Original article 435
Comparison of the incisions for the open surgical treatment of gluteal muscle contracture Jian Xu*, Xiang Geng*, Hassan Muhammad, Xu Wang, Jia-Zhang Huang, Chao Zhang and Xin Ma Gluteal muscle contracture is not very common, but cases are still seen in China. Open surgical treatment is considered as an efficient method to treat this disease. However, the type of incision that can provide best results is yet to be determined. The authors therefore compared various incisions to determine the better one. In this retrospective study, patients who underwent surgery with a traverse straight incision, a curved incision, a longitudinal straight incision, or an ‘S’-shaped incision above the greater trochanter were enrolled and divided into four groups: A, B, C, and D. In each group, the patients were divided into different levels according to a specific standard. The four groups were compared in terms of incision length, postoperative drainage amounts, wound healing rates, visual analog scale scores, and improvement in the degree of range of motion (ROM). During the follow-up period, the validity of the results, complications, and recurrent cases were evaluated. In our study, incision length and visual analog scale score of the four groups showed no significant differences (P > 0.05). Wound healing rates, drainage amount, improvement in ROM, validity of the results, and
Introduction Gluteal muscle contracture (GMC), first reported by Fernandez de Valderrama [1], is a clinical syndrome characterized by lower-limb dysfunction and gait abnormality [2,3]. GMC is either caused by repeated intramuscular injection of methanol-diluted penicillin or has other unknown etiology [4–8]. Numerous cases of GMC have been reported in China because of the frequent use of benzyl alcohol as a solvent for penicillin in the 1970s and 1980s [9]. GMC is manifested through the formation of a fibrotic band in the gluteal region, tightening the gluteal muscles and resulting in the dysfunction of the lower limb and hip [1]. Patients with GMC typically present with fixed hip abduction and external rotation when squatting from the standing position. Physical examination shows a characteristic gait due to hip adduction and internal thigh rotation. To treat GMC, medical practitioners have used several surgical procedures, including endoscopic surgery. Retrospective studies have shown that endoscopic release provides better results than open surgical treatment [6]. However, with the lack of high-quality evidence for direct data comparison [10], open surgical treatment remains an efficient method to treat this 1060-152X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
recurrences in group D were significantly the best (P < 0.05). No significant differences in wound healing rates, drainage amount, and improvement in ROM were found in groups A, B, and C. In terms of validity of the results and 1-year recurrence, no significant difference was observed between groups A and B; however, these factors were better than those in group C. We concluded that the ‘S’-shaped incision above the greater trochanter is the most efficient among the incisions described in this study. This incision has the following advantages: clear exposure, less damage, high safety rate, excellent results, and low recurrence rate. J Pediatr Orthop B 23:435–440 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Journal of Pediatric Orthopaedics B 2014, 23:435–440 Keywords: gluteal muscle contracture, incisions, open surgical treatment Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China Correspondence to Xin Ma, PhD, Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, 200040 China Tel: + 86 21 5288 999; fax: + 86 21 6248 9191; e-mail: [email protected] *Jian Xu and Xiang Geng contributed equally to the writing of this article.
disease because it has numerous advantages including easy operating procedures, clearer exposure, and low hospitalization costs. Different kinds of incisions are used in open surgery; however, few studies have compared the outcomes in patients with different incisions. To determine the specific incision that can be used more effectively in open surgical procedures, we described our experiences with using four types of incisions when we treated our patients with GMC. The four incisions were also compared in terms of several aspects. We considered the common etiology of injection, or the lateral upper side used as a common injection site, to simulate the most severe contracture that often occurs around the lower one-third part of the line of the iliac spine and the trochanter. Considering the sites of pathological changes and hip anatomy, we hypothesized that better results can be obtained using an ‘S’-shaped incision compared with other incisions.
Methods Study design
A retrospective study was conducted to compare the four incisions used to treat GMC. A total of 516 patients were operated upon consecutively at our hospital including DOI: 10.1097/BPB.0000000000000067
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
436 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
Table 1
Classification of gluteal muscle contracture [6]
Grading Level I (mild)
Level II (moderate)
Level III (severe)
Signs and symptoms The external rotation of the lower limb is mild, the abduction contracture is < 15° with both the hip and the knee joint in 90° flexion, or adduction range < 20° with no flexion. Ober’s sign and frog-squatting sign are weakly positive. The limp gait is not apparent, with lateral inclination of the pelvis on the anteroposterior radiograph being < 10° The external rotation of the lower limb is moderate, the abduction contracture ranges from 15° to 60° with both the hip and the knee joint in 90° flexion, or adduction range < 10° with no flexion. Ober’s sign and frog-squatting sign are positive. The limp gait is apparent, with lateral inclination of the pelvis on the anteroposterior radiograph being < 20° The external rotation of the lower limb is severe, the abduction contracture is > 60° with both the hip and the knee joint in 90° flexion, or adduction range < 0° with no flexion. Ober’s sign and frog-squatting sign are strongly positive. The limp gait is remarkably apparent, with lateral inclination of pelvis on the anteroposterior radiograph being > 20°
those who underwent endoscopic and open surgical treatment between October 2008 and March 2012. A total of 379 patients who underwent open surgery with a traverse straight incision, a curved incision, a longitudinal straight incision, and an ‘S’-shaped incision above the greater trochanter were also included in the study. These patients were divided into four groups: group A (traverse straight incision, n = 86), group B (curved incision, n = 93), group C (longitudinal straight incision, n = 94), and group D (‘S’-shaped incision, n = 106). The procedures, including operations and dressing changes, were performed by the same doctors. All of the surgical procedures were performed under general anesthesia. This study was reviewed and approved by our institutional review board. Informed consent was provided by the patients (or children’s parents) involved in the study. This study was also approved by the local ethical committee. Preoperative clinical evaluations
The detailed history of each patient was reviewed to determine the injection site around the gluteal region, premorbid and current activity levels, walking aid requirement, and nonoperative treatment mode received (including medications, herbs, physiotherapy, and acupuncture). The following parameters were also evaluated before the operation: (i) gait pattern, (ii) gluteal muscle wasting, (iii) loss of lumbar lordosis or hyperlordotic lumbosacral spine, (iv) excessive external rotation of the hip at rest, (v) dimpling of skin around the gluteal region, (vi) hip pain, (vii) presence of a snapping hip, (viii) adduction and flexion ranges of motion (ROMs) of the hip, (ix) tightness of the iliotibial band, (x) Ober’s sign, (xi) neurological deficit, (xii) squatting and crouching ability with both hips in a neutral position, and (xiii) cross-legged sitting. All of the patients had been injected around the gluteal region and exhibited simultaneous abnormal out-toe walking gait and positive Ober’s sign. The patients who suffered from neuromuscular diseases, spinal deformity, and iliotibial band contracture around the knee joint were excluded from this research. According to the grading system (Table 1) proposed by Zhao et al. [11], all of the sides of every patient were classified into three levels. Among the 379 patients, 90,
267, and 226 sides were classified into levels I, II, and III, respectively. Among the patients, 204 were operated on both sides and 175 were operated unilaterally. Patients Group A (traverse straight incision)
Eighty-six patients, 47 female and 39 male, were included in this group. These patients were aged between 7 and 33 years, with a mean age of 18.8 ± 7.7 years. As the serum albumin concentration is related to incision recovery and drainage to some extent, this factor was taken into consideration for comparison of every group before surgery. The serum albumin concentration ranged from 28 to 50 g/l, with a mean of 38.6 ± 7.4 g/l. According to the grading system, 17, 61, and 56 sides were classified as levels I, II, and III, respectively. Among all of the patients in this group, 48 suffered bilaterally and 38 suffered unilaterally, among whom 25 and 13 experienced suffering on the right side and the left side, respectively. Group B (curved incision)
A total of 93 patients, 51 female and 42 male, were included in this group. These patients were aged between 6 and 35 years, with a mean age of 20.5 ± 8.7 years. Serum albumin concentration ranged from 32 to 48 g/l, with a mean of 39.7 ± 5.6 g/l. According to the grading system, 26, 65, and 54 sides were classified as levels I, II, and III, respectively. Among these patients, 52 suffered bilaterally and 41 suffered unilaterally, among whom 28 and 13 experienced suffering on the right side and the left side, respectively. Group C (longitudinal straight incision)
A total of 94 patients, 61 female and 33 male, were included in this group. These patients were aged between 6 and 38 years, with a mean age of 24.4 ± 7.7 years. Serum albumin concentration ranged from 31 to 46 g/l, with a mean of 36.7 ± 5.8 g/l. According to the grading system, 19, 67, and 58 sides were classified as levels I, II, and III, respectively. Among these patients, 50 suffered bilaterally and 44 suffered unilaterally, among whom 27 and 17 experienced suffering on the right side and the left side, respectively.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Comparison of the incisions of GMC Xu et al. 437
Group D (‘S’-shaped incision)
A total of 106 patients, 63 female and 43 male, were included in this group. These patients were aged between 8 and 44 years, with a mean age of 28.4 ± 5.7 years. Serum albumin concentration ranged from 33 to 48 g/l, with a mean of 36.2 ± 6.6 g/l. According to the grading system, 28, 74, and 58 sides were classified as levels I, II, and III, respectively. Among these patients, 54 suffered bilaterally and 52 suffered unilaterally, among whom 29 and 23 experienced suffering on the right side and the left side, respectively. Data were analyzed using SPSS 20.0 (SPSS Inc., Chicago, Illinois, USA). No evident difference was observed among the four groups in terms of age, serum albumin concentration, and severity. Operative management
With the patients in a lateral position, the skin was incised (5–10 cm; Fig. 1a–d). Both sides of the same patients were similarly incised. The total number of incisions was 583. A longitudinal straight incision was made directly on the greater trochanter. A traverse straight incision and a curved incision were made 2 cm Fig. 1
(a)
(b)
(c)
(d)
above the greater trochanter, and an ‘S’-shaped incision was made in the posterior superior area 2 cm above the greater trochanter, such that the ‘S’-shaped incision was tilted 30° from the body’s vertical axis. After the incision had been made, the fibrotic band was exposed. Thereafter, a Z-plasty technique was used in the operation [12]. Considering the category or severity of the disease, we released the tensor fasciae, gluteus maximus, gluteus medius, gluteus mimimus, or joint capsula until Ober’s sign disappeared. The following results were observed: the back-extending test was negative; the unequal lengths of the legs were improved; the hip joint could move freely; and the clicks disappeared. A drainage catheter was then placed, and the two legs were fixed side by side with the knees and the hips flexed. The patients’ muscle contracture was carefully recorded, and excessive release was avoided if muscle weakness was observed in the lower limbs. Considering that several patients suffered bilaterally, we operated each of these patients on one side and then on the other side by turning and repositioning. All the surgeries were completed by the same group of doctors. Postsurgical treatment
After the operation, the patients were instructed to lie in a lateral position to compress one side, as a 2 kg ice bag was placed on the other side. To ensure good hemostasis, we switched the patient’s position every 1–2 h. In the four groups, drainage tubes were placed and kept in the body for 1–2 days after surgery. Fluid exudates from the wound during the first 48–72 h were carefully observed and recorded in terms of nature and amount. After the drainage tubes were removed, the patients were required to begin functional exercises such as walking in a line, straightening waist, adducting hip joint several times a day, standing on one leg, squatting with the knees positioned side by side, and sitting with the two legs crossed. The patients with legs of unequal length were instructed to perform additional exercises, including low limb skin traction, pelvis and hip movement, and downward and upward movement of the two legs in a supine position to straighten up the hip muscles and maintain balance. Most of the patients stopped taking analgesics within 48 h. Pain-sensitive patients were required to place their legs on a continuous passive motion machine to improve the normal range of movement. Any other healing measure, such as millimeter wave, ultrashort wave, ultrasonic wave, or hyperbaric oxygenation, to promote recovery depended on the preference and financial status of the patient, and the severity of the condition. Evaluation of efficacy
(a) Traverse straight incision, (b) curved incision, (c) longitudinal straight incision, (d) ‘S’-shaped incision.
Two weeks after the surgery, the length of the incision, the drainage amount, pain intensity, which was measured using a 10 cm visual analog scale score, improvement in
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
438 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
Table 2
Comparison of the clinical results from the four groups Drainage amount (ml)
Group Group A Group B Group C Group D P-value
Level I
Level II
VAS Level III
138.1 ± 11.3 216.6 ± 52.6 313.9 ± 50.1 143.6 ± 11.7 214.7 ± 50.8 312.9 ± 49.6 131.5 ± 12.3 225.8 ± 41.5 298.7 ± 57.8 93.4 ± 10.8 156.6 ± 47.8 209.7 ± 51.5 PA–B = 0.970, PA–C = 0.875 PA–D = 0.023 PB–C = 0.735 PB–D = 0.015, PC–D = 0.007
Level I
Level II
Primary wound healing rates Level III
2.5 ± 0.6 3.3 ± 1.0 3.6 ± 0.9 2.6 ± 0.6 3.2 ± 1.1 3.5 ± 0.7 3.0 ± 0.4 3.6 ± 1.4 3.8 ± 1.1 2.8 ± 0.5 3.1 ± 1.0 3.2 ± 1.3 PA–B = 0.932, PA–C = 0.965 PA–D = 0.729, PB–C = 0.831 PB–D = 0.712, PC–D = 0.907
Level I
Level II
Level III
91.4% 87.8% 84.2% 89.3% 80.0% 85.1% 86.1% 83.2% 79.1% 97.8% 93.1% 94.1% PA–B = 0.813, PA–C = 0.898 PA–D = 0.015, PB–C = 0.724 PB–D = 0.008, PC–D = 0.017
Length of incision (cm) 5.3 ± 0.6 5.1 ± 0.6 5.6 ± 1.0 5.4 ± 1.3 PA–B = 0.783, PA–C = 0.768 PA–D = 0.865, PB–C = 0.797 PB–D = 0.679, PC–D = 0.917
PA–B, PA–C, PA–D, PB–C, PB–D, and PC–D correspond to group A versus group B, group C, and group D; group B versus group C, group D; and group C versus group D, respectively. VAS, visual analog scale.
the degree of ROM, and primary wound healing rates were compared. The criteria according to Liu et al. [13] were applied to evaluate the results during the follow-up period. The validity of the results was described in terms of four grades: excellent, good, fair, and poor. The results were considered excellent if the following conditions were observed: first-stage wound healing, normal gait, disappearance of preoperative signs and pelvic tilt, equal lengths of the legs, hip muscle strength at level 5, and normal ROM. The conditions for good results were similar to those for excellent results except hip muscle strength was set at level 4 and ROM loss was less than 10%. The results were considered fair if the following conditions were observed: first-stage wound healing without complications, disappearance of most preoperative signs and abnormal gait, slight pelvic tilt, difference in length of legs less than 1.5 cm, hip muscle strength at level 3 or 4, and 10–25% loss of ROM. The results were considered poor if a patient achieved firststage wound healing without complications but still exhibited uncorrected gait; a poor grade was given if the following conditions were observed: positive signs present preoperatively, pelvic tilt, difference in the length of legs greater than 1.5 cm, hip muscle strength less than level 3, and greater than 25% loss of ROM. All of the patients were followed up at regular intervals from 6 months to 2.5 years, with a mean of 2 years. The complications with 1-year recurrence were evaluated. Table 3
Statistical analysis
Statistical analysis was carried out using SPSS 20.0 software. Enumerated data were analyzed using χ2-tests, and measured data were analyzed using t-tests. P less than 0.05 was considered statistically significant.
Results Several aspects were analyzed. No statistical significance (P > 0.05) was observed in the length of incisions among the four groups, in which the average lengths (Table 2) were 5.3 ± 0.6 cm (group A), 5.1 ± 0.6 cm (group B), 5.6 ± 1.0 cm (group C), and 5.4 ± 1.3 cm (group D). Using the visual analog scale score, we found no significant differences among the four groups (P > 0.05; Table 2). Tables 2–5 show that wound healing rates, drainage amount, improvement in ROM, efficacy results, and recurrences were significantly better in group D (P < 0.05). However, no significant difference was found in groups A, B, and C in terms of wound healing rates, drainage amount, and improvement in ROM (Table 3). The efficacy results and 1-year recurrence showed that groups A and B were not significantly different, although these groups showed better results than group C (Tables 4 and 5). No complications of hematoma formation in the wound were observed. The majority of the patients showed primary wound healing. All of the cases of failure of primary wound healing were due to malnutrition, infection, and fat liquefaction, although these patients recovered after a nutritional supplement was
Comparison of the improved degree of range of motion in the all groups Increased degree of abduction ROM
Group Group A Group B Group C Group D P-value
Increased degree of flexion ROM
Level I
Level II
Level III
Level I
Level II
Level III
9.9 ± 1.6 10.5 ± 1.8 8.6 ± 2.3 13.4 ± 1.9 PA–B = 0.723 PB–C = 0.615
16.0 ± 3.0 15.6 ± 2.6 14.9 ± 4.3 25.7 ± 7.3 PA–C = 0.425 PB–D = 0.019
24.3 ± 3.4 22.7 ± 3.8 24.6 ± 2.9 37.4 ± 6.6 PA–D = 0.018 PC–D = 0.022
20.0 ± 3.9 21.0 ± 4.1 17.7 ± 3.4 25.4 ± 4.3 PA–B = 0.861 PB–C = 0.525
25.8 ± 5.8 23.1 ± 4.9 24.9 ± 5.3 35.4 ± 6.3 PA–C = 0.836 PB–D = 0.011
23.6 ± 5.5 22.2 ± 6.1 20.2 ± 4.6 41.7 ± 7.6 PA–D = 0.034 PC–D = 0.002
PA–B, PA–C, PA–D, PB–C, PB–D, and PC–D correspond to group A versus group B, group C, group D; group B versus group C, group D; and group C versus group D, respectively. ROM, range of motion.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Comparison of the incisions of GMC Xu et al. 439
Table 4
Validity of the results in the follow-up period Group A
Validity Excellent Good Fair Poor P-value
Group B
Level I
Level II
Level III
9 4 3 1
31 21 2 7
27 13 6 10
Level I
Level II
Group C Level III
Level I
Level II
Group D Level III
Level I
13 34 30 7 23 20 20 6 17 11 3 13 12 4 6 9 6 5 14 11 3 1 5 7 4 13 15 1 PA–B = 0.326, PA–C = 0.035, PA–D = 0.027, PB–C = 0.043, PB–D = 0.002, PC–D = 0.001
Level II
Level III
56 10 5 3
37 14 3 4
The validity of the results in this table was evaluated on the basis of the improvement observed in different sides with various suffering. PA–B, PA–C, PA–D, PB–C, PB–D, and PC–D correspond to group A versus group B, group C, group D; group B versus group C, group D; and group C versus group D, respectively.
Table 5
Recurrence of all groups in the follow-up Group A
Group
Group B
Level I
Level II
Level III
1
3
3
Recurrence P-value
Level I
Level II
Group C Level III
Level I
Level II
Group D Level III
Level I
0 2 3 2 7 6 0 PA–B = 0.895, PA–C = 0.046, PA–D = 0.017, PB–C = 0.043, PB–D = 0.002, PC–D = 0.001
Level II
Level III
0
1
PA–B, PA–C, PA–D, PB–C, PB–D, and PC–D correspond to group A versus group B, group C, group D; group B versus group C, group D; and group C versus group D, respectively.
provided and liquefacient fat or infected tissue was debrided. The functional improvements were the most significant. Two weeks after surgery, all of the patients could crouch with both knees close to each other and sit with their legs crossed. No clicking sound or Ober’s sign was observed during the rotation of the hip. All of the patients showed improvement in ROM of abduction and flexion, whereas group D showed a significant increase with an average of 13.4 ± 1.9° and 25.4 ± 4.3° (level I), 25.7 ± 7.3° and 35.4 ± 6.3° (level II), and 37.4 ± 6.6° and 41.7 ± 7.6° (level III). The follow-up period ranged from 1 to 5 years, with an average of 3 years. During the follow-up period, no adverse effects were observed. We did not observe any sign of sciatic nerve injury and myasthenia reaction as a result of excessive release. Considering 1-year recurrence, we found that 28 cases recurred mostly because of cicatricial contraction caused by the lack of postoperative functional exercises. Only few cases were due to insufficient release. The 2- and 3-year recurrence results remained the same as the 1-year recurrence results.
Discussion GMC release can effectively relieve symptoms. Patients with GMC should be treated early to prevent complications such as knee osteoarthritis and pelvis obliquity. As GMC can affect the growth of the pelvis and femur, the children who are over 2 years old can be operated upon. Open surgery is considered as one of the most effective procedures to treat GMC and to improve the patients’ quality of life [2,13,14]. White et al. [15] showed that a longitudinal straight incision yields excellent results. Chen et al. [16] reported on the diagnosis and treatment of unilateral GMC and concluded that a curved incision
above the greater trochanter of the femur can also yield excellent results. Other studies on incisions have also been conducted. However, few studies have compared the effects of incisions used in open surgery. Considering previous studies, we developed a modified incision, namely the ‘S’-shaped incision, and compared it with the different incisions made in a relatively safe region to avoid neurovascular injuries [17]. In our study, a novel grading system with three levels was used. In addition, the sides of the patients in the four groups were divided according to this system for a more detailed comparison and to reduce systematic error. Our results showed that lower levels yielded better outcome because the contractured tissues were less, whereas excellent results was achieved mostly in patients classified as level I in the four groups, particularly in group D. The results also showed that the ‘S’-shaped incision has numerous advantages compared with the other three types of incisions. First, the ‘S’-shaped incision conforms to the biomechanics of patients who suffer from GMC and cannot maintain their lower extremity abducted and supinated for a long time; as such, their skin and subcutaneous tissues become contractured. After muscle contracture was released, the ‘S’-shaped incision straightened because of the contractural skin and subcutaneous tissues. Therefore, the ‘S’-shaped incision possibly lowered the tension at the site of incision. Other incisions were ruptured because of tension, particularly adduction and flexion. Second, the ‘S’-shaped incision was located on the lateral side of the distal one-third part of the line between the greater trochanter and the posterior superior iliac spine. This location is distant from the superficial branches of the inferior gluteal vessels and the inferior gluteal nerves. Therefore, neurovascular injuries
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
440
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
can be avoided. In our study, groups A and B showed better results than group C in terms of efficacy and recurrence because these groups were exposed more clearly than group C. No primary wound healing was observed in several patients, partly because of fat liquefaction in the incision and infection. This situation could be avoided by carefully performing postsurgical treatment. During the follow-up period, recurrent cases were observed in the four groups mostly because of insufficient functional exercises. Therefore, functional exercises have an important role in GMC treatment [18]. Several surgical points should also be considered in operative management. Almost all of the contractures were located on the upper half of the fiber of the gluteal muscle; most of these contractures were found on the iliotibial tract band on the surface of the gluteus medius and fasciae latae superficial to the tensor fasciae latae. These muscles are the major parts that should be released. Another factor involves the excessive release of muscles, particularly the gluteus medius and the gluteus minimus [19], which should be avoided to maintain the abduction function and achieve hip stability [20,21]. The gluteus maximus should be released with the superficial muscle to avoid sciatic nerve damage. An electrotome should be used properly to avoid normal tissue damage. All in all, our study provides useful information on the treatment of GMC. However, we should lay more emphasis on the prevention of this disease such as using a proper route of administration of antibiotics so that the number of patients can be decreased. Our study has several limitations. First, this study is a retrospective review of specifically selected cases. Second, several assessment criteria were evaluated on the basis of subjective judgment; therefore, the evaluated results may be biased and inaccurate. Despite these limitations, our case series was fairly large, in which 379 patients were included, and the follow-up period was at least 6 months. Hence, further prospective studies should be conducted to confirm these results.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2
3
4
5 6
7
8 9
10
11
12 13
14 15
16
17
18
Conclusion
The ‘S’-shaped incision above the greater trochanter is the most efficient among the incisions described in this study. This incision has the following advantages: clear exposure, less damage, high safety rate, excellent results, and low recurrence rate.
19
20 21
Fernandez de Valderrama JA, Esteve de Miguel R. Fibrosis of the gluteus maximus: a cause of limited flexion and adduction of the hip in children. Clin Orthop Relat Res 1981; 156:67–78. Liu G, Du J, Yang S, Zheng Q, Li J. A retrospective analysis of the gluteal muscles contracture and discussion of the relative problems. J Tongji Med Univ 2000; 20:70–71. Lejman T, Sulko J, Michno P. Surgical treatment of post-injection contracture of the hip in children. Chir Narzadow Ruchu Ortop Pol 1995; 60:39–41. Liu YJ, Wang Y, Xue J, Lui PP, Chan KM. Arthroscopic gluteal muscle contracture release with radiofrequency energy. Clin Orthop Relat Res 2009; 467:799–804. Sirinelli D, Oudjhane K, Khouri N. Case report 605: gluteal amyotrophy: a late sequela of intramuscular injection. Skeletal Radiol 1990; 19:221–223. Fu D, Yang S, Xiao B, Wang H, Meng C. Comparison of endoscopic surgery and open surgery for gluteal muscle contracture. J Pediatr Orthop 2011; 31:e38–e43. Chen SS, Chien CH, Yu HS. Syndrome of deltoid and/or gluteal fibrotic contracture: an injection myopathy. Acta Neurol Scand 1988; 78:167–176. Ganel A, Blankstein A. Congenital gluteus maximus contracture. Orthop Rev 1989; 18:95–97. Chung DC, Ko YC, Pai HH. A study on the prevalence and risk factors of muscular fibrotic contracture in Jia-Dong Township, Pingtung County, Taiwan. Gaoxiong Yi Xue Ke Xue Za Zhi 1989; 5:91–95. Khan M, Adamich J, Simunovic N, Philippon MJ, Bhandari M, Ayeni OR. Surgical management of internal snapping hip syndrome: a systematic review evaluating open and arthroscopic approaches. Arthroscopy 2013; 29:942–948. Zhao CG, He XJ, Lu B, Li HP, Wang D, Zhu ZZ. Classification of gluteal muscle contracture in children and outcome of different treatments. BMC Musculoskelet Disord 2009; 10:34. Brignall CG, Stainsby GD. The snapping hip. Treatment by Z-plasty. J Bone Joint Surg Br 1991; 73:253–254. Liu G, Yang S, Du J, Zheng Q, Shao Z, Yang C. Treatment of severe gluteal muscle contracture in children. J Huazhong Univ Sci Technolog Med Sci 2008; 28:171–173. Krebs DE, Robbins CE, Lavine L, Mann RW. Hip biomechanics during gait. J Orthop Sports Phys Ther 1998; 28:51–59. White RA, Hughes MS, Burd T, Hamann J, Allen WC. A new operative approach in the correction of external coxa saltans: the snapping hip. Am J Sports Med 2004; 32:1504–1508. Chen X, Tang X, Jiang X, Wang D, Peng M, Liu L. Diagnosis and treatment of unilateral gluteal muscle contracture. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2011; 25:530–532. Ye B, Zhou P, Xia Y, Chen Y, Yu J, Xu S. New minimally invasive option for the treatment of gluteal muscle contracture. Orthopedics 2012; 35: e1692–e1698. Liu GH, Cao FQ, Yang SH, Zhu JF. Factors influencing the treatment of severe gluteal muscle contracture in children. J Pediatr Orthop B 2011; 20:67–69. Beck M, Sledge JB, Gautier E, Dora CF, Ganz R. The anatomy and function of the gluteus minimus muscle. J Bone Joint Surg Br 2000; 82:358–363. Hamstra-Wright KL, Huxel BK. Effective exercises for targeting the gluteus medius. J Sport Rehabil 2012; 21:296–300. Reiman MP, Bolgla LA, Loudon JK. A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Physiother Theory Pract 2012; 28:257–268.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Comparison of the incisions for the open surgical treatment of gluteal muscle contracture Jian Xu*, Xiang Geng*, Hassan Muhammad, Xu Wang, Jia-Zhang Huang, Chao Zhang and Xin Ma Gluteal muscle contracture is not very common, but cases are still seen in China. Open surgical treatment is considered as an efficient method to treat this disease. However, the type of incision that can provide best results is yet to be determined. The authors therefore compared various incisions to determine the better one. In this retrospective study, patients who underwent surgery with a traverse straight incision, a curved incision, a longitudinal straight incision, or an ‘S’-shaped incision above the greater trochanter were enrolled and divided into four groups: A, B, C, and D. In each group, the patients were divided into different levels according to a specific standard. The four groups were compared in terms of incision length, postoperative drainage amounts, wound healing rates, visual analog scale scores, and improvement in the degree of range of motion (ROM). During the follow-up period, the validity of the results, complications, and recurrent cases were evaluated. In our study, incision length and visual analog scale score of the four groups showed no significant differences (P > 0.05). Wound healing rates, drainage amount, improvement in ROM, validity of the results, and
Introduction Gluteal muscle contracture (GMC), first reported by Fernandez de Valderrama [1], is a clinical syndrome characterized by lower-limb dysfunction and gait abnormality [2,3]. GMC is either caused by repeated intramuscular injection of methanol-diluted penicillin or has other unknown etiology [4–8]. Numerous cases of GMC have been reported in China because of the frequent use of benzyl alcohol as a solvent for penicillin in the 1970s and 1980s [9]. GMC is manifested through the formation of a fibrotic band in the gluteal region, tightening the gluteal muscles and resulting in the dysfunction of the lower limb and hip [1]. Patients with GMC typically present with fixed hip abduction and external rotation when squatting from the standing position. Physical examination shows a characteristic gait due to hip adduction and internal thigh rotation. To treat GMC, medical practitioners have used several surgical procedures, including endoscopic surgery. Retrospective studies have shown that endoscopic release provides better results than open surgical treatment [6]. However, with the lack of high-quality evidence for direct data comparison [10], open surgical treatment remains an efficient method to treat this 1060-152X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
recurrences in group D were significantly the best (P < 0.05). No significant differences in wound healing rates, drainage amount, and improvement in ROM were found in groups A, B, and C. In terms of validity of the results and 1-year recurrence, no significant difference was observed between groups A and B; however, these factors were better than those in group C. We concluded that the ‘S’-shaped incision above the greater trochanter is the most efficient among the incisions described in this study. This incision has the following advantages: clear exposure, less damage, high safety rate, excellent results, and low recurrence rate. J Pediatr Orthop B 23:435–440 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Journal of Pediatric Orthopaedics B 2014, 23:435–440 Keywords: gluteal muscle contracture, incisions, open surgical treatment Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, China Correspondence to Xin Ma, PhD, Department of Orthopedics, Huashan Hospital, Fudan University, Shanghai, 200040 China Tel: + 86 21 5288 999; fax: + 86 21 6248 9191; e-mail: [email protected] *Jian Xu and Xiang Geng contributed equally to the writing of this article.
disease because it has numerous advantages including easy operating procedures, clearer exposure, and low hospitalization costs. Different kinds of incisions are used in open surgery; however, few studies have compared the outcomes in patients with different incisions. To determine the specific incision that can be used more effectively in open surgical procedures, we described our experiences with using four types of incisions when we treated our patients with GMC. The four incisions were also compared in terms of several aspects. We considered the common etiology of injection, or the lateral upper side used as a common injection site, to simulate the most severe contracture that often occurs around the lower one-third part of the line of the iliac spine and the trochanter. Considering the sites of pathological changes and hip anatomy, we hypothesized that better results can be obtained using an ‘S’-shaped incision compared with other incisions.
Methods Study design
A retrospective study was conducted to compare the four incisions used to treat GMC. A total of 516 patients were operated upon consecutively at our hospital including DOI: 10.1097/BPB.0000000000000067
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
436 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
Table 1
Classification of gluteal muscle contracture [6]
Grading Level I (mild)
Level II (moderate)
Level III (severe)
Signs and symptoms The external rotation of the lower limb is mild, the abduction contracture is < 15° with both the hip and the knee joint in 90° flexion, or adduction range < 20° with no flexion. Ober’s sign and frog-squatting sign are weakly positive. The limp gait is not apparent, with lateral inclination of the pelvis on the anteroposterior radiograph being < 10° The external rotation of the lower limb is moderate, the abduction contracture ranges from 15° to 60° with both the hip and the knee joint in 90° flexion, or adduction range < 10° with no flexion. Ober’s sign and frog-squatting sign are positive. The limp gait is apparent, with lateral inclination of the pelvis on the anteroposterior radiograph being < 20° The external rotation of the lower limb is severe, the abduction contracture is > 60° with both the hip and the knee joint in 90° flexion, or adduction range < 0° with no flexion. Ober’s sign and frog-squatting sign are strongly positive. The limp gait is remarkably apparent, with lateral inclination of pelvis on the anteroposterior radiograph being > 20°
those who underwent endoscopic and open surgical treatment between October 2008 and March 2012. A total of 379 patients who underwent open surgery with a traverse straight incision, a curved incision, a longitudinal straight incision, and an ‘S’-shaped incision above the greater trochanter were also included in the study. These patients were divided into four groups: group A (traverse straight incision, n = 86), group B (curved incision, n = 93), group C (longitudinal straight incision, n = 94), and group D (‘S’-shaped incision, n = 106). The procedures, including operations and dressing changes, were performed by the same doctors. All of the surgical procedures were performed under general anesthesia. This study was reviewed and approved by our institutional review board. Informed consent was provided by the patients (or children’s parents) involved in the study. This study was also approved by the local ethical committee. Preoperative clinical evaluations
The detailed history of each patient was reviewed to determine the injection site around the gluteal region, premorbid and current activity levels, walking aid requirement, and nonoperative treatment mode received (including medications, herbs, physiotherapy, and acupuncture). The following parameters were also evaluated before the operation: (i) gait pattern, (ii) gluteal muscle wasting, (iii) loss of lumbar lordosis or hyperlordotic lumbosacral spine, (iv) excessive external rotation of the hip at rest, (v) dimpling of skin around the gluteal region, (vi) hip pain, (vii) presence of a snapping hip, (viii) adduction and flexion ranges of motion (ROMs) of the hip, (ix) tightness of the iliotibial band, (x) Ober’s sign, (xi) neurological deficit, (xii) squatting and crouching ability with both hips in a neutral position, and (xiii) cross-legged sitting. All of the patients had been injected around the gluteal region and exhibited simultaneous abnormal out-toe walking gait and positive Ober’s sign. The patients who suffered from neuromuscular diseases, spinal deformity, and iliotibial band contracture around the knee joint were excluded from this research. According to the grading system (Table 1) proposed by Zhao et al. [11], all of the sides of every patient were classified into three levels. Among the 379 patients, 90,
267, and 226 sides were classified into levels I, II, and III, respectively. Among the patients, 204 were operated on both sides and 175 were operated unilaterally. Patients Group A (traverse straight incision)
Eighty-six patients, 47 female and 39 male, were included in this group. These patients were aged between 7 and 33 years, with a mean age of 18.8 ± 7.7 years. As the serum albumin concentration is related to incision recovery and drainage to some extent, this factor was taken into consideration for comparison of every group before surgery. The serum albumin concentration ranged from 28 to 50 g/l, with a mean of 38.6 ± 7.4 g/l. According to the grading system, 17, 61, and 56 sides were classified as levels I, II, and III, respectively. Among all of the patients in this group, 48 suffered bilaterally and 38 suffered unilaterally, among whom 25 and 13 experienced suffering on the right side and the left side, respectively. Group B (curved incision)
A total of 93 patients, 51 female and 42 male, were included in this group. These patients were aged between 6 and 35 years, with a mean age of 20.5 ± 8.7 years. Serum albumin concentration ranged from 32 to 48 g/l, with a mean of 39.7 ± 5.6 g/l. According to the grading system, 26, 65, and 54 sides were classified as levels I, II, and III, respectively. Among these patients, 52 suffered bilaterally and 41 suffered unilaterally, among whom 28 and 13 experienced suffering on the right side and the left side, respectively. Group C (longitudinal straight incision)
A total of 94 patients, 61 female and 33 male, were included in this group. These patients were aged between 6 and 38 years, with a mean age of 24.4 ± 7.7 years. Serum albumin concentration ranged from 31 to 46 g/l, with a mean of 36.7 ± 5.8 g/l. According to the grading system, 19, 67, and 58 sides were classified as levels I, II, and III, respectively. Among these patients, 50 suffered bilaterally and 44 suffered unilaterally, among whom 27 and 17 experienced suffering on the right side and the left side, respectively.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Comparison of the incisions of GMC Xu et al. 437
Group D (‘S’-shaped incision)
A total of 106 patients, 63 female and 43 male, were included in this group. These patients were aged between 8 and 44 years, with a mean age of 28.4 ± 5.7 years. Serum albumin concentration ranged from 33 to 48 g/l, with a mean of 36.2 ± 6.6 g/l. According to the grading system, 28, 74, and 58 sides were classified as levels I, II, and III, respectively. Among these patients, 54 suffered bilaterally and 52 suffered unilaterally, among whom 29 and 23 experienced suffering on the right side and the left side, respectively. Data were analyzed using SPSS 20.0 (SPSS Inc., Chicago, Illinois, USA). No evident difference was observed among the four groups in terms of age, serum albumin concentration, and severity. Operative management
With the patients in a lateral position, the skin was incised (5–10 cm; Fig. 1a–d). Both sides of the same patients were similarly incised. The total number of incisions was 583. A longitudinal straight incision was made directly on the greater trochanter. A traverse straight incision and a curved incision were made 2 cm Fig. 1
(a)
(b)
(c)
(d)
above the greater trochanter, and an ‘S’-shaped incision was made in the posterior superior area 2 cm above the greater trochanter, such that the ‘S’-shaped incision was tilted 30° from the body’s vertical axis. After the incision had been made, the fibrotic band was exposed. Thereafter, a Z-plasty technique was used in the operation [12]. Considering the category or severity of the disease, we released the tensor fasciae, gluteus maximus, gluteus medius, gluteus mimimus, or joint capsula until Ober’s sign disappeared. The following results were observed: the back-extending test was negative; the unequal lengths of the legs were improved; the hip joint could move freely; and the clicks disappeared. A drainage catheter was then placed, and the two legs were fixed side by side with the knees and the hips flexed. The patients’ muscle contracture was carefully recorded, and excessive release was avoided if muscle weakness was observed in the lower limbs. Considering that several patients suffered bilaterally, we operated each of these patients on one side and then on the other side by turning and repositioning. All the surgeries were completed by the same group of doctors. Postsurgical treatment
After the operation, the patients were instructed to lie in a lateral position to compress one side, as a 2 kg ice bag was placed on the other side. To ensure good hemostasis, we switched the patient’s position every 1–2 h. In the four groups, drainage tubes were placed and kept in the body for 1–2 days after surgery. Fluid exudates from the wound during the first 48–72 h were carefully observed and recorded in terms of nature and amount. After the drainage tubes were removed, the patients were required to begin functional exercises such as walking in a line, straightening waist, adducting hip joint several times a day, standing on one leg, squatting with the knees positioned side by side, and sitting with the two legs crossed. The patients with legs of unequal length were instructed to perform additional exercises, including low limb skin traction, pelvis and hip movement, and downward and upward movement of the two legs in a supine position to straighten up the hip muscles and maintain balance. Most of the patients stopped taking analgesics within 48 h. Pain-sensitive patients were required to place their legs on a continuous passive motion machine to improve the normal range of movement. Any other healing measure, such as millimeter wave, ultrashort wave, ultrasonic wave, or hyperbaric oxygenation, to promote recovery depended on the preference and financial status of the patient, and the severity of the condition. Evaluation of efficacy
(a) Traverse straight incision, (b) curved incision, (c) longitudinal straight incision, (d) ‘S’-shaped incision.
Two weeks after the surgery, the length of the incision, the drainage amount, pain intensity, which was measured using a 10 cm visual analog scale score, improvement in
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
438 Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
Table 2
Comparison of the clinical results from the four groups Drainage amount (ml)
Group Group A Group B Group C Group D P-value
Level I
Level II
VAS Level III
138.1 ± 11.3 216.6 ± 52.6 313.9 ± 50.1 143.6 ± 11.7 214.7 ± 50.8 312.9 ± 49.6 131.5 ± 12.3 225.8 ± 41.5 298.7 ± 57.8 93.4 ± 10.8 156.6 ± 47.8 209.7 ± 51.5 PA–B = 0.970, PA–C = 0.875 PA–D = 0.023 PB–C = 0.735 PB–D = 0.015, PC–D = 0.007
Level I
Level II
Primary wound healing rates Level III
2.5 ± 0.6 3.3 ± 1.0 3.6 ± 0.9 2.6 ± 0.6 3.2 ± 1.1 3.5 ± 0.7 3.0 ± 0.4 3.6 ± 1.4 3.8 ± 1.1 2.8 ± 0.5 3.1 ± 1.0 3.2 ± 1.3 PA–B = 0.932, PA–C = 0.965 PA–D = 0.729, PB–C = 0.831 PB–D = 0.712, PC–D = 0.907
Level I
Level II
Level III
91.4% 87.8% 84.2% 89.3% 80.0% 85.1% 86.1% 83.2% 79.1% 97.8% 93.1% 94.1% PA–B = 0.813, PA–C = 0.898 PA–D = 0.015, PB–C = 0.724 PB–D = 0.008, PC–D = 0.017
Length of incision (cm) 5.3 ± 0.6 5.1 ± 0.6 5.6 ± 1.0 5.4 ± 1.3 PA–B = 0.783, PA–C = 0.768 PA–D = 0.865, PB–C = 0.797 PB–D = 0.679, PC–D = 0.917
PA–B, PA–C, PA–D, PB–C, PB–D, and PC–D correspond to group A versus group B, group C, and group D; group B versus group C, group D; and group C versus group D, respectively. VAS, visual analog scale.
the degree of ROM, and primary wound healing rates were compared. The criteria according to Liu et al. [13] were applied to evaluate the results during the follow-up period. The validity of the results was described in terms of four grades: excellent, good, fair, and poor. The results were considered excellent if the following conditions were observed: first-stage wound healing, normal gait, disappearance of preoperative signs and pelvic tilt, equal lengths of the legs, hip muscle strength at level 5, and normal ROM. The conditions for good results were similar to those for excellent results except hip muscle strength was set at level 4 and ROM loss was less than 10%. The results were considered fair if the following conditions were observed: first-stage wound healing without complications, disappearance of most preoperative signs and abnormal gait, slight pelvic tilt, difference in length of legs less than 1.5 cm, hip muscle strength at level 3 or 4, and 10–25% loss of ROM. The results were considered poor if a patient achieved firststage wound healing without complications but still exhibited uncorrected gait; a poor grade was given if the following conditions were observed: positive signs present preoperatively, pelvic tilt, difference in the length of legs greater than 1.5 cm, hip muscle strength less than level 3, and greater than 25% loss of ROM. All of the patients were followed up at regular intervals from 6 months to 2.5 years, with a mean of 2 years. The complications with 1-year recurrence were evaluated. Table 3
Statistical analysis
Statistical analysis was carried out using SPSS 20.0 software. Enumerated data were analyzed using χ2-tests, and measured data were analyzed using t-tests. P less than 0.05 was considered statistically significant.
Results Several aspects were analyzed. No statistical significance (P > 0.05) was observed in the length of incisions among the four groups, in which the average lengths (Table 2) were 5.3 ± 0.6 cm (group A), 5.1 ± 0.6 cm (group B), 5.6 ± 1.0 cm (group C), and 5.4 ± 1.3 cm (group D). Using the visual analog scale score, we found no significant differences among the four groups (P > 0.05; Table 2). Tables 2–5 show that wound healing rates, drainage amount, improvement in ROM, efficacy results, and recurrences were significantly better in group D (P < 0.05). However, no significant difference was found in groups A, B, and C in terms of wound healing rates, drainage amount, and improvement in ROM (Table 3). The efficacy results and 1-year recurrence showed that groups A and B were not significantly different, although these groups showed better results than group C (Tables 4 and 5). No complications of hematoma formation in the wound were observed. The majority of the patients showed primary wound healing. All of the cases of failure of primary wound healing were due to malnutrition, infection, and fat liquefaction, although these patients recovered after a nutritional supplement was
Comparison of the improved degree of range of motion in the all groups Increased degree of abduction ROM
Group Group A Group B Group C Group D P-value
Increased degree of flexion ROM
Level I
Level II
Level III
Level I
Level II
Level III
9.9 ± 1.6 10.5 ± 1.8 8.6 ± 2.3 13.4 ± 1.9 PA–B = 0.723 PB–C = 0.615
16.0 ± 3.0 15.6 ± 2.6 14.9 ± 4.3 25.7 ± 7.3 PA–C = 0.425 PB–D = 0.019
24.3 ± 3.4 22.7 ± 3.8 24.6 ± 2.9 37.4 ± 6.6 PA–D = 0.018 PC–D = 0.022
20.0 ± 3.9 21.0 ± 4.1 17.7 ± 3.4 25.4 ± 4.3 PA–B = 0.861 PB–C = 0.525
25.8 ± 5.8 23.1 ± 4.9 24.9 ± 5.3 35.4 ± 6.3 PA–C = 0.836 PB–D = 0.011
23.6 ± 5.5 22.2 ± 6.1 20.2 ± 4.6 41.7 ± 7.6 PA–D = 0.034 PC–D = 0.002
PA–B, PA–C, PA–D, PB–C, PB–D, and PC–D correspond to group A versus group B, group C, group D; group B versus group C, group D; and group C versus group D, respectively. ROM, range of motion.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Comparison of the incisions of GMC Xu et al. 439
Table 4
Validity of the results in the follow-up period Group A
Validity Excellent Good Fair Poor P-value
Group B
Level I
Level II
Level III
9 4 3 1
31 21 2 7
27 13 6 10
Level I
Level II
Group C Level III
Level I
Level II
Group D Level III
Level I
13 34 30 7 23 20 20 6 17 11 3 13 12 4 6 9 6 5 14 11 3 1 5 7 4 13 15 1 PA–B = 0.326, PA–C = 0.035, PA–D = 0.027, PB–C = 0.043, PB–D = 0.002, PC–D = 0.001
Level II
Level III
56 10 5 3
37 14 3 4
The validity of the results in this table was evaluated on the basis of the improvement observed in different sides with various suffering. PA–B, PA–C, PA–D, PB–C, PB–D, and PC–D correspond to group A versus group B, group C, group D; group B versus group C, group D; and group C versus group D, respectively.
Table 5
Recurrence of all groups in the follow-up Group A
Group
Group B
Level I
Level II
Level III
1
3
3
Recurrence P-value
Level I
Level II
Group C Level III
Level I
Level II
Group D Level III
Level I
0 2 3 2 7 6 0 PA–B = 0.895, PA–C = 0.046, PA–D = 0.017, PB–C = 0.043, PB–D = 0.002, PC–D = 0.001
Level II
Level III
0
1
PA–B, PA–C, PA–D, PB–C, PB–D, and PC–D correspond to group A versus group B, group C, group D; group B versus group C, group D; and group C versus group D, respectively.
provided and liquefacient fat or infected tissue was debrided. The functional improvements were the most significant. Two weeks after surgery, all of the patients could crouch with both knees close to each other and sit with their legs crossed. No clicking sound or Ober’s sign was observed during the rotation of the hip. All of the patients showed improvement in ROM of abduction and flexion, whereas group D showed a significant increase with an average of 13.4 ± 1.9° and 25.4 ± 4.3° (level I), 25.7 ± 7.3° and 35.4 ± 6.3° (level II), and 37.4 ± 6.6° and 41.7 ± 7.6° (level III). The follow-up period ranged from 1 to 5 years, with an average of 3 years. During the follow-up period, no adverse effects were observed. We did not observe any sign of sciatic nerve injury and myasthenia reaction as a result of excessive release. Considering 1-year recurrence, we found that 28 cases recurred mostly because of cicatricial contraction caused by the lack of postoperative functional exercises. Only few cases were due to insufficient release. The 2- and 3-year recurrence results remained the same as the 1-year recurrence results.
Discussion GMC release can effectively relieve symptoms. Patients with GMC should be treated early to prevent complications such as knee osteoarthritis and pelvis obliquity. As GMC can affect the growth of the pelvis and femur, the children who are over 2 years old can be operated upon. Open surgery is considered as one of the most effective procedures to treat GMC and to improve the patients’ quality of life [2,13,14]. White et al. [15] showed that a longitudinal straight incision yields excellent results. Chen et al. [16] reported on the diagnosis and treatment of unilateral GMC and concluded that a curved incision
above the greater trochanter of the femur can also yield excellent results. Other studies on incisions have also been conducted. However, few studies have compared the effects of incisions used in open surgery. Considering previous studies, we developed a modified incision, namely the ‘S’-shaped incision, and compared it with the different incisions made in a relatively safe region to avoid neurovascular injuries [17]. In our study, a novel grading system with three levels was used. In addition, the sides of the patients in the four groups were divided according to this system for a more detailed comparison and to reduce systematic error. Our results showed that lower levels yielded better outcome because the contractured tissues were less, whereas excellent results was achieved mostly in patients classified as level I in the four groups, particularly in group D. The results also showed that the ‘S’-shaped incision has numerous advantages compared with the other three types of incisions. First, the ‘S’-shaped incision conforms to the biomechanics of patients who suffer from GMC and cannot maintain their lower extremity abducted and supinated for a long time; as such, their skin and subcutaneous tissues become contractured. After muscle contracture was released, the ‘S’-shaped incision straightened because of the contractural skin and subcutaneous tissues. Therefore, the ‘S’-shaped incision possibly lowered the tension at the site of incision. Other incisions were ruptured because of tension, particularly adduction and flexion. Second, the ‘S’-shaped incision was located on the lateral side of the distal one-third part of the line between the greater trochanter and the posterior superior iliac spine. This location is distant from the superficial branches of the inferior gluteal vessels and the inferior gluteal nerves. Therefore, neurovascular injuries
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
440
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
can be avoided. In our study, groups A and B showed better results than group C in terms of efficacy and recurrence because these groups were exposed more clearly than group C. No primary wound healing was observed in several patients, partly because of fat liquefaction in the incision and infection. This situation could be avoided by carefully performing postsurgical treatment. During the follow-up period, recurrent cases were observed in the four groups mostly because of insufficient functional exercises. Therefore, functional exercises have an important role in GMC treatment [18]. Several surgical points should also be considered in operative management. Almost all of the contractures were located on the upper half of the fiber of the gluteal muscle; most of these contractures were found on the iliotibial tract band on the surface of the gluteus medius and fasciae latae superficial to the tensor fasciae latae. These muscles are the major parts that should be released. Another factor involves the excessive release of muscles, particularly the gluteus medius and the gluteus minimus [19], which should be avoided to maintain the abduction function and achieve hip stability [20,21]. The gluteus maximus should be released with the superficial muscle to avoid sciatic nerve damage. An electrotome should be used properly to avoid normal tissue damage. All in all, our study provides useful information on the treatment of GMC. However, we should lay more emphasis on the prevention of this disease such as using a proper route of administration of antibiotics so that the number of patients can be decreased. Our study has several limitations. First, this study is a retrospective review of specifically selected cases. Second, several assessment criteria were evaluated on the basis of subjective judgment; therefore, the evaluated results may be biased and inaccurate. Despite these limitations, our case series was fairly large, in which 379 patients were included, and the follow-up period was at least 6 months. Hence, further prospective studies should be conducted to confirm these results.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2
3
4
5 6
7
8 9
10
11
12 13
14 15
16
17
18
Conclusion
The ‘S’-shaped incision above the greater trochanter is the most efficient among the incisions described in this study. This incision has the following advantages: clear exposure, less damage, high safety rate, excellent results, and low recurrence rate.
19
20 21
Fernandez de Valderrama JA, Esteve de Miguel R. Fibrosis of the gluteus maximus: a cause of limited flexion and adduction of the hip in children. Clin Orthop Relat Res 1981; 156:67–78. Liu G, Du J, Yang S, Zheng Q, Li J. A retrospective analysis of the gluteal muscles contracture and discussion of the relative problems. J Tongji Med Univ 2000; 20:70–71. Lejman T, Sulko J, Michno P. Surgical treatment of post-injection contracture of the hip in children. Chir Narzadow Ruchu Ortop Pol 1995; 60:39–41. Liu YJ, Wang Y, Xue J, Lui PP, Chan KM. Arthroscopic gluteal muscle contracture release with radiofrequency energy. Clin Orthop Relat Res 2009; 467:799–804. Sirinelli D, Oudjhane K, Khouri N. Case report 605: gluteal amyotrophy: a late sequela of intramuscular injection. Skeletal Radiol 1990; 19:221–223. Fu D, Yang S, Xiao B, Wang H, Meng C. Comparison of endoscopic surgery and open surgery for gluteal muscle contracture. J Pediatr Orthop 2011; 31:e38–e43. Chen SS, Chien CH, Yu HS. Syndrome of deltoid and/or gluteal fibrotic contracture: an injection myopathy. Acta Neurol Scand 1988; 78:167–176. Ganel A, Blankstein A. Congenital gluteus maximus contracture. Orthop Rev 1989; 18:95–97. Chung DC, Ko YC, Pai HH. A study on the prevalence and risk factors of muscular fibrotic contracture in Jia-Dong Township, Pingtung County, Taiwan. Gaoxiong Yi Xue Ke Xue Za Zhi 1989; 5:91–95. Khan M, Adamich J, Simunovic N, Philippon MJ, Bhandari M, Ayeni OR. Surgical management of internal snapping hip syndrome: a systematic review evaluating open and arthroscopic approaches. Arthroscopy 2013; 29:942–948. Zhao CG, He XJ, Lu B, Li HP, Wang D, Zhu ZZ. Classification of gluteal muscle contracture in children and outcome of different treatments. BMC Musculoskelet Disord 2009; 10:34. Brignall CG, Stainsby GD. The snapping hip. Treatment by Z-plasty. J Bone Joint Surg Br 1991; 73:253–254. Liu G, Yang S, Du J, Zheng Q, Shao Z, Yang C. Treatment of severe gluteal muscle contracture in children. J Huazhong Univ Sci Technolog Med Sci 2008; 28:171–173. Krebs DE, Robbins CE, Lavine L, Mann RW. Hip biomechanics during gait. J Orthop Sports Phys Ther 1998; 28:51–59. White RA, Hughes MS, Burd T, Hamann J, Allen WC. A new operative approach in the correction of external coxa saltans: the snapping hip. Am J Sports Med 2004; 32:1504–1508. Chen X, Tang X, Jiang X, Wang D, Peng M, Liu L. Diagnosis and treatment of unilateral gluteal muscle contracture. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2011; 25:530–532. Ye B, Zhou P, Xia Y, Chen Y, Yu J, Xu S. New minimally invasive option for the treatment of gluteal muscle contracture. Orthopedics 2012; 35: e1692–e1698. Liu GH, Cao FQ, Yang SH, Zhu JF. Factors influencing the treatment of severe gluteal muscle contracture in children. J Pediatr Orthop B 2011; 20:67–69. Beck M, Sledge JB, Gautier E, Dora CF, Ganz R. The anatomy and function of the gluteus minimus muscle. J Bone Joint Surg Br 2000; 82:358–363. Hamstra-Wright KL, Huxel BK. Effective exercises for targeting the gluteus medius. J Sport Rehabil 2012; 21:296–300. Reiman MP, Bolgla LA, Loudon JK. A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Physiother Theory Pract 2012; 28:257–268.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
