Hip Review Clinic
Hip Revision Surgery
One of the major groups of muscles around the hip joint is the abductors. These muscles are responsible for keeping the pelvis level while standing upon one leg. The attachment of these muscles can fail, either by rupture of the tendon or avulsion of the bone.
DiagnosisFailure of these muscles causes a permanent limp, or dipping gait. Avulsion fracture of the greater trochanter causes significant weakness of the hip, when lifting the to the side. It may be difficult to differentiate abductor failure from the normal post-operative weakness in the first few weeks. When there is suspicion a standing x-ray is helpful.
For soft tissue avulsion, where the tendon of the muscle is pulled off the trochanter, MRI scan may be required to make the diagnosis [ MRI of Failed Total Hip Replacement Caused by Abductor Muscle Avulsion. Akram Twair1, Martin Ryan, Martin O'Connell, Tom Powell, John O'Byrne and Stephen Eustace December 2003, Volume 181, Number 6. http://www.ajronline.org/doi/full/10.2214/ajr.181.6.1811547 ].
When identified during a hip operation there are a number of recognised methods for re-attaching the bone [ Fixation of Chevron trochanteric osteotomy with two wire loops in isolated acetabular component revision. Panousis KT, Tsifetakis SD, Orfanos J, Giannoulis P, Pilichos J, Papagelopoulos PJ. Orthopedics. 2004 Dec;27(12):1236-9. http://www.healio.com/~/media/Journals/ORTHO/2004/12_December/Fixation%20of%20Chevron%20Trochanteric%20Osteotomy%20With%20Two%20Wire%20Loops%20In%20Isolated%20Acetabular%20Comp%201555/Fixation%20of%20Chevron%20Trochanteric%20Osteotomy%20With%20Two%20Wire%20Loops%20In%20Isolated%20Acetabular%20Comp%201555.pdf ]. Gentle rehabilitation with a period of protected weight bearing is recommended. Some patients may complain of local tenderness due to prominence of the metalwork.
Post-operative fractures may be treated non-operatively as long as there is no significant displacement (<2cm). Often the bone fragment will stabilise, forming a fibrous union, and give good function [ Fracture of the greater trochanter after hip replacement. Pritchett JW. Clin Orthop Relat Res. 2001 Sep;(390):221-6. ].
If the fragment "escapes" then re-fixation with a cable plate may be considered. Operative treatment is best reserved to treat symptomatic weakness, rather than local tenderness [ Management of abductor mechanism deficiency following total hip replacement. Odak S, Ivory J. Bone Joint J. 2013 Mar;95-B(3):343-7. http://www.bjj.boneandjoint.org.uk/content/95-B/3/343.full.pdf ] [ The role of trochanteric wire revision after total hip replacement. Bernard AA, Brooks S. Bone Joint Surg Br. 1987 May;69(3):352-4. http://www.bjj.boneandjoint.org.uk/content/69-B/3/352.full.pdf ].