上海的连续酷暑终于告一段落。朋友圈中跑友也见到活跃起来。图说运医新技术系列今天聊一聊跑友中常见的髋关节周围疼痛的一种症状-臀中肌撕裂的手术治疗。原文来源于2022年7月份《Arthroscopy》杂志。<div><br></div> <h3 style="text-align: center;">髋关节周围肌腱群（从左到右分别是臀中肌，臀大肌和臀小肌）</h3> 臀中肌起源于髂骨的后表面，在臀后线和臀前线之间插入大转子的外侧和上后小关节。由于肌肉的不对称性质，撕裂更容易发生在肌腱足印较薄的前外侧部分。臀中肌撕裂可分为间质性、部分厚度撕裂和回缩性、全厚度撕裂，可能由创伤引起，但更常见的是慢性变性的结果。患者常表现为患侧负重和侧卧加重髋侧疼痛，外展乏力，体格检查可见Trendelenburg征（前倾角征）。 <h3 style="text-align: center">臀中肌撕裂</h3> <h3 style="text-align: center">跑友跑步时常见疼痛的部位</h3> <h3 style="text-align: center">右髋，前外视角臀中肌足印附着点</h3> <h3 style="text-align: center">Trendelenburg征（前倾角征）</h3> 手术指征包括保守治疗失败和超声或磁共振成像研究显示肌腱撕裂。手术的目的是通过缝合锚钉将撕裂的肌腱重新固定到大转子上的肌腱足印上。开放式和内窥镜技术已被证明是治疗臀中肌撕裂的短期和长期随访的有效方法。然而，内窥镜技术已被证明可以减少术后并发症，如再次撕裂。 <h3 style="text-align: center">臀中肌手术体位及修复示意</h3> <h3 style="text-align: center">髋关节镜手术</h3> 手术治疗臀中肌撕裂<div><ul><li>可以关节镜下或者开放做</li><li>修复技术取决于撕裂大小，肌腱质量和医生技术</li><li>双排锚钉固定可以最大限度地扩大了肌腱和骨骼之间的接触面积，并已被证明优于内镜技术的单排修复。</li><li>慢性全层撕裂如果肌腱质量较差可能用到加强固定材料（如补片、同种异体肌腱）</li></ul></div> 单排锚钉固定臀中肌 <h3 style="text-align: center">置入锚钉</h3> <h3 style="text-align: center">过线</h3> <h3 style="text-align: center">固定肌腱</h3> 双排固定臀中肌 <h3 style="text-align: center">置入内排钉</h3> <h3 style="text-align: center">过线</h3> <h3 style="text-align: center">置入外排钉</h3> 最近的一项系统综述和荟萃分析发现，较严重的脂肪浸润(FI)患者在切开修复后可能获得更大的改善，而较轻的脂肪浸润患者可能从内镜治疗中获益更多。双排修复最大限度地扩大了肌腱和骨骼之间的接触面积，并已被证明优于内镜技术的单排修复。 <h3 style="text-align: center">PEEK内排钉</h3> <h3 style="text-align: center">PEEK外排钉</h3> 参考资料：<div>1，Morgan W. Rice, B.S., Robert B. Browning, M.D., and Shane J. Nho, M.D., M.S.； Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 38, No 7 (July), 2022: pp 2115-2117；Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.</div><div>2，Domb BG, Carreira DS. Endoscopic repair of full-thickness gluteus medius tears. Arthrosc Tech 2013;2:e77-e81.</div><div>3，Domb BG, Nasser RM, Botser IB. Partial-thickness tears of the gluteus medius: Rationale and technique for trans-tendinous endoscopic repair. Arthroscopy 2010;26:1697-1705.</div><div>4，Kahlenberg CA, Nwachukwu BU, Jahandar H, Meyers KN, Ranawat AS, Ranawat AS. Single- versus double-row</div>repair of hip abductor tears: A biomechanical matched<br>cadaver study. Arthroscopy 2019;35:818-823.<div>5，Looney AM, Bodendorfer BM, Donaldson ST, Browning RB, Chahla JA, Nho SJ. Influence of fatty infiltration on hip abductor repair outcomes: A systematic review and metaanalysis [published online September 8, 2021]. Am J Sports </div>Med. https://doi.org/10.1177/03635465211027911.<div>6，Okoroha KR, Beck EC, Nwachukwu BU, Kunze KN, Nho SJ. Defining minimal clinically important difference and patient acceptable symptom state after isolated endoscopic gluteus medius repair. Am J Sports Med 2019;47:3141-3147.</div><div>7，Perets I, Mansor Y, Yuen LC, Chen AW, Chaharbakhshi EO, Domb BG. Endoscopic gluteus medius repair with</div>concomitant arthroscopy for labral tears: A case series with minimum 5-year outcomes. Arthroscopy 2017;33:<br>2159-2167.<div>8，Pianka MA, Serino J, DeFroda SF, Bodendorfer BM. Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology. SAGE Open Med 2021;9:20503121211022582.</div><div>9，Robertson WJ, Gardner MJ, Barker JU, Boraiah S,</div>Lorich DG, Kelly BT. Anatomy and dimensions of the<br>gluteus medius tendon insertion. Arthroscopy 2008;24:<br>130-136.<div>10，Tsutsumi M, Nimura A, Akita K. The gluteus medius tendon and its insertion sites: An anatomical study with possible implications for gluteus medius tears. J Bone Joint Surg Am 2019;101:177-184.</div>