Acetabular Cup Revision Combined With TFL Reconstruction

Acetabular Cup Revision Combined With Tensor Fascia Lata Reconstruction For Management Of Massive Adductor Avulsion After Failed Total Hip Arthroplasty


We report on 17 patients with massive abductor avulsions after total hip arthroplasty (THA) treated with medialization of the acetabular component and tensor fascia lata (TFL) reconstruction. All patients had severe limp, positive Trendelenburg sign, and avulsion of the adductor insertion confirmed on MRI.   Mean age was 69 years (range, 50 to 83 years), and mean follow-up period was 36 months (range, 18-78 month). After surgery, 9 patients had no limp (47%), 8 patients had a mild limp, and adductor power improved from mean 2.5/5 to mean 3.8 (p<0.0001). At latest follow-up, the Harris Hip Score was excellent in 6 hips (37%), good in 7 (43%) hips, and fair or poor in 3 (23%).  Two patients with mild limp were not satisfied with their procedure.

INTRODUCTION- Impaired or absent adductor function after total hip arthroplasty (THA) is a difficult management issue. The loss of hip adductors usually results in a refractory limp and positive Trendelenburg sign, loss of joint function, and potentially an increased risk of recurrent hip dislocation.

While surgical repair of adductor avulsion can improve gait and reduce pain, the results have not been uniformly good, especially with regards to dbductor defects following THA . The size of the adductor defect is important, both with regards to the surgical technique and the functional outcome.  Options direct reattachment of the gluteus medius to the greater trochanter with small defects, primary repair in conjunction with a soft tissue reconstruction (advancement of the vastus lateralis) for medium defects, and soft tissue reconstruction with gluteus maximus or posterolateral transfer of the psoas tendon in the setting of chronic, retracted defects.

In this study we present our experience of treating massive tears of the adductor muscle in patients after THA, by revising the acetabular component to a superior and medial hip center, in combination with a tensor fascia lata (TFL) soft tissue reconstruction.


Patient population

Between 2006 and 2011, a revision of the acetabular component to a superior and medial hip center was combined with soft tissue reconstruction of the adductor muscle deficiency in patients who presented with adductor avulsion after failed primary THA.

MRI- All patients had a complete, full thickness tear of gluteus medius and minimus confirmed by preoperative MRI, using techniques to suppress the artefact from the adjacent implants

Surgical technique

All procedures were performed under combined spinal-epidural anesthesia with the patient in a lateral position. The gluteus minimus was elevated with a cobb elevator from the ilium, beginning approximately 2 cm above the superior margin of the acetabulum This release was performed to allow the gluteal muscles to be pulled distally as a sleeve for later closure. The hip was dislocated anteriorly, the femoral head removed, and the femoral component examined for evidence of stability.  Acetabular reaming was then performed by hand in a superior and medial position to the previous acetabular component. The leg was then brought into adduction of about 300 to allow for the repair and reconstruction of the adductor musculature. Initially the gluteus minimus and the posterior half of the gluteus medius were sutured, the repair was augmented with tensor fascia lata.  Firstly the posterior TFL, then the anterior limb are sutured to the gluteal musculature and the superior margin of the vastus lateralis insertion.

Post-operative management

Patients are allowed to touch weight bear using 2 crutches / walker for 6 weeks. During this period, active hip adduction, passive flexion beyond 70°, adduction, and external rotation of the hip are prohibited.


No patients were excluded from analysis, leaving a total of 17 acetabular medializations and gluteal reconstructions in 17 patients available for radiographic and review at a minimum of two year follow-up.  The cohort was comprised of 6 males and 11 females, with a mean age of 69 years (range, 50 to 83 years) at the time of the index operation. The mean follow up was 42 months (range, 24 to 79 months).

Clinical Outcome

All patients had a severe limp and positive Trendelenburg sign prior to the surgery.  After surgery, at minimum two year follow up, 9 patients had no limp (47%), while 8 patients had a mild limp (p=0.008).  With regards to post-operative Trendelenburg sign, 8 patients were positive and 9 patients negative (p=0.0085). The pre-operative abductor power was a mean of 2.56 (range, 1.5 – 4), which improved postoperatively to a mean of 3.81 (range, 2.5 – 4.5) (p=0.001). Pre-operatively, all patients required the constant use of a cane or walker as aid (10 walkers, 7 canes); post-operatively, 9 patients no longer required an aid to walk, while 5 patients continue to require the use of an cane and 3 continued to use a walker.

The HHS at most recent follow up was good for 47% of patients (8/17 hips), fair in 35% (6/17 hips) and poor in 17.6% (3/17 hips) at minimum two years after the operation. No complications such as infection or dislocation were seen. Only one patient was not satisfied with the procedure and two patients would not have the procedure again.

Radiographic Assessment –At latest follow-up, no patient had radiographic evidence of acetabular or femoral loosening.


Large and massive tears of the adductor muscles after primary THA are a relatively uncommon problem. In the chronic setting, this degree of adductor deficiency is often insufficiently treated by soft tissue repair alone, due to significant muscle retraction and atrophy.  Repair is even more difficult in the setting of leg lengthening secondary to THA.  In this case series, we have described revision of the acetabular component to a superior and medial position, in order to decrease tension on the gluteus reconstruction.  Furthermore, we have described the use of the tensor fascia lata for gluteal reconstruction, a muscle which fulfills the criteria for functional transfer to replace gluteus medius muscle deficiency. By revising the acetabular component to supero-medial position, a primary repair of the gluteal tendons to the greater trochanter, with augmentation by the TFL becomes possible.

Relatively few studies report the outcome of treating adductor muscle deficiency after THA, with multiple options described. Miozzari et al. reported late surgical reattachment of an avulsed adductor insertion in 12 patients and Fehm et al. described adductor reconstruction using an Achilles tendon allograft in seven patients.


After a mean follow-up of 42 months, we found that revising the acetabulum to a superior and medial position in combination with a tensor fascia lata reconstruction was an acceptable treatment for chronic, large adductor muscle avulsions after primary total hip arthroplasty.

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