Gluteale Insuffizienz: Pathogenese, Diagnostik und Therapie

Zusammenfassung

Einleitung: Glutealmuskuläre Insuffizienzen stellen eine diagnostische und therapeutische Herausforderung mit Unterschätzung in der Vergangenheit dar. Neue Erkenntnisse zu Pathobiomechanik und Klinik chronischer Insuffizienzen der Hüftabduktoren führen zu immer breiter gefächerten differenzialdiagnostischen Überlegungen extraartikulärer Hüftschmerzen. Die Sammeldiagnose „chronische Bursitis trochanterica“ wird dabei zunehmend in den Hintergrund gedrängt. Klinik: Eine „gluteale Insuffizienz“ spiegelt sich häufig in chronischen peritrochantären Hüftschmerzen und, je nach Ausmaß der Schädigung, belastungsabhängigem Insuffizienzhinken wider. Klinisch bestehen meist peritrochantäre Druckschmerzen und Abschwächung der Abduktionskraft im Hüftbereich sowie die Tendenz des Beines, bei verminderter Innenrotationskraft eine Außenrotationsstellung einzunehmen. Bildgebung: Bildgebend wird zunächst eine konventionelle Röntgendiagnostik durchgeführt. Hier können artikuläre Ursachen peritrochantärer Schmerzen bei nativem Gelenk oder einliegender Hüft-TEP ausgeschlossen oder bestätigt werden. Als diagnostischer Goldstandard gilt die Magnetresonanztomografie (MRT) mit standardisierten Protokollen und Artefaktreduktion bei einliegender Hüft-TEP. Hier zeigen sich häufig eine kompensatorische Hypertrophie des M. tensor fasciae latae (TFL) und, bei manifester glutealer Insuffizienz, eine fettige Degeneration speziell des M. gluteus medius (GMed). Therapie: Therapeutisch-konservativ werden physiotherapeutische Maßnahmen mit Hüftkopfzentrierung, Kräftigung des GMed und GMin unter Aussparung des TFL und exzentrische Beübung durchgeführt. Die operative anatomische Versorgung bei höhergradigen bzw. therapieresistenten Schädigungen umfasst bei Partialrupturen voll endoskopische Fadenankertechniken und bei kompletten Rupturen mit Beteiligung der vorderen und/oder lateralen Facette am Trochanter major aufwendige minimalisiert-offene Rekonstruktionen. Hierbei werden Doppelreihen-Refixationstechniken zur biologischen Refixation favorisiert. Aufgrund der hohen perikoxalen Beanspruchung sind zum Erreichen eines guten postoperativen Ergebnisses aufwendige Nachbehandlungsschemata mit langen Rekonvaleszenzen nötig. Ergebnisse und Schlussfolgerung: Die Rekonstruktion glutealer Muskelschäden stellt häufig das einzig probate Mittel bei chronischen Hüftschmerzen aufgrund einer glutealen Insuffizienz dar. Mittlerweile zeigen Nachbeobachtungsdaten eine deutliche Verbesserung der Schmerzproblematik und auch Abduktionskraft im mittelfristigen Verlauf.

Abstract

Introduction: Gluteal insufficiency is a common and challenging complaint. New concepts in pathobiomechanics and improved clinical understanding of chronic gluteal dysfunction have unmasked gluteus medius (GMed) tears as an underlying cause of enhanced trochanteric pain syndrome (GTPS). These tears are often missed or misdiagnosed as bursitis, but lead to prolonged chronic peritrochanteric pain. Clinic: The clinical signs are often dull pain on the lateral hip aspect, reduced hip abduction strength with positive Trendelenburg testing and a tendency for the leg to external rotation, as the internal rotation strength is reduced. Imaging: Radiography and ultrasound may be used to confirm the diagnosis, whereas MRI is the modality of choice for imaging. Compensatory hypertrophy of the tensor fascia latae muscle (TFL) and fatty involution (especially of the GMed) are also seen. Therapy: Conservative treatment regimens for partial thickness tears involve hip joint centering and strengthening of abductor muscles, sparing TFL. Failed conservative treatment and full thickness tears are treated surgically. Partial tears can be addressed endoscopically with suture anchors for tendon footprint reconstruction. Larger tears involving the anterior and/or lateral facets of the tendon or failed conservative treatment are repaired with minimally invasive open reduction techniques. Double row suture anchor techniques provide anatomical tendon footprint reconstruction. Postoperative rehabilitation is prolonged, due to high acting forces in the peritrochanteric region, and needs to be carried out under professional surveillance. Conclusion: Reconstruction of gluteal tendon tears is often the only solution in the treatment of chronic hip pain due to gluteal insufficiency. Available data suggest that reduction in pain and restoration of abduction power can be achieved in mid-term follow-up.

Schlüsselwörter

gluteale Insuffizienz - Fadenankerrefixation - Hüfte - Arthroskopie

Key words

gluteal insufficiency - suture anchor refixation - hip - arthroscopy

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