Doctors on Gluteus Maximus Tendon
Thanks to Vince DePalma for bringing up the subject of the gluteus maximus tendon.
Gluteus Maximus Tendon
--Hello, I am new to this group. I am a 54 year old male with osteoarthiris in both hips, a former quarter miler at Bucknell University who can barely walk now. I have been very impressed by conversations I have had with Dr. James Pritchett in Seattle. Dr. Pritchett agrees with Dr. DeSmet in not reconnecting the gluteus maximum tendon (due to risk of impinging the sciatic nerve). By contrast, Dr. Vijay Bose strongly advocates that the gluteus maximus tendon be stitched back at the end of the surgery. In his email this morning he said the risk to the sciatic nerve is only during surgery.
On the other hand, Dr. Tom Gross does not take down the gluteus maximus tendon all the way, only a small portion and says it will heal on its own, therefore there is no need for suture. I watched Dr. Bose perform the surgery on Youtube and was impressed with his extreme care taken to preserve the whole bursa and femoral capsule. Nevetheless, I remain confused on gluteus max tendon issue. Having said this, my decison on a doctor might ultimaley be more influenced by which one is in the CIGNA network. Any feedback or encouragement on the subject would be appreciated. Best regards, Vince
Dr. Pritchett said he does not always take down the gluteus max tendon but would expect to do so in my case because of my gender and size. He would take it down and not reconnect it. De Smet would agree, but I am not sure why reconnecting it is an issue. Dr. Gross takes it down only partially and also does not suture it back. Dr. Vijay Bose on the other hand does reconnect it. I believe the risk is nerve palsy cause by entrapment of the sciatic nerve in the suture. Below is a exerpt from a paper writen by Dr. De Smet, published by Orthopedic Clinics of North America (2005):
"All surgeries were performed through an extended standard posterior approach. The maximus split extends about 10 to 15 cm into the muscle. The insertion of the gluteus maximus tendon is fully released to allow easy anterior displacement of the femur and femoral head to perform the acetabular procedure. The gluteus maximus tendon is released with cauterization close to the bone. The tendon is never reattached for risk of entrapment of the sciatic nerve in the suture. Exposure is never jeopardized by a smaller or minimal incision. The capsule is divided circumferentially near the border of the acetabulum
(1 cm). The posterior part of the capsule is incised as posterior as possible to not damage the soft tissue of the femoral neck. The circumflex vessels are always coagulated and divided. The soft tissues around the femoral neck are kept completely intact, and the capsule is not removed. Acetabular reaming is done as in a normal total hip procedure. A cup position of no more than 45 degrees of abduction and an anatomic anteversion of 20 degrees to 30 degrees are aimed for. Less anteversion can result in groin pain from local conflict with anterior structures and the psoas tendon. All resurfacing devices are chrome/cobalt alloys, which are stiffer implants than the more often used uncemented total hip titanium alloy cups. Therefore, a bigger force is needed to impact the cup.The absence of holes in the cup to see if it is fully seated explains the need for a hammer of at least 1 kg."
Dr. De Smet told me today regarding his practice that the gluteaus maximus tendon is not cut anymore, and that since he changed closure of the procedure this changed to a 0 sciatic problem since 12/2003.
Dr. Bose response
Thanks for the info.
If one does not suture the tendon of gluteus maximus, it is commonly believed that it would cause sagging of the buttocks. This is good enough reason for me to stitch it back However I think that it does contribute to function as well . How can such a large tendon be without any function. ? The risk of sciatic nerve damage with this tendon is related to translating the femur anteriorly without releasing it. This was shown by Dr Chit Ranawat many yrs ago. I do not think that there is any risk in suturing it back although I am aware that koen holds a contradictory view on this. The patients whom you are referring to who have poor function is due to the damage of the muscle caused during surgery. If one is struggling with the exposure, it tends to tear the muscles inadvertently and this would translate as poor function post op. Exposure during surgery must be clean without the use of undue force.
I hope the above helps
With best regards
Dr. Su’s response
About this topic, I do release a portion of the gluteus maximus tendon in all patients, which I believe serves 2 purposes. First of all, I believe it allows a greater rotation and translation of the femoral head, which gives me better access to position both the socket and femoral cap. Secondly, I think that it could help protect the sciatic nerve, which may be impinged upon by the tendon in certain positions. I don't routinely take this tendon down in a total hip replacement, but I do for the resurfacings for the above reasons. Although there may be some patients that don't require it taken down and their nerve would be fine, I do it just in case. When I first started resurfacing, I took the entire tendon down; now I just take a portion of it down. I always repair it afterwards, and I respectfully disagree with Koen on this point; I think that it can be repaired quite easily without worry of entrapping the sciatic nerve.