BÜYÜK TROKANTERİK AĞRI SENDROMU

Fatma Gül Ülkü Demir

Kayseri Şehir Hastanesi, Fiziksel Tıp ve Rehabilitasyon Kliniği, Kayseri, Türkiye

Ülkü Demir FG. Büyük Trokanterik Ağrı Sendromu. Çalış M, Talay Çalış H ed. Ağrıda Odak Noktası Kalça. 1. Baskı. Ankara: Türkiye Klinikleri; 2025. p.117-132.

ÖZET

Büyük trokanterik ağrı sendromu (BTAS), periartiküler, peritrokanterik bölge anatomisini yansıtan geniş bir etiyoloji yelpazesine sahip, lateral kalça ağrısına neden olan ve toplumda yaygın olarak gözlenen bölgesel bir ağrı sendromudur. BTAS terimi tarihsel trokanterik bursit olarak isimlendirilmesinin aksine trokanterik bursa dışında bu bölgedeki diğer bursal alanlarda inflamasyon ve efüzyon ile tendinopatileri ve tendinöz yırtıkları içerir. Peritrokanterik bölge, bursalar (trokanterik bursa, gluteus medius ve gluteus minimus bursaları) büyük trokantere yapışan abdüktör tendonlardan (Gluteus medius, GMed; gluteus minimus, GMin) ve fasia latadan oluşur. Trokanterik bursit, gluteus medius- minimus tendinozisi, parsiyel ya da tam kat yırtıkları ve koksa saltans BTAS’la ilişkili klinik durumlardır. BTAS, 40-60 yaş civarında özellikle kadınlarda daha sık görülür, insidansı binde 1,8 iken prevalansı

%17,6’dır. BTAS için risk faktörleri arasında ileri yaş, obezite, kadın cinsiyet, alt ekstremite uzunluk farkı, alt ekstremite eklemleriyle ilişkili artrit, skolyoz, lomber spinal patolojiler yer almaktadır. Alt ekstremite biyomekaniğini etkileyen bozukluklar BTAS oluşumuna zemin hazırlar. BTAS, öykü ve fizik muayene ile klinik olarak tanı alır. Klinik değerlendirmede öncelikle patolojik postür/yürüme paterni varlığı, kalça eklem hareket açıklığı, alt ekstremiteye yönelik nörolojik muayene, alt ekstremite uzunluk farkı ölçümü gibi temel muayeneler yapılır. Ayırıcı tanı amacıyla trendelenburg belirtisi, tek ayak üstünde durma, dirençli dış derotasyon, dirençli abdüksiyon ile birlikte addüksiyon, Patrick Testi gibi özel/provokatif testler uygulanır. BTAS, kalça osteoartriti, kalça avasküler nekrozu, femur boynu stres kırıkları, femoroasetabular impingiment, meraljia parestetika gibi kalça bölgesine lokalize hastalıklar, lomber disk patolojileri, fibromiyalji gibi hastalıklarla karışabilir. BTAS süresine, şiddetine, tutulum bölgesine ve bu bölgedeki patolojiye (bursit, tendinopati vs) uygun olarak tedavi edilir. Tedavi seçenekleri arasında medikal olmayan yöntemler (aktivite modifikasyonu, kilo kontrolü, egzersiz, fizik tedavi modaliteleri) ve farmakolojik (oral/ topikal non-steroidal antinflamatuar ilaçlar, trokanterik bölgeye steroid/lokal anestezik/plateletten zengin plazma enjeksiyonu vb) yöntemler yer alır. BTAS’ta konservatif tedaviye rağmen dirençli semptomları olan hastalar cerrahi tedaviye adaydır. Cerrahide hedef anatomik bölgeler; kalça abdüktör tendonları, trokanterik bursa ve iliotibal banttır. Açık veya endoskopik cerrahi teknikler hastanın klinik ve anatomik bulgularına göre uygulanır. En sık GMed ve GMin patolojilerinde tenotomi, tendon tamiri şeklinde uygulanır. Bursektomi, tensor fasia lata gevşetilmesi de tek başına veya kombine cerrahi tedavi uygulamaları arasındadır.

Anahtar Kelimeler: Büyük trokanterik ağrı sendromu; Trokanterik bursit; Gluteal tendon yırtıkları; Eksternal atlayan kalça; Ekstra-artiküler kalça ağrısı

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