DOI: 10.5301/hipint.5000099
Hip Int 2014; 24 ( 2): 180-186
Original Article
Vastus lateralis transfer for severe hip abductor deficiency: a salvage procedure Kemble Wang 1, Stacey Cole 1, Dean C. White 1, Michael S. Armstrong 2 1 2
Eastern Health, Melbourne, Victoria - Australia Monash University Eastern Health, Melbourne, Victoria - Australia
Introduction: Abductor muscle deficiency can be a debilitating problem following hip arthroplasty surgery. We report outcomes of a novel method of abductor muscle function reconstruction surgery in patients with chronic, irreparable gluteus medius and minimus defects Patients and methods: Four consecutive patients who underwent our method of abductor reconstruction surgery were retrospectively reviewed. All patients had severe pain and positive Trendelenberg gait before surgery. Technique: the vastus lateralis (VL) muscle was raised on its neurovascular pedicle and transferred 12-14 centimetres by proximal translation. The proximal portion of VL was reattached via bony anchors to the external surface of the iliac wing just below the iliac crest. The distal portion of VL reattached to the lateral femoral shaft, lateral intermuscular septum, and the fascia of vastus intermedius. Results: Average follow-up was 10 months (range 7-15 months). Three of the four patients report dramatic improvement in pain as measured by the visual analogue pain scale. The same three patients report being “extremely satisfied” with the pain relief achieved and “extremely satisfied” with the operation overall. Two patients reported being “extremely satisfied” with improvements in walking. Hip abduction power improved in all patients but to varying degrees. Conclusion: The results show that our method of VL transfer may be a viable option for patients with severe abductor deficiency. Modest but clinically relevant early results are seen. Keywords: Hip abductors, Hip replacement, Muscle flap, Trendelenberg gait, Vastus lateralis Accepted: August 7, 2013
INTRODUCTION Abductor deficiency can follow hip replacement surgery, especially when a trans-gluteal approach had been utilised (1). The problem can be compounded when multiple procedures have been done on the same hip, with detachment and reattachment of the abductor muscles every time the hip joint is entered. Severe abductor deficiencies can thus result. Left chronically, a detached gluteus medius and minimus undergoes retraction and fatty degeneration (2) In cases where enough degeneration and retraction of the tendon has occurred, direct repair of the muscle can be surgically 180
impossible, even with maximal mobilisation of the muscle/ tendon unit. The resultant abductor deficit can lead to functional impairment either due directly to loss of abduction power, or secondarily from painful trochanteric inflammation, bursitis, and scar tissue. Several methods have been tried and reported in literature for treating abductor deficiencies that are not amenable to primary repair. These include bridging grafts using Achilles tendon (3) or synthetic materials (4, 5). Whilst being capable of bridging the physical gap, tendon and synthetic grafts alone do not provide additional power to an already weakened abductor muscle complex. Muscle flap transfers have
© 2013 Wichtig Editore - ISSN 1120-7000
Wang et al
also been proposed in response to the need to augment or replace the functional power of the native abductor muscles (6, 7). The gluteus maximus muscle transfer, which involves detachment of a posterior portion of this muscle and reattaching part of its insertion to the greater trochanter, has shown promising results in small case series (6). This technique however, is not based on an identifiable neurovascular pedicle and thus function of the transferred muscle is questionable. In addition, the resulting force vector on the greater trochanter is inevitably altered and more posterior than the vectors rendered by the native abductor muscles. Beck et al were the first to describe a proximal transfer of VL on its neurovascular pedicle to treat irreparable hip abductor defects (7). The technique involves: dissection and mobilisation of VL from rectus femoris and vastus intermedius, mobilisation of its (usually) two neurovascular pedicles (arising from the femoral nerve and descending branch of the lateral femoral circumflex artery), proximal transfer of the muscle on its two pedicles by 7-10 cm, reattachment of the proximal end of the VL flap to the remaining abductor muscle stump which is retracted proximally, and reattachment distally of the VL flap to the proximal femur and lateral intermuscular septum. Optimistic results have been achieved in two small series (8, 9). However, this originally described technique relies on viable abductor stump for proximal attachment of VL. In theory, it also relies on two separate muscle groups (residual hip abductors and VL) with two separate nerve supplies (superior gluteal nerve and femoral nerve) working synergistically to affect hip abduction. Failure of either of these two nervemuscle-tendon units will lead to decreased functionality of the construct. We report on a modified technique of Beck’s original description. Following mobilisation of the muscle, we attach the proximal portion of the VL flap directly to ilium, on the lateral surface of the iliac wing as superior as allowed by the neurovascular pedicle. Thus we eliminate the requirements of viable residual abductor tendon and synergistic action of the abductors together with VL if the two were attached in series. We report on the outcome of this technique in four patients treated at our institution.
MATERIALS AND METHODS This study was reviewed and approved by the institutional ethics review committee (study ID LR47/1213).
Patients Four consecutive patients at our institution who underwent proximal VL transfer were included for retrospective review. The relevant surgical history prior to VL transfer is presented in Table I. Patients were referred to our institution with chronic intractable abductor deficiency-related symptoms, and had failed extensive physical, hydro and analgesic therapies. All had undergone a trans-gluteal approach for their initial hip operations. Inclusion criteria are a definite positive Trendelenberg test, presence of a Trendelenberg gait, inability to sleep on the affected side, and severe pain and discomfort on the lateral hip significantly limiting ability to ambulate. All patients had multiple prior hip procedures for various complications following index hip arthroplasty surgery. Radiological confirmation of abductor defects were not routinely obtained as patients were noted intraoperatively in their previous procedures the existence of significant degeneration and retraction of the abductor muscles not amenable to primary repair. At time of VL transfer surgery, three of the four patients required concomitant bi-valved cadaveric proximal femoral allograft incorporating the greater trochanter because prosthetic wear osteolysis and prolonged abductor detachment had resulted in extensive bone loss.
Surgical technique Surgery was performed jointly between an Orthopaedic Surgeon (MA) and a Plastic and Reconstructive Surgeon (DW). The patient was placed in the lateral position. A lateral incision was made starting from just below the iliac crest extending to the lateral patella margin. Fascia lata and iliotibial band was split in line with its fibres. VL was mobilised according to the technique described by Beck et al (7). In brief, the plane between VL and rectus femoris, VL and vastus intermedius was developed proximal to distal. Care was taken to preserve the nerve supply to vastus intermedius. The neurovascular bundles (usually two) to VL were dissected and followed proximally (Figs. 1A and B). Insertion into quadriceps tendon was divided with a small margin of tendon to allow repair. The VL muscle was thus rendered mobile and can be transferred proximally by up to 15 cm. In patients with significant GT bone loss, femoral strut allograft was used at this stage to restore proximal femoral bone stock and secured with trochanteric grip plate and cables.
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A viable salvage procedure
TABLE I - RELEVANT SURGICAL HISTORY PRIOR TO VASTUS LATERALIS TRANSFER SURGERY Age
Index hip Implant operation used at index operation*
Time between index operation and VLT
Complication arising from index operation
Relevant medical history
Procedures following index operation
Number of Previous operations attempted prior to VLT abductor repair
Previous injections to abductors/ trochanteric bursa
Patient 1
79
THR
Zweimuller plus
6 years
Infected subfascial haematoma
On warfarin for past DVT
Multiple washout + debridement
6
LARS graft no
Patient 2
74
THR
Autofour
35 years
Cup protrusion
Rheumatoid arthritis
2x cup revisions
3
Direct repair with anchors
2 injections
Patient 3
60
Resurf
Birmingham
8 years
Wear osteolysis, ALVAL
Seronegative Washout of arthropathy ALVAL, revise to conventional THR
5
Direct repair with anchors
No
Patient 4
63
THR
Sulzer
12 years
Nil Cellulitis, wear osteolysis, retained lubricant induced aseptic loosening (Sulzer)
3
Nil
2 injections
Exploratory washout, 2x cup revisions for loosening
*Index hip operation: refers to the first initial operation patient underwent on their native hip. ALVAL: aseptic lymphocyte-dominated vasculitis-associated lesion. VLT: vastus lateralis transfer.
A
B
A
B
Fig. 1 - A, B) VL flap is mobilised and separated from RF (rectus femoris) and the rest of the quadriceps muscle. Neurovascular bundles (usually 2) enter the muscle near its proximal end. White arrow (Fig. 1A) is pointing to the (dominant) neurovascular pedicle embedded in surrounding fatty tissue. Left is distal in Fig. 1A.
Fig. 2 - A, B) VL flap secured in new position, attached distally to femur, vastus intermedius, and lateral intermuscular septum. Proximally attached to ilium. Left is distal in Fig. 2A.
The VL flap was then transferred as superiorly as allowed by the neurovascular pedicle, which is usually not far below the iliac crest, 12 to 14 cm above its original position. The proximal end of the VL flap was then attached to the anterolateral surface of the ilium using multiple titanium cork-screw anchors. The hip is then abducted by 30 degrees, and the
distal portion of the graft is secured to the trochanteric grip plate (if used), the lateral intermuscular septum, and the lateral femur (Figs. 2A and B). Post-operatively, touch weight-bearing in an abduction brace was allowed for the first six weeks. Thereafter gradual hip abduction exercises were commenced together
182
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Wang et al
ment), and distance calculated by calibrating with known prosthesis dimensions.
with full weight-bearing. Hydrotherapy was encouraged in all patients.
Follow-up assessment
RESULTS
Patients were reviewed at two weeks and six weeks postoperatively, and thereafter at every three months. Outcome data presented here are those obtained at the latest followup assessment. Hip abduction strength was measured and graded according to the British Medical Research Council Scale (M0 to M5). Oxford Hip score (10) and the modified WOMAC score for the hip (11) were recorded. Patients were asked to complete 11-point visual analogue pain scales ranging from 0 to 10, with 0 being no pain and 10 being the worst pain. A patient satisfaction questionnaire was also completed, containing four grades of satisfaction ranging from “extremely satisfied” to “dissatisfied” for each question. No statistical analyses were carried out due to the low number of patients involved. The distance over which VL was transferred proximally was measured radiologically. A direct line was drawn from the junction between GT and femoral shaft (the most proximal extent of VL origin) to the most superior corkscrew anchor (representing the most superior point of muscle reattach-
All four patients were women with an average age of 69 years. The average follow-up is 10 months (range 7-15 months). Patients had undergone an average of 4.3 (range 3-6) prior operations on the affected hip before vastus lateralis transfer surgery. Three patients had extensive GT osteolysis and required femoral strut allograft which was performed at time of vastus lateralis transfer. In two of the three patients, this was attributed to wear debris osteolysis. In the third patient, it was attributed to a combination of wear debris and previous infection-related osteolysis. Strut grafts were secured with trochanteric grip plates and cables and lie underneath the VL graft. Pre- and postoperative functional status are presented in Table II. Two of the four patients were able to stop using gait aids altogether whereas prior to VL transfer they were heavily dependent on them. Three of the four patients were able to reduce their analgesia requirement, with two pa-
TABLE II - FUNCTIONAL STATUS PRE AND POST VASTUS LATERALIS TRANSFER Follow-up Fibular duration strut graft
Gait aids
Analgesic requirements
Ability to lie on affected side
Hip abduction power
Oxford WOMAC hip score hip score
Pre VLT
Post VLT
Pre VLT
Post VLT
Pre VLT
Post VLT
Pre VLT
Post VLT
Post VLT
Post VLT
Patient 1 15 months yes
4 wheel walker
Nil
Paracetamol Oxycodone Tramadol
Nil
No
Occasionally
M1
M4
42
86.7
Patient 2 14 months No
Forearm crutch
Nil
Paracetamol Oxycodone
Nil
No
Yes
M1
M2
45
96.9
Patient 3 5 months
Yes
Single point stick
Single point stick
Paracetamol/ codeine Buprenorphine patch Tramadol
Paracetamol/ codeine
No
Occasionally
M1
M2
24
57
Patient 4 7 months
Yes
Single point stick
Single point stick
Paracetamol Oxycodone
Paracetamol Oxycodone
No
No
M1
M3
32
67.7
VLT: vastus lateralis transfer. © 2013 Wichtig Editore - ISSN 1120-7000
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A viable salvage procedure
tients no longer requiring any analgesia after many years of dependency. All four patients experienced modest improvements in hip abduction power. However, all four patients were still Trendelenberg test positive. Patient-perceived pain and satisfaction scores are presented in Table III. There was a significant improvement in pain scores for all patients except Patient 4. Three of the four patients were extremely satisfied with pain relief achieved by the operation, were extremely satisfied with the operation overall, and would be willing to undergo the same operation again. In general, satisfaction with pain relief is higher than with gait improvement. At time of latest follow-up, no complications were observed in any of the patients. One patient (Patient 1) required acetabular revision at three months postoperatively for symptomatic subluxation of the prosthetic femoral head which was a known occurrence prior to vastus lateralis transfer. It was originally hoped that the vastus lateralis transfer would increase stability and resolve this issue. However, when subluxation persisted, decision was made to revise the inclination of the acetabular component. The patient had no further stability problems since. During revision surgery for the acetabular component, it was noted that the vastus lateralis was healthy and viable and reactive to stimulation with electrocautery. The mean distance over which VL was advanced, as measured radiologically, was 13.4 cm (range 12.8-14.0 cm).
DISCUSSION This paper describes our modified VL transfer technique and the outcomes of this procedure in four patients with severe hip abductor deficiency. Our technique involves
direct attachment of proximal VL to ilium, thus removing the need to rely on viable residual abductor muscle stump. Modest but clinically relevant improvements in pain, function, and abduction power have been achieved. Importantly, three of the four patients were “extremely satisfied” with the improvements achieved from the operation. Based on measurements in cadaveric studies, Beck suggested that the maximum distance the VL flap can be proximalised is 10 cm, even if a 180º rotation of the flap was trialled (7). We conjecture that this may have contributed to that author’s practice of reattaching VL to the residual abductor stump rather than to the ilium. In our series, we were able to directly advance VL by an average of 13.4 cm, without the need for a 180º flap rotation. Whilst the difference may be partly attributable to different modes of measurement (radiological versus cadaveric), we believe that with adequate pedicle mobilisation and selective division of minor pedicles, a greater transfer distance could be safely achieved. The increased distance allowed us to attach the proximal end of VL directly to bony ilium rather than relying on a sometimes poor or even non-existent abductor stump. Three of the four patients received concomitant femoral strut allograft to GT at time of VL transfer for severe osteolysis. This additional procedure is also frequently utilised in previous reports of VL transfer (8, 9). In our series, GT was reconstructed with femoral allograft for the following reasons: to increase bone stock and prevent future prosthetic stem instability; to allow a greater abduction lever arm for the transferred VL to act on; and to improve the chance of biological integration of VL by preventing it from being in direct contact with a large area of bare femoral stem. We acknowledge that the postoperative joint function scores achieved in our patients are poor, particularly in patients 3 and 4. However, reported joint function scores
TABLE III - PATIENT PERCEIVED PAIN AND SATISFACTION RATINGS Pain Score
Satisfaction with pain relief
Satisfaction with gait improvement
Overall satisfaction with operation
Will undergo same operation again?
Pre VLT
Post VLT
Patient 1
7
0
Extremely satisfied
Extremely satisfied
Extremely satisfied
Yes
Patient 2
9
0
Extremely satisfied
Extremely satisfied
Extremely satisfied
Yes
Patient 3
10
3
Extremely satisfied
Somewhat satisfied
Extremely satisfied
Yes
Patient 4
5
3
Mostly satisfied
Somewhat satisfied
Mostly satisfied
Undecided
VLT: vastus lateralis transfer.
184
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Wang et al
following VL transfers by other authors are similarly poor (9). Patients who undergo this operation usually have had a high number of previous operations, which not only explain the reason for their irreparable abductor defects, but also the poor general soft tissue envelope of their hip joint. It is a weakness of this study that unfortunately we do not have preoperative functional scores to make meaningful comparison with. From the satisfaction survey (Tab. III), it appears that our patients were generally more satisfied with the pain relief achieved from the VL transfer than the improvement in gait. A bare, denuded GT can be a potent source of pain, as can a “vanished” GT with exposed prosthetic shoulder rubbing on overlying structures, leading to a painful bursitis. A transferred VL flap that interposes between the GT and overlying soft tissue may be an important reason why pain relief is achieved. We acknowledge that it is possible the benefits of this operation may largely come from this interposition effect rather than from the effects of an increased abduction force. Further postoperative electromyographical and gait analysis studies will likely shed more light on this topic. To the best of the authors’ knowledge, the gluteus maximus transfer (6) is the only other salvage method described for abductor-augmenting surgery in end-stage abductor dysfunction (not including simple bridging grafts which do not provide additional abduction power). Compared to the gluteus maximus transfer technique, the VL transfer offers the following theoretical advantages: no restriction of hip flexion, a more likely functional muscle as it is based on a distinct neurovascular pedicle, and a more normal force vector for hip abduction. VL is also activated in the same part of the gait cycle as hip abductors, which may have advantages in rehabilitation and muscle retraining. Further
REFERENCES 1.
2.
comparative studies are needed to assess which technique achieves superior clinical outcomes. There are many limitations to the current report. Firstly, our numbers are small with only four patients included. However, indication for VL transfer is very limited, as most abductor tears are amenable to direct repair, or even if not amenable, patients may not be symptomatic enough or medically suitable for such procedure. A high case load is difficult to achieve even in large centres. Secondly our follow-up duration is short. Thirdly, our postoperative joint function scores are difficult to interpret as regretfully we did not gather formal preoperative joint function scores.
CONCLUSION VL transfer surgery for hip abductor dysfunction is a very new procedure, and only a handful of cases have been reported in literature. Results of our method of VL transfer are optimistic in a small number of patients at an early stage. It is possible that VL transfer may be a viable salvage procedure in the setting of advanced, irreparable hip abductor defects. Financial Support: None. Conflict of Interest: No conflict of interest for any authors. Address for correspondence: Kemble Wang Department of Orthopaedic Surgery Eastern Health Box Hill Melbourne Victoria 3128, Australia [email protected]
3.
Howell GE, Biggs RE, Bourne RB. Prevalence of abductor mechanism tears of the hips in patients with osteoarthritis. J Arthroplasty. 2001;16(1):121-3. Pfirrmann CW, Notzli HP, Dora C, Hodler J, Zanetti M. Abductor tendons and muscles assessed at MR imaging after total hip arthroplasty in asymptomatic and symptomatic patients. Radiology. 2005;235(3):969-76.
Fehm MN, Huddleston JI, Burke DW, Geller JA, Malchau H. Repair of a deficient abductor mechanism with Achilles tendon allograft after total hip replacement. J Bone Joint Surg Am. 2010;92(13):2305-11. 4. Bajwa AS, Campbell DG, Comely AS, Lewis PL. Gluteal tendon reconstruction in association with hip arthroplasty. Hip Int. 2011;21(3):288-92. 5. Ozaki T, Kaneko S, Kunisada T, et al. Reconstruction of the hip abductors after resection of the proximal femur. Int Orthop. 1999;23(3):182-3.
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6.
7.
8.
9.
186
Whiteside LA, Nayfeh T, Katerberg BJ. Gluteus maximus flap transfer for greater trochanter reconstruction in revision THA. Clin Orthop Relat Res. 2006;(453):203-10. Beck M, Leunig M, Ellis T, Ganz R. Advancement of the vastus lateralis muscle for the treatment of hip abductor discontinuity. J Arthroplasty. 2004;19(4):476-80. Kohl S, Evangelopoulos DS, Siebenrock KA, Beck M. Hip abductor defect repair by means of a vastus lateralis muscle shift. J Arthroplasty. Apr 2012;27(4):625-9. Betz M, Zingg PO, Peirrmann CW, Dora C. Advancement
of the vastus lateralis muscle for irreparable hip abductor tears: clinical and morphological results. Acta Orthop Belg. 2012;78(3):337-43. 10. Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of patients about total hip replacement. J Bone Joint Surg Br. 1996;78(2):185-90. 11. Klassbo M, Larsson E, Mannevik E. Hip disability and osteoarthritis outcome score. An extension of the Western Ontario and McMaster Universities Osteoarthritis Index. Scand J Rheumatol. 2003;32(1):46-51.
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Hip Int 2014; 24 ( 2): 180-186
Original Article
Vastus lateralis transfer for severe hip abductor deficiency: a salvage procedure Kemble Wang 1, Stacey Cole 1, Dean C. White 1, Michael S. Armstrong 2 1 2
Eastern Health, Melbourne, Victoria - Australia Monash University Eastern Health, Melbourne, Victoria - Australia
Introduction: Abductor muscle deficiency can be a debilitating problem following hip arthroplasty surgery. We report outcomes of a novel method of abductor muscle function reconstruction surgery in patients with chronic, irreparable gluteus medius and minimus defects Patients and methods: Four consecutive patients who underwent our method of abductor reconstruction surgery were retrospectively reviewed. All patients had severe pain and positive Trendelenberg gait before surgery. Technique: the vastus lateralis (VL) muscle was raised on its neurovascular pedicle and transferred 12-14 centimetres by proximal translation. The proximal portion of VL was reattached via bony anchors to the external surface of the iliac wing just below the iliac crest. The distal portion of VL reattached to the lateral femoral shaft, lateral intermuscular septum, and the fascia of vastus intermedius. Results: Average follow-up was 10 months (range 7-15 months). Three of the four patients report dramatic improvement in pain as measured by the visual analogue pain scale. The same three patients report being “extremely satisfied” with the pain relief achieved and “extremely satisfied” with the operation overall. Two patients reported being “extremely satisfied” with improvements in walking. Hip abduction power improved in all patients but to varying degrees. Conclusion: The results show that our method of VL transfer may be a viable option for patients with severe abductor deficiency. Modest but clinically relevant early results are seen. Keywords: Hip abductors, Hip replacement, Muscle flap, Trendelenberg gait, Vastus lateralis Accepted: August 7, 2013
INTRODUCTION Abductor deficiency can follow hip replacement surgery, especially when a trans-gluteal approach had been utilised (1). The problem can be compounded when multiple procedures have been done on the same hip, with detachment and reattachment of the abductor muscles every time the hip joint is entered. Severe abductor deficiencies can thus result. Left chronically, a detached gluteus medius and minimus undergoes retraction and fatty degeneration (2) In cases where enough degeneration and retraction of the tendon has occurred, direct repair of the muscle can be surgically 180
impossible, even with maximal mobilisation of the muscle/ tendon unit. The resultant abductor deficit can lead to functional impairment either due directly to loss of abduction power, or secondarily from painful trochanteric inflammation, bursitis, and scar tissue. Several methods have been tried and reported in literature for treating abductor deficiencies that are not amenable to primary repair. These include bridging grafts using Achilles tendon (3) or synthetic materials (4, 5). Whilst being capable of bridging the physical gap, tendon and synthetic grafts alone do not provide additional power to an already weakened abductor muscle complex. Muscle flap transfers have
© 2013 Wichtig Editore - ISSN 1120-7000
Wang et al
also been proposed in response to the need to augment or replace the functional power of the native abductor muscles (6, 7). The gluteus maximus muscle transfer, which involves detachment of a posterior portion of this muscle and reattaching part of its insertion to the greater trochanter, has shown promising results in small case series (6). This technique however, is not based on an identifiable neurovascular pedicle and thus function of the transferred muscle is questionable. In addition, the resulting force vector on the greater trochanter is inevitably altered and more posterior than the vectors rendered by the native abductor muscles. Beck et al were the first to describe a proximal transfer of VL on its neurovascular pedicle to treat irreparable hip abductor defects (7). The technique involves: dissection and mobilisation of VL from rectus femoris and vastus intermedius, mobilisation of its (usually) two neurovascular pedicles (arising from the femoral nerve and descending branch of the lateral femoral circumflex artery), proximal transfer of the muscle on its two pedicles by 7-10 cm, reattachment of the proximal end of the VL flap to the remaining abductor muscle stump which is retracted proximally, and reattachment distally of the VL flap to the proximal femur and lateral intermuscular septum. Optimistic results have been achieved in two small series (8, 9). However, this originally described technique relies on viable abductor stump for proximal attachment of VL. In theory, it also relies on two separate muscle groups (residual hip abductors and VL) with two separate nerve supplies (superior gluteal nerve and femoral nerve) working synergistically to affect hip abduction. Failure of either of these two nervemuscle-tendon units will lead to decreased functionality of the construct. We report on a modified technique of Beck’s original description. Following mobilisation of the muscle, we attach the proximal portion of the VL flap directly to ilium, on the lateral surface of the iliac wing as superior as allowed by the neurovascular pedicle. Thus we eliminate the requirements of viable residual abductor tendon and synergistic action of the abductors together with VL if the two were attached in series. We report on the outcome of this technique in four patients treated at our institution.
MATERIALS AND METHODS This study was reviewed and approved by the institutional ethics review committee (study ID LR47/1213).
Patients Four consecutive patients at our institution who underwent proximal VL transfer were included for retrospective review. The relevant surgical history prior to VL transfer is presented in Table I. Patients were referred to our institution with chronic intractable abductor deficiency-related symptoms, and had failed extensive physical, hydro and analgesic therapies. All had undergone a trans-gluteal approach for their initial hip operations. Inclusion criteria are a definite positive Trendelenberg test, presence of a Trendelenberg gait, inability to sleep on the affected side, and severe pain and discomfort on the lateral hip significantly limiting ability to ambulate. All patients had multiple prior hip procedures for various complications following index hip arthroplasty surgery. Radiological confirmation of abductor defects were not routinely obtained as patients were noted intraoperatively in their previous procedures the existence of significant degeneration and retraction of the abductor muscles not amenable to primary repair. At time of VL transfer surgery, three of the four patients required concomitant bi-valved cadaveric proximal femoral allograft incorporating the greater trochanter because prosthetic wear osteolysis and prolonged abductor detachment had resulted in extensive bone loss.
Surgical technique Surgery was performed jointly between an Orthopaedic Surgeon (MA) and a Plastic and Reconstructive Surgeon (DW). The patient was placed in the lateral position. A lateral incision was made starting from just below the iliac crest extending to the lateral patella margin. Fascia lata and iliotibial band was split in line with its fibres. VL was mobilised according to the technique described by Beck et al (7). In brief, the plane between VL and rectus femoris, VL and vastus intermedius was developed proximal to distal. Care was taken to preserve the nerve supply to vastus intermedius. The neurovascular bundles (usually two) to VL were dissected and followed proximally (Figs. 1A and B). Insertion into quadriceps tendon was divided with a small margin of tendon to allow repair. The VL muscle was thus rendered mobile and can be transferred proximally by up to 15 cm. In patients with significant GT bone loss, femoral strut allograft was used at this stage to restore proximal femoral bone stock and secured with trochanteric grip plate and cables.
© 2013 Wichtig Editore - ISSN 1120-7000
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A viable salvage procedure
TABLE I - RELEVANT SURGICAL HISTORY PRIOR TO VASTUS LATERALIS TRANSFER SURGERY Age
Index hip Implant operation used at index operation*
Time between index operation and VLT
Complication arising from index operation
Relevant medical history
Procedures following index operation
Number of Previous operations attempted prior to VLT abductor repair
Previous injections to abductors/ trochanteric bursa
Patient 1
79
THR
Zweimuller plus
6 years
Infected subfascial haematoma
On warfarin for past DVT
Multiple washout + debridement
6
LARS graft no
Patient 2
74
THR
Autofour
35 years
Cup protrusion
Rheumatoid arthritis
2x cup revisions
3
Direct repair with anchors
2 injections
Patient 3
60
Resurf
Birmingham
8 years
Wear osteolysis, ALVAL
Seronegative Washout of arthropathy ALVAL, revise to conventional THR
5
Direct repair with anchors
No
Patient 4
63
THR
Sulzer
12 years
Nil Cellulitis, wear osteolysis, retained lubricant induced aseptic loosening (Sulzer)
3
Nil
2 injections
Exploratory washout, 2x cup revisions for loosening
*Index hip operation: refers to the first initial operation patient underwent on their native hip. ALVAL: aseptic lymphocyte-dominated vasculitis-associated lesion. VLT: vastus lateralis transfer.
A
B
A
B
Fig. 1 - A, B) VL flap is mobilised and separated from RF (rectus femoris) and the rest of the quadriceps muscle. Neurovascular bundles (usually 2) enter the muscle near its proximal end. White arrow (Fig. 1A) is pointing to the (dominant) neurovascular pedicle embedded in surrounding fatty tissue. Left is distal in Fig. 1A.
Fig. 2 - A, B) VL flap secured in new position, attached distally to femur, vastus intermedius, and lateral intermuscular septum. Proximally attached to ilium. Left is distal in Fig. 2A.
The VL flap was then transferred as superiorly as allowed by the neurovascular pedicle, which is usually not far below the iliac crest, 12 to 14 cm above its original position. The proximal end of the VL flap was then attached to the anterolateral surface of the ilium using multiple titanium cork-screw anchors. The hip is then abducted by 30 degrees, and the
distal portion of the graft is secured to the trochanteric grip plate (if used), the lateral intermuscular septum, and the lateral femur (Figs. 2A and B). Post-operatively, touch weight-bearing in an abduction brace was allowed for the first six weeks. Thereafter gradual hip abduction exercises were commenced together
182
© 2013 Wichtig Editore - ISSN 1120-7000
Wang et al
ment), and distance calculated by calibrating with known prosthesis dimensions.
with full weight-bearing. Hydrotherapy was encouraged in all patients.
Follow-up assessment
RESULTS
Patients were reviewed at two weeks and six weeks postoperatively, and thereafter at every three months. Outcome data presented here are those obtained at the latest followup assessment. Hip abduction strength was measured and graded according to the British Medical Research Council Scale (M0 to M5). Oxford Hip score (10) and the modified WOMAC score for the hip (11) were recorded. Patients were asked to complete 11-point visual analogue pain scales ranging from 0 to 10, with 0 being no pain and 10 being the worst pain. A patient satisfaction questionnaire was also completed, containing four grades of satisfaction ranging from “extremely satisfied” to “dissatisfied” for each question. No statistical analyses were carried out due to the low number of patients involved. The distance over which VL was transferred proximally was measured radiologically. A direct line was drawn from the junction between GT and femoral shaft (the most proximal extent of VL origin) to the most superior corkscrew anchor (representing the most superior point of muscle reattach-
All four patients were women with an average age of 69 years. The average follow-up is 10 months (range 7-15 months). Patients had undergone an average of 4.3 (range 3-6) prior operations on the affected hip before vastus lateralis transfer surgery. Three patients had extensive GT osteolysis and required femoral strut allograft which was performed at time of vastus lateralis transfer. In two of the three patients, this was attributed to wear debris osteolysis. In the third patient, it was attributed to a combination of wear debris and previous infection-related osteolysis. Strut grafts were secured with trochanteric grip plates and cables and lie underneath the VL graft. Pre- and postoperative functional status are presented in Table II. Two of the four patients were able to stop using gait aids altogether whereas prior to VL transfer they were heavily dependent on them. Three of the four patients were able to reduce their analgesia requirement, with two pa-
TABLE II - FUNCTIONAL STATUS PRE AND POST VASTUS LATERALIS TRANSFER Follow-up Fibular duration strut graft
Gait aids
Analgesic requirements
Ability to lie on affected side
Hip abduction power
Oxford WOMAC hip score hip score
Pre VLT
Post VLT
Pre VLT
Post VLT
Pre VLT
Post VLT
Pre VLT
Post VLT
Post VLT
Post VLT
Patient 1 15 months yes
4 wheel walker
Nil
Paracetamol Oxycodone Tramadol
Nil
No
Occasionally
M1
M4
42
86.7
Patient 2 14 months No
Forearm crutch
Nil
Paracetamol Oxycodone
Nil
No
Yes
M1
M2
45
96.9
Patient 3 5 months
Yes
Single point stick
Single point stick
Paracetamol/ codeine Buprenorphine patch Tramadol
Paracetamol/ codeine
No
Occasionally
M1
M2
24
57
Patient 4 7 months
Yes
Single point stick
Single point stick
Paracetamol Oxycodone
Paracetamol Oxycodone
No
No
M1
M3
32
67.7
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A viable salvage procedure
tients no longer requiring any analgesia after many years of dependency. All four patients experienced modest improvements in hip abduction power. However, all four patients were still Trendelenberg test positive. Patient-perceived pain and satisfaction scores are presented in Table III. There was a significant improvement in pain scores for all patients except Patient 4. Three of the four patients were extremely satisfied with pain relief achieved by the operation, were extremely satisfied with the operation overall, and would be willing to undergo the same operation again. In general, satisfaction with pain relief is higher than with gait improvement. At time of latest follow-up, no complications were observed in any of the patients. One patient (Patient 1) required acetabular revision at three months postoperatively for symptomatic subluxation of the prosthetic femoral head which was a known occurrence prior to vastus lateralis transfer. It was originally hoped that the vastus lateralis transfer would increase stability and resolve this issue. However, when subluxation persisted, decision was made to revise the inclination of the acetabular component. The patient had no further stability problems since. During revision surgery for the acetabular component, it was noted that the vastus lateralis was healthy and viable and reactive to stimulation with electrocautery. The mean distance over which VL was advanced, as measured radiologically, was 13.4 cm (range 12.8-14.0 cm).
DISCUSSION This paper describes our modified VL transfer technique and the outcomes of this procedure in four patients with severe hip abductor deficiency. Our technique involves
direct attachment of proximal VL to ilium, thus removing the need to rely on viable residual abductor muscle stump. Modest but clinically relevant improvements in pain, function, and abduction power have been achieved. Importantly, three of the four patients were “extremely satisfied” with the improvements achieved from the operation. Based on measurements in cadaveric studies, Beck suggested that the maximum distance the VL flap can be proximalised is 10 cm, even if a 180º rotation of the flap was trialled (7). We conjecture that this may have contributed to that author’s practice of reattaching VL to the residual abductor stump rather than to the ilium. In our series, we were able to directly advance VL by an average of 13.4 cm, without the need for a 180º flap rotation. Whilst the difference may be partly attributable to different modes of measurement (radiological versus cadaveric), we believe that with adequate pedicle mobilisation and selective division of minor pedicles, a greater transfer distance could be safely achieved. The increased distance allowed us to attach the proximal end of VL directly to bony ilium rather than relying on a sometimes poor or even non-existent abductor stump. Three of the four patients received concomitant femoral strut allograft to GT at time of VL transfer for severe osteolysis. This additional procedure is also frequently utilised in previous reports of VL transfer (8, 9). In our series, GT was reconstructed with femoral allograft for the following reasons: to increase bone stock and prevent future prosthetic stem instability; to allow a greater abduction lever arm for the transferred VL to act on; and to improve the chance of biological integration of VL by preventing it from being in direct contact with a large area of bare femoral stem. We acknowledge that the postoperative joint function scores achieved in our patients are poor, particularly in patients 3 and 4. However, reported joint function scores
TABLE III - PATIENT PERCEIVED PAIN AND SATISFACTION RATINGS Pain Score
Satisfaction with pain relief
Satisfaction with gait improvement
Overall satisfaction with operation
Will undergo same operation again?
Pre VLT
Post VLT
Patient 1
7
0
Extremely satisfied
Extremely satisfied
Extremely satisfied
Yes
Patient 2
9
0
Extremely satisfied
Extremely satisfied
Extremely satisfied
Yes
Patient 3
10
3
Extremely satisfied
Somewhat satisfied
Extremely satisfied
Yes
Patient 4
5
3
Mostly satisfied
Somewhat satisfied
Mostly satisfied
Undecided
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Wang et al
following VL transfers by other authors are similarly poor (9). Patients who undergo this operation usually have had a high number of previous operations, which not only explain the reason for their irreparable abductor defects, but also the poor general soft tissue envelope of their hip joint. It is a weakness of this study that unfortunately we do not have preoperative functional scores to make meaningful comparison with. From the satisfaction survey (Tab. III), it appears that our patients were generally more satisfied with the pain relief achieved from the VL transfer than the improvement in gait. A bare, denuded GT can be a potent source of pain, as can a “vanished” GT with exposed prosthetic shoulder rubbing on overlying structures, leading to a painful bursitis. A transferred VL flap that interposes between the GT and overlying soft tissue may be an important reason why pain relief is achieved. We acknowledge that it is possible the benefits of this operation may largely come from this interposition effect rather than from the effects of an increased abduction force. Further postoperative electromyographical and gait analysis studies will likely shed more light on this topic. To the best of the authors’ knowledge, the gluteus maximus transfer (6) is the only other salvage method described for abductor-augmenting surgery in end-stage abductor dysfunction (not including simple bridging grafts which do not provide additional abduction power). Compared to the gluteus maximus transfer technique, the VL transfer offers the following theoretical advantages: no restriction of hip flexion, a more likely functional muscle as it is based on a distinct neurovascular pedicle, and a more normal force vector for hip abduction. VL is also activated in the same part of the gait cycle as hip abductors, which may have advantages in rehabilitation and muscle retraining. Further
REFERENCES 1.
2.
comparative studies are needed to assess which technique achieves superior clinical outcomes. There are many limitations to the current report. Firstly, our numbers are small with only four patients included. However, indication for VL transfer is very limited, as most abductor tears are amenable to direct repair, or even if not amenable, patients may not be symptomatic enough or medically suitable for such procedure. A high case load is difficult to achieve even in large centres. Secondly our follow-up duration is short. Thirdly, our postoperative joint function scores are difficult to interpret as regretfully we did not gather formal preoperative joint function scores.
CONCLUSION VL transfer surgery for hip abductor dysfunction is a very new procedure, and only a handful of cases have been reported in literature. Results of our method of VL transfer are optimistic in a small number of patients at an early stage. It is possible that VL transfer may be a viable salvage procedure in the setting of advanced, irreparable hip abductor defects. Financial Support: None. Conflict of Interest: No conflict of interest for any authors. Address for correspondence: Kemble Wang Department of Orthopaedic Surgery Eastern Health Box Hill Melbourne Victoria 3128, Australia [email protected]
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of the vastus lateralis muscle for irreparable hip abductor tears: clinical and morphological results. Acta Orthop Belg. 2012;78(3):337-43. 10. Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of patients about total hip replacement. J Bone Joint Surg Br. 1996;78(2):185-90. 11. Klassbo M, Larsson E, Mannevik E. Hip disability and osteoarthritis outcome score. An extension of the Western Ontario and McMaster Universities Osteoarthritis Index. Scand J Rheumatol. 2003;32(1):46-51.
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