Zusammenfassung
Hintergrund
Die Indikation zur Hüfttotalendoprothese (Hüft-TEP) wird meist aufgrund von Schmerzen, Funktionsverlust, dem röntgenologischen Arthrosenachweis sowie der nicht erfolgreichen konservativen Therapie gestellt. Bisher sind diese Kriterien kaum systematisch recherchiert und es existieren keine allgemein akzeptierten Leitlinien. Ziel der Arbeit war es, im Rahmen des Leitlinienprojekts „Evidenz- und konsensbasierte Indikationskriterien zur Hüfttotalendoprothese“ (EKIT-Hüfte) die gängige Praxis in der Indikationsstellung zur Hüft-TEP bei Koxarthrose unter Orthopäden und Unfallchirurgen in Deutschland zu erfragen.
Material und Methoden
Von 10/2019–07/2020 erfolgte die deutschlandweite, anonymisierte Befragung von 218 Ärzten aus der Orthopädie und Unfallchirurgie nach den Kriterien zur Hüft-TEP, Kontraindikationen sowie zu den erwünschten Behandlungszielen.
Ergebnisse
147 vollständige Fragebögen wurden ausgewertet. Schmerzen (99 %), Einschränkung der Beweglichkeit (99 %) sowie der Gehstrecke (97 %) und der subjektive Leidensdruck (97 %) wurden als häufigste Leitindikationen genannt. Rund 97 % der befragten Studienteilnehmer bewerten Schmerzmedikation und 96 % Physiotherapie im Vorfeld einer Operation als notwendig durchgeführte, nicht mehr erfolgreiche Maßnahmen. Rund 87 % stellen die Indikation zur Hüft-TEP ab einem röntgenologischen Grad III nach Kellgren und Lawrence. Für 48 % besteht eine Kontraindikation ab einem BMI ≥ 40 kg/m2 und für 96 % bei einem floriden Infekt des Hüftgelenkes.
Diskussion
Die erfasste gängige Praxis der Indikationsstellung zur Hüft-TEP in Deutschland deckt sich weitestgehend mit nationalen und internationalen Empfehlungen. Besondere Beachtung finden personenbezogene Faktoren wie Schmerzen, Funktionseinschränkung und subjektiver Leidensdruck. Vorausgegangene konservative Maßnahmen werden betrachtet und Kontraindikationen, wie ein schlecht eingestellter Diabetes mellitus oder eine Infektsituation, sind Teil des Entscheidungsprozesses. Risikofaktoren wie die Adipositas per magna werden nicht konsistent als Kontraindikation gesehen.
Abstract
Background
The decision for total hip arthroplasty (THA) is based on pain, loss of function, radiological changes and failed conservative therapy. These criteria are rarely based on systematic research and have not been integrated in generally accepted treatment guidelines. Aim of our study was, therefore, to analyse which decision criteria German orthopaedic and trauma surgeons use in order to recommend THA for patients with hip osteoarthritis.
Materials and methods
From 10/2019 to 07/2020 we conducted a nation-wide survey among 218 orthopaedic and trauma surgeons about their criteria for and against THA surgery, as well as their treatment objectives.
Results
147 fully completed questionnaires were analysed. Pain (99%), limitation of movement (99%), as well as impairment of walking distance (97%), and the subjective burden (97%) were the most frequent criteria. 97% and 96% of surgeons consider prescription of analgesics and physical therapy, as well as a lack of their effectiveness, as criteria for THA. 87% see radiological changes grade Kellgren & Lawrence III as threshold. A recommendation against surgery is triggered by obesity (BMI ≥ 40 kg/m2) in 48% and by the presence of an active infection in 96%.
Conclusions
Current surgeons’ practice criteria of recommendations for THA in Germany seem to reflect widely nationally and internationally discussed recommendations. Particular attention is given to patient factors like pain, loss of function and subjective burden, as well as previous conservative treatment and contraindications, like poorly controlled diabetes or an active infection, whereas morbid obesity is not seen as contraindication by all surgeons.
Abbreviations
- AAOS:
-
American Academy of Orthopaedic Surgeons
- ADL :
-
Activities of Daily Living
- AE :
-
Deutsche Gesellschaft für Endoprothetik
- BMI :
-
Body-Mass-Index
- DGOU :
-
Deutsche Gesellschaft für Orthopädie und Unfallchirurgie
- DKOU :
-
Deutscher Kongress für Orthopädie und Unfallchirurgie
- EKIT-Hüfte :
-
Evidenz- und konsensbasierte Indikationskriterien zur Hüfttotalendoprothese
- EULAR :
-
European League Against Rheumatism
- ICM :
-
International Consensus Meeting on Orthopaedic Infections
- NICE :
-
National Institute for Health and Care Excellence
- OARSI :
-
Osteoarthritis Research Society International
- RACGP :
-
The Royal Australian College of General Practitioners
- TEP :
-
Totalendoprothese
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A. Postler ist Mitglied in der Arbeitsgruppe „Evidenzbasierte Medizin in Orthopädie und Unfallchirurgie“ der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU). A. Postler, C. Lützner, T. Lange, J. Schmitt, J. Lützner und K.-P. Günther geben an, dass kein Interessenkonflikt besteht.
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Postler, A., Lützner, C., Lange, T. et al. Indikationsstellung zur Hüfttotalendoprothese – die ärztliche Perspektive. Orthopäde 50, 278–286 (2021). https://doi.org/10.1007/s00132-021-04078-9
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DOI: https://doi.org/10.1007/s00132-021-04078-9