[Hip pain]

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

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.

[Avulsion injuries of the gluteus medius and gluteus minimus muscles]

Avulsion injuries of the gluteus medius and gluteus minimus muscles represent a diagnostic and therapeutic challenge. Such injuries are rarely to be expected in high-energy trauma. Degenerative damage or iatrogenic injuries in the context of hip surgery are more frequently identified as the cause. Clinically, in addition to lateral hip pain, limping is an important finding and depends on the extent of the tendon damage. In addition to the medical history and clinical examination, imaging by means of sonography and, above all, magnetic resonance imaging (MRI, possibly with artifact-reduced sequences in the presence of an endoprosthesis) are diagnostically groundbreaking. Therapeutically, a stepwise approach is indicated according to the extent of rupture and quality of the gluteal tendon and muscle tissues. Specific conservative training regimens, mini-open/endoscopic anatomic reconstruction techniques in cases of gluteal muscle integrity and muscle transfer techniques as salvage option with chronic mass ruptures are available. The common goal is the restoration of everyday occupational and private activities to regain the quality of life.

[Gluteal insufficiency]

Gluteal insufficiency or hip abductor mechanism deficiency mainly following (revision) total hip replacement is associated with highly painful complaints and severe suffering of patients. It represents a great diagnostic and therapeutic challenge. Differentiated conservative treatment pathways, open surgical and endoscopic anatomic repair techniques with intact gluteal musculature and muscle transfer are available as salvage procedures for chronic not anatomically reconstructable mass ruptures. A stepwise diagnostic and therapeutic approach is required for restoration of the quality of life and painless or almost painless mobility of affected patients in occupation and daily life.