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Biologisches Downsizing

Azetabuläre Knochendefekte in der Hüftrevisionsendoprothetik

Biological downsizing

Acetabular defect reconstruction in revision total hip arthroplasty

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Zusammenfassung

Hintergrund

Periazetabuläre Defekte stellen weiterhin eine große Herausforderung in der Revisionsendoprothetik des Hüftgelenkes dar. Neben der Klassifikation der Defektsituation mit Auswahl des geeigneten Revisionsimplantates ist neben der primärstabilen Verankerung der Implantate der suffiziente biologische Wiederaufbau des Defektes mit Wiederherstellung eines tragfähigen Implantatlagers essenziell für den Langzeiterfolg der azetabulären Revisionschirurgie. Die biologische Defektrekonstruktion verfolgt das Ziel eines „Downsizing“ des periazetabulären Defektes vor dem Hintergrund möglicher zukünftiger Revisionsoperationen.

Techniken

Zur biologischen Augmentation periazetabulärer Knochendefekte stehen verschiedene Verfahren zur Verfügung. Autologe Transplantate bieten den Vorteil einer sehr guten Osseointegration. Limitierungen bestehen in Form von Hebedefekten und Restriktionen der verfügbaren Volumina. Solide allogene Transplantate hingegen zeigen im Langzeitverlauf nur eine geringe Tragfähigkeit mit mitunter hohen Versagensraten. Im klinischen Alltag haben sich homologe (kortiko-) spongiöse Knochentransplantate in Kombination mit überbrückenden Abstützschalen mit guten Langzeitverläufen etabliert. Im Falle superolateraler Pfannenerker- und dorsaler Pfeilerdefekte sollten zusätzlich makroraue oder makrostrukturierte Metallkonstrukte Verwendung finden, da hier die biologischen Augmentationen ebenfalls hohe Versagensraten zeigen.

Ausblick

Der Artikel bietet einen Überblick über die klinisch verfügbaren biologischen Augmentationsmethoden von periazetabulären Knochendefekten. Aufgrund der Limitierungen von auto- und allogenen Knochentransplantaten bezüglich Verfügbarkeit und Größe liegen die Hoffnungen in der Entwicklung neuartiger implantierbarer Tissue-Engineering-Lösungen, deren Charakteristika ebenfalls Inhalt der Übersichtsarbeit sind.

Abstract

Background

Periacetabular bony defects remain a great challenge in revision total hip arthroplasty. After assessment and classification of the defect and selection of a suitable implant the primary stable fixation and sufficient biological reconstitution of a sustainable bone stock are essential for long term success in acetabular revision surgery. Biological defect reconstruction aims for the down-sizing of periacetabular defects for later revision surgeries.

Technique

In the field of biological augmentation several methods are currently available. Autologous transplants feature a profound osseointegrative capacity. However, limitations such as volume restrictions and secondary complications at the donor site have to be considered. Structural allografts show little weight bearing potential in the long term and high failure rates. In clinical practice, the usage of spongious chips implanted via impaction bone grafting technique in combination with antiprotrusio cages for the management of contained defects have shown promising long time results. Nevertheless, when dealing with craniolateral acetabular and dorsal column defects, the additional implantation of macroporous metal implants or augments should be considered since biological augmentation has shown little clinical success in these particular cases.

Prospect

This article provides an overview of the current clinically available biological augmentation methods of peri-acetabular defects. Due to the limitations of autologous and allogeneic bone transplants in terms of size and availability, the emerging field of innovative implantable tissue engineering constructs gains interest and will also be discussed in this article.

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Authors and Affiliations

  1. Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Rheinische Friedrich-Wilhelms-Universität Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland

    S. Koob, S. Scheidt, T. M. Randau, M. Gathen, M. D. Wimmer,  D. C. Wirtz &  S. Gravius

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S. Koob, S. Scheidt, T. M. Randau, M. Gathen, M. D. Wimmer, D. C. Wirtz und S. Gravius geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Koob, S., Scheidt, S., Randau, T.M. et al. Biologisches Downsizing. Orthopäde 46, 158–167 (2017). https://doi.org/10.1007/s00132-016-3379-x

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