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Arthroskopische Behandlung des femoroazetabulären Impingements

Hip arthroscopy for femoroacetabular impingement

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Zusammenfassung

Das femoroazetabuläre Impingement (FAI) stellt eine der Ursachen der Entwicklung einer Koxarthrose bei jüngeren Patienten dar. Bisher wurden die verschiedenen Formen des FAI über eine offene Hüftluxation behandelt. Im Hinblick auf die Invasivität und lange Rehabilitation dieses Eingriffs haben sich in den vergangenen Jahren erste arthroskopische Verfahren entwickelt. Der vorliegende Beitrag stellt das aktuelle arthroskopische Verfahren einschließlich seiner technischen Aspekte und Grenzen vor.

Die Arthroskopie des Hüftgelenks wird in der üblichen Weise mit und ohne Traktion zur Inspektion und Behandlung des zentralen und peripheren Kompartiments durchgeführt. Unter Distraktion wird insbesondere der ventrosuperiore Knorpel und die angrenzende Basis des Labrum acetabulare auf häufige Läsionen wie Lappenrisse oder Delaminationen vom subchondralen Knochen überprüft. Ein verknöchertes Labrum kann zurückgetrimmt werden. Zum gegenwärtigen Zeitpunkt sind Techniken zur temporären Ablösung des Labrum, Zurücktrimmen des darunter liegenden knöchernen Pfannenrandes und anschließender Refixation des Labrum mit Nahtankern in der Erprobung. Anschließend wird das periphere Kompartiment ohne Traktion inspiziert, ein positiver Impingementtest ist unter Beugung, Innenrotation und Adduktion zu provozieren. Auch im Hinblick auf die häufige Reduktion der Innenrotation werden die Zona orbicularis und das Lig. iliofemorale eingeschnitten oder teilweise reseziert. Der ventrolaterale „Bump“ wird mit einer Fräse zurückgetrimmt.

Wir beginnen ab dem 1. postoperativen Tag mit einer Motorschienenbehandlung, um Verklebungen zwischen der Gelenkkapsel und der blutenden Knochenoberfläche des Kopf-Hals-Übergangs zu vermeiden. Die Belastung wird schmerzadaptiert gesteigert, sofern keine Maßnahmen zur Faserknorpelbildung erfolgten. Die ersten klinischen Ergebnisse sind vielversprechend. Es ist davon auszugehen, dass das arthroskopische Verfahren die offene Hüftluxation zunehmend in den Hintergrund drängen wird.

Abstract

Femoroacetabular impingement (FAI) is likely one of the main causes for osteoarthritis in young adults. Surgical treatment has until now been performed via open dislocation of the hip joint. With respect to its invasive nature and long rehabilitation, arthroscopic techniques have become established in recent years. The following article presents the latest developments in hip arthroscopy for FAI with a detailed description of technical aspects, pitfalls, and limitations.

Hip arthroscopy is performed in the standard fashion with and without traction for arthroscopy of the central and peripheral compartments. Under traction, the anterosuperior cartilage and adjacent base of the acetabular labrum have to be inspected for frequent lesions such as cartilage flap tears and delaminations of the cartilage from the subchondral bone. An ossified labrum can be trimmed back with a burr. Currently, techniques are being developed for temporary detachment of the labrum, trimming of the acetabular rim, and refixation of the labrum with suture anchors. Without traction, femoroacetabular impingement has to be confirmed arthroscopically under flexion, internal rotation, and adduction of the hip. With respect to the frequent loss of internal rotation, the zona orbicularis and the iliofemoral ligament are released and removed if needed. The anterolateral bump of the head-neck junction is trimmed back for restoration of a more physiological head-neck offset.

Postoperatively, continuous passive motion is important to prevent adhesions between the bleeding bone of the head-neck junction and the articular capsule. Weight bearing as tolerated is allowed if no treatment of cartilage defects or refixation of the acetabular labrum was performed. The early results after hip arthroscopy for FAI are very promising. Arthroscopic techniques will upstage open exposures of the hip joint for the treatment of FAI.

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

    M. Wettstein &  M. Dienst

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

    M. Dienst

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Wettstein, M., Dienst, M. Arthroskopische Behandlung des femoroazetabulären Impingements. Orthopäde 35, 85–93 (2006). https://doi.org/10.1007/s00132-005-0897-3

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