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Chirurgische Therapie des ischiofemoralen Impingements mittels lateralisierender intertrochantärer Korrekturosteotomie

Surgical therapy of ischiofemoral impingement by lateralizing intertrochanteric osteotomy

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Zusammenfassung

Operationsziel

Intertrochantäre Korrekturosteotomie (ITO) zur Vergrößerung des ischiofemoralen Raums, um schmerzhafte Annäherung des Trochanter minor an das Os ischium und Einklemmen des M. quadratus femoris zu beseitigen.

Indikationen

Symptomatisches sekundäres ischiofemorales Impingement (IFI) durch Coxa valga et antetorta, Coxa valga, Coxa antetorta oder Schenkelhalsverkürzung.

Kontraindikationen

IFI-typische Pathologie bei klinisch asymptomatischen Patienten. Symptomatisches sekundäres IFI mit anderer zugrundeliegender Pathologie. Symptomatische Valgusdeformität des Kniegelenks.

Operationstechnik

Bestimmung der femoralen Antetorsion. Planung von Osteotomie, Lateralisation, Korrekturwinkel, Derotation, Offset- und Beinlängenveränderung sowie der Osteosyntheseplatte. Rücken- oder Seitenlage. 15-cm-Hautschnitt lateral, beginnend an der Trochanterspitze entlang der Femurachse nach distal. L‑förmiges Anheben des M. vastus lateralis. Anlegen eines Kirschner(K-)Drahts an den ventralen Schenkelhals zur Bestimmung der Antetorsion. Anlegen eines Winkels an die laterale Femurschaftkortikalis zur Bestimmung des Varisationswinkels. Vorbohren eines K‑Drahts im geplanten Winkel knapp unterhalb der kranialen Schenkelhalskortikalis zentriert. Aufbohren des Klingeneintrittspunkts ca. 5 mm unterhalb des vorgebohrten K‑Drahts. Einschlagen der Klinge in den Schenkelhals. Anschließend Lockerung und leichtes Zurückziehen der Klinge. Rotationsmarkierung proximal und distal der geplanten Osteotomie. Osteotomie und bei geplanter Varisation mit Verkürzung Entnahme eines medialen Knochenkeils. Einschlagen der Klingenplatte ohne Unterstellung zur Femurlateralisation. Reposition des Femurschafts unter Lateralisation an die Platte unter Rotationskorrektur. Osteotomiekompression mit Plattenspanner, Besetzen der distalen Schraubenlöcher. Wundverschluss.

Postoperative Behandlung

Für 6 Wochen 15-kg-Teilbelastung, dann Röntgenkontrolle. Bei beginnender knöcherner Konsolidierung Aufbelastung (15 kg/Woche). Für 6 Wochen Limitierung auf 90°-Flexion im Hüftgelenk. Elektive Materialentfernung ab 12–18 Monaten postoperativ.

Ergebnisse

Bisher sind keine Studien der modifizierten ITO zur IFI-Behandlung publiziert. Langzeitstudien zur konventionellen varisierenden, derotierenden, ITO zeigen im 25-Jahres-Follow-up gute funktionelle Ergebnisse mit wenig Komplikationen. Zur arthroskopischen Resektion des Trochanter minor als operative IFI-Therapie gibt es nur Einzelfalldarstellungen und kleine Fallserien. Vorteile der ITO sind die kausale Therapie der Offset-Störung sowie der Erhalt der Insertion der Iliopsoassehne.

Abstract

Objective

Lateralizing, derotating intertrochanteric varus osteotomy to increase the ischiofemoral space to counter painful impingement of the lesser trochanter and the os ischium with resulting entrapment of quadratus femoris muscle.

Indications

Symptomatic ischiofemoral impingement (IFI) caused by Coxa valga et antetorta, Coxa valga or Coxa antetorta, or a short femoral neck.

Contraindications

Anatomic configuration suggestive of IFI in asymptomatic patients. Symptomatic IFI caused by another underlying pathology. Valgus deformity of the knee.

Surgical technique

Measurement of femoral antetorsion. Planning of the osteotomy, lateralization, varus angle for correction, rotation and offset correction, leg length change, and osteosynthesis plate. General or spinal anesthesia in supine or lateral position. Skin incision (15 cm) beginning lateral of the greater trochanter tip, distally along the axis of the femur. Preparation onto the femur by L‑shaped dissection of the vastus lateralis from the bone. A Kirschner(K-)wire is then positioned along the anterior femoral neck to designate the femoral neck antetorsion. A triangle set on the lateral femoral cortexis is used to determine the osteotomy angle. In the thus determined angle, a second K‑wire is shot centrally along the femoral neck axis just inferior to its cranial cortex. About 5 mm distal to the second wire, the entry for the blade is prepared using a drill. Using the blade setting instrument, the blade is introduced into the femoral neck, then slightly pulled back. The rotation is then marked on the anterior femoral cortex proximal and distal to the planned osteotomy and the osteotomy is performed. A blade plate without displacement is impacted. The osteotomy is then reduced, the distal fragment pulled laterally onto the plate, and the screws inserted after compression of the osteotomy with a tension device.

Postoperative management

Touch-toe bearing for 6 weeks, then radiological assessment of osteotomy healing before an increase in weight bearing (15 kg/week). Hip flexion limited to 90° for 6 weeks. Elective implant removal after 12–18 months.

Results

Studies of this lateralizing varus osteotomy have not been published. The 25-year results of the conventional derotating intertrochanteric varus osteotomy technique show good functional results and low complication rates, with non-union being the most common. Arthroscopic resection of the lesser trochanter has been reported as a surgical alternative in the treatment of IFI in case reports and small series. Advantages of the osteotomy are the restoration of biomechanics and preservation of iliopsoas tendon insertion.

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Authors and Affiliations

  1. Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland

    C. Suren, R. Burgkart, I. J. Banke, G. Hertel, J. Schauwecker & R. von Eisenhart-Rothe

  2. ECOM – Excellent Center of Medicine, Arabellastr. 17, 81925, München, Deutschland

    H. Gollwitzer

  3. Chirurgische Klinik, München-Bogenhausen, Deutschland

    H. Gollwitzer

  4. ATOS Klinik München, München, Deutschland

    H. Gollwitzer

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  1. C. Suren
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Correspondence to H. Gollwitzer.

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C. Suren, R. Burgkart, I. J. Banke, G. Hertel, J. Schauwecker, R. von Eisenhart-Rothe und H. Gollwitzer geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren. Alle Patienten, die über Bildmaterial oder anderweitige Angaben innerhalb des Manuskripts zu identifizieren sind, haben hierzu ihre schriftliche Einwilligung gegeben. Im Fall von nichtmündigen Patienten liegt die Einwilligung eines Erziehungsberechtigten oder des gesetzlich bestellten Betreuers vor.

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Suren, C., Burgkart, R., Banke, I.J. et al. Chirurgische Therapie des ischiofemoralen Impingements mittels lateralisierender intertrochantärer Korrekturosteotomie. Oper Orthop Traumatol 30, 98–110 (2018). https://doi.org/10.1007/s00064-018-0540-1

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