Hip Abductor Deficiency after Total Hip Arthroplasty: Diagnostic and Therapeutic Methods

Abstract

Abductor deficiency after total hip arthroplasty is a severe complication with functional limitations and a significant reduction in the patient's quality of life. Common causes are degenerative ruptures or approach-related iatrogenic damage to the gluteus medius and minimus muscle and the inferior gluteal nerve, fractures of the greater trochanter and incorrect reconstruction of leg length and femoroacetabular offset. With a standardised diagnosis consisting of a clinical examination, conventional X-ray and MRI, the causes of the functional problems can often be reliably determined. Therapy of abductor deficiency is challenging for both patients and physicians and is often tedious. However, with a clear diagnostic and therapeutic algorithm and straightforward patient education, good treatment results can be achieved even in this challenging condition. Conservative therapy with eccentric stretching and muscle strengthening are the basis of the treatment. In cases of progression of complaints despite intensive conservative treatment, various anatomical and extra-anatomical surgical reconstruction methods are available to relieve pain and improve function. Anatomical reconstruction of the gluteal tendon insertion is an option in cases of low-grade fatty infiltration and moderate retraction of the gluteal muscles. In situations with advanced degenerative changes in the gluteus medius and minimus muscles and an intact gluteus maximus muscle, transfer of the anterior portion of the gluteus maximus according to Whiteside is an option. For high-grade defects of the soft tissue, there is also the option of an isolated or combined transfer of the vastus lateralis muscle.

Zusammenfassung

Die pelvitrochantäre Insuffizienz nach Hüftprothesenimplantation stellt eine schwerwiegende Komplikation mit gravierenden funktionellen Einschränkungen und einer deutlichen Reduktion der Lebensqualität für den Patienten dar. Häufige Ursachen sind degenerative Rupturen oder zugangsbedingte iatrogene Schädigungen der Mm. gluteus medius und minimus sowie des N. gluteus inferior, Trochanter-major-Frakturen und Probleme in der Rekonstruktion der Beinlänge und des femoroazetabulären Offsets. Mit einer standardisierten Diagnostik aus klinischer Untersuchung, konventionellem Röntgen und MRT können die Ursachen der funktionellen Probleme häufig gut eruiert werden. Die Therapie der pelvitrochantären Insuffizienz ist für Patient und Behandler herausfordernd und meist langwierig. Mit einem klaren diagnostischen und therapeutischen Algorithmus und einer guten Aufklärung des Patienten kann es jedoch gelingen, auch in diesem herausfordernden Krankheitsbild gute Behandlungserfolge zu erzielen. Die konservative Therapie mit exzentrischer Dehnung und Muskelkräftigung bildet dabei das Fundament der Behandlung. Im Falle von frustranen Verläufen trotz intensiver konservativer Behandlung stehen unterschiedliche anatomische und extraanatomische operative Rekonstruktionsverfahren zur Verfügung, um Schmerzen zu lindern und die Funktion zu verbessern. Die anatomische Rekonstruktion der glutealen Sehneninsertion kommt bei geringgradiger fettiger Degeneration und moderater Retraktion der Glutealmuskulatur infrage. Bei fortgeschrittenen degenerativen Veränderungen der Mm. gluteus medius und minimus und intaktem M. gluteus maximus kann die Verschiebeplastik nach Whiteside angewandt werden. Für höhergradige Weichteildefekte besteht außerdem die Möglichkeit eines isolierten oder additiven Versatzes des M. vastus lateralis.

Key words

hip abductor deficiency - total hip arthroplasty - muscle reconstruction

Schlüsselwörter

Glutealinsuffizienz - Hüftendoprothetik - Muskelrekonstruktion

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