Abstract
Background: Gluteal muscle contracture (GMC) is a clinical syndrome characterized by limited hip movements.
Methods: In this prospective study, 23 patients received traditional incision surgery and 22 patients received small incision surgery for the treatment of GMC. The two groups were compared for duration of surgery, length of incisions, requirement of postsurgical analgesia, postsurgical complications, off-bed activity times, duration of hospitalisation, clinical outcomes and one year recurrence rates. Statistical analysis was performed with SPSS software; enumeration data were analysed by χ2 tests; and measurement data were analysed by t tests.
Results: The small incision surgery group was significantly superior to traditional incision surgery group in terms of incision lengths and requirement of postsurgical analgesia. Differences were not statistically significant for patient satisfaction, postsurgical complications and recurrence rate. Aesthetic –conscious patients were particularly satisfied with the treatment because of smaller incisions and minimum surgery scars.
Conclusion: The small incision surgery of gluteal muscle contracture is safe and reliable, with the advantage of less trauma, less postsurgical pain, better rehabilitation and return of functional activities. Its application, though, should be carefully controlled based on the indication and the treating surgeon needs to be well experienced in this field.
Introduction
Gluteal muscle contracture (GMC) is a pathological condition in which the gluteal muscle and the underlying fascia become degenerated, necrosed and/or fibrosed. This leads to a limitation of the hip movement. The condition is characterised by poor functioning of the lower limb leading to gait abnormality. GMC was first reported by Valderama around four decades ago. With respect to the etiology of the condition, it is believed that GMC is associated with repeated intramuscular (IM) injections administered during childhood years into the gluteal region. In some cases though, it can also be congenital. It is prevalent in the US, a few European countries and a few Asian countries. It is especially, widely reported in the Chinese population. This could be due to frequent use of benzyl alcohol, used as a dissolvent for IM penicillin injections. Injecting penicillin using benzyl alcohol as dissolvent is widely practised in some regions of China. Research has shown that benzyl alcohol is the main culprit behind the development of the condition just a few years after its use.
The degeneration of gluteal muscles results in an abnormal gait of varying severity due to impaired internal rotation of the hip joint. As the affected individual grows, the pathologic changes continue to increase in severity to include discrepancy in the leg length, pelvic oblique, compensatory scoliosis and bilateral dislocation of hip joints in severe cases. Especially, immunodeficient individuals are more prone to develop GMC.
Once diagnosed, non-operative management includes stretching exercises which are useful in mild conditions, but moderate and severe conditions require a surgical intervention. Traditional incision surgeries are associated with complications and post-operative pain due to a larger wound area. In view of this, the current study was aimed at comparing small incision surgery to traditional incision surgery in the treatment of GMC. The researchers hypothesized that the treatment with small incision would decrease the wound area, promote faster healing and decrease the requirement for post-operative analgesia as compared to traditional incisions.
Study design:
A prospective design was used to compare the relative efficacy and safety of traditional and small incision approaches in the treatment of GMC. Between March 2004 and September 2008, 50 patients with a diagnosis of GMC were included in the study. Of this, 5 patients defaulted on the 6 month follow-up period and had to be excluded on account of default. Of the remaining 45 patients, 22 patients were randomly assigned to treatment with small incision surgery (Group A) and 23 patients were assigned to traditional incision surgery (Group B). All surgical procedures were carried out under the influence of general anaesthesia. The study was permitted by the Ethical Board and informed consent was provided by all the patients in the study. If the patient was a child, written consent was provided by the parent/guardian.
Patients included in the study were those in the age group of 8 to 22 years and had positive Ober’s sign and frog squatting. The intorsion of lower limb was restricted with abduction contracture in both hip and knee joint at 90 degrees. Adduction range was less than 20 degrees with no flexion. The condition was bilateral. The hip joint had no osseous defect at the pelvis anteroposterior radiograph. Of the 45 patients studied, 43 patients had a history of intramuscular injections and a palpable stick or plate on the hip.
Methods:
Small incision treatment group (Group A):
In Group A, the 22 patients selected were placed in lateral position to expose the affected side. A longitudinal skin and subcutaneous tissue incision of 4 to 6 cm was made above the greater trochanter. Depending on the category or severity of disease, Ober and post extension were confirmed negative. Adduction, internal and external rotation of both legs, and hip and knee flexions were confirmed. While releasing the deeper muscles, the sciatic nerve needs to be carefully protected. Finally, the wounds were irrigated, drainage tubes or pieces were placed and incisions were closed.
Traditional incision treatment group (Group B):
In Group B, the selected 23 patients were made to lie down in lateral position and each patient was operated upon by a skin incision 7 to 15 cm long at the lower part of a line between the greater trochanter and the posterosuperior iliac spine. A “Z-shaped releasing operation” was performed. The soft tissue was dissociated until the contracture region of the gluteus maximus, medius and minimus were released. In severe cases of GMC, the sciatic nerve should be protected carefully when the deeper muscles are released. A drainage piece or tube was placed and the two legs were fixed side by side, with knee and hip in bending position.
Postsurgical treatment
Postoperatively, in all the patients who underwent surgery, drainage tubes were kept in the body for maximum of a couple of days after surgery, and then removed. Patients were instructed to perform off-bed functional exercises like walking on a straight line, straightening waist, adducting hip joint several times a day, squatting with knees side by side, with the heel on the ground to gradually achieve flexion between hip and knee greater than 90 degrees, sitting with the two legs crossed and straightening the waist to make the back of one thigh touch the front of another thigh, thereby extending hip muscles and moving the hip joint. The patients with unequal leg length were asked to do additional exercises, including traction of low limb skin, movement of pelvis and hip and downward and upward movement of the two legs in supine position (short leg stepping downward while long leg moving upward, repeatedly) to straighten up the hip muscles and maintain the leg balance, which could help correct the pelvic tilt and lengthen the shortened legs. Sutures were removed after 2 weeks of surgery in the traditional incision group and just a week after surgery in the small incision group.
Statistical analysis
The two groups were compared for the duration of surgery, the length of the incisions, postsurgical pain and requirement of postsurgical analgesia, duration of hospitalisation, postsurgical complications, recurrence after two years and lastly, patient’s overall satisfaction with the achieved results. All 45 patients were followed up at 2 weeks, 1, 3, 6, 12 and 24 months. Visual analog scale was used to measure the postsurgical pain.
Statistical analysis was performed with SPSS software (version 19.0; SPSS, Chicago, IL). Enumeration data were analysed by χ2 tests, and measurement data were analysed by t tests. A P-value ＜ 0.05 was considered to be statistically significant.
Results:
There were 45 patients (29 males and 16 females) diagnosed with GMC in this study and treated with two type of surgeries. Surgical time required to carry out the incisions was relatively similar in both the groups (39.82 ± 7.2 for small incision vs. 38.34 ± 6.27 for traditional incisions, p = 0.468). The incision length required in Group A (5.03±0.74) was just almost half the length of incision in traditional surgery (10.34±2.29) p=0.000. Postsurgical analgesia was required in just 15 patients of Group A as compared to 19 patients of Group B. Duration of hospitalisation was 10.23±2.29 in the small incision group as compared to 9.57±2.41 days in the traditional incision group. Table 2 shows the comparison of clinical outcomes from the two surgical treatment groups.
The postsurgical complications associated with both the groups were fairly similar e.g., hematoma and wound seepage occurred in both the groups. There was necrosis of the edge of the wound skin in the small incision group, but the traditional incision group had a major complication of dislocation of the hip which may be due to excessive release of deeper soft tissues. One patient with GMC in the traditional incision group presented with a recurrence of the condition after 1 year while no case of recurrence was reported in the small incision group.
Discussion
The goal of any surgical procedure is to correct the condition and improve the health related quality of life of the patient. Since the time GMC was first reported, the treatment was usually stretching exercises. Once contractures are established, stretching exercises do not work and the condition needs to be surgically treated. Traditionally, open surgical procedures were carried out, but with as any other surgery, there are complications with a traditional incision. Extensive tissue manipulation results in hematoma formation and a slow recovery. Sometimes, a scar-like tissue growth may develop around the area of incision postoperatively which can affect not only the aesthetics, but can also lead to psychological issues with the young individual.
In a study of 187 patients with traditional incision, there were 62 cases reported of cicatricle band formation, six cases of hematoma formation, one case of wound dehiscence, and three cases of secondary infection of the wound. Since the time Valderrama first reported GMC, surgeons always believed that surgery is an effective way to cure the condition and many feel nonoperative management is invalid. The current study compared the clinical effects between a traditional incision surgery and a small incision surgery for GMC which ensured that the latter approach had a smaller incision length which corresponds to faster healing and lesser requirement of postsurgical analgesia as compared to that required for the traditional incision surgery. Thus, compared to traditional open surgeries, the small incision surgery presented many advantages including minimal surgical trauma, smaller incision and minimal requirement of postsurgical analgesia. However, the small incision surgery can have few limitations. The field of view during the surgery is small; hence it is relatively difficult to operate when a patient presents with a larger GMC area. Therefore, appropriate selection of patients for small incision surgery is important. Secondly, the small incision surgery needs to be performed by well experienced and confident surgeons (surgeon who has performed over 50 cases of traditional incision surgeries). If the surgeon is not experienced enough, there is always a scare of injury to the sciatic nerve and the deeper muscles may not be release completely.
One postsurgical complication observed in the small incision surgery group was the development of necrosis along the edge of the wound. This could be due to excessive pulling /stretching of the skin during small incision. In severe GMC cases, care should be taken while releasing the deeper tissues. If the capsule is released completely, it may lead to hip joint dislocation. Overall, appropriate case selection and experienced surgeon is a must for small incision surgeries.
In conclusion, small incision surgeries for the management of GMC have clear clinical efficacy and safety profile, reduced post-operative pain, accelerated recovery and improvement in aesthetics for patients, thus promoting psychological well-being for the patient.
