Zusammenfassung
Der endoprothetische Ersatz des Hüftgelenks ist bei Patienten der älteren Altersgruppe sehr effektiv. Patienten unter 55 Jahren weisen jedoch eine höhere Lockerungsrate auf, weshalb der Oberflächenersatz des Hüftgelenks als Alternative für den jungen aktiven Patienten mit degenerativer Hüftgelenkerkrankung entwickelt wurde. Weitere Vorteile liegen in der Erhaltung von Knochensubstanz und Optimierung der Kraftübertragung im Bereich des proximalen Femurs, sowie der besseren Gelenkstabilität und -beweglichkeit der Hüfte.
Das Scheitern der ersten Generation des Oberflächenersatzes war weitgehend eine Konsequenz aus der Verwendung ungeeigneter Materialien, schlechtem Implantatdesign und Operationstechnik und nicht ausgereiftem Implantationsinstrumentarium. Dass es nicht ein Problem des Verfahrens selbst war, lässt sich unschwer an den positiven, aktuellen Frühergebnissen erkennen, bei denen im Vergleich zu den 1970er und 1980er Jahren Frühlockerungen und Schenkelhalsfrakturen nicht mehr im gleichen Ausmaß auftreten. Obwohl Frühergebnisse immer mit großer Vorsicht interpretiert werden müssen, geben doch die neuen Implantatdesigns mit Metall-Metall-Gleitpaarung bei kritischer Patientenauswahl die Möglichkeit, die Anatomie bestmöglichst zu erhalten und die Funktion wiederherzustellen.
Um Implantate für den Oberflächenersatz mit konstant guten, tribologischen Eigenschaften herzustellen, bedarf es eines hohen technischen Standards. Die Technologie scheint sich im Vergleich zu den früheren Implantaten erheblich verbessert zu haben, jedoch bleiben nach wie vor Unklarheiten bezüglich der möglichen biologischen Effekte erhöhter Serumspiegel von Metallionen bei Patienten mit Metall-Metall-Gleitpaarung. Negative Berichte sind diesbezüglich bisher nicht publiziert. Nur Langzeitergebnisse und die weitere Verbreitung dieser Implantatform werden zeigen, ob der Oberflächenersatz eine dauerhafte Lösung für das arthrotische Hüftgelenk ist oder ob es sich um eine möglichst knochenerhaltende Technik vor der Notwendigkeit eines konventionellen Hüftgelenkersatzes handelt.
Abstract
Total hip replacement in its current form has proved to be very effective in late middle-aged and elderly patients. However, in the younger patient population the survival rate is still not acceptable. Since the very beginning of hip resurfacing, the procedure has been advocated as an attractive concept to preserve proximal femoral bone stock. Furthermore, it is supposed to optimize stress transfer to the proximal femur and because of the large head size improves joint stability and range of motion. The failure of previous resurfacings has been described to be due to inappropriate materials, poor design, and poor instrumentation and not as an inherent problem of the procedure itself.
Progress in materials and material design (metal-on-metal) as well in experience in surgical technique seem to have overcome formerly experienced difficulties. This means a lower rate of femoral neck fractures and aseptic loosenings, at least in the short-term and midterm follow-up of patients with good function.
High manufacturing standards are required to consistently produce low-wear metal-on-metal bearings and it is still unclear whether high metal ion levels, which occur in all patients with metal-on-metal hip replacements, have any biologic effect. At least so far there is no evidence of any negative clinical effect in this regard. Only long-term results in a higher number of patients and a more widespread use of this procedure will tell whether early success is durable or it is just a bone-preserving, intermittent step before conventional total hip replacement.
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Rechl, H., Pilge, H. & Rudert, M. Die Entwicklung des Oberflächenersatzes der Hüfte. Orthopäde 37, 626–633 (2008). https://doi.org/10.1007/s00132-008-1312-7
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DOI: https://doi.org/10.1007/s00132-008-1312-7