Article

Limitations of the Vastus Lateralis Muscle as a Substitute for Lost Abductor Muscle Function: An Anatomical Study

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... These are salvage techniques described to manage chronic end-stage abductor tears with remarkable tendon insufficiency or gluteal atrophy. Two main surgical techniques have been proposed using either gluteus maximus (GMax) [32][33][34] or vastus lateralis (VL) muscle transfer [35,36]. ...
... This is the other salvage technique to manage nonreparable chronic end-stage abductor tears [35,36]. Following a lateral incision across the whole length of the thigh, the iliotibial band is incised in line. ...
... The advantages of the method include the partial restriction of hip flexion, the separate neurovascular pedicle and the activation of VL in the same part of the gait cycle as hip abductors. However, the complex procedure, the decreased quadriceps muscle strength and the potential neurovascular damage due to overstretching of the neurovascular bundles are the main drawbacks [35,36]. ...
Chapter
The pathology of abductors’ tendons is the most common cause of greater trochanteric pain syndrome (GTPS). Half of the patients suffering from GTPS demonstrate gluteal tendinosis or ruptures. The rate of GTPS increases with age. The chief complaint of abductor tendon pathology is lateral thigh pain. A thorough clinical examination should be performed including the evaluation of muscle strength, neurologic status, lumbar spine, and hip pathology or the integrity of an existing prosthetic joint. Magnetic resonance imaging is the gold-standard examination of the pathology of the abductor muscles and tendons. The treatment of GTPS syndrome usually starts conservatively, including different modalities. Surgical management is mainly indicated for full or partial gluteal tendon ruptures that are nonresponsive to conservative treatment following at least 3 months of therapy, eliciting pain and disability to the patient. The patients that are scheduled to undergo surgical repair of gluteal tendon tears must have a thorough preoperative evaluation. Three are the main direct open methods, including open nonaugmented repair using bone tunnels or suture anchors or augmented repair with synthetic grafts or allografts and reconstruction for chronic end-stage abductor tears using muscle transfer.
... 12 The blood supply to and from the vastus lateralis is via branches of the lateral circumflex femoral artery and vein, mainly from the descending branch 10 and branches from the deep femoral artery which perforate the lateral intermuscular septum. 13,14 Branches from these main vessels form an anastomosing 15,16 network. Most distally, the geniculate network contributes as well. ...
... 13,15 Anastomoses could be traced between the two systems in 12 of the 28 muscles. Using latex injection into the lateral circumflex femoral artery and branches of the deep femoral artery, Grob et al 14 showed extensive anastomoses between the lateral circumflex and deep femoral branches as well as lateral circumflex-lateral circumflex and deep-deep anastomoses. Most of these were missed in this study, probably because they were too delicate to be traced by free hand dissection. ...
Article
Full-text available
A density model of neurovascular structures was generated from 28 human vastus lateralis muscles isolated from embalmed cadavers. The intramuscular portion of arteries, veins and nerves was dissected, traced on transparencies and digitised before adjustment to an average muscle shape using Procrustes analysis to generate density distributions for the relative positions of these structures. The course of arteries, veins and nerves was highly variable between individual muscles. Nevertheless, a zone of lower average neurovascular density was found between the tributaries from the lateral circumflex femoral and the deep femoral arteries. While the area with the lowest density was covered by the iliotibial tract and would therefore not be suitable for biopsies, another low‐density area was located in the distal portion of vastus lateralis. This was just anterior to the iliotibial tract, in a zone that has been described as a good needle biopsy site. The reported complication rates of needle biopsies (0.1‐4%) are in the range of expectations when simulated based on this model. It is concluded that the optimal human vastus lateralis biopsy site is in the distal portion of the muscle, between ½ and ¾ of the length from the greater trochanter to the lateral epicondyle, just anterior to the iliotibial band. This article is protected by copyright. All rights reserved.
... However, previous anatomical dissections revealed that the interaction between the components of the quadriceps muscle group is more complex and intricate than was initially described. Furthermore, dissections revealed different morphological findings between the VI and VM compared to classic descriptions in the literature [10,12,13]. Loss of knee extension occurs most rapidly due to inactivity of the VM (28). ...
... This interpretation is supported by the innervation pattern of both muscles (Fig. 5). With regard to its innervation, the VI can also be divided into a medial and lateral section [10][11][12][13]. ...
Article
Purpose: Although the vastus medialis (VM) is closely associated with the vastus intermedius (VI), there is a lack of data regarding their functional relationship. The purpose of this study was to investigate the anatomical interaction between the VM and VI with regard to their origins, insertions, innervation and function within the extensor apparatus of the knee joint. Methods: Eighteen human cadaveric lower limbs were investigated using macro-dissection techniques. Six limbs were cut transversely in the middle third of the thigh. The mode of origin, insertion and nerve supply of the extensor apparatus of the knee joint were studied. The architecture of the VM and VI was examined in detail, as was their anatomical interaction and connective tissue linkage to the adjacent anatomical structures. Results: The VM originated medially from a broad hammock-like structure. The attachment site of the VM always spanned over a long distance between: (1) patella, (2) rectus femoris tendon and (3) aponeurosis of the VI, with the insertion into the VI being the largest. VM units were inserted twice-once on the anterior and once on the posterior side of the VI. The VI consists of a complex multi-layered structure. The layers of the medial VI aponeurosis fused with the aponeuroses of the tensor vastus intermedius and vastus lateralis. Together, they form the two-layered intermediate layer of the quadriceps tendon. The VM and medial parts of the VI were innervated by the same medial division of the femoral nerve. Conclusion: The VM consists of multiple muscle units inserting into the entire VI. Together, they build a potential functional muscular complex. Therefore, the VM acts as an indirect extensor of the knee joint regulating and adjusting the length of the extensor apparatus throughout the entire range of motion. It is of clinical importance that, besides the VM, substantial parts of the VI directly contribute to the medial pull on the patella and help to maintain medial tracking of the patella during knee extension. The interaction between the VM and VI, with responsibility for the extension of the knee joint and influence on the patellofemoral function, leads readily to an understanding of common clinical problems found at the knee joint as it attempts to meet contradictory demands for both mobility and stability. Surgery or trauma in the anteromedial aspect of the quadriceps muscle group might alter a delicate interplay between the VM and VI. This would affect the extensor apparatus as a whole.
... However, some studies have shown higher surgical blood loss and complication rates [6,47], particularly for less-experienced surgeons [16,43] or for patients who are obese [39]. Additionally, the distal extension of the approach is less familiar to most surgeons and a recent anatomic study by Grob et al. [10] suggested that it may pose a risk to the neurovascular supply to portions of the vastus lateralis. Other authors, however, have described techniques for safely extending the approach [20]. ...
Article
Background: Total hip arthroplasty (THA) relieves pain and improves physical function in patients with hip osteoarthritis, but requires a year or more for full postoperative recovery. Proponents of intermuscular surgical approaches believe that the direct-anterior approach may restore physical function more quickly than transgluteal approaches, perhaps because of diminished muscle trauma. To evaluate this, we compared patient-reported physical function and other outcome metrics during the first year after surgery between groups of patients who underwent primary THA either through the direct-anterior approach or posterior approach. Questions/purposes: We asked: (1) Is a primary THA using a direct-anterior approach associated with better patient-reported physical function at early postoperative times (1 and 3 months) compared with a THA performed through the posterior approach? (2) Is the direct-anterior approach THA associated with shorter operative times and higher rates of noninstitutional discharge than a posterior approach THA? Methods: Between October 2008 and February 2010, an arthroplasty fellowship-trained surgeon performed 135 THAs. All 135 were performed using the posterior approach. During that period, we used this approach when patients had any moderate to severe degenerative joint disease of the hip attributable to any type of arthritis refractory to nonoperative treatment measures. Of the patients who were treated with this approach, 21 (17%; 23 hips) were lost to followup, whereas 109 (83%; 112 hips) were available for followup at 1 year. Between February and September 2011, the same surgeon performed 86 THAs. All 86 were performed using the direct-anterior approach. During that period, we used this approach when patients with all types of moderate to severe degenerative joint disease had nonoperative treatment measures fail. Of the patients who were treated with this approach, 35 (41%; 35 hips) were lost to followup, whereas 51 (59%; 51 hips) were available for followup at 1 year. THAs during the surgeon's direct-anterior approach learning period (February 2010 through January 2011) were excluded because both approaches were being used selectively depending on patient characteristics. Clinical outcomes included operative blood loss; allogeneic transfusion; adverse events; patient-reported Veterans RAND-12 Physical (PCS) and Mental Component Summary (MCS) scores, and University of California Los Angeles (UCLA) activity scores at 1 month, 3 months, and 1 year after surgery. Resource utilization outcomes included operative time, length of stay, and discharge disposition (home versus institution). Outcomes were compared using logistic and linear regression techniques. Results: After controlling for relevant confounding variables including age, sex, and BMI, the direct-anterior approach was associated with worse adjusted MCS changes 1 and 3 months after surgery (1-month score change, -9; 95% CI, -13 to -5; standard error, 2), compared with the posterior approach (3-month score change, -9; 95% CI, -14 to -3; standard error, 3) (both p < 0.001), while the direct-anterior approach was associated with greater PCS improvement at 3 months compared with the posterior approach (score change, 6; 95% CI, 2-10; standard error, 2; p = 0.008). There were no differences in adjusted PCS at either 1 month or 12 months, and no clinically important differences in UCLA scores. Although the PCS score differences are greater than the minimum clinically important difference of 5 points for this endpoint, the clinical importance of such a small effect is questionable. At 1 year after THA, there were no intergroup differences in self-reported physical function, although both groups had significant loss-to-followup at that time. Operative time (skin incision to skin closure) between the two groups did not differ (81 versus 79 minutes; p = 0.411). Mean surgical blood loss (403 versus 293 mL; p < 0.001; adjusted, 119 more mL; 95% CI, 79-160; p < 0.001) and in-hospital transfusion rates (direct-anterior approach, 20% [17/86] versus posterior approach, 10% [14/135], p = 0.050; adjusted odds ratio, 3.6; 95% CI, 1.3-10.1; p = 0.016) were higher in the direct-anterior approach group. With the numbers available, there was no difference in the frequency of adverse events between groups when comparing intraoperative complications, perioperative Technical Expert Panel complications, and other non-Technical Expert Panel complications within 1 year of surgery, although this study was not adequately powered to detect differences in rare adverse events. Conclusions: With suitable experience, the direct-anterior approach can be performed with expected results similar to those of the posterior approach. There may be transient and small benefits to the direct-anterior approach, including improved physical function at 3 months after surgery. However, the greater operative blood loss and greater likelihood of blood transfusions, even when the surgeon is experienced, may be a disadvantage. Given some of the kinds of bias present that we found, including loss to followup, the conclusions we present should be considered preliminary, but it appears that any benefits that accrue to the patients who had the direct-anterior approach would be transient and modest. Prospective randomized studies on the topic are needed to address the differences between surgical approaches more definitively. Level of evidence: Level III, therapeutic study.
... In another study by the same authors, the use of the VL as a substitute for lost abductor muscle function was examined. A 2-fold innervation of the VL was found in all specimens with proximal short branches interwoven with vessels of the ascending and transverse branches of the LFCA and distal long branches coursing with the descending branch of the LFCA [23]. In the present study, identical findings were seen with the short nerve branches travelling in the proximal neurovascular bundle and the long branches in the distal neurovascular bundle. ...
Article
Background: The direct anterior approach (DAA) is becoming more popular as the standard surgical approach for primary total hip arthroplasty. However, femoral complications of up to 2.8% have been reported. Therefore, it is important for surgeons to understand the periarticular neurovascular anatomy in order to safely deal with intraoperative complications. Methods: Anatomic dissections were performed on 20 cadaveric hips. The neurovascular structures anterior to the femur and distal to the intertrochanteric line were dissected and its position was described in relation to anatomic landmarks easily identified through the DAA: anterior superior iliac spine (ASIS), the insertion of the gluteus minimus (GM), and the lesser trochanter (LT). Results: Two clearly distinguishable neurovascular bundles running to the vastus lateralis were seen in 17 of 20 specimens. The average distances to the landmarks were as follows: ASIS-1st bundle = 12.3 cm (range, 9.7-14.5); GM-1st bundle = 3.2 cm (range, 2.2-4); LT-1st bundle = 1.6 cm (range, 0.7-2.8); 1st bundle-2nd bundle = 3.3 cm (range, 1.8-6.1). Conclusion: A consistent pattern of 2 clearly distinguishable neurovascular bundles was seen in 85% of the specimens. Knowledge of the position of these neurovascular bundles in relation to the anatomic landmarks makes distal femoral extension of the DAA feasible. Further clinical studies are needed to confirm the safety of the extensile anterior approach.
... This reflects the limitation of MR imaging in recognizing fascial or aponeurotic planes or distinguishing adjacent muscle components. Confusion also exists regarding the separation of the different elements of the vastii macroscopically when the VL is harvested as a muscle flap (Beck et al., 2004a(Beck et al., , 2004bGrob et al., 2015;Schipper et al., 2006) Both the anatomic and the corresponding virtual dissection with MR imaging revealed a multilayered organization in this study (Figs. 1-7). ...
Article
The tensor of the vastus intermedius (TVI) is a newly described component of the extensor apparatus of the knee joint. The objective of this study was to evaluate the appearance of the TVI on magnetic resonance (MR) imaging and its association with the adjacent vastus lateralis (VL) and vastus intermedius (VI) muscles and to compare these findings with the corresponding anatomy. MR images were analyzed from a cadaveric thigh where the TVI, as part of the extensor apparatus of the knee joint, had been dissected. The course of the TVI in relation to the adjacent VL and VI was studied. The anatomic dissection and MR imaging revealed a multi-layered organization of the lateral extensor apparatus of the knee joint. The TVI is an intervening muscle between the VL and VI that combined into a broad flat aponeurosis in the mid-thigh and merged into the quadriceps tendon. Dorsally, the muscle fibers of the TVI joined those of the VL and VI and blended into the attachment at the lateral lip of the linea aspera. In this area, distinguishing between these three muscles was not possible macroscopically or virtually by MR imaging. In the dorsal aspect the onion-like muscle layers of the VL, TVI and VI fuse to a hardly separable muscle mass indicating that these muscles work in conjunction to produce knee extension torque when knee joint action is performed. This article is protected by copyright. All rights reserved.
... However, procedure complexity, reduced quadriceps muscle strength and the possibility of neurovascular damage due to overstretch of the neurovascular bundles were the main disadvantages. 27 On the other hand, the anatomic position, including the origin and insertion, as well as the original function and muscle fibre's direction of the GM and TFL closely match that of the insufficient abductors. 13,14 The neurovascular supply of these muscles facilitates their transfer to the greater trochanter without compromising the power of the donor site. ...
Article
Introduction The treatment options of chronic abductor insufficiency in the setting of muscle degeneration, are limited and technically demanding. We present the outcomes of a salvage technique for unreconstructable, chronic abductor tears performed by a single surgeon. Methods We retrospectively evaluated 38 patients who were surgically managed for chronic abductor insufficiency. Patients without hip implants and patients following primary or revision total hip arthroplasty (THA) were involved. All patients had a Trendelenburg gait, impaired muscle strength of abduction (⩽M4) and fatty degeneration of muscles (Goutallier ⩾3). They underwent transfer of a flap of the anterior third of gluteus maximus to the greater trochanter that was sutured under the slightly mobilised vastus lateralis. The level of pain, functional scores, muscle strength and Trendelenburg gait were re-evaluated at 12 postoperative months. Results The mean age of patients was 70.2 years. 10 patients received the tendon transfer on a native hip, 6 following primary THA and 22 after revision THA. The mean pain level (3.2 vs. 7, p < 0.001) and Harris Hip Score (80.2 vs. 41.6, p < 0.001) and the median abductor strength (4 vs. 3, p < 0.001) was significantly improved compared to the preoperative scores. 26 patients demonstrated negative and 12 positive Trendelenburg sign at 12 postoperative months. No serious complications were reported. Conclusions This salvage technique improved the strength of abduction and functional results and reduced the level of pain in 80% of patients with chronic abductor tears. The short-term outcomes of the procedure were favourable; however, further evaluation is needed.
... Beim vorderen Zugang zum Hüftgelenk können Nerven auf drei Ebenen direkt geschädigt werden [1][2][3]6]. ...
... Muscle transfers have reported good-to-excellent early outcomes 16-20 ; however, this nonanatomic procedure may have increased morbidity leading to reduced functional benefit, relegating it to a salvage procedure. 21,22 A few case series reporting the use of synthetic, allograft, and autograft tissue for augmentation or reconstruction have provided positive early results. [23][24][25][26][27][28] Suppauksorn et al. 29 proposed a superior gluteal reconstruction (SGR), which uses an acellular dermal allograft matrix for reconstruction of the massive, irreparable hip abductor tendon tear and is the senior author's technique of choice for large, irreparable gluteus medius tears. ...
Article
Full-text available
Purpose To evaluate the 1-year outcomes of a small patient series following open gluteus medius/minimus repair with human dermal allograft incorporated into the repair construct using a double-row repair. Methods Data from consecutive patients undergoing a superior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy by a single fellowship trained surgeon from January 2018 to May 2019 were collected and analyzed. Baseline demographic data and magnetic resonance imaging were collected preoperatively. Clinical outcomes including Hip Outcome Score–Activities of Daily Living (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris hip score (mHHS), international Hip Outcome Score-12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were recorded at 1-year postoperatively. Results A total of 8 patients underwent open superior gluteal reconstruction for severe hip abductor deficiency. The mean age and body mass index were 62.6 ± 7.3 years and 29.6 ± 5.3 kg/m², respectively. The majority of patients were female (N = 7, 87.5%). Three (37.5%) patients had undergone previous endoscopic gluteus medius repair and presented for revision surgery. All patients had full-thickness tears with gluteus medius and gluteus minimus involvement. Patients were evaluated at an average of 11.5 ± 1.7 months from the initial surgical intervention and reported a mean HOS-ADL of 82.9 ± 24.3, HOS-SS of 73.2 ± 37.3, mHHS of 83.6 ± 17.1, iHOT-12 of 63.9 ± 27.4, VAS Pain of 30.0 ± 23.1, and VAS Satisfaction of 87.1 ± 17.0. There was no evidence of retears in this patient cohort as defined by physical examination findings and/or corroborating magnetic resonance imaging. Conclusions Superior gluteal reconstruction for massive, irreparable abductor tendon tears with severe tendon loss and atrophy is a technique that demonstrates promising 1-year postoperative outcomes in both primary and revision patients. Level of Evidence Level IV, therapeutic case series.
Chapter
Modularity in total hip arthroplasty (THA) allows surgeons to optimize implant reconstruction to patient anatomy intraoperatively. Dual-modular femoral neck stem or “dual-taper” THA implants possess interchangeable necks, providing additional modularity at the neck stem interface. Modular taper designs have the potential to allow precise reconstruction of center of rotation of the hip by facilitating adjustments in limb length, femoral neck version, and hip offset in order to optimize hip biomechanical parameters. Recently, there is increasing concern regarding this stem design as a result of the growing numbers of clinical failures due to fretting and corrosion at neck-stem taper junction, in a process that has been described as mechanically assisted crevice corrosion (MACC). Implant, surgical, and patient factors have been identified as likely contributing factors responsible for taper corrosion in dual-modular neck stem THA. There should be a low threshold to conduct a systematic clinical evaluation of patients with dual-modular neck stem THAs as early recognition and diagnosis will ensure prompt and appropriate treatment. As painful dual-modular neck stem total hip arthroplasties have various intrinsic and extrinsic causes, patients should be evaluated utilizing systematic risk stratification algorithms. Although specialized test such as metal ion analysis and cross -sectional imaging modalities such as MARS MRI and ultrasound should be used to optimize clinical decision- making, over-reliance on any single investigative tool in the clinical decision-making process should be avoided. Further research is required to gain understanding of implant, surgical, and patient risk factors associated with taper corrosion in dual- modular neck stem THA.
Chapter
Tears of the gluteus medius and/or minimus may be associated with tendinosis, retraction, fatty infiltration, and atrophy that preclude or compromise primary repair. Several techniques have emerged to address these concerns, including tendon transfers and augmentation with allograft, autograft, xenograft, or synthetic tissue. However, available techniques are limited and clinical efficacy remains unknown. The current chapter reviews superior gluteal reconstruction (SGR) utilizing an acellular dermal allograft matrix for reconstruction of the massive, irreparable hip abductor tendon tear. Special attention is dedicated to the relevant pathoanatomy, preoperative workup, surgical indications, operative technique, postoperative rehabilitation, and outcomes. Pearls and pitfalls are summarized to highlight critical steps of the procedure. The goal of the current chapter is to equip the surgeon with a practical guide to SGR for management of chronic irreparable abductor tendon tears of the hip.
Article
Background The current study examines PROMIS Computer Adaptive Test scores for domains of physical function(PF) and pain interference(PI) in patients undergoing elective THA from either a direct anterior(DA) or posterior surgical approach. Methods 1,358 patients who underwent THA at our institution from 1/1/2015 to 12/1/2018 were identified. Visual analog scale (VAS) pain scores, PROMIS CAT physical function(PF) and pain interference(PI) data were collected at the last preoperative visit as well as 6 weeks, 6 months, and 1-2 years postoperatively. Literature derived minimum clinically important difference(MCID) for PROMIS CAT PF metric with regards to THA was utilized for data comparison. Results 409 patients were included in the final analysis. 51% underwent a posterior approach, and 49% underwent a DA approach. Both approaches led to a significant improvement in PROMIS CAT PF and PI scores. Patients undergoing a DA approach had significantly higher preoperative and postoperative PROMIS CAT PF scores as well as significantly lower preoperative PROMIS CAT PI scores. Each approach yielded similar interval improvements of PROMIS CAT PF and PI. 103 direct anterior approach THA patients(51%) and 119 posterior approach THA patients(57.5%) achieved PROMIS PF MCID at 1-2 year follow-up. Conclusions Neither the DA, nor posterior THA surgical approach conferred an advantage to postoperative improvements of PROMIS CAT PF and PI scores. Adult reconstructive surgeons should continue to execute the direct anterior or posterior THA surgical approaches based upon personal preference. Despite surgeon confidence in THA, the potential for further innovation exists given the number of THA patients who failed to achieve PROMIS PF MCID.
Chapter
Cam femoroacetabular impingement (Cam FAI) is the femoral-induced component of FAI. It results from either local deformity of the head–neck transition or global orientation pathologies. The combination of the deformity with forceful flexion and mostly internal rotation leads to outside-in shearing forces between the femoral head and the acetabular rim resulting in cartilage damage, chondrolabral and chondroosseous separation, cartilage delamination, and tearing of the acetabular labrum. A strategy for patient selection and operative decision making is suggested. A step-by-step guide for arthroscopic cam resection using the peripheral compartment first access technique is described. Operative key points, including portal placement, cam exposure, and the technique of resection of anterolateral and more difficult posterolateral Cam deformities, including important pitfalls and measures how to avoid complications, are added.
Article
Full-text available
Abductor tendon lesions and insertional tendinopathy are the most common causes of lateral thigh pain. Gluteal tendon pathology is more prevalent in women and frequency increases with age.Chronic atraumatic tears result in altered lower limb biomechanics. The chief complaint is lateral thigh pain. Clinical examination should include evaluation of muscle strength, lumbar spine, hip and fascia lata pathology. The hip lag sign and 30-second single leg stance tests are useful in diagnosing abductor insufficiency.Magnetic resonance imaging (MRI) is the gold-standard investigation to identify abductor tendon tears and evaluate the extent of muscle fatty infiltration that has predictive value on the outcome of abductor repair.Abductor tendinosis treatment is mainly conservative, including non-steroidal anti-inflammatory medications, activity modification, local corticosteroid injections, plasma-rich protein, physical and radial shockwave therapy. The limited number of available high-quality studies on treatment outcomes and limited evidence between tendinosis and partial ruptures make it difficult to provide definite conclusions regarding the best management of gluteal tendinopathy.Surgical management is indicated in complete and partial gluteal tendon tears that are unresponsive to conservative treatment.There are various open and arthroscopic surgical procedures for direct repair of abductor tendon tears. There is limited evidence concerning surgical management outcomes. Prerequisites for effective tendon suturing are neurologic integrity and limited muscle fatty infiltration. Chronic irreparable tears with limited muscle atrophy and limited fatty infiltration can be augmented with grafts. Gluteus maximus or/vastus lateralis muscle transfers are salvage reconstruction procedures for the management of chronic end-stage abductor tears with significant tendon insufficiency or gluteal atrophy. Cite this article: EFORT Open Rev 2020;5:464-476. DOI: 10.1302/2058-5241.5.190094.
Article
Purpose: Abductor tendon tears are increasingly recognised as a common cause of lateral hip pain. Surgical treatment of these tears has been recommended, but the indications and types of open surgery have not been precisely elucidated yet. This manuscript aimed to critically review the literature concerning all open treatment options for this condition while identifying knowledge gaps and introducing a treatment algorithm. Methods: Literature search was conducted, including PubMed, Cochrane library, ScienceDirect and Ovid MEDLINE from 2000 to May 2020. Inclusion criteria were set as: (i) clinical studies reporting outcomes following open surgical treatment of acute or chronic hip abductor tendon tears, (ii) studies reporting an open direct or augmented suturing or muscle transfer procedure, (iii) acute or chronic tears found in native or prosthetic hips. Results: A total of 34 studies published between 2004 and 2020 were included. The vast majority of studies were uncontrolled case series of a single treatment method. A total of 970 patients (76% women) with an age range between 48 and 76 years were involved. Women between 60 and 75 years old were most commonly treated. Preoperative evaluation of patients and reporting of open surgical technique and outcomes are inconsistent. All studies reported variable improvement of pain, functional outcomes and gait of patients. Overall, complication rates ranged from 0 to 31.2%. Conclusion: The current literature on this topic is highly heterogeneous, and the overall level of the available evidence is low. A roadmap to develop practical guidelines for open surgery of acute and chronic tears of abductor tendons is provided. The anatomy and chronicity of the lesion, the extent of fatty infiltration and neurologic integrity of hip abductor muscles may influence both treatment choice and outcome. Further high-quality studies with standardisation of preoperative evaluation of patients and reporting of outcomes will help delineate best treatments. Level of evidence: IV.
Article
The femoral nerve (FN) is described as originating from the lumbar plexus (L2, L3 and L4) and in its course it emits branches destined to each one of the quadriceps femoral muscle (QFm), which are originated in an isolated way or, from common trunks. The detail of the distribution of the FN in the QFm, allows to diminish risks associated with different surgical interventions carried out in the anterior thigh area. With the purpose of describing the distribution of FN in the QFm components. Fifteen formalized lower limbs were used, 10 on the left side and 5 on the right side of adult individuals, Brazilians, located in the Anatomy Laboratories of the State University of Ciências da Saúde de Alagoas (UNCISAL) , Maceió, Brazil. The FN was classified into four types according to its branch and distribution. Type II was subdivided into 3 subtypes and presented in 60 % of the samples and type III in 20 %. The FN was divided from medial to lateral in 5 branches (B1, B2, B3, B4, B5), where B1 was the most medial. The B1 gave rise to an average of 2.47 secondary branches (sB) and to 2.58 tertiary branches (tB), in 13.3 % the B1 did not emit sB. In 73.3 %, only one component of the QFm was invested; B2 gave rise to an average of 3.93 sB and 3.58 tB. In 26.7 %, it invested only one component of the QFm; B3 gave rise to an average of 3.33 sB and 2.0 tB. In 80 %, it invested only one component of the QFm. The distribution of B4 and B5 are shown in the text. Biometric results of origin, diameter and length of the mentioned branches are shown in tables. The data obtained in this research complements the knowledge of the regional anatomy, being able to be used by the surgical clinic and to carry out treatments that improve neurological disorders that affect the region.
Article
Full-text available
Outcome after advancement of the vastus lateralis muscle for irreparable disruption of the hip abductor mechanism was evaluated in 9 patients. Seven to 10 cm defects were bridged without complications. After a mean follow-up of 33 months (range: 12-60 months), the majority of patients reported a 69% satisfaction and a reduction of both pain medication and gait assists. Six out of 9 patients would undergo the same treatment again and one was undecided. On physical examination hip function was significantly improved but still poor. A significant loss of quadriceps muscle strength was the only donor site morbidity encountered. Overall, very modest but relevant improvement of hip function can be achieved with this procedure without relevant donor site morbidity and complications.
Article
Full-text available
Three patients with malignant bone tumors of the proximal femur underwent implantation of an endoprosthesis with reconstruction of the joint capsule and hip abductors using artificial mesh.
Article
Full-text available
Maxillary ameloblastoma is a benign odontogenic neoplasm. Excision should involve wide margins because of its high recurrence rate and, ideally, be followed by reconstruction. A 23 year-old female patient presented with recurrent ameloblastoma. Two years previously, she had undergone a curettage excision. The recurrent lesion was managed by a total maxillectomy including inferior orbital rim. Simultaneous reconstruction was performed with an iliac crest bone graft for the orbital floor, and a vastus lateralis muscle flap for obliteration of the maxillary sinus and repair the oral and nasal cavities. The transferred vastus lateralis muscle already had spontaneous mucosalization over its surface two weeks after surgery. Postoperative follow up after fourteen months revealed no recurrence and no diplopia. The patient was satisfied with her appearance. The use of a single vastus lateralis muscle flap to repair both oral and nasal cavities is advantageous. It helps avoid hyper-nasal speech and maintain the stability of removable partial dentures. The conventional iliac bone graft supported by a well vascularized muscle eventually survived and provided a good functional and cosmetic result.
Article
We compared two methods of reconstruction of the abductor mechanism in 15 patients after prosthetic replacement of the upper femur, to assess abductor strength and function. Six patients in group I had direct fixation of the gluteus medius tendon and a segment of the original bone to the prosthesis. Nine patients in group 2 had the abductor tendon fixed to the iliotibial band. We assessed clinical function, isometric muscle strength and muscle cross-sectional area for each patient. The patients in group 1 had better clinical and functional results (p = 0.059), with average peak torques for hip abduction of 92% of that in the non-operated leg in group 1, and of 57% in group 2. Group 1 had a mean muscle cross-sectional area of 69% and a mean value of strength per cross-sectional area of 134% when compared with the control side. The respective values for group 2 were 52% and 91%. Direct fixation of the abductor muscles to the prostheses gave improved function and higher isometric abductor muscle force.
Article
The vastus lateralis muscle can provide a broad sheet of muscle for repair of defects of the lower abdomen, groin, perineum, hip, and ischium. The authors limit the use of the vastus lateralis muscle to situations in which more traditional techniques are not feasible. This muscle is especially suitable for defects involving irradiated tissue, infected bone, or infected prosthetic materials. Although the vastus lateralis muscle has no cutaneous component, it may be used to augment an overlying tensor fascia lata flap.
Article
Avulsion of the abductor muscles of the hip may cause severe limp and pain. Limited literature is available on treatment approaches for this problem, and each has shortcomings. This study describes a muscle transfer technique to treat complete irreparable avulsion of the hip abductor muscles and tendons. Ten adult cadaver specimens were dissected to determine nerve and blood supply point of entry in the gluteus maximus and tensor fascia lata (TFL) and evaluate the feasibility and safety of transferring these muscles to substitute for the gluteus medius and minimus. In this technique, the anterior portion of the gluteus maximus and the entire TFL are mobilized and transferred to the greater trochanter such that the muscle fiber direction of the transferred muscles closely matches that of the gluteus medius and minimus. Five patients (five hips) were treated for primary irreparable disruption of the hip abductor muscles using this technique between January 2008 and April 2011. All patients had severe or moderate pain, severe abductor limp, and positive Trendelenburg sign. Patients were evaluated for pain and function at a mean of 28 months (range, 18-60 months) after surgery. All patients could actively abduct 3 months postoperatively. At 1 year postoperatively, three patients had no hip pain, two had mild pain that did not limit their activity, three had no limp, and one had mild limp. One patient fell, fractured his greater trochanter, and has persistent limp and abduction weakness. The anterior portion of the gluteus maximus and the TFL can be transferred to the greater trochanter to substitute for abductor deficiency. In this small series, the surgical procedure was reproducible and effective; further studies with more patients and longer followup are needed to confirm this. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Article
Impaired abductor function of the hip resulting from a discontinuous gluteus medius often is encountered in revision hip surgery. If the gluteus medius can be reattached to the proximal femur, functional results are satisfactory. If this is not possible, it would be desirable to restore the continuity of the gluteus medius by bridging the defect with local tissue. An anatomic study was performed in 15 cadavers, and proximal advancement of the vastus lateralis without injury to the neurovascular pedicle was 8 cm (range, 7–10 cm). Clinically, the technique was used in 3 patients. At follow-up, both living patients walked without a cane and both were able to hold the leg abducted against moderate pressure. Proximal advancement of the vastus lateralis can successfully bridge defects of the gluteus medius and partially restores abductor function.
Article
Abductor insufficiency of the hip remains a difficult problem in orthopedic surgery. Although a variety of procedures have been described, abductor function cannot be satisfactorily restored. Because of the location and innervation of the vastus lateralis muscle, its transfer might provide a promising alternative to replacing dysfunctional hip abductors. Physiological cross-sectional area, muscle fiber length, and time of action during the gait cycle are all similar to the gluteus medius muscle. To investigate the potential usefulness of the vastus lateralis muscle for treating abductor dysfunction of the hip, we dissected 15 thighs, 6 of them after arterial injection with colored latex to further study the vascular supply. The vastus lateralis was found to be vascularized from branches of the lateral femoral circumflex artery in all specimens. In 14 cases, we found a dual innervation from the femoral nerve. The vastus lateralis muscle could be completely mobilized on its neurovascular pedicle and rotated 180° without difficulty. This allowed firm suture fixation to both the iliac crest and the greater trochanter. Clinically, the technique was used in 5 patients. In 2 patients with unfavorable biomechanics, the results were not satisfactorily. In the other 3 patients with normal biomechanics, the clinical results were satisfying. Based on our clinical experience, we feel that this transfer should be reserved for patients with an abductor-deficient hip, considerable associated functional loss, and few other reconstructive options. In the appropriately selected patient, this transfer can restore some of the abductor function.
Article
The anterolateral thigh flap can be used in a variety of ways to reconstruct defects in many areas. As a pedicled flap islanded on its vascular pedicle, it is used to reconstruct the inguinal region. As a free microvascular transfer, it is used to resurface defects throughout the body. It offers bulk, sensate cover, and has an enormous skin replacement potential. Its constant, long, large calibre vessels make it a flap worth considering as a first option for skin and soft tissue reconstructions.
Article
Repeated soft tissue injuries around the knee represent challenging clinical situations where functional prognosis of the joint is often poor, especially in the presence of total knee arthroplasty (TKA). When gastrocnemius muscle flap techniques have already been used and failed, therapeutic solutions become rare. The authors suggest a regional solution to salvage these cases by the transfer of distally-based vastus lateralis muscle flaps. Four clinical operations of this muscle flap transfer are described, with three around TKA revision and one case of a post-traumatic knee amputation resulting from a compound open knee injury. Technical details of the intervention are presented. In all cases, skin closure was achieved, even if distal marginal necrosis was seen in two cases related to the type of muscle flap vascularisation. Final joint mobility was always poor (45° on average). Distally-based vastus lateralis muscle flaps represent a salvage procedure to correct iterative soft tissue defects around the knee that threaten short-term joint function. These muscle flaps do not require microsurgical anastomosis.
Article
Scarring or detachment of the hip abductors, particularly of the gluteus medius, from their insertion may lead to severe abductor weakness, recurrent dislocations, pain, and diminished quality of life. We performed a retrospective study to evaluate whether vastus lateralis shift is associated with satisfactory results and low rate of complications. Eleven adults underwent vastus lateralis shift to bridge a well-documented abductor muscles' insertion defect. Preoperative and postoperative hip functions were assessed applying the Merle d'Aubigne score, British Medical Council scale, and Visual Analog Scale. Significant postoperative improvement was noted in mean Merle d'Aubigne score, gluteus medius muscle force, and quality of life. Vastus lateralis shift represents a viable treatment option for hip abductor deficiency, significantly improving abductor strength and overall quality of life.
Article
Loss of the abductor portions of the gluteus medius and gluteus minimus muscles due to THA causes severe limp and often instability. To minimize the symptoms of limp and instability, the anterior ½ of the gluteus maximus was transferred to the greater trochanter and sutured under the vastus lateralis. A separate posterior flap was transferred under the primary flap to substitute for the gluteus minimus and capsule. To ensure tight repair, the flaps were attached and tensioned in abduction. The technique was performed in 11 patients (11 hips) with complete loss of abductor attachment; the procedure was performed in nine patients during THA and in two later as a secondary procedure. Preoperatively, all patients had abductor lurch, positive Trendelenburg sign, and no abduction of the hip against gravity. Minimum followup was 16 months (mean, 33 months; range, 16-42 months). Postoperatively, nine patients had strong abduction of the hip against gravity, no abductor lurch, and negative Trendelenburg sign. One patient had weak abduction against gravity, negative Trendelenburg sign, and slight abductor lurch. One patient failed to achieve strong abduction, had severe limp after 6 months of protection and physical therapy, and was lost to followup. Gluteus maximus transfer can restore abductor function in THA with a high success rate.
Article
We present a case of successful operative management of an iatrogenic rectourethral fistula with a pedicled vastus lateralis musculofascial flap. The fistula was created during radical prostatectomy operation. During the operation, it was deemed possible to spare this patient from a diverting colostomy and primarily repair a rectal injury. Postoperatively, however, a rectourethral fistula occurred, which was confirmed on retrograde urethrogram. A first attempt failed to close the fistula utilizing the transanal rectal flap advancement technique. A novel technique was attempted using a pedicled vastus lateralis musculofascial flap. This is the first report to our knowledge of repairing a rectourethral fistula with a pedicled vastus lateralis musculofascial flap.
Article
13 patients with tears in the gluteus medius tendon following total hip arthroplasty were studied. The diagnosis of a gluteal tear was made on the basis of clinical signs and a positive arthrogram of the hip in all cases. 11 patients underwent gluteus medius repair and two patients declined surgery. 10 patients attended a review clinic (eight gluteal repair patients and two conservatively managed patients) and three were reviewed by telephone and medical notes. The mean follow up was 61 months (range 12–116 months). The mean age at follow up was 71.42 years (69–79 years) and the male to female ratio was 5:8. The mean duration of symptoms prior to repair was 16 months. An anterolateral transgluteal approach had been used for primary surgery in nine cases and in four cases the original surgical approach was unknown. The mean Harris Hip score prior to repair was 77.4 (range 55–87), which improved to a mean post operative Harris hip score of 86.97 (range 79–96) following repair. The Oxford hip score prior to repair was 20 (range 16–25) which improved to a mean of 14.2 after repair (range 4–29). 9 out of 11 patients who had the repair were satisfied and would recommend the procedure. We believe an accurate and timely diagnosis together with repair can reduce the morbidity associated with this post-operative complication following THA.
Article
The abductor release sometimes does not heal after a transgluteal approach for hip arthroplasty. Factors influencing the success of subsequent repair are unclear. We used magnetic resonance imaging (MRI) to compare the condition of the gluteus medius with clinical outcome after late repair of abductor dehiscence in 12 total hip patients. Evaluation included a pain rating, gait evaluation, Trendelenburg test, strength grading, and Harris Hip Score. Most had both prerepair and postrepair MRI studies to assess the repair and to grade abductor muscle fatty degeneration. Two repairs without MRI were explored surgically. Although average pain, limp, and strength scores improved significantly, rerupture occurred in 4 subjects and fatty degeneration in the gluteus medius did not improve, even with intact repair. Nine patients were satisfied; 7 of these had an intact repair. Magnetic resonance imaging and operative observations suggest that chronic degeneration in the abductor mechanism is the major impediment to successful repair.
Article
The use of a vastus lateralis muscle flap is suggested as an approach to the surgical repair of trochanteric pressure sores in paraplegic patients. The details of the anatomy of the muscle are outlined, and our surgical technique for its use is described.
Article
The suitability of the thigh as a donor site for a new free flap was examined in 100 cadavers. It was found that the vastus lateralis muscle can be used to form a myocutaneous or fasciomuscular flap, the raising of which causes no technical problems and leads to no functional and only minor aesthetic impairments. Depending on the muscle segment from which the flap is raised, a neurovascular pedicle measuring between 8 and 20 cm with a diameter of 2 to 2.5 mm (artery) or 2.5 to 4 mm (vein) can be formed. The skin island in the myocutaneous flap measures on average 8 x 16 cm and is located above the middle portion of the muscle. The diameter of the supplying perforator vessel is between 0.7 and 1.2 mm. The flap can be raised parallel to head and neck surgery and applied as a myocutaneous flap for coverage of extensive or perforating defects or intraorally as a fasciomuscular flap.
Article
The blood supply to the vastus lateralis muscle has been evaluated by dye injection techniques in fresh cadaver dissections. The main dominant blood supply is the descending branch of the lateral femoral circumflex artery. Vascular contributions from distal perforators of the superficial femoral artery, the superior geniculate artery, fill the main vascular pedicle in a retrograde fashion. Latex staining is observed consistently in the proximal third of the muscle. Five patients are presented in whom the distally based vastus lateralis muscle flap was successfully used to cover defects above the knee. Superficial muscle necrosis is a complication of this operation but has not precluded its usefulness. It is anticipated that this flap will be useful in the armamentarium of reconstructive surgeons treating such problematic patients.
Article
The vastus lateralis muscle can provide a broad sheet of muscle for repair of defects of the lower abdomen, groin, perineum, hip, and ischium. The authors limit the use of the vastus lateralis muscle to situations in which more traditional techniques are not feasible. This muscle is especially suitable for defects involving irradiated tissue, infected bone, or infected prosthetic material. Although the vastus lateralis muscle has no cutaneous component, it may be used to augment an overlying tensor fascia lata flap.
Article
One danger of converting an arthrodesed hip to a total hip arthroplasty, especially after many years, is that the abductors may be degenerate and this could cause subluxation or dislocation. The condition can be successfully managed by attaching the tensor fascia lata muscle to the bed of the greater trochanter to act as a hip stabilizer.
Article
We describe the anatomy of the vastus lateralis musculocutaneous flap, and propose its use in the treatment of trochanteric pressure sores. This new technique is simple and reliable. A good padding is given to the recipient site in this particularly mobile and exposed area; the donor site is closed primarily. Indications depend on the possibilities and limitations of other available methods, which should always be considered with every paraplegic patient.
Article
We compared two methods of reconstruction of the abductor mechanism in 15 patients after prosthetic replacement of the upper femur, to assess abductor strength and function. Six patients in group I had direct fixation of the gluteus medius tendon and a segment of the original bone to the prosthesis. Nine patients in group 2 had the abductor tendon fixed to the iliotibial band. We assessed clinical function, isometric muscle strength and muscle cross-sectional area for each patient. The patients in group 1 had better clinical and functional results (p = 0.059), with average peak torques for hip abduction of 92% of that in the non-operated leg in group 1, and of 57% in group 2. Group 1 had a mean muscle cross-sectional area of 69% and a mean value of strength per cross-sectional area of 134% when compared with the control side. The respective values for group 2 were 52% and 91%. Direct fixation of the abductor muscles to the prostheses gave improved function and higher isometric abductor muscle force.
Article
To find out the applications, usefulness and advantages of the microsurgically anastomosed vastus lateralis flap. We evaluated the results of 60 consecutive oral and maxillofacial reconstructions and established typical indications for use of this flap. The transplant was applied as a pure muscle flap in 17 cases, four of those being a split-skin flap for coverage of defects on the scalp. Further reconstructions were done with myocutaneous flaps for the tongue (n = 13), floor of the mouth (n = 16) and external skin defects (n = 6) as well as to close perforating defects (n = 8). The long and high-calibre vascular pedicle, the unvarying anatomy, and the time-saving possibility of simultaneously resecting the tumour and raising the flap in the head and neck region proved to be particularly advantageous during flap transfer. The best results were obtained in extensive, deep, or perforating defects and in tongue reconstruction; neuromuscular connection of the transplant is possible. Pure muscle transplants have only a few indications for application in the oral cavity because of their tendency to shrink. Donor site morbidity was generally low; the flap was lost in 5 cases. This hitherto rarely used transplant is well-suited for maxillofacial reconstructions if the correct indications apply.
Article
In search of an alternative soft tissue free flap donor site to radial forearm flap and rectus abdominis flap in head and neck reconstruction, we used the anterolateral thigh flap for reconstruction of various defects in the head and neck in 59 patients. The aim was to demonstrate the versatility of this donor site and propose a new approach to achieve a safer flap dissection. With the exception of three cases, all defects resulted from excision of malignant tumours. The defects were categorised as full thickness defects of the mandible (33.9%), full thickness defects of the cheek (52.5%) and others (13.6%). During the flap dissection a direct septocutaneous pedicle was observed in 12% of the cases. In the remaining cases there were only musculocutaneous perforators and the flaps were raised either as a split vastus lateralis musculocutaneous flap (72%) or as a perforator flap (16%), depending on the required thickness. Total flap survival was 96.7% with one total and one partial failure and two re-explorations (3.3%). The mean follow-up time was 7.1 months (range: 1-12 months). In conclusion, the anterolateral thigh flap is a versatile and dependable flap that can be adapted to any type of defect by modifying the flap design and composition. It should be considered to be a musculocutaneous flap of the vastus lateralis muscle that can also be raised as a perforator flap. When harvested and used in this context, the flap dissection becomes very safe and consistent, nullifying the only major disadvantage associated with this donor site.
Article
Impaired abductor function of the hip resulting from a discontinuous gluteus medius often is encountered in revision hip surgery. If the gluteus medius can be reattached to the proximal femur, functional results are satisfactory. If this is not possible, it would be desirable to restore the continuity of the gluteus medius by bridging the defect with local tissue. An anatomic study was performed in 15 cadavers, and proximal advancement of the vastus lateralis without injury to the neurovascular pedicle was 8 cm (range, 7-10 cm). Clinically, the technique was used in 3 patients. At follow-up, both living patients walked without a cane and both were able to hold the leg abducted against moderate pressure. Proximal advancement of the vastus lateralis can successfully bridge defects of the gluteus medius and partially restores abductor function.
Article
The vastus lateralis muscle is an accessory extensor for the knee suitable as a free myocutaneous flap in reconstructive head and neck surgery. We report the use of this muscle as a flap. We have used the free myocutaneous vastus lateralis flap for reconstruction following ablative head and neck tumour surgery in six patients. The clinical outcome, time of surgery for flap preparation and anatomosis, follow-up and functional outcome were analysed. Five of our patients showed a very satisfactory functional and cosmetic outcome. Post-operatively, there was no prolonged immobilisation and no limitation of movement to the hip and knee. No unfavourable side-effects at the donor side were noted. We find this flap a very useful addition to our free myocutaneous flap armamentarium. It has a specific suitability for replacing large defects.
Article
We evaluated the results of an operative technique used in five patients (five hips) to reconstruct the greater trochanter with a gluteus maximus flap transfer during revision total hip arthroplasty. We exposed the hip through a posterior approach that split the gluteus maximus in its midsubstance. We then raised a flap from the posterior portion of the gluteus muscle that was elevated proximally to create a triangular muscle flap. The flap was sewn into the gap between the greater trochanter and lateral cortex of the femur and secured to the inner surface of the anterior capsule of the hip. With the hip abducted 10 degrees to 15 degrees, the edges of the gluteus maximus were closed over the flap and the greater trochanter. We compared the results of these patients with those of five patients (five hips) who had the trochanter left unrepaired and those of four patients (four hips) who had excision of the greater trochanter and suture closure of the intervening gap. The flap group had less pain, lower incidence of limp and Trendelenburg sign, and less need for support than the other two groups, but range of motion decreased.
Article
The lateral surgical approach to the proximal femur potentially damages the nerve supply to the vastus lateralis (VL) muscle. This study describes the detailed anatomy of the nerve supply to the VL muscle based on dissection of ten cadaveric lower limbs. In all specimens, a single nerve trunk arose from the femoral nerve, which is most subsequently divided into two main divisions. These divisions gave two branches each. These branches coursed from anteriorly and proximally to posteriorly and distally within the muscle. When the muscle was reflected anteriorly from its attachment to the linea aspera, there was no damage to its innervation. Splitting of the VL in the midlateral line of the femur, however, resulted in denervation of the posterior half of the muscle. Precise knowledge of the nerve supply to the VL will help avoid iatrogenic denervation of the muscle in surgical procedures at the proximal femur through the lateral approach.
Schematic drawing of a longitudinal section (a) and cross section (b) through the thigh showing the nerve supply to the vastus lateralis (VL) and vastus intermedius
  • Fig
Fig. 8. Schematic drawing of a longitudinal section (a) and cross section (b) through the thigh showing the nerve supply to the vastus lateralis (VL) and vastus intermedius (VI).