Abductor Muscle Repair/Reconstruction
Adam Hart
Rafael J. Sierra
Key Concepts
Abductor deficiency following total hip replacement is a major problem that may lead to pain, Trendelenburg gait, and instability. Multiple etiologies should be considered:
Prior anterolateral (transgluteal) approach to the hip resulting in
Failure of the abductor repair (Figure 43.1A), or
Injury to the superior gluteal nerve.
Periprosthetic fracture of the greater trochanter occurring intraoperatively or postoperatively (Figure 43.1B).
Adverse local soft tissue reaction with destruction of the abductors (Figure 43.1C).
Abductor deficiency generally presents as 3 distinct clinical scenarios:
Moderate abductor deficiency and limp, often with some lateral hip pain, but without total hip arthroplasty instability. This is most commonly seen after hip replacement performed through an anterolateral approach with a failed abductor tendon repair.
Severe abductor-related Trendelenburg limp with varying degrees of pain. This may present in the setting of a trochanteric avulsion fracture or when there is complete avulsion of the abductor mechanism from the trochanter.
Recurrent dislocations of the hip in association with abductor deficiency. In cases in which there is no apparent etiology for the dislocation, abductor muscle necrosis as seen in cases with severe taper corrosion should be investigated.
Sterile Instruments and Implants
Perioperative—consider the use of tranexamic acid, local and regional anesthesia
Heavy Ethibond sutures for tendon reattachment and Fiberwire sutures for tendon reinforcement
High-speed burr
Fresh frozen Achilles allograft (when allograft augmentation is planned)
Surgical Approaches
Anterolateral or posterolateral according to surgeon preference. The authors prefer a posterior approach, splitting the gluteus maximus near its midportion so that a gluteus maximus muscle transfer may be utilized if needed.
Preoperative Planning
Detailed history and physical examination are essential. Onset and severity of symptoms should be clarified. The operative note from the index surgery should be reviewed to determine the approach, implants, and any pertinent intraoperative findings. The examination should assess the patient’s abductor strength, presence of an antalgic gait or Trendelenburg gait, and tenderness over the greater trochanter.
Figure 43.1 ▪ Abductor deficiency etiologies: failure of the anterior head of gluteus medius to heal to the greater trochanter footprint but intact attachment of the vertical head following hip replacement through an anterolateral approach (A), avulsion fracture of the greater trochanter following total hip replacement (B), and large cystic pseudotumor with significant destruction of the abductors secondary to trunionosis (C).
Radiographs of the hip to assess the current implants and presence of a greater trochanter fracture.
Magnetic resonance imaging (MRI) evaluation using metal suppression provides valuable information on the tear morphology and status of the gluteal muscles. In particular, fatty infiltration of the abductors should be assessed on the axial T1 sequence (Figure 43.2). Fatty atrophy of the anterior two-thirds of the gluteus minimus is common, whereas significant fatty atrophy of the gluteus medius portends a poor prognosis following repair and may prompt the surgeon to use a muscle transfer.
An electromyography study is indicated to confirm and quantify a gluteal nerve injury when suspected.
Bone, Implant, and Soft Tissue Techniques
Abductor repair—When preoperative MRI demonstrates reasonable muscle quality of the gluteus medius, a direct repair with augmentation is the preferred treatment.
Exposure is according to the surgeon’s preference and may utilize the previous incision. The fascia is opened in-line with the femur distally, and the author’s preference is to split the gluteus maximus near its midportion such that a transfer may be performed if needed.
Figure 43.2 ▪ Axial T1 MRI in 3 patients with abductor deficiency demonstrating increasing fatty infiltration from A to C of the gluteus medius (delineated by the dotted lines).
Figure 43.3 ▪ Direct repair of the gluteus minimus and medius with Achilles allograft augmentation. Development of flaps from torn sections of gluteus minimus and medius (A), reattachment of the gluteus minimus with 4 transosseous sutures (B), anchoring of the Achilles tendon to the vastus lateralis (C), reinforcement of the gluteus minimus repair with the Achilles allograft using Krackow sutures (D), reattachment of the gluteus medius (E), and concealing the sutures by covering the repair with bursal tissue (F).
There is often hypertrophied bursa and scar tissue overlying the greater trochanter—we attempt to divide this tissue to expose the underlying vastus and gluteus medius. This tissue sometimes is useful to close overtop the repair when possible (Figure 43.3F).Related posts:
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