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Das Kranialpfannensystem zur defekttypassoziierten Therapie von Azetabulumdefekten

Standardized Reconstruction of Acetabular Bone Defects Using the Cranial Socket System

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Zusammenfassung

Operationsziel

Verankerung einer zementfreien, kranial aufgesockelten Hüftpfannenprothese bei primären oder sekundären Azetabulumdefekten (D’Antonio Typ I–IV) zur Wiederherstellung einer schmerzfreien Gelenkfunktion und Belastbarkeit.

Indikationen

Gelockerte Pfannenprothese. Pfannendefekt nach Tumorresektion. Pfannendefekt nach septischem Prothesenausbau. Azetabuläre Defektsituation bei kongenitaler Hüftdysplasie.

Kontraindikationen

Persistierender Infekt. Knochendefekt, der das sakrumnahe Ilium mit einschließt (Verankerung des Iliumstiels nicht mehr möglich).

Operationstechnik

Komplette Darstellung des Azetabulumdefekts. Entfernung von Granulationsgewebe aus dem Pfannengrund und Weichteilen im azetabulären Randbereich. Fräsen des Azetabulumeingangs, bis eine möglichst große Kontaktfläche zur Implantation der Kranialpfanne erreicht wird. Bei Defekten vom Typ I und II nach D’Antonio mit erreichbarer Dreiflächenfixation Verwendung der einfachen Kranialpfanne. Beim Typ III oder fehlender Pressfit-Verankerung der einfachen Kranialpfanne wird die Kranialpfanne mit anatomischer Lasche angewendet. Fehlen sowohl vorderer und hinterer Pfeiler oder liegt eine Beckendiskontinuität vor (D’Antonio Typ IV), ist die Kombination der Kranialpfanne mit anatomischer Lasche und einem strukturierten Stiel in einer Länge von 30, 50 oder 70 mm notwendig. Zusätzlich zur Pressfit-Verankerung der Pfanne erfolgt die Fixation mit Spongiosaschrauben im Kranialpfannengrund und durch die Lasche.

Weiterbehandlung

Teilbelastung der operierten Gliedmaße mit 10 kg für 6–12 Wochen. Danach Belastungssteigerung um 10 kg pro Woche. Thromboseprophylaxe bis zur Vollbelastung. Physiotherapie und Gangschulung.

Ergebnisse

50 Pfannenwechsel auf ein ESKA-Kranialsockelsystem wurden mit einem durchschnittlichen Beobachtungszeitraum von 65,7 ± 28,5 Monaten (26–123 Monate) klinisch und radiologisch nachuntersucht. Bei 21 Patienten lag ein zweitgradiger Defekt des Azetabulums nach D’Antonio vor. 23 Patienten wiesen einen Defektgrad III auf. Eine Beckendiskontinuität (D’Antonio IV) lag bei sechs Patienten zugrunde. Der Harris-Hip-Score stieg von 40 präoperativ auf 68,3 zum Zeitpunkt der Nachuntersuchung. In vier Fällen kam es zu rezidivierenden Luxationen, wobei konsekutiv ein Inlaywechsel durchgeführt wurde. Bei vier Patienten musste aufgrund einer aseptischen Lockerung ein erneuter Pfannenwechsel vorgenommen werden. Somit lag das Implantatüberleben mit dem Endpunkt Pfannenrevision bei einem durchschnittlichen Nachuntersuchungszeitraum von 5,4 Jahren bei 92%.

Abstract

Objective

Management of primary or secondary acetabular bone loss (D’Antonio type I–IV ). Implantation and stable fixation using a cementless, cranially extended oval press-fit cup to restore painless joint function and loading capacity.

Indications

Septic or aseptic loosening of the acetabular component after total hip arthroplasty. Acetabular bone loss after tumor resection. Primary acetabular bone defects in developmental dysplasia of the hip.

Contraindications

Persistent deep infection. Bone defects including the parts of the iliac bone adjoining the sacrum (fixation of the stem in the ilium is not possible any more).

Surgical Technique

Complete exposure of the acetabular defect using a standard approach. Removal of the loose cup. Excision of soft and granulation tissue from the acetabular ground and the rim. Reaming of the acetabulum with sequentially larger hemispheric reamers until an adequate bony bed is created for the insertion of the cranial socket. Eccentric cranial sockets without a craniolateral flap are preferable for use in type I and II defects with teardrop lysis mostly involving the craniolateral acetabulum, if a trihedral press-fit fixation can be achieved. Supplementary screw fixation through the acetabular ground, is possible. If a type III defect is present, the authors recommend the use of cranial sockets with an anatomic flap in order to increase primary stability by supplementary screw fixation. This is especially recommended for the management of deficiencies in the medial or posterior wall. If there is pelvic discontinuity (type IV), adequate acetabular reconstruction with primary stability of the component can only be achieved by a supplementary intramedullary structured stem fixed in the dorsal part of the ilium.

Postoperative Management

Partial loading of the operated limb with 10 kg for a period of 6–12 weeks. Then increased loading with 10 kg per week. Thrombosis prophylaxis until full weight bearing. Physiotherapy and gait training.

Results

A total of 50 cup revisions using the ESKA cranial socket system were clinically and radiologically analyzed with an average follow-up of 65.7 ± 28.5 months (26–123 months). Defects were classified according to D’Antonio. There were 21 type II, 23 type III, and six type IV defects. The Harris Hip Score increased from 40 preoperatively to 68.3 points postoperatively. Four patients had recurrent hip dislocation requiring replacement of the inlay. In four cases of aseptic loosening, the acetabular component had to be revised. With revision of the acetabular component as an endpoint, implant survival was 92% after an average of 5.4 years.

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Literatur

  1. Berry DJ. Antiprotrusio cages for acetabular revision. Clin Orthop Relat Res 2004;420:106–12.

    Article  PubMed  Google Scholar 

  2. Blom AW, Wylde V, Livesey C. Impaction bone grafting of the acetabulum at hip revision using a mix of bone chips and a biphasic porous ceramic bone graft substitute. Acta Orthop 2009;80:150–4.

    Article  PubMed  Google Scholar 

  3. Bozic KJ, Kurtz SM, Lau E. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 2009;91:128–33.

    Article  PubMed  Google Scholar 

  4. Civinini R, Capone A, Carulli C. Acetabular revisions using a cementless oblong cup: five to ten year results. Int Orthop 2008;32:189–93.

    Article  CAS  PubMed  Google Scholar 

  5. Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am 1979;61:15–23.

    CAS  PubMed  Google Scholar 

  6. D’Antonio JA. Periprosthetic bone loss of the acetabulum. Classification and management. Orthop Clin North Am 1992;23:279–90.

    PubMed  Google Scholar 

  7. Deijkers RL, Bloem RM, Petit PL. Contamination of bone allografts: analysis of incidence and predisposing factors. J Bone Joint Surg Br 1997;79:161–6.

    Article  CAS  PubMed  Google Scholar 

  8. Della Valle CJ, Berger RA, Rosenberg AG. Cementless acetabular reconstruction in revision total hip arthroplasty. Clin Orthop Relat Res 2004;420:96–100.

    Article  PubMed  Google Scholar 

  9. Dohmae Y, Bechtold JE, Sherman RE. Reduction in cement-bone interface shear strength between primary and revision arthroplasty. Clin Orthop Relat Res 1988;236:214–20.

    PubMed  Google Scholar 

  10. Elke R, Berli B, Wagner A. Acetabular revision in total hip replacement with a press-fit cup. J Bone Joint Surg Br 2003;85:1114–9.

    Article  CAS  PubMed  Google Scholar 

  11. Fink B, Grossmann A. Technik der Implantation einer zementlosen Pressfit-Pfanne bei Pfannenrevisionen mit größeren Knochendefekten. Oper Orthop Traumatol 2008;20:157–67.

    Article  PubMed  Google Scholar 

  12. Gill TJ, Sledge JB, Muller ME. The Burch-Schneider anti-protrusio cage in revision total hip arthroplasty: indications, principles and long-term results. J Bone Joint Surg Br 1998;80:946–53.

    Article  CAS  PubMed  Google Scholar 

  13. Götze C, Sippel C, Wendt G. Grenzen der zementfreien Revisionsarthroplastik: mittelfristige Resultate mit der längsovalen Revisionspfanne. Z Orthop Ihre Grenzgeb 2003;141:182–9.

    Article  PubMed  Google Scholar 

  14. Herrera A, Martinez AA, Cuenca J. Management of types III and IV acetabular deficiencies with the longitudinal oblong revision cup. J Arthroplasty 2006;21:857–64.

    Article  PubMed  Google Scholar 

  15. Herzog R, Morscher E. Morselized homologous grafts in revision arthroplasty of the acetabulum. Chir Organi Mov 1994;79:371–8.

    CAS  PubMed  Google Scholar 

  16. Hooper GJ, Rothwell AG, Stringer M. Revision following cemented and uncemented primary total hip replacement: a seven-year analysis from the New Zealand Joint Registry. J Bone Joint Surg Br 2009;91:451–8.

    Article  CAS  PubMed  Google Scholar 

  17. Kosashvili Y, Backstein D, Safir O. Acetabular revision using an anti-protrusion (ilio-ischial) cage and trabecular metal acetabular component for severe acetabular bone loss associated with pelvic discontinuity. J Bone Joint Surg Br 2009;91:870–6.

    Article  CAS  PubMed  Google Scholar 

  18. Kosashvili Y, Safir O, Backstein D. Salvage of failed acetabular cages by nonbuttressed trabecular metal cups. Clin Orthop Relat Res 2010;468:466–71.

    Article  PubMed  Google Scholar 

  19. Koster G, Rading S. Revision of failed acetabular components utilizing a cementless oblong cup: an average 9-year follow-up study. Arch Orthop Trauma Surg 2009;129:603–8.

    Article  PubMed  Google Scholar 

  20. Lakstein D, Backstein D, Safir O. Trabecular metal cups for acetabular defects with 50% or less host bone contact. Clin Orthop Relat Res 2009;467:2318–24.

    Article  PubMed  Google Scholar 

  21. Leopold SS, Jacobs JJ, Rosenberg AG. Cancellous allograft in revision total hip arthroplasty. A clinical review. Clin Orthop Relat Res 2000;371:86–97.

    Article  PubMed  Google Scholar 

  22. Malchau H, Herberts P, Eisler T. The Swedish Total Hip Replacement Register. J Bone Joint Surg Am 2002;84:Suppl 2:2–20.

    PubMed  Google Scholar 

  23. Moskal JT, Higgins ME, Shen J. Type III acetabular defect revision with bilobed components: five-year results. Clin Orthop Relat Res 2008;466:691–5.

    Article  PubMed  Google Scholar 

  24. Nehme A, Lewallen DG, Hanssen AD. Modular porous metal augments for treatment of severe acetabular bone loss during revision hip arthroplasty. Clin Orthop Relat Res 2004;429:201–8.

    Article  PubMed  Google Scholar 

  25. Niedhart C, Pingsmann A, Jurgens C. Komplikationen nach Entnahme autologen Knochens aus dem ventralen und dorsalen Beckenkamm — eine prospektive, kontrollierte Studie. Z Orthop Ihre Grenzgeb 2003;141:481–6.

    Article  CAS  PubMed  Google Scholar 

  26. Paprosky WG, Magnus RE. Principles of bone grafting in revision total hip arthroplasty. Acetabular technique. Clin Orthop Relat Res 1994;298:147–55.

    PubMed  Google Scholar 

  27. Paprosky WG, Sekundiak TD. Total acetabular allografts. Instr Course Lect 1999;48:67–76.

    CAS  PubMed  Google Scholar 

  28. Paprosky WG, Sporer SS, Murphy BP. Addressing severe bone deficiency: what a cage will not do. J Arthroplasty 2007;22:111–5.

    Article  PubMed  Google Scholar 

  29. Perka C, Ludwig R. Reconstruction of segmental defects during revision procedures of the acetabulum with the Burch-Schneider anti-protrusio cage. J Arthroplasty 2001;16:568–74.

    Article  CAS  PubMed  Google Scholar 

  30. Ranawat CS, Dorr LD, Inglis AE. Total hip arthroplasty in protrusio acetabuli of rheumatoid arthritis. J Bone Joint Surg Am 1980;62:1059–65.

    CAS  PubMed  Google Scholar 

  31. Regis D, Magnan B, Sandri A. Long-term results of anti-protrusion cage and massive allografts for the management of periprosthetic acetabular bone loss. J Arthroplasty 2008;23:826–32.

    Article  PubMed  Google Scholar 

  32. Schafer P, Fink B, Sandow D. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis 2008;47:1403–9.

    Article  PubMed  Google Scholar 

  33. Schlegel UJ, Bitsch RG, Pritsch M. Mueller reinforcement rings in acetabular revision: outcome in 164 hips followed for 2–17 years. Acta Orthop 2006;77:234–41.

    Article  PubMed  Google Scholar 

  34. Schlegel UJ, Bitsch RG, Pritsch M. Abstützschalen in der Revisionsendoprothetik der Hüfte: mittelfristige Ergebnisse von 298 Implantaten. Orthopäde 2008;37:904, 906-13.

    Article  CAS  PubMed  Google Scholar 

  35. Schreurs BW, Busch VJ, Welten ML. Acetabular reconstruction with impaction bone-grafting and a cemented cup in patients younger than fifty years old. J Bone Joint Surg Am 2004;86:2385–92.

    PubMed  Google Scholar 

  36. Siegmeth A, Duncan CP, Masri BA. Modular tantalum augments for acetabular defects in revision hip arthroplasty. Clin Orthop Relat Res 2009;467:199–205.

    Article  PubMed  Google Scholar 

  37. Slooff TJ, Buma P, Schreurs BW. Acetabular and femoral reconstruction with impacted graft and cement. Clin Orthop Relat Res 1996;324:108–15.

    Article  PubMed  Google Scholar 

  38. Springer BD, Fehring TK, Griffin WL. Why revision total hip arthroplasty fails. Clin Orthop Relat Res 2009;467:166–73.

    Article  PubMed  Google Scholar 

  39. Symeonides PP, Petsatodes GE, Pournaras JD. The effectiveness of the Burch-Schneider antiprotrusio cage for acetabular bone deficiency: five to twenty-one years’ follow-up. J Arthroplasty 2009;24:168–74.

    Article  PubMed  Google Scholar 

  40. Trieb K. Unterschiedliche Pfannenrevisionsimplantate im Vergleich. Orthopäde 2009;38:704–10.

    Article  CAS  PubMed  Google Scholar 

  41. van Haaren EH, Heyligers IC, Alexander FG. High rate of failure of impaction grafting in large acetabular defects. J Bone Joint Surg Br 2007;89:296–30.

    Article  PubMed  Google Scholar 

  42. Whaley AL, Berry DJ, Harmsen WS. Extra-large uncemented hemispherical acetabular components for revision total hip arthroplasty. J Bone Joint Surg Am 2001;83:1352–7.

    PubMed  Google Scholar 

  43. Wirtz DC, Niethard FU. Ursachen, Diagnostik und Therapie aseptischer Hüftendoprothesenlockerungen — eine Standortbestimmung. Z Orthop Ihre Grenzgeb 1997;135:270–80.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Orthopädische Klinik König Ludwig Haus, Lehrstuhl für Orthopädie, Universität Würzburg, Würzburg, Germany

    Maximilian Rudert & Boris Michael Holzapfel

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

    Florian Kratzer & Reiner Gradinger

  3. Orthopädische Klinik König Ludwig Haus, Lehrstuhl für Orthopädie Universität Würzburg, Brettreichstraße 11, 97074, Würzburg, Germany

    Maximilian Rudert

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  1. Maximilian Rudert
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  2. Boris Michael Holzapfel
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  3. Florian Kratzer
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  4. Reiner Gradinger
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Correspondence to Maximilian Rudert.

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Zeichner: Rüdiger Himmelhan, Heidelberg

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Rudert, M., Holzapfel, B.M., Kratzer, F. et al. Das Kranialpfannensystem zur defekttypassoziierten Therapie von Azetabulumdefekten. Orthop Traumatol 22, 241–255 (2010). https://doi.org/10.1007/s00064-010-9003-z

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  • DOI: https://doi.org/10.1007/s00064-010-9003-z

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