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Herausforderungen der primären Hüftendoprothetik bei hoher Hüftluxation

Challenges of primary hip arthroplasty with high hip dislocation

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Zusammenfassung

Hintergrund

Die endoprothetische Versorgung der hohen Hüftluxation ist aufgrund der anatomischen Besonderheiten besonders anspruchsvoll. Das Azetabulum ist flach und schmal, der Knochen häufig osteopenisch, ein Defekt am Pfannendach kann vorliegen. Es besteht ein ventrales, teils auch dorsales Überdachungsdefizit. Häufig finden sich ein enger Markraum, eine Coxa valga und eine vermehrte Antetorsion. Der Trochanter major kann verbreitert sein. Das Offset ist vermindert. Die absolute Beinlänge kann vermehrt sein. Voroperationen bedingen weitere Abweichungen von der normalen Anatomie.

Behandlungsziel

Ziele der endoprothetischen Versorgung sind die Herstellung eines optimalen Rotationszentrums, eines optimalen Offsets und der korrekten Beinlänge.

Behandlung

Erreicht wird dies u. a. durch die Medialisierung der Pfanne, ggf. mit Einsatz einer kontrollierten medialen Fraktur mit autologer Knochenplastik für den Pfannengrund, ggf. unter Anwendung einer Pfannendachplastik. Ist die Rekonstruktion der Primärpfanne nicht möglich, kann eine gering nach kranial versetzte Implantation erfolgen. Eine Verkürzungsosteotomie, reorientierende Osteosynthese, Aufbohren des Femurs bei engem Markraum und die korrekte Implantatwahl sind weitere Optionen. Wegen der starken Weichteilverkürzungen ist ein sorgfältiges Weichteilmanagement erforderlich. Die Operation muss im Detail geplant werden.

Abstract

Background

Endoprosthetic care of high hip dislocation is a surgical challenge. The hip anatomy is greatly altered in these patients, including a rather flat and small acetabulum with impaired bone quality and a relevant chance of a bony defect of the acetabular roof. Additionally, the front coverage and in some cases even the dorsal coverage of the hip are missing. The proximal femur is characterized with an increased antetorsion, a coxa valga position and an enlarged greater trochanter. The medullary cavity is narrowed, the offset is reduced, and the absolut leg length can be enlarged. Further anatomic variations can have been caused by previous surgeries.

Aim of the treatment

The goal of the endoprosthetic care is the re-creation of a hip with an anatomic center of rotation, an anatomic offset and equal leg length.

Treatment

This can be achieved by a medial shift of the acetabular cup. An acetabular osteotomy including central cancellous bone graft or a bony graft to reinforce the acetabular roof might be necessary. In cases in which an anatomic acetabular cup placement is not possible, a more cranial placement can be done. Further strategies that are essential in several cases are shortening or re-orientation osteotomies of the femur, reaming of the medullary cavity and correct implant selection. Additionally, thorough soft tissue management is of main importance. Generally, the surgery should be well prepared preoperatively.

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Abbreviations

CCD:

Centrum-Collum-Diaphyse

K-Draht:

Kirschner-Draht

RR:

Revisionsrisiko

TEP:

Totalendoprothese

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Danksagung

Die Autoren danken der Leipziger Künstlerin Frau Dr. Maren Sandrock für die Anfertigung der anatomischen Zeichnungen.

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Authors and Affiliations

  1. Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie Bereich Endoprothetik/Orthopädie, Universitätsklinik Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland

    A. Roth, S. Goralski, J. Fakler, M. Ghanem, C. Pempe, R. Hennings, U. Spiegl & D. Zajonz

  2. Deutsches Zentrum für Orthopädie, Professur für Orthopädie des Universitätsklinikums Jena, Waldkliniken Eisenberg, Jena, Deutschland

    F. Layher

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A. Roth, S. Goralski, F. Layher, J. Fakler, M. Ghanem, C. Pempe, R. Hennings, U. Spiegl und D. Zajonz geben an, dass kein Interessenkonflikt besteht.

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Roth, A., Goralski, S., Layher, F. et al. Herausforderungen der primären Hüftendoprothetik bei hoher Hüftluxation. Orthopäde 48, 300–307 (2019). https://doi.org/10.1007/s00132-019-03694-w

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