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Komplikationen bei Metall-Metall-Gleitpaarungen

Complications of metal-on-metal tribological pairing

  • Leitthema
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Zusammenfassung

Hintergrund

Metall-Metall-(Metal-on-metal[MoM])-Gleitpaarungen erzeugen weniger volumetrischen Abrieb als Paarungen mit herkömmlichem Polyethylen und sind mit einem geringeren Risiko an Materialversagen gegenüber anderen Hart-Hart-Paarungen verbunden. Ein gehäuftes Auftreten von Komplikationen hat in den vergangenen Jahren zu einer deutlichen Verunsicherung geführt. Vor diesem Hintergrund sollen im Rahmen der vorliegenden Arbeit aktuelle Aspekte der Epidemiologie, Ätiologie, Diagnostik und Behandlung von Komplikationen bei MoM-Hüftendoprothesen besprochen werden.

Epidemiologie/Ätiologie

Anhand von Ergebnissen aus nationalen Endoprothesenregistern und ausgewählten klinischen Studien wird eine Bewertung der Rate lokaler Komplikationen von MoM-Gleitpaarungen vorgenommen. Dabei wird eine Unterscheidung von MoM-Paarungen in gestielte Kleinkopfendoprothesen (≤ 32 mm), Großkopf- (> 32 mm) sowie OFE-Endoprothesen vorgenommen. MoM-Endoprothesen setzen jährlich pro Patient durchschnittlich 1012–1014 Kobalt(Co)- und Chrom(Cr)-Nanopartikel frei. Die Freisetzung von Metallionen bzw. -partikeln kann zu unterschiedlichen Gewebereaktionen führen.

Diagnostik

Zwischen der regulären Routinediagnostik im Rahmen der Implantatnachsorge und spezifischen Untersuchungen beim Auftreten von Beschwerden muss unterschieden werden. Die Diagnostik bei mit Metall-Metall-Hüftendoprothesen versorgten Patienten umfasst ein standardisiertes, stufenförmiges Vorgehen unter Würdigung möglicher Differenzialdiagnosen und Nutzung aktueller laborchemischer und radiologischer Methoden. Beim Auftreten von Beschwerden sollten metallosebedingte Beschwerden vorrangig von mechanischen Problemen (z. B. Prothesenlockerung, Impingement etc.) und Symptomen im Rahmen eines periprothetischen Infekts abgegrenzt werden.

Komplikationstherapie

Für periprothetische Infektionen, Frakturen und sonstige allgemeine Komplikationen gelten die üblichen Standards in der Hüftendoprothetik. Spezifische Maßnahmen ergeben sich jedoch bei den Komplikationen, die auf metallspezifische Risiken zurückgeführt werden können.

Abstract

Background

Metal-on-metal (MoM) tribological pairing results in less volumetric abrasion than pairing with the conventionally used polyethylene and is associated with a lower risk of material failure compared to other hard-hard pairings. An increased frequency of problem cases in recent years has led to a great increase in uncertainty. Against this background in this article the current aspects of epidemiology, etiology, diagnostics and treatment of complications in MoM hip joint endoprostheses will be discussed.

Epidemiology and etiology

Based on the results from national endoprosthesis registers and selected clinical studies an evaluation of the rate of local complications from MoM tribological pairings was undertaken. A differentiation was made between MoM pairings in pedicled small head prostheses (≤ 32 mm), large head (> 32 mm) and surface replacement (OFE) endoprostheses. Each year MoM endoprostheses release on average 1012–1014 cobalt (Co) and chromium (Cr) nanoparticles per patient. This release of metal ions and particles can lead to a variety of tissue reactions.

Diagnostics

A differentiation must be made between regular routine diagnostics within the framework of implant follow-up screening and specific investigations due to the occurrence of complaints. The diagnostics for patients treated with MoM hip endoprostheses consists of a standardized step-wise approach considering possible differential diagnoses and the utilization of modern laboratory chemical and radiological methods. When problems occur, a differentiation should preferentially be made between complaints not caused by metal and mechanical problems (e.g. prosthesis loosening and impingement) and symptoms due to periprosthetic infections.

Therapy of complications

The normal standards for hip endoprosthetics are also valid for periprosthetic infections, fractures and other general complications. Specific measures are, however, necessary for complications due to metal-specific risks

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Einhaltung ethischer Richtlinien

Interessenkonflikt. K.-P. Günther, M. Stiehler, F. Zobel, F. Hannemann, J. Schmitt, J. Lützner, S. Kirschner, A. Hartmann weisen auf folgende Beziehungen hin: Forschungsarbeiten der Orthopädischen Universitätsklinik Dresden zu Metallgleitpaarungen wurden partiell mit finanzieller Unterstützung von Implantatherstellern (Zimmer Inc., Smith & Nephew, DePuy) sowie der Deutschen Arthrose-Hilfe e. V. gefördert. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. UniversitätsCentrum für Orthopädie und Unfallchirurgie, Klinik für Orthopädie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland

    M. Stiehler, F. Zobel, J. Lützner, S. Kirschner,  K.-P. Günther & A. Hartmann

  2. UniversitätsCentrum für Evidenzbasierte Gesundheitsversorgung, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland

    F. Hannemann & J. Schmitt

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  1. M. Stiehler
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Correspondence to K.-P. Günther.

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Stiehler, M., Zobel, F., Hannemann, F. et al. Komplikationen bei Metall-Metall-Gleitpaarungen. Orthopäde 43, 79–91 (2014). https://doi.org/10.1007/s00132-013-2131-z

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  • DOI: https://doi.org/10.1007/s00132-013-2131-z

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