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Classification of gluteal muscle contracture in children and outcome of different treatments
© Zhao et al; licensee BioMed Central Ltd. 2009
Received: 27 August 2008
Accepted: 07 April 2009
Published: 07 April 2009
Gluteal muscle contracture (GMC) is a clinical syndrome due to multiple etiologies in which hip movements may be severely limited. The aim of this study was to propose a detailed classification of GMC and evaluate the statistical association between outcomes of different management and patient conditions.
One hundred fifty-eight patients, who were treated between January 1995 and December 2004, were reviewed at a mean duration of follow-up of 4.8 years. Statistical analyses were performed using X2 and Fisher's exact tests.
Non-operative management (NOM), as a primary treatment, was effective in 19 of 49 patients (38.8%), while operative management was effective in all 129 patients, with an excellence rating of 83.7% (108/129). The outcome of NOM in level I patients was significantly higher than in level II and III patients (P < 0.05). The results of NOM and operative management in the child group were better than the adolescent group (P < 0.05). Complications in level III were more than in level II.
NOM was more effective in level I patients than in level II and III patients. Operative management was effective in patients at all levels, with no statistical differences between levels or types. We recommend NOM as primary treatment for level I patients and operative management for level II and III patients. Either NOM or operative management should be carried out as early as possible.
Gluteal muscle contracture(GMC), reported by Valderrama for the first time, is a clinical syndrome pathologically-characterized by degeneration, necrosis, and fibrosis of the gluteal muscles and fascia, leading to serious limitation of hip movements . Either congenital or acquired, GMC is not uncommon and exists worldwide, involving the US, France, Italy, Poland, Australia, Spain, China, and India [2–9].
Although numerous reports have outlined the clinical features and surgical treatments for GMC, thus far the classification of GMC, as well as the association between outcome and patient conditions, has not been described.
The purpose of this study was to propose a detailed classification of GMC and evaluate the statistical association between outcome of different management and patient conditions, including severity, pathologic type, and age by reviewing 158 of our patients over the past 10 years.
Between January 1995 and December 2004, 172 patients diagnosed with GMC were treated in our department. One hundred fifty-eight patients (males, 83; females, 75) 4–17 years of age, were followed for 3–8 years (average, 4.8 years). All of our studies were permitted by the Ethical Board of the 2nd Affiliated Hospital of the Medical College of Xi'an JiaoTong University, and written consent for publication was obtained from the patients or their relatives.
Classification of gluteal muscle contracture
Category according to level
The extorsion of lower limb is mild, the abduction contracture is less than 15° with both hip and knee joint in 90° of flexion or adduction range is less than 20° with no flexion. Ober's sign and frog squatting sign is weakly positive. The limp gait is not apparent with lateral inclination of pelvis on anteroposterior radiograph being less than 10°
The extorsion of lower limb is moderate, the abduction contracture ranges from 15° to 60° with both hip and knee joint in 90° of flexion or adduction range is less than 10° with no flexion. Ober's sign and frog squatting sign is positive. The limp gait is apparent with lateral inclination of pelvis on anteroposterior radiograph being less than 20°
The extorsion of lower limb is severe, the abduction contracture is more than 60° with both hip and knee joint in 90° of flexion or adduction range is less than 0° with no flexion. Ober's sign and frog squatting sign is strongly positive. The limp gait is remarkably apparent with lateral inclination of pelvis on anteroposterior radiograph being more than 20°
Category according to type
Gluteus maximus contraction type
Gluteus medius and minimus contraction type
Gluteus maximus, medius and minimus contraction type (All gluteal muscle contraction type)
Non-operative management (NOM)
Massage and physiotherapy, such as shortwave diathermy and hot packs, were the basic NOM techniques for patients. Following NOM, the patients could engage in the following exercises: squats with the knees close to each other, walking on a line, and moving the hips with effort. Active and passive exercise methods should be undertaken and NOM should be performed for at least last one-half year.
Evaluation after treatment
Patients who completely recovered were considered to have excellent results for level I or an adduction angle that improved > 45° for level II, and 60° for level III. Failure indicated that the situation was not improved or even worse, and patients needed another operative intervention. Fair result would be improved, but were not excellent.
Statistical analyses were performed using X2 test and Fisher's exact test. A P value < 0.05 was considered statistically significant.
Gluteal muscle contracture cases according to level and type
Outcome of nonoperative management
Outcome according to level
Outcome according to type
Outcome of operative management
Outcome according to level
Outcome according to type
Complications after operative management only appeared in level II and III patients, and included scar swelling (II = 16; III = 48 [some severe cases exceeded 0.7 cm]), hematomas (III = 4), infections (II = 1; III = 1), and wound dehiscence (III = 1).
Although several factors might be the cause of GMC, we found that repeated injections in the buttocks was perhaps the main cause from our previous epidemiologic survey, which was consistent with other reports [9, 10]. For all of the patients in this study, 108 parents of the patients recalled repeated injection in the buttocks of their children at an early age; 5 parents denied injections in the buttocks, and were thus idiopathic just as some other reports have suggested and it would take more effort for confirmation [11, 12]. Two patients appeared to have a genetic tendency, as both the children and their fathers were diagnosed with GMC, although this possibility also needs further work to be identified. One patient was diagnosed with a fibroma in the left hip joint. The diagnosis of GMC mainly depends on anamnesis, and typical clinical manifestations; X-ray and MRI studies would not be requisite, but could always help eliminate other osteopathologic changes and make available additional information before surgery [13, 14].
Reasonable classification would help us to achieve a better understanding of pathologic features of this disease and indicate more suitable treatments. Previous studies have mainly focused on contracture of the gluteus maximus, which always included the most severe cases, or created a classification emphasizing the aesthetic aspects more than the functional aspects, and which would be helpful to plastic surgeons [11, 15, 16]. However, our classification system was based on all types of contractures with different levels focusing on functional and pathologic changes. Out of concern regarding clinical manifestations and anatomic changes, we proposed a classification scheme consisting of 3 levels and 3 types. Type MA only involves the gluteus maximus, so patients with this type would represent extorsion of the lower limb, adduction disorders when the hip joint is flexed, especially while sitting and squatting and with a limitation of flexion. The gluteus medius and minimus play an important role in abduction of the hip and it had functions of both extorsion and intorsion. Based on the location in which muscle injections are usually performed, it would only result in an extorsion abnormity. Therefore, contracture of the gluteus medius and minimus (type MI) would be in extorsion abnormalities, and adduction disorders, even without flexion and limp gait when the lesions on the two sides are not in parallel. Some patients with limp gait would appear to have an incline of the pelvis and compensatory scoliolosis. However, some reports have revealed that the lesion of their patients were only limited to the gluteus medius or gluteus minimus, leading to a disorder of limp gait, but we did not encounter such . For type AGM, both two types of the clinical manifestations would appear.
Recommendation of treatment strategy
Levels of Patients
Recommendation of treatment strategy
NOM as first choice, operation as recruitment treatment. Interogluteal incision or use arthroscopic technique is recommended.
Operative management as first choice, NOM as choice for recruitment treatment for waiting for operation or after operation. Surgeons could adopt interogluteal incision or use arthroscopic technique depending on the condition of patients.
Operative management as first choice, NOM as choice for recruitment treatment for waiting for operation or after operation. Operation under direct-viewing with conventional incision is commended, in order for complete releasing.
The success of operative management rested in two points: 1) complete release of fibrotic tissue and 2) protection of intact tissue. Incomplete releasing would result in incomplete disappearance of complaints and physical sign, while excessive releasing would harm the stability of the hip joint which might lead to Trendelenburg gait. Six patients came to our department for a second operation and 2 patients for a third procedure; all of them were due to incomplete release. It was very important to check whether the Ober's sign is positive intraoperatively, especially in type MEI and AGM.
Our work is a retrospective study of gluteal muscle contractures in children. We proposed a detailed classification of GMC and have assessed the outcomes of different management techniques. NOM was more effective in level I patients than in level II and III patients. Operative management was valid in patients at all levels with no statistical difference. We recommend NOM as primary treatment for level I patients and operative management for level II and III patients. Age was one important factor which influenced the final result, which suggested that either NOM or surgery should be carried out as early as possible.
This study was supported by a grant from The Food and Drug Administration of Shannxi Province (Y200 334002). Written consent for publication was obtained from the patients or their relatives.
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