Battle: Operationsindikation beim Hip-Spine-Syndrom – Die Hüfte oder die Wirbelsäule zuerst?

Die Sicht des Endoprothetikers

Battle: Total hip arthroplasty or spine surgery first in patients with hip-spine-syndrome?

The arthroplasty surgeon’s point of view

Zusammenfassung

Hintergrund

Nicht selten besteht bei Patienten eine Beschwerdesymptomatik an der Hüfte und der Lendenwirbelsäule (LWS), wobei gleichzeitig eine operative Behandlungsnotwendigkeit bestehen kann. Daher stellt sich bei diesen Patienten die Frage, ob die Hüfte oder LWS zuerst versorgt werden sollte? Diese Übersichtsarbeit soll aus der Sicht des Endoprothetikers schildern, welche evidenzbasierten Argumente für die jeweilige priorisierte operative Versorgung sprechen.

Entscheidungsfindung

Bei Patienten mit akuten neurologischen Ausfällen sollte primär eine wirbelsäulenchirurgische Intervention erfolgen. Bei Patienten ohne akute neurologische Ausfälle zeigt die aktuelle Literatur, dass bei Patienten mit einer symptomatischen Koxarthrose und degenerativen LWS-Erkrankung bei gleichzeitig bestehender relativer Operationsindikation der Implantation der Hüftendoprothese der Vorzug gegeben werden sollte. Patienten mit einer Versteifung der LWS vor Implantation einer Hüftendoprothese zeigen in der Literatur eine deutlich erhöhte Luxationsrate, im Vergleich zur umgekehrten Reihenfolge (4,6 vs. 1,7 % nach 2 Jahren; p < 0,001). Dennoch besteht – unabhängig von der Reihenfolge beider Operationen – in beiden Fällen immer noch ein erhöhtes Luxationsrisiko. Daher sollte auf eine optimale Implantatorientierung, die Rekonstruktion der Hüftgelenksanatomie und die Weichteilspannung geachtet sowie die Auswahl von möglichst große Prothesenköpfen (36 mm) oder tripolaren Pfannen in Betracht gezogen werden. In komplexen Einzelfällen sollte eine enge interdisziplinäre Zusammenarbeit von spezialisierten Endoprothetikern und Wirbelsäulenchirurgen erfolgen, um ein individuelles Therapiekonzept zu erarbeiten.

Abstract

Background

Frequently, patients with hip complaints also report lower back pain, and elective surgery may be indicated due to end-stage hip osteoarthritis and degenerative disc disease. Thus, we aim to answer the question of whether total hip arthroplasty (THA) or lumbar spine surgery should be performed first in patients with hip-spine-syndrome, from an arthroplasty surgeon’s point of view.

Decision-making

The present review demonstrates that in patients with an acute neurological deficit, lumbar spine surgery should be performed first. However, in patients without these symptoms, several arguments favour performing THA first, especially the increased risk of dislocation when performing THA after lumbar spine fusion (LSF) in comparison to “THA first” (4.6 vs. 1.7% after 2 years; p < 0,001). However, the risk of dislocation after THA remains increased in both scenarios, independent of surgical order. Consequently, arthroplasty surgeons should pay great attention to optimum component positioning, reconstruction of the hip anatomy, leg length and soft-tissue tension, while considering using large prosthesis heads or dual mobility cups when performing primary THA in patients with an increased risk of dislocation. In complex cases, we would encourage arthroplasty and spine surgeons working in cooperation on highly individual treatment concepts.

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Abbreviations

HTEP:

Hüfttotalendoprothese

LWS :

Lendenwirbelsäule

WOMAC :

Western Ontario and McMaster Universities Osteoarthritis Index

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Correspondence to Prof. Dr. med. M. Clarius.

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Interessenkonflikt

M. Clarius, M. Farweez und M.M. Innmann geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Clarius, M., Farweez, M. & Innmann, M.M. Battle: Operationsindikation beim Hip-Spine-Syndrom – Die Hüfte oder die Wirbelsäule zuerst?. Orthopäde 49, 899–904 (2020). https://doi.org/10.1007/s00132-020-03974-w

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Schlüsselwörter

  • Hüftgelenk
  • Hüftluxation
  • Spondylodese
  • Hüftgelenkersatz/Endoprothese
  • Wirbelsäule

Keywords

  • Hip joint
  • Dislocation
  • Fusion
  • Hip replacement
  • Spine