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Revisionsendoprothetik der Hüfte

Bedeutung von Instabilität, Impingement, Offset und Glutealinsuffizienz

Revision total hip arthroplasty

Significance of instability, impingement, offset and gluteal insufficiency

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Zusammenfassung

Hintergrund

Die Instabilität ist eine häufige Versagensursache in der Primär- und Revisionsendoprothetik des Hüftgelenkes. Die Ursachen liegen u. a. in einer Implantatfehlpositionierung, einem Impingement, einer unzureichenden Offsetrekonstruktion und einer Glutealinsuffizienz. Ein Impingement nach Hüft-TEP(H-TEP)-Implantation oder -Revision kann intra- oder extraprothetisch lokalisiert sein. Es verursacht neben einer Instabilität Schmerzen im Bereich des Hüftgelenkes. Die Offsetrekonstruktion bei einer H‑TEP-Revision ist von entscheidender biomechanischer Bedeutung. Eine insuffiziente Offsetrekonstruktion verursacht ebenfalls Schmerzen und kann zu einer Luxation führen. Ein weiteres bekanntes Problem nach H‑TEP-Revision sind Läsionen und Degenerationen im Bereich der Abduktoren. Häufig resultieren diese klinisch in einer Veränderung des Gangbildes, Instabilitäten und Schmerzen.

Ziel

Das Ziel dieses Beitrags ist es, die diagnostischen und therapeutischen Algorithmen der Instabilität, des Impingements, der unzureichenden Offsetrekonstruktion und der Abduktoreninsuffizienz im Rahmen einer H‑TEP-Revision darzustellen. Hierbei liegt der Fokus auf der exakten Diagnostik der Instabilität sowie deren Ursachen und weiteren Pathologien.

Ergebnisse und Diskussion

Zur Diagnostik der H‑TEP-Instabilität und der schmerzhaften H‑TEP gehört die Anamnese, körperliche Untersuchung und vor allem die Bildgebung. Basieren auf diesen Informationen kann in fast allen Fällen die Ursache festgestellt und therapiert werden. Eine H‑TEP-Dislokation im frühen postoperativen Zeitraum kann ggf. konservativ behandelt werden. Spätluxationen erfordern häufig eine operative Therapie. Zur Vermeidung eines Impingements ist die intraoperative Kontrolle essenziell. Die Offsetrekonstruktion richtet sich, wenn möglich, nach der ursprünglichen Anatomie und kann über modulare Prothesen, Halsadapter und Kopflängen erzielt werden. Eine Glutealinsuffizienz tritt häufig nach Revisionen auf und kann bei einer ausgeprägten klinischen Beschwerdesymptomatik und fettiger Degeneration der Abduktoren operativ behandelt werden.

Abstract

Background

Instability is a common cause of failure in primary and, especially, revision total hip arthroplasty. The reasons for instability include implant malpositioning, impingement, inadequate offset reconstruction, and gluteal insufficiency. Impingement following THA and revision THA is divided into prosthetic and bony impingement, and in addition to instability also causes pain in the area of the hip joint. Offset reconstruction during revision THA is of particular biomechanical importance, since insufficient reconstruction leads not only to instability and pain but also to dislocation. Abductor deficiency often occurs after revision THA and leads to a change in gait pattern, instability and pain.

Aim

Current diagnostic and treatment procedures for instability, impingement, insufficient offset reconstruction and abductor deficiency after THA and revision THA are summarized.

Results and discussion

Diagnosis of an instable THA and painful THA includes patient history, physical examination and medical imaging. Thus, in almost all cases, the cause can be determined and treated. Dislocation after primary THA in the early postoperative period can often be treated conservatively if accurate component placement is observed, while a late-onset and recurrent dislocation after primary and revision THA usually needs surgical procedures. To avoid bony and prosthetic THA impingement intraoperative control is absolutely necessary. If possible, the offset reconstruction is based on the condition of the native hip joint and can be achieved by using modular prostheses, neck adapters and different head lengths. Abductor deficiency also occurs frequently after revision THA and can be treated surgically if severe clinical symptoms and fatty degeneration of the abductors have been diagnosed.

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Abbreviations

CCD:

Centrum-Collum-Diaphyse

CT:

Computertomographie

EMG:

Elektromyographie

H-TEP:

Hüfttotalendoprothese

MRT:

Magnetresonanztomografie

PE:

Polyethylen

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Author information

Authors and Affiliations

  1. Klinik für Orthopädie, Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland

    B. Rath, J. Eschweiler, F. Migliorini, W. Alrawashdeh & M. Tingart

  2. Sportklinik Stuttgart GmbH, Taubenheimstraße 8, 70372, Stuttgart, Deutschland

    J. Beckmann

  3. Eifelklinik St. Brigida, Kammerbruchstraße 8, 52152, Simmerath, Deutschland

    F. Migliorini

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  1. B. Rath
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  2. J. Eschweiler
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  4. F. Migliorini
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  5. W. Alrawashdeh
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  6. M. Tingart
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Correspondence to B. Rath.

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Interessenkonflikt

B. Rath, J. Eschweiler, J. Beckmann, F. Migliorini, W. Alrawashdeh und M. Tingart geben an, dass kein Interessenkonflikt besteht.

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

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Rath, B., Eschweiler, J., Beckmann, J. et al. Revisionsendoprothetik der Hüfte. Orthopäde 48, 315–321 (2019). https://doi.org/10.1007/s00132-019-03704-x

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