Treatment of diseases of the hip joint area

• We relieve pain and inflammation in ligaments and tendons in 1-2 sessions
• Restoring joint mobility
• Improving nutrition of tendons and ligaments

Tendonitis (tenosynovitis, tenosynovitis) is a disease accompanied by the development of aseptic inflammation in the tendon. Tendinitis can occur either acutely or have a long-term, chronic nature. Any tendon can be affected, but the disease most often affects tendons in the elbow, shoulder, knee and hip joints. Tendinitis begins with damage to the tendon sheath (tenosynovitis) or tendon bursa (tenobursitis). In addition, inflammation can spread to the muscles that are adjacent to the tendon. One of the main causes is chronic injury to the tendons, so tendonitis most often occurs in athletes and people who do the same type of physical work. The occurrence of tendinitis does not depend on a person’s age or gender.

Symptoms

Pain manifests itself with active movements. Projected over the area of ​​the affected tendon. There is no pain with passive movements. In addition, there is pain on palpation of the affected tendon, changes in the skin in the area of ​​the affected tendon: possible redness, a local increase in temperature, local edema, swelling in the area of ​​the affected tendon, the intensity of the pain syndrome increases over time. At first, a person is bothered by minor pain in the area of ​​the affected tendon, which does not interfere with his daily life. But gradually the pain syndrome intensifies, the pain becomes excruciating, strong, unbearable, disrupting the normal rhythm of life.

Problem Status

Total hip replacement has been called the operation of the twentieth century, which is associated with a revolutionary improvement in the quality of life after its implementation in patients suffering from coxarthrosis [1]. Thus, S. Kurtz et al. [2] claim that the number of total arthroplasty operations will increase by 174% by 2030. Recently, there has been a significant expansion of indications for this intervention and a large number of young patients of working age, for whom speedy rehabilitation and a return to the usual active rhythm of life are especially important components of treatment [3]. In patients of this age group, special attention should be paid to preserving the abductor muscles, the poor condition of which can lead to pain, lameness and a deterioration in the quality of life [4].

The gluteus medius muscle plays a large role in the functioning of the hip joint and is one of its important stabilizers. The anatomy of the attachment of this muscle, according to recent research, is much more complex than previously thought. The muscle consists of 3 bundles - anterior, middle and posterior, which are innervated by the superior gluteal nerve. The fibers of the anterior and middle bundles are oriented vertically, and the fibers of the posterior bundle are horizontal, which are located parallel to the neck of the femur [5]. W. Robertson et al. [6] showed that the gluteus medius tendon attaches to the greater trochanter on both sides—lateral and posterosuperior. The posterior bundle of the muscle is attached to the posterosuperior side of the greater trochanter, and most of the central and anterior bundles are attached to its lateral surface. F. Gottschalk et al. [5] studied the functional anatomy of this muscle and, using electromyography, found that the gluteus medius and minimus muscles are primarily stabilizers and rotators of the pelvis, and the main adductor is the tensor fascia lata. Thus, the posterior bundle of the gluteus medius muscle is responsible for stabilizing the femoral head in the acetabulum during foot roll. The middle fascicle is responsible for the initiation of femoral abduction, and the anterior fascicle is considered the internal rotator of the hip.

The good condition of this muscle after endoprosthetics ensures rapid rehabilitation and activation of the patient in the early postoperative period [7]. Damage to this muscle can lead to lameness, difficulty walking and a positive Trendelenburg sign, as well as pain along the lateral thigh [4, 8–10]. Particularly often, separation of the tendon of the gluteus medius muscle, its atrophy or bursitis can occur when performing total hip replacement using the direct lateral Harding approach [11], which can cause the development of pain in the postoperative period [12] and lead to lameness in 4-29 % of cases [13]. The Harding access was designed to recognize that m. gluteus medius

and
m.
vastus lateralis form a single anatomical and functional complex, connected by a massive tendon-periosteal layer. This approach allows an excellent view of the acetabulum while keeping the femoral external rotators intact, but it does damage the anterior portion of the gluteus medius tendon. Worldwide, about 42% of orthopedists use this approach and its modifications for total hip arthroplasty [14]. The incidence of fatty degeneration of the anterior portion of the gluteus medius muscle after this approach during primary arthroplasty can reach 12% [15], and according to G. Howell et al. [16] - 20%. When performing this approach during revision surgery, it should be borne in mind that repeated damage to the anterior part of the gluteus medius muscle may adversely affect the function of the limb. Thus, after performing 2 or more revisions, almost 70% of the anterior and 40% of the central portion undergo fatty degeneration [15].

Diagnosis of muscle damage

In addition to clinical methods for assessing the degree of damage to the abductor muscles, there are various instrumental methods. Among the methods of pre- and postoperative diagnostics, mention should be made of ultrasound and MRI studies. Computed tomography can determine the degree of fatty muscle degeneration. For this purpose, the Goutallier classification is used, which was originally used to assess the condition of the muscles of the rotator cuff (grade 0 - normal muscle, 1 - the presence of fat spaces, 2 - muscle tissue predominates over fat, 3 - muscle and fat tissue occupy equal space, 4 - fat tissue predominates over muscle). This classification was then adapted for use in MRI [17].

V. Khoury et al. [18] adapted this classification for ultrasound assessment of muscle condition: grade 0 - normal echogenicity and feathery structure, 1-2 - average echogenicity and smoothed feathery structure, 3-4 - moderate to pronounced; pronounced hyperechogenicity and absence of a feathery structure.

In order to divide the muscle condition according to the degree of atrophy, the Thomazeau classification was developed, used in ultrasound and MRI studies [19]: I - mild atrophy (>0.60), II - moderate atrophy (0.40-0. 60), III - severe atrophy (<0.40).

To provide a simpler and more specialized assessment of gluteal fatty degeneration, the Quartile classification was developed in 2012 with comparable accuracy and reliability. This classification divides patients into 5 groups according to the percentage of fatty degeneration of the gluteus medius muscle [8]: 0 - normal, 1 - 1-25% of the muscles have undergone fatty degeneration, 2 - 25-50%, 3 - 50-75%, 4 - 75-100%.

The simplest clinical method is to assess the strength of the abductor muscles using a hand-held dynamometer, for this purpose the researcher holds the dynamometer in the area of ​​the outer ankle, and the subject begins to abduct the leg [20].

For intraoperative assessment of muscle condition, M. Zywiel et al. [21] developed a classification according to which muscle defects are divided into 4 groups: 0 - complete absence of abductor muscles, I - pronounced defect of abductor muscles, II - pronounced fibrous and cicatricial restructuring, absence of a defect, III - absence of fibrous restructuring, absence of a defect.

Ruptures of the gluteus medius muscle were first described by T. Bunker et al. [22] and A. Kagan [23] in the late 90s; Due to the similarity of tears of this muscle with tears of the rotator cuff muscles, the term “rotator cuff” was coined. P. Lachiewicz [24] identified three groups of patients with this diagnosis. Group 1 consisted of patients experiencing pain along the lateral surface of the thigh, with chronic insufficiency of the abductor muscles, but without signs of arthrosis of the hip joint. Patients in this group complained of pain on the lateral side of the thigh and weakness of the hip abductor apparatus, which persisted up to 1 year after surgery. Their MRI showed fluid in the trochanteric bursa and tears of the gluteus medius tendon from its insertion or ruptures near the bone. To treat ruptures in patients of this group, the authors used the technique of transosseous fixation of the gluteus medius tendon [26, 27]. Group 2 included patients with complex ruptures of the gluteal muscle group, accidentally discovered during total arthroplasty or osteosynthesis of femoral neck fractures. Ruptures in patients in this group are represented by a defect in the tendon of the gluteus medius muscle, which is round or oval in shape. Their trochanteric bursa was filled with fluid, and the surface of the greater trochanter was subject to sclerosis and the formation of osteophytes. For the treatment of ruptures and defects T. Bunker et al. [22] performed removal of osteophytes, decortication of sclerotic areas of the greater trochanter of the femur, and transosseous fixation of the tendon. Group 3 included patients with tendon separation from the attachment site after total arthroplasty through the lateral or anterolateral approaches. Such patients experience severe pain along the lateral thigh and require surgical treatment [24].

There are many tactics for treating this condition: transosseous fixation of the muscle, endoscopic interventions, Achilles tendon plastic surgery, various techniques for plastic surgery of the gluteus maximus muscle and the lateral head of the quadriceps muscle, and the use of various allografts. A number of authors [28, 29] note that for surgical correction of small ruptures of the gluteus medius muscle, transosseous fixation of its tendon to the place of attachment, open or endoscopic, is sufficient, while massive defects and chronic injuries require more complex soft tissue plastic surgery and reconstructions.

The authors [25, 30-32], who evaluated the technique of transosseous fixation of the gluteus medius tendon, stated that this operation can significantly improve the quality of life and function of the hip joint. The surgical technique of this operation consists of acute separation of the aponeurosis of the gluteus medius muscle and the lateral head of the quadriceps from the adjacent iliotibial tract and tensor fascia lata. These muscles are then mobilized from the anterosuperior portion of the capsule and fascia lata and, if necessary, from the ilium to achieve optimal coverage of the greater trochanter without undue tension. Treatment of the muscle tendon attachment area involves excision of the greater trochanter down to the bleeding bone and drilling holes for subsequent transosseous fixation (Fig. 1).

Rice. 1. Treatment of the attachment zone of the tendon of the gluteus medius muscle. Transosseous fixation is performed using non-absorbable suture material (Fig. 2).

Rice. 2. Transosseous fixation of the gluteus medius tendon.

After applying this technique, A. Lubbeke et al. [33] noted that patients had decreased lameness and improved Harris scores in the early postoperative period, but failed to achieve functional recovery at later stages. The earlier a rupture is diagnosed, the greater the effect obtained from the operation. After fatty and cicatricial degeneration of tendons and muscles, surgery cannot guarantee a good result, which increases the importance of timely diagnosis of this pathology in patients. N. Miozzari et al. [32] tracked the results of treatment of chronic ruptures of the gluteus medius muscle using transosseous fixation and obtained a poor result in 25% of cases. M. Walsh et al. [34] analyzed the results of this operation in 72 patients and found that the average hip joint function score increased from 10.85 to 16.66 points. Before surgery, normal gait was observed in only 5% of patients, and after surgery - in 78%; the remaining 22% of patients walked without a cane after the intervention, but noted a slight limp. However, in 5.5% of patients there was a separation of the attached tendon from the greater trochanter up to 6 months after surgery.

Endoscopic restoration of the gluteus medius muscle using anchor fixation was first described by J. Voos et al. [35] in 2007. The absence of pain and complications was noted in 10 patients in the next 25 months after surgery; in all patients, the strength of the hip abductor muscles was 5 points out of 5 possible, and all of them gained full range of motion. The average Harris index after surgery was 94 points. The authors used standard lateral proximal and lateral distal ports on either side of the greater trochanter and used a 30° arthroscope and 40 mmHg pump, as well as 5.5 mm three-story anchors to secure the tendons to the bone. For large full-thickness tears or poor condition of the gluteus medius tendons, the authors supplemented this technique with transosseous sutures for a more secure repair—in this case, the surgeon uses an anchor for the proximal row of sutures and the ends of the sutures for a second row placed transosseously. After surgery, patients wear an abduction orthosis for 1 month and use crutches for 6 weeks to limit the load. A gradual return to daily activities is allowed after 3 months. F. McCormick et al. [36] found that the use of arthroscopic techniques and anchor fixation for large tears of the gluteus medius muscle allows one to achieve good and excellent results, the strength of the abductor muscles increases significantly, but the best result is achieved in younger patients.

M. Fehm et al. [37] described a technique for reconstructing the gluteus medius muscle using Achilles tendon grafting with a calcaneal block, which was fixed to the greater trochanter at the site of attachment of the abductor muscles. It was noted that this operation should be performed when the abductor muscles are in good condition and can tolerate reconstruction with a bone block. First, the authors prepared a section of Achilles tendon with a calcaneal block measuring 2 x 1.5 x 1 cm, with a dovetail-shaped proximal edge for better fixation to the greater trochanter and to prevent proximal migration. Next, a groove was formed in the greater trochanter for the bone block. The site of the previous insertion of the gluteus medius tendon was drilled until the bone bled. The abductor muscles were then mobilized to locate viable tissue for fixation to the allograft. The space between the gluteus minimus and gluteus medius muscles was widened to move the abductor muscles inferiorly for attachment to the allograft. The tendon portion of the allograft was passed through the intact gluteus medius muscle approximately 3 cm above the torn end, after which the tendon portion of the allograft was looped around this muscle. The femur was placed in a position of maximum abduction, and the bony portion of the allograft was placed in the trochanteric groove and secured with a cerclage that was wrapped around the bone block and the proximal femur. The tendon part of the allograft was sutured with interrupted non-absorbable sutures to the gluteus minimus muscle, the anterior part of the capsule and the intact part of the gluteus medius tendon. Then the range of motion in the hip joint and the consistency of the plastic were checked. The authors tracked the results of this operation in 7 patients for up to 24 months and found that the average HHS score increased from 34.7 to 85.9 points. In addition, this technique can reduce the intensity of pain, increase the strength of the abductor muscles, and achieve the disappearance of lameness and a positive Trendelenburg sign. After this operation, 3 patients walked without any assistance, 2 used a cane, and 2 used a cane only for walking long distances.

In the absence of a greater trochanter due to previous surgical interventions, it is possible to sutured the abductor muscles to the iliotibial tract. This increases the degree of stability of the operated joint, but does not relieve patients from lameness [38].

L. Whiteside et al. [39] described a plastic technique for avulsions from the greater trochanter and defects of the gluteus medius muscle by transposition of the gluteus maximus muscle. The authors used a posterior approach to the hip joint for this intervention. The anterior half of the gluteus maximus muscle was elevated and exposed sharply and bluntly to create a triangular flap with a proximal base (Fig. 3).

Rice. 3. Formation of a flap from the anterior part of the gluteus medius muscle. The anterior fascial edge of this flap was dissected down to the muscle tissue to achieve adequate tension on the muscle fibers. The deficiency of the posterior capsule and external rotators was compensated by the formation of an additional posterior flap from the gluteus maximus muscle. The area of ​​the distal attachment of the posterior portion of the gluteus maximus muscle to the tensor fascia lata 1.5 cm long was dissected to form a triangular-shaped posterior flap, which was wider in the proximal direction than in the distal direction (Fig. 4).

Rice. 4. Formation of a flap from the posterior part of the gluteus medius muscle. Creating this flap provides visibility to the sciatic nerve, which must be exposed and protected. The posterior flap of the gluteus maximus muscle was sutured with strong non-absorbable sutures to the anterior capsule and the anterior edge of the greater trochanter, additionally strengthened with knots of absorbable suture material. The greater trochanter was prepared for attachment of the anterior muscle flap. A sharp osteotome was used to remove a cortical layer with an area of ​​2x3 cm from the lateral surface of the greater trochanter. Many holes were drilled in this area (Fig. 5).

Rice. 5. Fixation of the posterior gluteus medius flap and preparation of the greater trochanter for attachment of the anterior gluteus medius flap. The lateral head of the quadriceps muscle was separated from its insertion 1.5 cm posteriorly and anteriorly. The thigh was then abducted 15° and the muscle flap was sutured to the greater trochanter under moderate tension using strong sutures (Figure 6).

Rice. 6. Fixation of the anterior muscle flap from the gluteus medius muscle. The triangular fascial border of the gluteus maximus muscle was placed under the lateral head of the quadriceps femoris muscle and held in place with strong nonabsorbable sutures. The lateral head of the quadriceps muscle was then sutured back to its attachment site on top of the anterior muscle flap. After this, the posterior edge of the anterior muscle flap was sutured to the posterior muscle flap, which lay underneath.

The authors compared the results of patients who underwent this operation with the results of patients in two groups: in group 1 ( n

=5) no interventions were performed, and in the 2nd (
n
=4) transosseous fixation of the gluteus medius muscle to the greater trochanter was performed. It has been established that the Whiteside operation can reduce the intensity of pain on the lateral surface of the thigh, lameness, promote the disappearance of Trendelenburg's symptom and improve the ability to abduct the hip, however, the range of motion in the hip joint is reduced [28, 39].

S. Kohl et al. [40] developed a technique for repairing defects of the gluteus medius muscle using the lateral head of the quadriceps femoris muscle. The authors used an incision from the anterosuperior spine to the superolateral border of the patella. The operation consisted of mobilizing the entire length of the lateral head of the quadriceps muscle, separating it from the quadriceps tendon and repositioning the femoral abductors in place, followed by attachment to the anterosuperior spine. The researchers evaluated the results of this technique in 11 patients over a period of up to 2 years. The use of this treatment method allowed us to achieve good functional results: there was no lameness, the quality of life and the strength of the abductor muscles improved. However, 27% of patients experienced complications. In 1 patient, compression of the peroneal nerve was noted due to a tight abductor splint pressing on the head of the fibula, in 1 patient there were complaints about the manifestations of developed Sudeck syndrome, in 1 patient, after plastic surgery of a rupture of the gluteus medius muscle, the formation of ossifications occurred, which required a repeat operation. Features of the technique include high demands on the skill of the surgeon, a very long skin incision required to perform this operation, and its significant traumatic nature.

M. Drexler et al. [41] developed a technique for repairing chronic hip abductor muscle deficiency using a fresh frozen hip extensor allograft that included the quadriceps tendon, patellar tendon, patellar tendon, and tibial tuberosity. Surgical intervention was performed with the patient in the lateral position using a transgluteal approach, which allowed for a sufficient overview of the hip abductor muscle group, their tendon and insertion site. The tensor fascia lata and the iliotibial tract were extended longitudinally, after which the trochanteric bursa, most often thinned and inflamed, was removed. Next, the greater trochanter of the femur and remnants of the femoral abductor tendons were identified and carefully mobilized. The tendon insertion site on the greater trochanter was processed down to the bleeding bone to fix the prepared allograft. After this, the attachment of the lateral head of the quadriceps muscle was mobilized in order to subsequently attach the patellar tendon to this place, and then the allograft was prepared - cartilage was removed from the surface of the patella using an oscillatory saw. The patient's hip was slightly abducted (approximately 10-15o). The allograft quadriceps tendon was then sutured to the remaining tensor fasciae lata and gluteus minimus and gluteus medius tendons. The patella was fixed to the greater trochanter with two or three 3.5 mm screws or using cerclages and wires. The allograft patellar tendon was sutured with strong, nonabsorbable sutures to the insertion of the lateral head of the quadriceps muscle, and the femur was carefully retracted to ensure the repair was complete. For significant defects of the proximal femur or greater trochanter, the patella was removed from the extensor mechanism allograft and the tuberosity was attached to the remaining portion of the femur with cerclage sutures. After this operation, the load on the limb was limited for 6 weeks, and for 3 months the patients wore an orthosis that limited abduction. The authors tracked the results of this surgical technique for an average of 33 months (range 24 to 41 months) after surgery. Before the intervention, all patients had significant lameness and a positive Trendelenburg sign, and after the operation, 2 patients did not limp at all, 7 had slight lameness, and 2 complained of serious gait disturbances. A negative Trendelenburg sign was detected in 7 patients, a positive one in 4. After reconstruction, the average strength of the abductor muscles increased from 2.15 to 3.8 points. Before surgery, 6 patients used a cane, 5 used walkers; after surgery, 4 patients did not use any aids, 5 used a cane, 2 walked with the help of walkers. There were no cases of infection or allograft displacement reported. The authors state that the outcome of surgical repair with a hip extensor mechanism allograft was good in 4 patients, fair in 2, and poor in 4.

M. Drexler et al. [42] also described a technique for treating massive defects of the gluteus medius muscle by revising the acetabular component of the endoprosthesis to move it upward and medially and performing plasty with the tensor fascia lata. The acetabular component was replaced regardless of its stability. According to the authors, reducing the distance between the beginning of the gluteus medius muscle and the greater trochanter made it possible to achieve adequate soft tissue tension and fix the shortened muscle. Surgery was performed with the patient in the lateral position, using an anterolateral approach to achieve an adequate view of the tensor fasciae lata and the anterior aspect of the gluteus medius muscle. The greater trochanter and abductor muscles were mobilized from scars. The gluteus minimus muscle was bluntly elevated from its attachment to the ilium to 2 cm above the upper border of the acetabulum. This release was carried out to achieve the ability to tighten the gluteal muscles 3-5 cm downwards. An anterolateral capsulotomy was then performed to adequately view the proximal femur. The femur was moved anteriorly and the femoral component of the hip replacement was inspected for signs of instability. Next, the neck of the endoprosthesis was moved with a hook posteriorly from the acetabular component, which was subsequently removed. The new acetabular component was then placed approximately 8–10 mm superior and 5 mm medial to the position of the extracted one, complemented by screw fixation. The limb was abducted 30° to perform reconstruction of the hip abductors. The posterior aspect of the gluteus medius and minimus muscles was sutured together and secured with nonabsorbable sutures to the superior aspect of the lateral head of the quadriceps muscle. The anterior half of the gluteus medius muscle was transosseously fixed to the greater trochanter of the femur and the lateral head of the quadriceps muscle. After reconstruction of the hip abductors, the posterior edge of the tensor fascia lata was sutured to the hip abductors and the superior edge of the attachment to the lateral head of the quadriceps muscle. Lastly, the tensor fascia lata was sutured to the iliotibial tract and gluteus maximus muscle, then the surgical wound was sutured. In the postoperative period, weight bearing on the limb was prohibited for up to 6 weeks; patients were explained the need to limit abduction, flexion, and internal rotation of the lower limb. The authors tracked the results of this operation in 17 patients for an average of 42 months (24–79 months). No cases of infection, loosening, or dislocation of the acetabular component have been reported. The average age of these patients was 69 years (50 years - 83 years). After surgery, 9 patients reported no lameness, 8 had only slight lameness. A positive Trendelenburg sign was detected in 8 of 17 patients. Abductor muscle strength increased from 2.56 to 3.81 points after surgery. Before the intervention, all patients used a cane when walking; after the operation, 5 patients used it, 3 walked with the support of a walker. Postoperative Harris scores were good in 47% of patients, fair in 35%, and poor in 17%. Before surgery, 23.5% of patients complained of severe pain, 70% of patients complained of moderate pain, and 6% of patients complained of severe pain. After the intervention, 42% of patients noted a complete absence of pain, and 59% noted the presence of mild pain.

B. Rao et al. [43] developed a technique for using artificial soft tissue allografts made from a collagen membrane. The results of the operation were assessed in 12 patients over a period of up to 34 months. Most patients reported decreased pain, improved gait, and good functional outcome. Thus, the pain syndrome significantly decreased: the score on the visual analogue scale (VAS) decreased - 8.25 points before surgery versus 2.33 points after it, and on the Harris scale increased from 34.05 to 81.26 points. Trendelenburg's sign was negative in all patients within 22 months after surgery. The technique of this operation consisted of mobilizing the scar, which contained the aponeurosis of the tendon of the gluteus medius and minimus muscles from the anterosuperior portion of the capsule and the tensor fascia lata. Next, the muscle fibers were separated from the distal part of the ilium insertion to allow the tendon of these muscles to be brought down to the greater trochanter insertion without tension. The site of attachment of the tendons to the trochanter was cleaned down to the bleeding bone. With the limb abducted approximately 20° and in neutral rotation, the stump was attached as close as possible to its normal location and fixed transosseously with non-absorbable suture material (using a Krakow suture). The bone-tendon interface was further strengthened with a Graft Jacket Matrix collagen membrane using absorbable sutures. This membrane covered the gluteus medius, greater trochanter of the femur, and lateral head of the quadriceps femoris.

B. Fink and L. Braun [44] also described the use of transosseous sutures followed by fixation with a non-absorbable membrane and tracked the results of this technique in 30 patients for 46.8 months (from 24 to 101 months). The surgeons achieved a significant reduction in pain: the average VAS score before surgery was 7 points, and after it was 0.83 points. Gluteus medius strength increased from an average of 2.09 to 3.3 points on the British Medical Research Council Scale. Before the intervention, all patients noted severe lameness; after surgery, 11 of them had no lameness, 14 had a slight limp, and 5 complained of severe lameness and a positive Trendelenburg sign. The average Harris score increased from 44.5 to 81.1 points. The authors found that the degree of fatty degeneration of the gluteus medius muscle significantly influences the results of surgery. Thus, in patients with grade IV muscle degeneration according to Quartile, the functional result is better than in patients with grades II and III. For patients with grade II, the average Harris score was 89.3 points, and abductor muscle strength was 4.16 points; for patients with grade III, it was 82.9 and 3.42 points, respectively. Quartile grade IV patients scored only 73.6 on the Harris scale and had abductor muscle strength of 2.6. In 1 patient with grade IV, a recurrent tear of the gluteus medius tendon occurred in the postoperative period, which required a Whiteside operation.

Thus, despite the many publications devoted to restoring the integrity of the gluteus medius and minimus muscles, all techniques have certain disadvantages, including short observation periods, a small number of subjects, and often lead to unsatisfactory treatment results. Therefore, the problem of surgically achieving good function of the hip abductor muscles remains open. Considering the lack of a generally accepted method for treating tears and defects of the gluteus medius muscle, which is an important factor in the stability of the hip joint, special attention should be paid to the earliest possible diagnosis of damage to this muscle, clinical and instrumental, since a number of authors note that the result directly depends on the time of surgical treatment. The prevalence and high morbidity of the Harding approach, which inevitably damages the anterior portion of the gluteus medius muscle with the risk of fatty degeneration, make one think about the use of minimally invasive and low-traumatic surgical approaches to the hip joint, leaving this muscle intact.

The authors declare no conflict of interest.

The authors declare no conflicts of interest.

Information about authors

Sineoky A.D. — e-mail; https://orcid.org/0000-0002-1819-8890

Pliev D.G. — https://orcid.org/0000-0002-1130-040X

Abolin A.B. — https://orcid.org/0000-0001-9901-8400

Mikhailova P.M. — https://orcid.org/0000-0003-1664-0865

Guatsaev M.S. — https://orcid.org/0000-0003-1948-0895

Shubnyakov M.I. — https://orcid.org/0000-0002-4774-4272

Mikhailov K.S. — https://orcid.org/0000-0003-4964-3616

Corresponding author:

Sineoky A.D. — e-mail: [email protected]

HOW TO QUOTE:

Sineokiy A.D., Pliev D.G., Abolin A.B., Mikhailova P.M., Guatsaev M.S., Shubnyakov M.I., Mikhailov K.S. Methods of surgical treatment of injuries to the gluteus medius muscle during total hip replacement. Surgery. Journal named after N.I. Pirogov

. 2019;7:96-104. doi: 10.17116/hirurgia2019071

Treatment

Treatment of tendinitis (tenosynovitis, tenosynovitis) should be comprehensive and include conservative therapy (rest, cold, use of non-steroidal anti-inflammatory drugs), as well as physiotherapeutic methods.

It must be remembered that treatment of tendonitis should include limiting physical activity, the use of physical therapy, the action of which will be aimed at speedy healing of the damaged tendon, elimination of the inflammatory process, as well as strengthening and maintaining the tone of the whole body. In addition, if you have tendonitis, your doctor may recommend wearing special orthoses that will have a positive effect on the healing of the damaged tendon. If tendonitis is characterized by a severe course, then antibiotic therapy and even surgical treatment are possible. Surgical treatment is used only when the use of conservative treatment and physiotherapeutic procedures does not bring the expected results.

An important step in the treatment of tendinitis is to determine the cause of the development of this disease. At our Clinic, doctors use modern diagnostic methods that help make a diagnosis quickly and accurately. After identifying the causes of tendinitis, our specialists will be able to prescribe you the most effective treatment, which will be aimed at eliminating the symptoms, and will also allow you to forget about the pain in the shortest possible time. At the Bone Clinic, the doctor will select an individual treatment program, taking into account the stage and course of the disease and the presence of concomitant pathologies.

You will be guaranteed the best treatment for tendinitis in our Clinic. Here you can get advice from experienced traumatologists. In our Clinic, doctors are specialists, professionals in their field, working at the highest level, while achieving maximum heights and success.

Causes and types

After forty years, dystrophic processes begin in the tendons of the gluteal muscles, which lead to their degenerative changes. The tendon fibers at the site of its attachment to the bone are replaced by fibrous cartilage. It first calcifies and is then replaced by bone tissue.

The onset of the disease is provoked by increased physical activity, which is typical for workers in certain professions and athletes. Under the influence of excessive load, the tendons receive microtraumas. They cannot recover in a short period of rest. Damage accumulates, necrosis of tendon areas occurs, tissue degeneration occurs, and an inflammatory process develops.

Primary tendonitis of the gluteal muscles is an independent disease that is caused by mechanical injuries to the tendon fibers. The disease rarely leads to inflammation of the gluteal and other thigh muscles in people who do not play sports. This is an occupational disease of track and field athletes.

The following causes of secondary tendinitis are distinguished:

• Infectious and autoimmune diseases;
• Pathology of the immune system;
• Degenerative processes in joints;
• Diseases of the endocrine system (diabetes mellitus, thyroid pathology);
• Rheumatic tissue lesions (arthritis, systemic lupus, deforming osteoarthritis);
• Congenital defects in the development of the hip joints;
• Decreased immunity after chemotherapy, taking antibiotics, and frequent respiratory viral diseases.

Rheumatologists at the Yusupov Hospital find out the cause of gluteal tendonitis in each patient in order to influence the factors causing the disease.

The treatment program for this disease at the Bone Clinic may include:

Shock wave therapy

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PRP therapy

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Acupuncture administration of ozone

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Teraquantum therapy

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Interference therapy

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