Zusammenfassung
Hintergrund
Tumoröse Destruktionen der periazetabulären Region und des proximalen Femurs können durch primäre, zumeist maligne Knochentumoren verursacht sein, sind aber ungleich häufiger die Folge metastastischer Läsionen. Unter allen Skelettabschnitten weist diese Region die höchste Rate pathologischer Frakturen auf.
Behandlungsmethoden
Fortgeschrittene Resektionstechniken, welche die onkologisch suffiziente Resektion selbst ausgedehnter Tumormanifestationen erlauben, und die Einführung moderner osteosynthetischer und endoprothetischer Rekonstruktionsmethoden für Becken und Femur, haben zu einer deutlichen Steigerung extremitätenerhaltender Eingriffe geführt, weisen aber auch eine Reihe typischer und schwerwiegender intra- und postoperativer Komplikationen auf.
Komplikationen
Neben der im Vergleich zur elektiven Hüftendoprothetik erhöhten Rate von Infekten, septischen/aseptischen Lockerungen, Luxationen, periprothetischen und pathologischen Frakturen und tiefen Becken-/Beinvenenthrombosen stellen die erhöhte intra- und postoperative Mortalität und das lokale Tumorrezidiv die schwerwiegendsten Komplikationen dar. Insgesamt weisen periazetabuläre Resektionen im Vergleich zur proximalen Femurresektion mit endoprothetischer Versorgung eine erhöhte Komplikationsrate auf.
Schlussfolgerungen
Um die Rate der intra- und postoperativen Komplikationen gering zu halten, sollte die Durchführung ausgedehnter kurativer und palliativer Resektionen muskuloskelettalen Tumorzentren mit ausgewiesener Expertise in osteosynthetischen und endoprothetischen Rekonstruktionsverfahren von Becken und Femur vorbehalten sein. Nur dort können eine effektive Komplikationsprophylaxe und – falls erforderlich – ein adäquates, interdisziplinäres Komplikationsmanagement sofort erfolgen.
Abstract
Background
Tumorous destruction of the periacetabular region and the proximal femur are a consequence of either primary malignant bone tumor manifestation or metastatic disease, which is observed much more frequently and occurs typically in these skeletal segments. Pathological fractures of the proximal femur and periacetabular regions of the pelvis have a high incidence and ultimately lead to severe pain and immobilization.
Treatment methods
Advanced resection techniques and different types of defect reconstruction, allowing for oncologically sufficient resection of extensive tumors have contributed to a marked increase in the limb salvage rate. However, these procedures are associated with an increasing rate of several, sometimes severe intraoperative and postoperative complications.
Complications
Compared to elective total hip arthroplasty, the rate of postoperative deep infections, dislocations, the incidence of pathological and periprosthetic fractures and the prevalence of deep vein thrombosis are increased with high rates of postoperative mortality and local tumor recurrence, being the most serious complications. Pelvic involvement and subsequent periacetabular resection have the highest complication rate when compared to proximal femur resection with endoprosthetic treatment.
Conclusion
In order to minimize the risk of these intraoperative and postoperative complications wide resection and advanced reconstruction as well as complicated palliative stabilization due to malignant bone tumor growth around the hip joint should be performed in musculoskeletal tumor centers with profound expertise in osteosynthetic and endoprosthetic reconstruction of the pelvis and the proximal femur. Only in specialized centers an effective, multidisciplinary emergency management of these complications and, more importantly, reliable prevention of complications can be ensured.
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Interessenkonflikt. K.-D. Schaser, I. Melcher, S. Märdian, C. Perka, R. Locher, P. Schwabe geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Schaser, KD., Melcher, I., Märdian, S. et al. Komplikationsmanagement nach Resektion und Defektrekonstruktion hüftgelenknaher Tumoren. Orthopäde 43, 92–102 (2014). https://doi.org/10.1007/s00132-013-2133-x
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DOI: https://doi.org/10.1007/s00132-013-2133-x