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Femoroazetabuläres Impingement als Auslöser der Koxarthrose

Femoroacetabular impingement: Trigger for the development of osteoarthritis

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Zusammenfassung

Das femoroazetabuläre Impingement (FAI) ist häufig, die geschätzte Prävalenz liegt bei 10–15%. Unsere bisher 10-jährige Erfahrung bestätigt das FAI als eine wesentliche, wenn auch nicht einzige Ursache der Koxarthrose. Isolierte azetabuläre oder femorale Fehlformen sind selten, obwohl bei Frauen die azetabuläre und bei Männern die femorale Pathomorphologie dominiert. Normalbefunde im Standardröntgen schließen ein FAI nicht aus. Symptome treten umso früher auf, je größer die Deformität und je intensiver hohe Bewegungsanforderungen gestellt werden. Die überwiegende Mehrzahl der Patienten ist <40 Jahre alt.

Im Unterschied zum Impingement bei der Hüftendoprothetik ist das natürliche Gelenk mechanisch viel satter gefasst, was kein Ausweichen im Sinne der Subluxation oder gar Luxation ermöglicht. Entsprechend hoch sind die Impingementkräfte, die beim häufigen, nicht-sphärischen Hüftkopf (femorale Fehlform, Cam-FAI) mit schnellen Bewegungen der Beugung und Innenrotation eine von außen nach innen verlaufende Ablösung des Pfannenknorpels hervorrufen. Der Knorpel des sphärischen Hüftanteils bleibt zunächst intakt, ein Bild, das mit der klassischen Entstehungstheorie der Koxarthrose nicht in Einklang zu bringen ist. Erst wenn der Hüftkopf in die Zone des geschädigten Pfannenknorpels migriert, beeinflussen auch vertikal verlaufende Kräfte den Arthroseverlauf. Risse zwischen Labrum und Knorpel, wie sie im MRT beobachtet werden, sind nicht als Abrisse des Labrum vom Knorpel, sondern Abrisse des Knorpels vom Labrum zu verstehen. Bei der azetabulären Über-Überdachung (azetabuläre Fehlform, Pincer-FAI) ist das Labrum die erste Struktur, die geschädigt wird, der Knorpelschaden tritt sekundär auf. Die Behandlung des FAI bei Patienten <40 Jahren erfolgt, wenn möglich, gelenkerhaltend. Ist die Knorpelschädigung ausgedehnt, ist bei gleichem Aufwand ein schlechteres Ergebnis der chirurgischen Therapie zu erwarten als bei geringem Schaden. Entsprechend wichtig ist die frühe Diagnosestellung, mit der neben der Einleitung der kausalen Therapie auch die beruflichen und sportlichen Weichen angepasst werden sollen.

Abstract

Femoroacetabular impingement (FAI) is frequent; the estimated prevalence ranges between 10 and 15%. Our 10-years experience strongly suggests that FAI leads to osteoarthritis. Isolated acetabular or femoral abnormalities are rare, even though in women acetabular and in men femoral abnormalities predominate. Normal radiographs do not exclude the presence of FAI. Symptoms are related to the degree of deformity and occur earlier in the presence of activities requiring high levels of motion. The majority of patients with FAI are under the age of 40 years.

In contrast to impingement in total hip replacement, the natural hip is under much higher constraint, not allowing to escape from impingement-induced shear forces by subluxation or complete dislocation. FAI-induced shear forces due to an aspherical femoral head/neck (cam type) are therefore high, causing outside-in damage with cleavage lesions of the acetabular cartilage by forced flexion and internal rotation. The cartilage of the femoral head remains initially intact, which cannot be explained by the classic concept of osteoarthritis. After the femoral head has migrated into the acetabular cartilage defect, vertical forces contribute to the further course of osteoarthritis. Tears between the labrum and cartilage, as seen by MRI, are not avulsions of the labrum from the cartilage but rather outside-in avulsions of the cartilage from the labrum. In acetabular overcoverage (pincer type) the labrum is the first structure to fail and acetabular cartilage damage develops thereafter.

The treatment of FAI in patients under the age of 40 years is aimed at joint preservation. The clinical result is worse in the presence of significant cartilage damage. Therefore, early appreciation of FAI and timely therapeutic intervention as well as professional and athletic adjustment are important if osteoarthritis is to be prevented.

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Authors and Affiliations

  1. Orthopädische Klinik Balgrist, Universität, Zürich, Schweiz

    M. Leunig, C. Dora & R. Ganz

  2. Department Hand-, Orthopädische- und Plastische Chirurgie, Inselspital, Universität Bern, Schweiz

    M. Beck

  3. Orthopädie, Schulthess Klinik, Lengghalde 2, CH-8008, Zürich, Schweiz

    M. Leunig

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  1. M. Leunig
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  2. M. Beck
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  3. C. Dora
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  4. R. Ganz
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Correspondence to M. Leunig.

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Leunig, M., Beck, M., Dora, C. et al. Femoroazetabuläres Impingement als Auslöser der Koxarthrose. Orthopäde 35, 77–84 (2006). https://doi.org/10.1007/s00132-005-0896-4

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