomings. This study describes a muscle transfer technique to treat complete irreparable avulsion of the hip abductor muscles and tendons.

DESCRIPTION OF TECHNIQUE

Ten adult cadaver specimens were dissected to determine nerve and blood supply point of entry in the gluteus maximus and tensor fascia lata (TFL) and evaluate the feasibility and safety of transferring these muscles to substitute for the gluteus medius and minimus. In this technique, the anterior portion of the gluteus maximus and the entire TFL are mobilized and transferred to the greater trochanter such that the muscle fiber direction of the transferred muscles closely matches that of the gluteus medius and minimus.

METHODS

Five patients (five hips) were treated for primary irreparable disruption of the hip abductor muscles using this technique between January 2008 and April 2011. All patients had severe or moderate pain, severe abductor limp, and positive Trendelenburg sign. Patients were evaluated for pain and function at a mean of 28 months (range, 18-60 months) after surgery.

RESULTS

All patients could actively abduct 3 months postoperatively. At 1 year postoperatively, three patients had no hip pain, two had mild pain that did not limit their activity, three had no limp, and one had mild limp. One patient fell, fractured his greater trochanter, and has persistent limp and abduction weakness.

CONCLUSIONS

The anterior portion of the gluteus maximus and the TFL can be transferred to the greater trochanter to substitute for abductor deficiency. In this small series, the surgical procedure was reproducible and effective; further studies with more patients and longer followup are needed to confirm this.

Chronic tibialis anterior tendon tear treated with an Achilles tendon allograft technique

Tibialis anterior tendon tear is an uncommon injury. Nontraumatic or degenerative tears are usually seen in the avascular zone of the tendon. Treatment can be conservative or surgical. Conservative treatment is adequate for low-demand older patients. For active patients, surgical treatment can be challenging for the surgeon because after debridement of degenerative tissue, a gap may be formed that can make side-to-side suture impossible. The authors present allograft Achilles tendon insertion for reconstruction of chronic degenerative tears. Using Achilles tendon allograft has the advantage of bone-to-bone fixation, allowing rapid incorporation and earlier full weight bearing.

Management of abductor mechanism deficiency following total hip replacement

Deficiency of the abductor mechanism is a well-recognised cause of pain and limping after total hip replacement (THR). This can be found incidentally at the time of surgery, or it may arise as a result of damage to the superior gluteal nerve intra-operatively, or after surgery owing to mechanical failure of the abductor muscle repair or its detachment from the greater trochanter. The incidence of abductor failure has been reported as high as 20% in some studies. The management of this condition remains a dilemma for the treating surgeon. We review the current state of knowledge concerning post-THR abductor deficiency, including the aetiology, diagnosis and management, and the outcomes of surgery for this condition.

Cite this article: Bone Joint J 2013;95-B:343–7.

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.

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.