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Arthrolyse des Hüftgelenks bei heterotoper Ossifikation

Hip Joint Arthrolysis Due to Heterotopic Ossification

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Zusammenfassung

Operationsziel

Wiederherstellung der Gelenkmobilität unter Erhaltung der Hüftkopfdurchblutung und bei Gewährleistung der Gelenkstabilität. Schmerzreduktion. Verbesserung der selbstständigen Mobilität im Alltag (falls von kognitiver Seite möglich) sowie der Sitzfähigkeit. Beim pflegebedürftigen, bettlägerigen Patienten Erleichterung der pflegerisch- hygienischen Aufgaben und Verbesserung des Patientenkomforts.

Indikationen

Bewegungseinschränkung, Gelenksteifigkeit mit Einschränkung der Lebensqualität.

Schmerzen.

Gelenkdeformität, insbesondere bei zunehmender Subluxation.

Kontraindikationen

Relativ: Röntgenologisch und szintigraphisch unreife heterotope Ossifikation (HO) mit mäßiger Bewegungseinschränkung und unzuverlässige Patienten, die nicht in der Lage sein werden, die anspruchsvolle Nachbehandlung durchzustehen.

Operationstechnik

Bei der beispielhaften Resektion ektopen Knochens vom Verknöcherungstyp Brooker IV hängt der gewählte Zugang von Größe und Lage der ektopen Knochenmasse ab. Diese wird einerseits aus den umgebenden Weichteilen, andererseits unter Nutzung der meist teilweise identifizierbaren Trennschicht zum genuinen kortikalen Knochen so weit wie möglich in toto herausgelöst. Bei dorsaler Lage ist der Nervus ischiadicus, bei ventraler Lage sind die ventralen neurovaskulären Strukturen darzustellen.

Weiterbehandlung

Bei Patienten jenseits des 50. Lebensjahrs postoperative Bestrahlung. Generell medikamentöse Rezidivprophylaxe mit nichtsteroidalen Antirheumatika. Intensive und aggressive physiotherapeutische Übungsbehandlung, vor allem bei neurologischen Ursachen. Je nach Ausmaß der Arthrolyse und Ursache der HO von Vollbelastung, schmerzadaptierter Aufbelastung bis Entlastung der Extremität über die ersten 6 postoperativen Wochen.

Ergebnisse

Die Literaturlage erlaubt keine sicheren Rückschlüsse bezüglich des Auftretens von HO. Die Inzidenz der HO nach primärer Alloarthroplastik des Hüftgelenks wird auf 42% geschätzt. Dabei kommt es in 9% der Fälle zu einer schweren HO mit erheblicher Funktionslimitierung oder zur Ankylose. Bei Patienten mit neurologischen Verletzungen (Schädel-Hirn-Trauma, Rückenmarkverletzungen) schwankt die Inzidenz zwischen 20% und 40%, wobei nur ein Drittel dieser Patienten eine eingeschränkte Funktion oder Ankylose aufweist. Nach operativer Arthrolyse beträgt die Rezidivrate in der Regel 25–30% nach durchschnittlich 6 Jahren.

Abstract

Objective

Restoration of joint mobility with preservation of femoral head perfusion and warranty of joint stability. Pain reduction. Enhancement of the autonomous daily mobility (if possible regarding the cognitive status) as well as the ability to sit. For nonambulatory, bedridden patients ease of sanitary tasks and improvement of patients’ convenience.

Indications

Joint stiffness with limitation of the quality of life.

Pain.

Joint deformity, especially in cases of progressive subluxation.

Contraindications

Relative: radiologically and scintigraphically immature heterotopic ossification (HO) with moderate limitation of motion and patients who are not able to tolerate the demanding postoperative management.

Surgical Technique

The patient is positioned depending on size and location of ectopic bone. Ectopic bone is released from surrounding soft tissue or by making use of a gap between original bone and ectopic bone from the femur or pelvis. If ectopic bone is close to neurovascular structures, these have to be identified and protected.

Postoperative Management

Postoperative irradiation in patients > 50 years. Generally, medicamentous prevention for recurrent cases with nonsteroidal anti-inflammatory drugs. Intensive and aggressive physical therapy, especially in patients with neurologic disorders. Depending on the extent of arthrolysis and the cause of HO, full, partial, or no weight bearing of the extremity over the first 6 postoperative weeks.

Results

The literature does not allow to draw firm conclusions regarding the occurence of HO. The incidence of HO after primary total hip arthroplasty is estimated at 42%. In 9% of these cases, a severe HO with major limitation of motion or ankylosis occurs. In patients with neurologic injuries (brain injuries, spinal cord injuries) the incidence varies between 20–40%, but only one third of these patients show limited function or ankylosis. After surgical arthrolysis, the recurrence rate amounts to 25–30% at a mean follow-up of 6 years.

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Authors and Affiliations

  1. Klinik für Orthopädie und Orthopädische Chirurgie, Universitätskliniken des Saarlandes, Homburg/Saar, Germany

    Konstantinos Anagnostakos, Nora Schmid & Dieter Kohn

  2. Klinik für Orthopädie und Orthopädische Chirurgie, Universitätskliniken des Saarlandes, Kirrbergerstraße 1, 66421, Homburg/Saar, Germany

    Konstantinos Anagnostakos

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  1. Konstantinos Anagnostakos
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Correspondence to Konstantinos Anagnostakos.

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Anagnostakos, K., Schmid, N. & Kohn, D. Arthrolyse des Hüftgelenks bei heterotoper Ossifikation. Orthop Traumatol 21, 557–570 (2009). https://doi.org/10.1007/s00064-009-2005-z

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