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Hüftgelenkendoprothetik bei kongenitaler Dysplasie

Anatomische Besonderheiten und technische Stolpersteine

Total hip replacement in developmental dysplasia

Anatomical features and technical pitfalls

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Zusammenfassung

Bei fortgeschrittener, symptomatischer Koxarthrose nach residueller Hüftgelenkdysplasie stellt die Implantation einer Endoprothese für die meisten Patienten die Therapieoption der Wahl dar. Die Komplexität dieses Eingriffs wird jedoch durch die anatomischen Besonderheiten des dysplastischen Hüftgelenks signifikant erhöht. Das relativ junge Patientenalter macht zudem eine begrenzte Standzeit des Implantats wahrscheinlich. Unter biomechanischen Gesichtspunkten sollte das primäre chirurgische Ziel die Rekonstruktion des anatomischen Drehzentrums sein. Die Pfanne sollte möglichst nahe am anatomischen Azetabulum implantiert werden. Zur suffizienten Stabilisierung der Pfanne stehen verschiedene operative Strategien zur Verfügung. Der anterolaterale Azetabulumdefekt kann durch eine Pfannendachplastik mit strukturellem oder spongiösem Autograft behoben werden. Auch eine kontrollierte Medialisierung der Pfanne oder die Implantation von Abstützpfannen und ovalen Sonderpfannen sind beschrieben. Eine zementlose biologische Fixierung der Pfanne führt insbesondere bei den überwiegend jungen Patienten zu besseren Langzeitergebnissen als eine zementierte Pfannenfixierung. Die Art der femoralen Rekonstruktion ist abhängig vom erwünschten Beinlängenausgleich und der Höhe des rekonstruierten Azetabulums. In einigen Fällen muss eine femorale Verkürzungsosteotomie durchgeführt werden. Im vorliegenden Artikel werden die Möglichkeiten der endoprothetischen Rekonstruktion in Abhängigkeit von der vorliegenden femoralen und azetabulären Deformität aufgezeigt.

Abstract

Total hip arthroplasty is the procedure of choice for most patients with advanced, symptomatic osteoarthritis due to congenital dysplasia of the hip. However, the complexity of arthroplasty is significantly increased because of anatomic abnormalities associated with dysplasia of the hip. In addition the relatively young age of patients may affect survival of the implant. From a biomechanical standpoint the primary surgical objective is reconstruction of the anatomical center of rotation. Independent of the pelvic bone stock the socket should be located as near as possible to the anatomical acetabular location. There are various operative strategies to ascertain sufficient stability of the socket. The anterolateral deficiency of the acetabulum can be reconstructed by bulk femoral autografting or bone impaction grafting. Furthermore controlled perforation of the medial wall or implantation of reinforcement rings and oval sockets have been described. Cementless, biological socket fixation shows superior long-term results compared to cemented cups, especially in these young patients. The location of the reconstructed acetabulum and the desired leg length influence the type of femoral reconstruction and in some cases femoral shortening is required. In this article endoprosthetic reconstructive options for developmental dysplasia of the hip are discussed depending on the femoral and acetabular deformity.

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  1. Orthopädische Klinik König-Ludwig-Haus, Julius-Maximilians-Universität Würzburg, Brettreichstr. 11, 97074, Würzburg, Deutschland

    B.M. Holzapfel, D. Bürklein, U. Nöth, M. Hoberg & M. Rudert

  2. Klinik für Orthopädie und Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland

    F. Greimel & H. Gollwitzer

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  1. B.M. Holzapfel
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  2. D. Bürklein
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  3. F. Greimel
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Holzapfel, B., Bürklein, D., Greimel, F. et al. Hüftgelenkendoprothetik bei kongenitaler Dysplasie. Orthopäde 40, 543–553 (2011). https://doi.org/10.1007/s00132-011-1754-1

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