Summary

Gluteus maximus anterior one third transfer and augmentation with Tensor Fascia lata reconstruction to replace deficient Hip abductors

Abstract

Background

Arthroplasties are mostly done to improve the quality of life, so a functional muscle group around the joint is necessary for better outcome. Literature published in 2020 suggests that in first year Hip arthroplasties have approximately 2% risk of post-operative hip dislocation, there after every 5 years it increases by 1%, to a maximum of about 7% by 25 years. Out of the listed 6 causes for instability, most which are implant related, surgical technique related, muscle weakness, one of them is abductor deficiency.

The common treatment methodologies for patients with recurrent instability include – elevated rims, oblique liners, larger-diameter femoral heads, but all these tends to fail in patients with deficient abductor mechanism.

The abductor group – Gluteus Medius, Gluteus Minimus, Tensor fasciae latae supplied by superior gluteal nerve.

Failures in abductor mechanism is not only caused as secondary to primary Hip arthroplasty but also caused by infections, trauma, inflammatory mediated tissue destruction, etc.

The absent hip abductors lead to frequent unstable hip, which most of the times result in pain free dislocation even while lying down.

Literature had one plausible technique for this dreaded complication published earliest in 2011.

Methodology

The technique we used here was to divide the anterior one-third of gluteus maximus along with its neurovascular supply (supplied by the inferior gluteal nerve), released from its distal attachment to Fascia lata, realign that segment and attach it to the greater trochanter, so that this muscle can cover the absent hip abductors. The cut ends of Fascia lata were then sutured on top of the Gluteus maximus flap attachment.

Result: Three year post- operative follow up with a regular cautious and thorough rehab protocol revealed Trendlenberg test being performed without difficulty. There were no more further episodes of hip dislocation, was able to abduct the hip and maintain that posture, also walk with a steady gait.

Conclusion

In cases with complete destruction of Hip abductors, and those with a functional Gluteus maximus, this method can be used to prevent dislocation, and with proper rehabilitation, muscle orientation and training can in fact result in a functional hip with good abduction and a proper gait without an abductor lurch.