Surgical technique: Transfer of the anterior portion of the gluteus maximus muscle for abductor deficiency of the hip

Abstract

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

Description of technique: To minimize the symptoms of limp and instability, the anterior ½ of the gluteus maximus was transferred to the greater trochanter and sutured under the vastus lateralis. A separate posterior flap was transferred under the primary flap to substitute for the gluteus minimus and capsule. To ensure tight repair, the flaps were attached and tensioned in abduction.

Patients and methods: The technique was performed in 11 patients (11 hips) with complete loss of abductor attachment; the procedure was performed in nine patients during THA and in two later as a secondary procedure. Preoperatively, all patients had abductor lurch, positive Trendelenburg sign, and no abduction of the hip against gravity. Minimum followup was 16 months (mean, 33 months; range, 16-42 months).

Results: Postoperatively, nine patients had strong abduction of the hip against gravity, no abductor lurch, and negative Trendelenburg sign. One patient had weak abduction against gravity, negative Trendelenburg sign, and slight abductor lurch. One patient failed to achieve strong abduction, had severe limp after 6 months of protection and physical therapy, and was lost to followup.

Conclusions: Gluteus maximus transfer can restore abductor function in THA with a high success rate.

Figures

Fig. 1

The posterior approach splits the gluteus maximus in line with its fibers approximately ½ of the length of the muscle and continues distally, splitting the fascia lata (A). The fascia just anterior to the gluteus maximus muscle is split in line with its fibers up to the iliac crest. The anterior incision is extended distally to form a long fascial tip for the anterior muscle flap (B). The anterior fascial portion of the flap is cut transversely to the edge of the muscle (C).

Fig. 2

The anterior gluteus maximus flap has been elevated. The anterior incision may extend up to the iliac crest if necessary, and the posterior incision extends approximately ½ of the length of the muscle. The distal portion of the flap is triangular-shaped and consists entirely of fascia lata. The anterior fibrous band, made up of the fascia lata, is transected with a knife (A) to allow the muscle fibers to be tensioned correctly when the flap is attached to the femur. The posterior flap is delineated (B).

Fig. 3

The posterior flap (A) has been elevated approximately ½ of the length of the muscle fibers. The sciatic nerve (B) is shown in the surgical field.

Fig. 4

The posterior gluteus maximus flap (A) has been passed over the top of the femoral neck, under the tip of the greater trochanter (B), and sutured into the anterior capsule and anterior edge of the greater trochanter.

Fig. 5

A sharp osteotome is used to make a slot in the greater trochanter from near its tip to just above the attachment of the vastus lateralis muscle to the femur, removing only the cortex.

Fig. 6

Drill holes are made in the walls of the greater trochanter with a 1/8-inch drill bit.

Fig. 7

The vastus lateralis muscle has been detached from its attachment to the femur and split in line with its fibers (A). The anterior gluteus maximus flap has been sutured to the slot in the greater trochanter (B). These sutures are angled so as to pull the flap distally. The distal fibrous tip of the anterior flap lies on the bone under the elevated vastus lateralis muscle (C).

Fig. 8

The vastus lateralis muscle has been sutured to the distal fibrous tip of the anterior gluteus maximus muscle.

Fig. 9

In the absence of the greater trochanter, the posterior flap (A) is sutured to the anterior capsule of the hip and the anterior flap (B) is passed under a cable that encircles the femur and is sutured to itself under moderate tension with the hip abducted 15°. The vastus lateralis shown as split and elevated in this drawing (C) is sutured over this construct.

Fig. 10

The posterior edge of the anterior gluteus maximus flap (A) is sutured to the posterior gluteus maximus flap (B), which passes under it.

Fig. 11

The lower ½ of the gluteus maximus muscle (A) has been sutured to the fascia lata (B). The upper edge of this portion of the gluteus maximus muscle (C) will be attached to the lower edge of the anterior flap (D), as depicted by the arrow.

Fig. 12

The posterior flap (A) passes under the anterior flap (B). The anterior fascial edge of the anterior flap (C) has not been sutured to allow pull of the transferred muscles to be exerted on the greater trochanter. The transverse cut in the anterior fascial portion of the flap is pulled open (D) by the tension of the closure.