Hip Abductor Deficiency after Total Hip Arthroplasty: Diagnostic and Therapeutic Methods

Abstract

Abductor deficiency after total hip arthroplasty is a severe complication with functional limitations and a significant reduction in the patient's quality of life. Common causes are degenerative ruptures or approach-related iatrogenic damage to the gluteus medius and minimus muscle and the inferior gluteal nerve, fractures of the greater trochanter and incorrect reconstruction of leg length and femoroacetabular offset. With a standardised diagnosis consisting of a clinical examination, conventional X-ray and MRI, the causes of the functional problems can often be reliably determined. Therapy of abductor deficiency is challenging for both patients and physicians and is often tedious. However, with a clear diagnostic and therapeutic algorithm and straightforward patient education, good treatment results can be achieved even in this challenging condition. Conservative therapy with eccentric stretching and muscle strengthening are the basis of the treatment. In cases of progression of complaints despite intensive conservative treatment, various anatomical and extra-anatomical surgical reconstruction methods are available to relieve pain and improve function. Anatomical reconstruction of the gluteal tendon insertion is an option in cases of low-grade fatty infiltration and moderate retraction of the gluteal muscles. In situations with advanced degenerative changes in the gluteus medius and minimus muscles and an intact gluteus maximus muscle, transfer of the anterior portion of the gluteus maximus according to Whiteside is an option. For high-grade defects of the soft tissue, there is also the option of an isolated or combined transfer of the vastus lateralis muscle.

Zusammenfassung

Die pelvitrochantäre Insuffizienz nach Hüftprothesenimplantation stellt eine schwerwiegende Komplikation mit gravierenden funktionellen Einschränkungen und einer deutlichen Reduktion der Lebensqualität für den Patienten dar. Häufige Ursachen sind degenerative Rupturen oder zugangsbedingte iatrogene Schädigungen der Mm. gluteus medius und minimus sowie des N. gluteus inferior, Trochanter-major-Frakturen und Probleme in der Rekonstruktion der Beinlänge und des femoroazetabulären Offsets. Mit einer standardisierten Diagnostik aus klinischer Untersuchung, konventionellem Röntgen und MRT können die Ursachen der funktionellen Probleme häufig gut eruiert werden. Die Therapie der pelvitrochantären Insuffizienz ist für Patient und Behandler herausfordernd und meist langwierig. Mit einem klaren diagnostischen und therapeutischen Algorithmus und einer guten Aufklärung des Patienten kann es jedoch gelingen, auch in diesem herausfordernden Krankheitsbild gute Behandlungserfolge zu erzielen. Die konservative Therapie mit exzentrischer Dehnung und Muskelkräftigung bildet dabei das Fundament der Behandlung. Im Falle von frustranen Verläufen trotz intensiver konservativer Behandlung stehen unterschiedliche anatomische und extraanatomische operative Rekonstruktionsverfahren zur Verfügung, um Schmerzen zu lindern und die Funktion zu verbessern. Die anatomische Rekonstruktion der glutealen Sehneninsertion kommt bei geringgradiger fettiger Degeneration und moderater Retraktion der Glutealmuskulatur infrage. Bei fortgeschrittenen degenerativen Veränderungen der Mm. gluteus medius und minimus und intaktem M. gluteus maximus kann die Verschiebeplastik nach Whiteside angewandt werden. Für höhergradige Weichteildefekte besteht außerdem die Möglichkeit eines isolierten oder additiven Versatzes des M. vastus lateralis.

Key words

hip abductor deficiency - total hip arthroplasty - muscle reconstruction

Schlüsselwörter

Glutealinsuffizienz - Hüftendoprothetik - Muskelrekonstruktion

^* This article is a republished version of: Krüger DR, Heller KD. Hip Abductor Deficiency after Total Hip Arthroplasty: Diagnostic and Therapeutic Methods. Z Orthop Unfall 2023;161(1):65–73.

Publication History

Article published online:
09 January 2025

• References/Literatur

• 1 Elbuluk AM, Coxe FR, Schimizzi GV. et al. Abductor Deficiency-Induced Recurrent Instability After Total Hip Arthroplasty. JBJS Rev 2020; 8: e0164
• 2 Ricciardi BF, Henderson PW, McLawhorn AS. et al. Gluteus Maximus Advancement Flap Procedure for Reconstruction of Posterior Soft Tissue Deficiency in Revision Total Hip Arthroplasty. Orthopedics 2017; 40: e495-e500
• 3 Miozzari HH, Dora C, Clark JM. et al. Late repair of abductor avulsion after the transgluteal approach for hip arthroplasty. J Arthroplasty 2010; 25: 450-457.e1
• 4 Caviglia H, Cambiaggi G, Vattani N. et al. Lesion of the hip abductor mechanism. SICOT J 2016; 2: 29
• 5 Müller M, Tohtz S, Dewey M. et al. Evidence of reduced muscle trauma through a minimally invasive anterolateral approach by means of MRI. Clin Orthop Relat Res 2010; 468: 3192-3200
• 6 Hasija R, Kelly JJ, Shah NV. et al. Nerve injuries associated with total hip arthroplasty. J Clin Orthop Trauma 2018; 9: 81-86
• 7 Abitbol JJ, Gendron D, Laurin CA. et al. Gluteal nerve damage following total hip arthroplasty. A prospective analysis. J Arthroplasty 1990; 5: 319-322
• 8 Hendry J, Biant LC, Breusch SJ. Abductor mechanism tears in primary total hip arthroplasty. Arch Orthop Trauma Surg 2012; 132: 1619-1623
• 9 Plaass C, Clauss M, Ochsner PE. et al. Influence of leg length discrepancy on clinical results after total hip arthroplasty–a prospective clinical trial. Hip Int 2011; 21: 441-449
• 10 Suh KT, Cheon SJ, Kim DW. Comparison of preoperative templating with postoperative assessment in cementless total hip arthroplasty. Acta Orthop Scand 2004; 75: 40-44
• 11 Roder C, Vogel R, Burri L. et al. Total hip arthroplasty: leg length inequality impairs functional outcomes and patient satisfaction. BMC Musculoskelet Disord 2012; 13: 95
• 12 Sariali E, Klouche S, Mouttet A. et al. The effect of femoral offset modification on gait after total hip arthroplasty. Acta Orthop 2014; 85: 123-127
• 13 Asayama I, Chamnongkich S, Simpson KJ. et al. Reconstructed hip joint position and abductor muscle strength after total hip arthroplasty. J Arthroplasty 2005; 20: 414-420
• 14 Mahmood SS, Mukka SS, Crnalic S. et al. Association between changes in global femoral offset after total hip arthroplasty and function, quality of life, and abductor muscle strength. A prospective cohort study of 222 patients. Acta Orthop 2016; 87: 36-41
• 15 Weber M, Merle C, Nawabi DH. et al. Inaccurate offset restoration in total hip arthroplasty results in reduced range of motion. Sci Rep 2020; 10: 13208
• 16 Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res 2002; (405) 46-53
• 17 Ugland TO, Haugeberg G, Svenningsen S. et al. 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. Bone Joint J 2019; 101-B: 793-799
• 18 von Roth P, Abdel MP, Wauer F. et al. Significant muscle damage after multiple revision total hip replacements through the direct lateral approach. Bone Joint J 2014; 96-B: 1618-1622
• 19 Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty 2001; 16: 121-123
• 20 Odak S, Ivory J. Management of abductor mechanism deficiency following total hip replacement. Bone Joint Journal 2013; 95-B: 343-347
• 21 Ruckenstuhl P, Wassilew GI, Müller M. et al. Functional Assessment and Patient-Related Outcomes after Gluteus Maximus Flap Transfer in Patients with Severe Hip Abductor Deficiency. J Clin Med 2020; 9: 1823
• 22 Ossendorf C, Bohnert L, Mamisch-Saupe N. et al. Is the internal rotation lag sign a sensitive test for detecting hip abductor tendon ruptures after total hip arthroplasty?. Patient Saf Surg 2011; 5: 7
• 23 Ortiz-Declet V, Chen AW, Maldonado DR. et al. Diagnostic accuracy of a new clinical test (resisted internal rotation) for detection of gluteus medius tears. J Hip Preserv Surg 2019; 6: 398-405
• 24 Dorn U, Landauer F, Hofstaedter T. Gluteussehnensyndrom. Z Orthop Unfall 2016; 154: 307-320
• 25 Banke IJ, Schauwecker J, Suren C. et al. [Hip pain]. MMW Fortschr Med 2017; 159: 51-57
• 26 Garcia FL, Picado CH, Nogueira-Barbosa MH. Sonographic evaluation of the abductor mechanism after total hip arthroplasty. J Ultrasound Med 2010; 29: 465-471
• 27 Connell DA, Bass C, Sykes CA. et al. Sonographic evaluation of gluteus medius and minimus tendinopathy. Eur Radiol 2003; 13: 1339-1347
• 28 Hartigan DE, Perets I, Walsh JP. et al. Radiographic Risk Factors and Signs of Abductor Tears in the Hip. Arthroscopy 2018; 34: 2389-2397
• 29 Pfirrmann CW, Notzli HP, Dora C. et al. Abductor tendons and muscles assessed at MR imaging after total hip arthroplasty in asymptomatic and symptomatic patients. Radiology 2005; 235: 969-976
• 30 Chi AS, Long SS, Zoga AC. et al. Prevalence and pattern of gluteus medius and minimus tendon pathology and muscle atrophy in older individuals using MRI. Skeletal Radiol 2015; 44: 1727-1733
• 31 Bogunovic L, Lee SX, Haro MS. et al. Application of the Goutallier/Fuchs Rotator Cuff Classification to the Evaluation of Hip Abductor Tendon Tears and the Clinical Correlation With Outcome After Repair. Arthroscopy 2015; 31: 2145-2151
• 32 Engelken F, Wassilew GI, Kohlitz T. et al. Assessment of fatty degeneration of the gluteal muscles in patients with THA using MRI: reliability and accuracy of the Goutallier and quartile classification systems. J Arthroplasty 2014; 29: 149-153
• 33 Glynn AA, Barattiero FY, Albers CE. et al. Surgical hip dislocation does not result in atrophy or fatty infiltration of periarticular hip muscles. J Hip Preserv Surg 2014; 1: 82-95
• 34 Rodriguez-Roiz JM, Bori G, Tomas X. et al. Hypertrophy of the tensor fascia lata muscle as a complication of total hip arthroplasty. Eur J Orthop Surg Traumatol 2017; 27: 255-259
• 35 Selkowitz DM, Beneck GJ, Powers CM. Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. J Orthop Sports Phys Ther 2013; 43: 54-64
• 36 Rompe JD, Segal NA, Cacchio A. et al. Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome. Am J Sports Med 2009; 37: 1981-1990
• 37 Dean BJ, Lostis E, Oakley T. et al. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum 2014; 43: 570-576
• 38 Schröder JH, Geßlein M, Schütz M. et al. [Open repair of gluteus medius and minimus tendons tears with double-row technique: Clinical and radiological results]. Orthopade 2018; 47: 238-245
• 39 Rajkumar S, Singer GC, Jones JR. Results following repair of gluteus medius defects following total hip arthroplasty. Hip Int 2011; 21: 293-298
• 40 Whiteside LA. Treating abductor deficiency: a transference technique. Orthopedics 2011; 34: e470-e472
• 41 Whiteside LA. Surgical technique: Transfer of the anterior portion of the gluteus maximus muscle for abductor deficiency of the hip. Clin Orthop Relat Res 2012; 470: 503-510
• 42 Chandrasekaran S, Darwish N, Vemula SP. et al. Outcomes of gluteus maximus and tensor fascia lata transfer for primary deficiency of the abductors of the hip. Hip Int 2017; 27: 567-572
• 43 Beck M, Leunig M, Ellis T. et al. Advancement of the vastus lateralis muscle for the treatment of hip abductor discontinuity. J Arthroplasty 2004; 19: 476-480
• 44 Betz M, Zingg PO, Peirrmann CW. et al. Advancement of the vastus lateralis muscle for irreparable hip abductor tears: clinical and morphological results. Acta Orthop Belg 2012; 78: 337-343
• 45 Kohl S, Evangelopoulos DS, Siebenrock KA. et al. Hip abductor defect repair by means of a vastus lateralis muscle shift. J Arthroplasty 2012; 27: 625-629
• 46 Wang K, Cole S, White DC. et al. Vastus lateralis transfer for severe hip abductor deficiency: a salvage procedure. Hip Int 2014; 24: 180-186