High Patient Satisfaction With Gluteus Maximus Transfer for Abductor Insufficiency Despite Persistent Trendelenburg Gait

Purpose

To evaluate short-term clinical and patient reported outcomes after gluteus maximus/tensor fascia lata (GM/TFL) transfer for abductor insufficiency.

Methods

This was a retrospective case series. Inclusion criteria were patients who underwent GM/TFL for chronic abductor insufficiency from 2017 to 2024 at a single institution with a minimum follow-up of 6 months and at least 1 recorded postoperative visit. Demographic, clinical, and outcome data were collected, including hip range of motion, abduction strength, presence of Trendelenburg gait, postoperative rehabilitation details, complications, and patient-reported outcomes. Statistical comparisons of pre- and postoperative objective measures were performed using the Wilcoxon signed-rank test.

Results

Ten patients (8 female, 2 male) with a mean age of 65.8 ± 11.2 years were included. Mean follow-up was 2.3 years (0.7-7.8). Postoperatively, range of motion and abduction strength showed no significant changes ( P >.05), and Trendelenburg gait persisted in 80% of patients. However, patient-reported outcome scores were strong, with a mean postoperative modified Harris Hip Score of 76.5 ± 22.4 and Non-Arthritic Hip Score of 74.1 ± 21.7. Patient satisfaction was high, with 100% of patients indicating they would undergo the procedure again. Three patients experienced complications (30%), including 2 patients who had persistent pain and seroma formation, and a patient who had a recurrent hematoma.

Conclusions

GM/TFL transfer does not consistently improve hip strength or gait mechanics; however, it provides pain relief and improved quality of life, as evidenced by high patient satisfaction and favorable modified Harris Hip Score outcomes. Three patients experienced complications (30%), including two patients who had persistent pain and seroma formation, and a patient who had a recurrent hematoma.

Level of Evidence

Level IV, retrospective therapeutic case series.

Chronic abductor insufficiency is a debilitating condition that substantially impacts patients’ mobility, gait, and overall quality of life. Often caused by irreparable gluteal tendon tears, this condition is particularly challenging to manage in older adults and those with substantial comorbidities. ^, Age-related degeneration, tendinopathy, and trauma are the most common causes of abductor insufficiency, apart from intraoperative complications. ^, Although conservative treatments, including physical therapy and corticosteroid injections, are successful approximately 80% of the time, surgical intervention becomes the option when this fails.

Surgical decision making for abductor insufficiency is complex because it depends on the patient’s surgical hip history, specific tendons involved, size of any tendon tears, degree of fatty infiltration, and so on. The gluteus maximus/tendon fascia lata (GM/TFL) transfer technique was first introduced by Whiteside in 2006 as another surgical option for chronic abductor insufficiency, with refinements made in 2014 that improved the technique to include TFL transfer and broadened its applicability. ^,^, The procedure can be applicable when there is an irreparable abductor tendon tear and a fully functional gluteus maximus. ^, It is often considered when patients have had a total hip arthroplasty and subsequently developed severe abductor deficiency. However, the indications for this procedure are uniquely variable, perhaps more so than most other surgery in orthopaedic practice. Unlike procedures with well-defined criteria—where specific clinical or radiographic findings dictate surgical intervention—GM/TFL transfer requires a nuanced, patient-specific approach. Each case presents distinct anatomical, functional, and symptomatic considerations, making the decision to proceed highly individualized rather than formulaic.

Given the critical role of the early postoperative period in determining long-term functional success, understanding short-term outcomes is vital to optimizing surgical and rehabilitation protocols. This case series aims to contribute to the limited literature that reports on the outcomes of GM/TFL transfer for abductor insufficiency. It evaluates the short-term outcomes, focusing on functional recovery, complication rates, and patient-reported outcomes (PROs). By analyzing these metrics in the context of a procedure that has only recently been established, this study contributes valuable evidence to the growing body of literature on the safety and efficacy of GM/TFL transfer. It also allows surgeons to better inform patients and refine surgical decision making, ultimately improving patient selection and postoperative expectations.

The purpose of this study was to evaluate short-term clinical and PROs after GM/TFL transfer for abductor insufficiency. We hypothesized that GM/TFL transfer would result in improved PROs and high satisfaction, although with limited improvements in objective measures such as hip abduction strength and gait mechanics.

Methods

Inclusion and Exclusion Criteria

This was a retrospective case series. Patients were included if they underwent GM/TFL for chronic abductor insufficiency from 2017 to 2024 at a single institution with a minimum follow-up of 6 months. Patients were excluded if they did not have at least 1 documented follow-up visit. Additional inclusion criteria included age ≥18 years and availability of preoperative and postoperative clinical data. Demographic, clinical, and outcome data were collected for each patient through examination of the patient’s electronic medical record. This was approved by an institutional review board of a large academic institution (institutional review board no. 15-00929; NYUMC Orthopedic research approval August 19, 2022: Retrospective Analysis of Patients Undergoing Hip Arthroscopy [i20-01686_MOD07]).

Data Collection

Demographic data collected included patient age, sex, and affected side. Clinical data included chronicity of symptoms, previous ipsilateral hip surgery, previous corticosteroid injection, preoperative and postoperative range of motion (ROM), abductor strength during physical examination, and the presence of a Trendelenburg gait. Postoperative rehabilitation data also were collected including immobilization period, weight-bearing, and therapy protocols. Outcome data included postoperative PROs and examination findings, postoperative complications, and any reoperations over the follow-up period.

Surgical Technique

All surgeries were completed by 1 of 3 sports medicine fellowship−trained orthopaedic surgeons (G.G.L., R.M., T.Y.). Indications for surgery were irreparable, full-thickness tears of the gluteus medius and/or minimus; evidence on magnetic resonance imaging (MRI) scans of Goutallier grade 3 or 4 fatty infiltration; limited ability of the patient to perform activities of daily living because of hip abductor weakness and pain or Trendelenburg gait; and nonresponse to conservative treatment (physical therapy, nonsteroidal anti-inflammatory drugs, steroid injections) for >6 months. Similar surgical techniques were used. The patients were positioned in the lateral decubitus position using hip positioners. A standard posterior incision centered over the greater trochanter was used. The subcutaneous tissue was divided, and the fascia was incised. The anterior third of the gluteus maximum and the posterior third of the tensor fascia lata were identified and freed to be used for the tendon transfer. Any trochanteric bursitis was excised. The gluteus medius and minimus tendons were identified, which largely revealed fatty atrophy. The tendons were released from the greater trochanter and their insertion site was decorticated, creating a cancellous bone bed for tendon reattachment. The gluteus maximum and tension fascia lata tendons were secured to the greater trochanter using either bone tunnels or multiple, all-suture anchors at 15 to 20° of hip abduction. One surgeon augmented all his fixations with a biological scaffold (BioBrace Bioinductive Implant; CONMED, Largo, FL). The wounds were irrigated and closed in a standard fashion.

One patient had a concomitant arthroscopic labral repair at the time of their tendon transfer surgery. One patient had only a gluteus maximus tendon transfer without the addition of the tensor fascia lata.

The 3 surgeons had slightly different postoperative protocols. Surgeon 1 did not instruct the patient to use a brace, limited the patient to partial weight-bearing (50%) for 8 weeks, and started active abduction at 8 weeks. Surgeon 2 similarly did not instruct the patient to use a brace, limited weight-bearing to 50% for 4 to 6 weeks, and advised avoiding abduction exercises until 3 months. Surgeon 3 instructed the patient to use an abduction brace for 4 weeks, limited weight-bearing to 50% with crutches for 6 weeks, and then started abduction strengthening starting at 2 months.

Statistical Analyses

Descriptive statistics were used to summarize demographic and clinical data. Data were not disaggregated by sex because of the small size of the cohort. Continuous variables were reported as means with standard deviations or medians with ranges, as appropriate. Categorical variables were summarized as frequencies and percentages. The Wilcoxon signed-rank test was used to compare preoperative and postoperative ROM and strength measurements due to the small sample size and nonparametric distribution of the data. Presence of Trendelenburg gait from preoperative to postoperative was compared using the McNemar exact test. A significance level of P <.05 was considered statistically significant. All analyses were performed using SPSS (IBM, Armonk, NY).

Results

Patient Characteristics

A total of 10 patients (8 female, 2 male) were included in this study. The mean age at the time of surgery was 65.8 ± 11.2 years (range, 47-85 years), and the mean body mass index was 28.2 ± 4.8 (range, 21.7-38.2). The mean follow-up period was 0.7 ± 1.9 years (range, 0.7-7.8 years). Two patients (20%) had undergone previous ipsilateral hip surgery, and 4 patients (40%) had received previous corticosteroid injections. The majority of patients had chronic symptoms exceeding 1 year (70%), with varied degrees of preoperative fatty infiltration as classified by the Goutallier and Fuchs grading systems. This information is summarized in Table 1 . Figure 1 demonstrates a preoperative MRI of one of our patients demonstrating a gluteus medius tear and fatty atrophy.

Table 1

Patient Characteristics

Age, yr, mean (range)	65.8 ± 11.2 (47-85)
Sex, n (%)
Male	2 (20%)
Female	8 (80%)
Body mass index	28.2 ± 4.8 (21.7-38.2)
Affected side, n (%)
Right	4 (40%)
Left	6 (60%)
Previous ipsilateral hip surgery, n (%)
Yes	2 (20%)
No	8 (80%)
Symptom chronicity, duration, n (%)
6-12 mo	7 (70%)
>1 yr	3 (30%)
Preoperative corticosteroid injections, n (%)
Yes	4 (40%)
No	6 (60%)
Goutallier classification, n (%)
Grade 0	1 (10%)
Grade 1	3 (30%)
Grade 2	2 (20%)
Grade 3	2 (20%)
Grade 4	2 (20%)
Fuch classification, n (%)
Grade 1	4 (40%)
Grade 2	3 (30%)
Grade 3	3 (30%)
Grade 4	0 (0%)