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The superior gluteal nerve may be damaged during total hip The direct lateral approach to the hip was described by
arthroplasty. We prospectively studied 40 patients who had Hardinge8 in 1982. With this approach, part of the gluteus
total hip arthroplasties using the Hardinge direct lateral ap- medius is sectioned and moved anteriorly with a portion of
proach to the hip to determine any correlation between su- the vastus lateralis. This creates a potential functional risk
perior gluteal nerve damage and abductor function. We used
for the abductor musculature by damage to the superior
the Trendelenburg test to clinically evaluate abductor func-
tion preoperatively and 1 year postoperatively. We evaluated
gluteal nerve or inadequate reinsertion of the musculoten-
superior gluteal nerve function by electromyography preop- dinous cuff into the greater trochanter.2,9,13
eratively and at 4, 8, and 12 weeks until its normalization Our experience with the direct lateral approach to the
over a maximum of 24 weeks postoperatively. The Tren- hip suggests some patients have persistence or develop-
delenburg test was positive in 20 patients (50%) preopera- ment of a positive Trendelenburg test. There is contro-
tively and in 10 patients (25%) 1 year postoperatively. Sev- versy in the literature regarding the causes of this finding.
enteen patients (42.5%) had damage to the superior gluteal Some authors13,14 associated it with damage to the supe-
nerve visible on the first electromyographic evaluation per- rior gluteal nerve whereas others1,11 found no correlation.
formed 4 weeks postoperatively; three (7.5%) of these pa- We asked whether patients who had primary total hip
tients showed changes when reevaluated 6 months postop- arthroplasties (THA) with the Hardinge approach have ab-
eratively; only one of the three patients had a positive Tren-
normalities of the superior gluteal nerve detectable by
delenburg test 1 year postoperatively. Nine of the 37 patients
with normal electromyography results had positive Tren-
electromyography. We also asked whether patients with
delenburg tests. Our results suggest there are frequent elec- electromyographic signs of impairment of the superior
tromyographic signs of damage to the superior gluteal nerve gluteal nerve evolve with a positive Trendelenburg sign.
using the direct lateral approach to the hip. However, the
damage tends to improve spontaneously and does not seem to
cause clinically apparent abductor insufficiency.
MATERIALS AND METHODS
209
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Clinical Orthopaedics
210 Picado et al and Related Research
given to finding fibrillation potentials and positive acute waves, TABLE 1. Electromyographic Results
changes in the morphologic features of the action potentials of
Normal EMG Abnormal EMG Total
the motor unit, and decreased motor units. Acute denervation Trendelenburg Number Number Number
was defined as the presence of fibrillation potentials and/or posi- Test (percent) (percent) (percent)
tive acute waves. Acute denervation was classified subjectively
Negative 28 (70%) 2 (5%) 30 (75%)
as mild when occasionally present in some points, moderate
Positive 9 (22.5%) 1 (2.5%) 10 (25%)
when present in all points, and severe when present in large Total 37 (92.5%) 3 (7.5%) 40 (100%)
amounts in all points.
We evaluated patients using the Trendelenburg test preopera- EMG = electromyography
tively and 1 year postoperatively. We used the direct lateral
approach to the hip described by Hardinge,8 extending the divi-
sion of the gluteus medius proximally for a maximum of 4 cm DISCUSSION
above the apex of the greater trochanter. We reinserted the mus-
culotendinous cuff into the greater trochanter using interrupted The superior gluteal nerve is formed by the L4, L5, and S1
polyglactin Number 2 sutures. Patients were instructed in using roots and leaves the pelvis through the greater sciatic fo-
a walker and partial weightbearing on the surgically treated limb. ramen in a direction immediately cranial to the piriformis
Weightbearing was limited for 1 month postoperatively in pa- muscle, running laterally and anteriorly between the glu-
tients with cemented prostheses and for 2 months postopera- teus medius and gluteus minimus muscles, innervating
tively in patients with noncemented or hybrid prostheses. them.11 The patterns of ramification and distribution of
this nerve,2,3,10,12 and the risk of damage during the direct
lateral approach to the hip have been studied exten-
RESULTS sively.1,2,6,7,11,13 Using continuous intraoperative EMG,
three maneuvers described as endangering the nerve are
All patients had normal preoperative EMG results, al- splitting the gluteus medius muscle, excessive retraction
though some had EMG abnormalities postoperatively.
Four weeks postoperatively, 23 patients (57.5%) had a
normal results and 17 (42.5%) patients showed abnormali-
ties compatible with mild partial denervation of the gluteus
medius. Nine of the 17 patients had normal results 8 weeks
postoperatively, for a total of 32 patients (80%) with nor-
mal results. However, eight patients (20%) continued to
show abnormalities. The eight patients were reevaluated
12 weeks postoperatively. Three patients had normal re-
sults, raising the total with normal results at 12 weeks to
35 (87.5%), with five (12.5%) patients showing mild and
improving EMG changes. Two of these five patients tested
normal 24 weeks postoperatively, with only three (7.5%)
of the initial 40 patients showing evidence of mild EMG
changes.
Not every patient with electromyographic signs of im-
pairment of the superior gluteal nerve had a positive Tren-
delenburg sign develop. Preoperatively, Trendelenburg
test results were positive in 20 patients (50%) and negative
in 16 (40%) patients. Four (10%) patients were unable to
keep the required one-foot test stance because of pain. One
year postoperatively, 30 patients (75%) had a negative
Trendelenburg test and 10 (25%) patients continued to
have a positive test. Of the three patients with EMG evi-
dence of partial damage to the superior gluteal nerve 24
weeks postoperatively, only one patient had a positive
Trendelenburg test 1 year postoperatively. Of the 37 pa-
Fig 1. A diagram shows the evolution and cumulative percent-
tients whose EMG results were normal or progressed to ages of the electromyographic assessments, illustrating fre-
normalization, nine patients presented with a positive quent damage to the superior gluteal nerve and the sponta-
Trendelenburg test 1 year postoperatively (Table 1; Fig 1). neous recovery that occurred in most patients.
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Number 455
February 2007 An Electromyographic and Clinical Study 211
for acetabular exposure, and positioning the leg across the grated 2 cm or greater from the markers 1 year postopera-
table for preparation of the femur.14 tively, and a limp occurred after migration greater than
We note two major limitations of our study. First, the 2.5 cm.
abductor function can be altered depending on how much Although damage to the superior gluteal nerve detected
of the muscle was cut during the surgery. Unfortunately, by EMG was frequent after the direct lateral approach to
we were not able to quantify this variable, but whatever the hip, this damage was partial, of mild intensity, and
degree of muscle damage occurred did not seem to have tended to improve spontaneously by 6 months postopera-
any major clinical implications. The second is the lack of tively. Mild damage to the superior gluteal nerve detected
any quantitative assessment of the nerve damage, because by EMG did not manifest clinically with abductor insuf-
EMG is a qualitative method and the graduation of its ficiency in most patients. Limp and a positive Trendelen-
abnormalities is subjective. Nevertheless, this is the stan- burg test after direct lateral approach to the hip were not
dard method to detect the presence of muscle and nerve exclusively provoked by damage to the superior gluteal
damage. Quantification might be important if a substantial nerve.
number of patients had residual clinical findings and one
wanted to know whether the amount of damage correlated
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.