Diagnostik und Behandlung von Abrieberkrankungen in der Hüftendoprothetik

Zusammenfassung

Die Diagnostik und Therapie von Abrieberkrankungen stellt ein relevantes Themengebiet in der Revisionsendoprothetik dar und umfasst ein weites Spektrum von klinischen und radiologischen Erscheinungsformen. Der Abrieberkrankung liegt die periartikuläre Ansammlung von Abriebpartikeln zugrunde, die aus jeder Gleitpaarung oder modularen Verbindung entstehen und je nach Konzentration mit einer schmerzhaften Entzündungsreaktion im Gelenk einhergehen kann. Des Weiteren geht die Ansammlung von vor allem PE- und Metallpartikeln mit einem inflammatorisch bedingten Knochenverlust einher, der zu periimplantären Osteolysen und im Verlauf auch zur lytischen Knochenresorption am Implantat-Knochen-Interface und damit zur aseptischen Lockerung führt. Das Ausmaß des Abriebs ist von verschiedenen Faktoren, wie z. B. dem Material, der Kopfgröße, dem Aktivitätslevel des Patienten wie auch von der Implantatposition abhängig. Metallgleitpaarungen setzen zusätzlich Chrom- und Kobaltionen frei, die über das Blut alle Organsysteme erreichen und in höherer Konzentration zytotoxisch sind. Des Weiteren weisen sie eine eher lymphozytäre Gewebsreaktion auf, die mit dem Auftreten einer ALT- (adverse local tissue) und ALVAL-Reaktion (aseptic lymphocyte-dominated vasculitis associated lesion) einhergehen und zu Pseudotumoren und Gewebsnekrosen führen kann. Für eine adäquate Therapie ist ein klares Behandlungskonzept notwendig. Dies ergibt sich aus einer exakten klinischen und radiologischen Untersuchung sowie aus der Beurteilung von verschiedenen Parametern aus Röntgen-, CT-, MRT-, paraklinischer und serumanalytischer Diagnostik. Die operative Therapie beinhaltet je nach Festigkeit der Pfannenkomponente entweder den alleinigen Gleitpaarungswechsel oder die komplette Pfannenrevision im Falle einer Lockerung. Stets ist eine suffiziente Revision der Osteolysen unter Verwendung von Allograft vorzunehmen. Klinische unauffällige Osteolysen und leicht erhöhte Metallionenkonzentrationen können zunächst abwartend konservativ therapiert und engmaschig im Verlauf kontrolliert werden. Die Revision von Gleitpaarung oder Pfanne geht mit einem erhöhten Risiko für das Auftreten von Komplikationen einher.

Abstract

Particle disease is caused by periarticular accumulation of attrition particles and the inflammatory reaction of the bodyʼs tissue. This process may result in osteolysis or soft tissue transformation which presents itself symptomless in the beginning and can proceed to aseptic implant loosening, fracture, implant breaking as a result of the inappropriate osseous support and to algetic and destructive soft tissue reactions as well. Attrition particles originate from tribological pairing, and the extent of the attrition or the particle concentration depend on different factors as there are the tribological pairingʼs material, the head size, the patientʼs level of activity, and the implant position. Attrition particles can also be found in the range of any modular connection. Particle disease and its resulting morphological alterations of the tribological pairing is one of the most frequent reasons for re-operation in hip endoprosthetics.

Key words

Hüftgelenksersatz - Abriebkrankheit - Abriebpartikel - Revisionsendoprothetik - Langzeitkomplikationen - Weichgewebereaktion

Key words

total hip replacement - particle disease - wear particle - revision total hip arthroplasty - long term complications - soft tissue reaction

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