Raul Kuchinad, Benedict Rogers, Shawn Garbedian Allan Gross, David Backstein, Oleg Safir University of Toronto, Department

of Surgery Mount Sinai Hospital, Toronto Ontario Introduction:

A well-known complication after both primary and revision hip arthroplasty is a deficient abductor mechanism. This problem leads to significant morbidity for patients and to date only a few studies have been published describing methods for reconstruction or repair. At our institution we have devised a method for reconstructing hip abductor deficiency with human allograft. We describe our initial series of patients with varied types of abductor reconstruction.

Results Continued:
8 patients had proximal humeral allografts with rotator cuff attached, 5 patients had tensor fascia lata allograft and 2 had patella with tibial tubercle and attached tendons for their respective reconstructions.
Fig. 1 Fig. 2 Fig. 3 Fig. 4

Post-operatively the majority (13/15) of patients had a reduction of their pain and 8/15 increased their abductor strength by almost a full grade. 3/15 Patients improved by half a grade and 4/15 had no improvement. Decreased presence of a lurch was found in 10 patients. One patient redislocated after a failed revision for instability. There were no infections.

Fig. 5

Fig. 6

Fig. 7

Methods:
All patients were identified as having deficient abductor mechanisms after primary or revision hip arthroplasty through X-Ray, MRI, clinical examination and intraoperative exploration. All patients underwent reconstruction of their hip abductors with various types of human allograft (proximal humerus, tensor fascia lata, quadriceps and patellar tendon). Frozen, irradiated allograft was thawed and prepared on the back table by a separate team while the deficient abductors were exposed. Depending on the specific pathology found, the type of allograft reconstruction used was customized to each patient. The general principles were to use heavy absorbable vicryl suture to secure the tendinous part of the proximal abductor. These were then attached to proximal femur (allograft bone to host bone) with cerclage wires. If a midsubstance rupture was found, an allograft to host tendon-tendon reconstruction was performed and re-inforced with fascia lata. Post-operatively all patients were prevented from active abduction and wore abduction
Figures 1 7 : These images depict a radiographic case of a single patient that initially shad an intraoperative fracture of the greater trochanter during a primary THA for OA (fig. 1) which was wired but went on to escape (fig. 2). Figure 3 is an failed claw plate that was attempted for GT fixation. The last radiography (fig. 4) shows the allograft abductor reconstruction with signs of incorporation. Figure 5 is an allograft of tibial tubercle and patella with both quadricep and patellar tendon attached. Figures 6 and 7 show intraoperative reconstruction of the abductor mechanism.

Methods Continued:
braces for 3 months after the reconstruction. Active abduction exercises were started and progressed after 3 months and were followed by a physiotherapist.

Conclusions:
Our series of fifteen patients is the largest that we know of describing the use of different allografts for reconstructing the abductors in the setting of hip arthroplasty. Early results have been promising for this difficult problem. We believe that use of human allograft has low morbidity and is relatively easy to use and is a viable solution for reconstruction of deficient hip abductors. Future prospective studies are recommended to better study this reconstruction. References:
1) 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

Results:
15 patients underwent allograft reconstruction over the last 18 months. Average age of the group was 66 years and average follow-up was 12.5 months. All deficiencies of the abductors with diagnosed via imaging, clinical examination or intraoperatively. Only one patient had an abductor deficiency after a primary total hip, while the rest of the patients had multiple hip revision surgery. Preoperatively all patients had an abductor lurch gait and positive trendelenburg test. Manual muscle strength testing showed significant weakness with a mean grade of 3+/5. Peri-trochanteric pain was cited as a significant complaint in > 80 % of patients.