OBJECTIVE: To compare the efficacy of arthroscopic treatment of gluteofascial contracture with that of conventional surgical treatment of gluteofascial contracture.
METHODS: The included cases were treated by two methods: conventional surgical incision and release of the gluteofascial contracture band under direct vision and arthroscopic minimally invasive operation to release the gluteofascial contracture band, and postoperative exercises were instructed, and the results of postoperative recovery were compared with respect to incision length, operation time, intraoperative bleeding, pain visual palpation score, postoperative time to the ground, hospitalization time and parallel knee squat test, and excellent rate, and followed up.
RESULTS: The postoperative results of the two groups of cases were observed and followed up to compare their postoperative hip popping, parallel knee squat test, recurrence rate, and patient satisfaction.
CONCLUSION: Arthroscopic treatment of gluteus fascioconus is a less invasive, easy to operate, fast postoperative recovery, and low recurrence rate method, and its conducive to shortening hospitalization time and saving medical resources.
Gluteal contracture is a clinical syndrome caused by the degeneration and contracture of the gluteal muscle and its fascia due to various factors such as repeated gluteal injections, scar physique, and abnormal immune function, which leads to the limitation of hip joint function and the expression of characteristic gait and signs. Gluteal muscle contracture (GMC), also known as gluteal muscle fibrosis, occurs in children, and some patients are diagnosed with abnormal gait, restricted squatting, and hip popping only in adulthood because their parents do not pay attention to it. Valderrama and Ma Chengxuan were the first to report this disease at home and abroad, and it has gradually attracted attention. In recent years, our hospital has adopted arthroscopic minimally invasive surgery combined with the concept of rapid rehabilitation to treat 67 cases of young and middle-aged hip contracture with 116 hips, which has achieved good results compared with 23 cases of young and middle-aged patients with 40 hips.
I. Clinical data.
1, general information.
Traditional surgery group: 10 male cases, 17 hips; 13 female cases, 21 hips. The age ranged from 18 to 31 years, with an average of 23.4 years. The disease duration was 16-26 years, average 20.3 years, referring to the classification standard of hip contracture by Zhang Zhong et al: moderate 7 hips, severe 20 hips.
Arthroscopic treatment group: 26 males, 40 hips; 41 females, 76 hips. The age ranged from 18 to 30 years, with an average of 22.4 years. The duration of disease ranged from 15 to 26 years, with an average of 21.1 years, 48 hips were moderate and 69 hips were severe. The specific etiology was unknown in 4 cases in the arthroscopic group and 3 cases in the traditional surgery group, while all other patients had a history of repeated hip injections. All patients had a typical outward eight gait, limited internal rotation and flexion of the hip joint bilaterally, and all could not squat with knees together, and the Ober sign was positive. All patients had positive Ober’s sign. All patients had radiographs to exclude bony lesions. There was no statistical significance in age, gender, and hip contracture score in both groups (P > 0.05). Incision length, operative time, intraoperative bleeding, pain visual mapping score, postoperative time to the ground, hospital stay and parallel knee squat test, and excellent rate were compared (t test and x2 test). All patients were first-time hip surgeons, and the presence of muscle strength, neurological hypoplasia, bilateral lower limb inequality and coagulation abnormalities were excluded in both the conventional surgery group and the arthroscopic group before surgery, and films were taken to exclude bony structural abnormalities.
2. Surgical methods.
(1) Conventional surgery group: epidural anesthesia, lateral recumbency, a curved incision concave to the greater trochanter was made 2cm~3cm above the posterior aspect of the greater trochanter, 200px~250px long, to reveal the tense gluteal fascia and completely release the contracture band, to achieve no abnormality in hip flexion, internal retraction, internal rotation and negative Ober’s sign as satisfactory. The skin was routinely intermittently sutured and analgesic, and infection was prevented.
(2) Arthroscopic group: Epidural anesthesia, lateral recumbency, marking 3 cm above and below the anterior and posterior aspects of the greater trochanter as the working channel and light source entrance. Before cutting, the surface of the contracture zone was separated by blunt stripping of the deep fascial surface to form a working cavity on its surface, and then replaced with an arthroscopic lens to reach in and observe (saline was continuously perfused to maintain the pressure in the cavity), and a small incision was made in the posterior lower part as before to identify the contracture tissue with a probe, and a mucosal blade was inserted to cut off the contracted fascia, and the Ober sign was repeatedly checked until it was negative, and the affected hip was moved without popping, and there was no abnormality in hip flexion, internal contraction, or internal rotation. The operation was considered successful when there was no abnormality in hip flexion, internal contraction and internal rotation, and after the operation, the hip was tied with a lap band under pressure and fixed with both knees together during sleep. After the anesthesia subsided, the hip joint flexion and extension activities were performed in bed with knees together, and the next day after the operation, the patients went down to the ground and practiced squatting with knees together, holding the guardrail.
Patients in both groups were discharged with normal knee squatting, no redness, swelling and oozing of the incision, and normal gait on the ground. The superiority rate was considered as excellent if the patients were satisfied, good if they were basically satisfied, and poor if there was no significant difference with the preoperative period or if there was weakness of the affected hip.
3. Statistical methods: SPSS 18.0 statistical software was used for statistical processing, and the measurement data were expressed as mean ± standard deviation (X ± S), and one-way ANOVA and t-test were used for comparison between groups, and P < 0.05 was considered statistically significant.
II.Results.
The case data of the two groups are shown in the table, and the incision length, operation time, intraoperative bleeding, pain visual mimicry score, postoperative time to the floor, hospital stay and gait, knee squatting and popping were compared (considered statistically significant at P < 0.05). One case of incisional ooze and subcutaneous infection occurred in the conventional surgery group after surgery, which healed after dressing change and debridement II/nail, two cases of subcutaneous hematoma, which absorbed on its own, and one case of gluteus medius weakness; two cases of posterior lateral edema of hip and hip joint occurred in the arthroscopic group, three cases of popping sound existed, but it was significantly weaker than before surgery, and two cases of partially restricted knee squatting, which returned to normal after practice, and there was no nerve injury in both groups. There was no statistical difference between the two groups in the comparison of walking gait and popping sensation after surgery, and only one case in the traditional surgery group was dissatisfied with the surgical effect for patients with gluteus medius weakness. There were 22 cases in the traditional surgery group with follow-up from 3 months to 36 months, with an average of 14 months, and 62 cases in the arthroscopic group with follow-up from 3 months to 24 months, with an average of 15 months. There was no recurrence in both the surgery and arthroscopic groups, and the results were satisfactory.
III. Discussion.
Older patients with severe hip contracture have more obvious functional impairment and may have pelvic tilt secondary to low back pain and hip arthropathy, and patients are not satisfied with walking posture, so they have a stronger demand for surgery. It is now usually considered that surgery is considered after diagnosis if there is no contraindication. The contracted fascial tissues are released and functional exercises are performed early after surgery to consolidate the surgical effect. In this study, no further popping and squatting limitation of the knee occurred in the conventional surgery group after surgery, while individual residual symptoms existed in the arthroscopic group, probably due to the following reasons.
1, the age of the included cases, more contracture tissue, arthroscopic field of view is relatively narrow, not reveal all contracted fascia.
2, Some patients also have more obvious contracture of the gluteus muscle, and the arthroscopy is probing palpation, so it is more likely that some contracted tissues remain.
3, For contracture tissue near the posterior, excessive release is often avoided to avoid sciatic nerve injury.
4, Patients are not sufficiently aware of functional exercise, so that they fail to exercise as required, causing recurrence.
Therefore, it is necessary to classify and individualize the treatment of gluteal myofascial contracture. It is also advocated that for striated contracture, the contracture band is found to be intermingled with the deeper layers of muscle fibers, and after cutting it, if there is still a popping sound and the Ober sign is positive, it may be an iliotibial tract contracture, and the contracted fibers should be cut obliquely below the greater trochanter of the femur; while for fan-shaped contracture, the muscle and its fascia are closely adhered to the subcutaneous tissue and skin, which may require extensive subcutaneous separation, and then the contracted tissues should be released, and if necessary, it should be The contracted fascia of the mixed type of contracture is mixed with normal muscle tissue and even involves deeper structures, so we should avoid missing the tissues that need to be released, but we should not cut off too many muscle fibers to prevent hip muscle failure. For extensive adhesions and contractures, prompt incisional surgery should be considered.
Arthroscopy, as a minimally invasive technique, has now achieved better results in the treatment of diseases other than joints, with the advantages of less trauma, faster recovery and smaller scars. This study shows that the minimally invasive treatment of gluteofascial contracture under arthroscopy has smaller incisions, less bleeding, earlier postoperative time on the ground, shorter hospital stay and less postoperative scar formation than traditional open surgery. However, there are still shortcomings, such as limitations for complex gluteofascial contracture, especially for older patients with muscle contracture or peripheral tissue contracture, and it requires a certain foundation in arthroscopic operation, the ability to skillfully establish the working space, control the pressure in the working space to reduce bleeding without increasing the occurrence of edema, and repeatedly detect the degree of contracture band release during the operation to The degree of contracture band release should be repeatedly detected during the operation to achieve complete release and to avoid interfering with the sciatic nerve posteriorly. To avoid postoperative bleeding, a plasma knife can be used to stop the bleeding, and the author prefers to use a sharp knife with a protective sheath or a meningeal blade during the operation, which can cut the contracture band more precisely and usually does not cause active bleeding after the operation. In this study, both groups achieved good results, and the differences were not statistically significant. Whether open or arthroscopic surgery is used, the key is to completely release all contracture tissues and perform functional exercises as early as possible to avoid postoperative scar adhesions and the reappearance of contracture bands, which may affect the surgical results.
Regardless of whether conventional or arthroscopic surgery is used to treat gluteus contracture, the first step should be to classify the treatment. For older, complex gluteus contracture, careful consideration should be given to whether the contracture can be completely released arthroscopically and the possible consequences after release. The contracted tissues, including the contracted gluteus muscle, its fascia, broad fascia, and joint capsule, should be treated thoroughly during surgery, but normal tissues should be avoided as much as possible, especially to avoid gluteus medius weakness, which may affect future walking. In older patients with gluteus contracture, their soft tissue conditions are worse than those of younger patients, so great importance should be attached to functional exercise after surgery, changing gait and squatting habits, and maintaining gluteus tone at rest to retract the disconnected fascia, and the release of contracted gluteus muscle mainly relies on intraoperative manipulation and postoperative squatting exercises with knees. In the postoperative exercise, the authors found that the postoperative squatting posture of older patients usually required repeated instruction and confidence to avoid bending instead of flexing the hip. In conclusion, for the treatment of these diseases, surgery and postoperative exercises should be closely combined to consolidate and improve the surgical results.