Tumorendoprothetik am distalen Femur: Indikationen und operative Technik

Zusammenfassung

Das distale Femur ist neben dem proximalen Femur und der proximalen Tibia ein Prädilektionsort für die Manifestaion von primär malignen und benignen/aggressiven Knochentumoren [11] der Extremitäten sowie eine Hauptlokalisation für metastatische Destruktionen. Bei malignen Skeletttumoren des distalen Femurs ist eine rasche Einleitung der Diagnostik zur Abklärung der Tumorbiologie (Entität und Grading) von essenzieller Bedeutung und determiniert die weitere onkologische Systembehandlung und tumororthopädische Lokaltherapie. Fehlerhaft durchgeführte Biopsien können falsch-negative Diagnosen erbringen und führen – wenn nicht nach bestimmten Richtlinien durchgeführt – zu schlechtem funktionellem Ergebnis nach Resektion, können den Extremitätenerhalt gefährden und beeinträchtigen die Prognose des Patienten. Chirurgisch stehen nach intra-/extraartikulärer weiter Resektion heutzutage vielfältige Rekonstruktionsmöglichkeiten zur Verfügung. Der tumorendoprothetische Ersatz stellt dabei das am häufigsten durchgeführte Rekonstruktionsverfahen nach Exzision kniegelenknaher Tumoren des distalen Femurs dar. Durch den distalen Femurersatz ist ein Extremitätenerhalt mit funktioneller und belastungsstabiler Wiederherstellung der Kniegelenkbeweglichkeit möglich. Er findet Anwendung zur Rekonstruktion bei massiven gelenknahen osteolytischen Destruktionen, bei pathologischen Frakturen, periprothetischen Frakturen oder in der Revisionsendoprothetik. Den Vorteilen einer raschen Mobilisation, sofortigen Vollbelastung, guter Funktion und kurzen Rehabilitationszeit stehen die zu erwartenden Revisionseingriffe bei erhöhter Komplikationsrate mit erhöhtem Infektionsrisiko (Megaprothese) sowie aseptische Lockerungen und Implantatversagen (inkl. Kopplungsmechanismus und PE-Inlays) gegenüber.

Abstract

Along with the proximal femur and the proximal tibia, the distal femur is the most affected site for the manifestation of primary malignant and benign/aggressive bone tumours [11] of the extremities, as well as being a principle site of metastatic destruction. In malignant, skeletal tumors of the distal femur, rapid initiation of complete diagnostic measures is essential for assessment of tumour biology (entity and grading) and guidance of the further oncological treatment, including both systemic and local orthopaedic therapy. Incorrectly performed biopsies can lead to false negative diagnosis, usually result in poor functional outcome, can compromise salvage of the extremity and adversely affect the patientʼs prognosis. After intra- or extraarticular resection, a wide range of surgical options is available. Following excision of tumours around the knee joint, endoprosthetic distal femur replacement is the most frequently performed reconstruction procedure and allows functional restoration of knee joint mobility. Distal femur replacement is typically performed in patients with massive osteolytic destruction, in pathological and periprosthetic fractures or for revision of total knee replacements. Rapid mobilisation without loading restrictions, a good range of motion and short rehabilitation periods are the advantages of the procedure. However, in comparison to conventional knee arthroplasty, distal femur replacement is associated with increased rates of complication, such as infection, aseptic loosening and hardware failure.

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