Erweiterte Zugänge bei Hüftprothesenwechseln und Muskelschonung. Geht das?

Zusammenfassung

Für die Revision von Hüftendoprothesen sind verschiedene Standard- und erweiterte Zugänge zur Darstellung und kontrollierten Entfernung der Prothese bzw. Reimplantation einer neuen Prothese möglich, die allesamt ihre Vor- und Nachteile haben. Sie sollten eine gute Darstellung erlauben und unkontrollierte Schädigungen des Knochens (v. a. Devaskularisierung und Frakturen) und der Weichteile vermeiden. Als erweiterten Zugang bevorzugen wir den transfemoralen Zugang nach Wagner in einer modifizierten Technik. Er ist unseres Erachtens indiziert bei Hüftprothesenwechseln mit gebrochenen Endoprothesenstielen, einer durch die Lockerung bedingten Achsabweichung des Femurs, einem deutlich ausgedünnten, frakturgefährdeten Knochen, einem stabilen Zementmantel, einem teilfixierten zementlosen Prothesenstiel und bei einer periprothetischen Fraktur. In einer eigenen, publizierten Studie zeigten 68 Patienten mit Hüftprothesenwechsel über einen modifizierten transfemoralen Zugang einen kontinuierlichen Anstieg des Harris Hip Scores von präoperativ 41,4 auf 85,9 Punkte 24 Monate postoperativ. Der Knochendeckel wies in 98,5 % eine knöcherne Konsolidierung auf. Zwei postoperativ entstandene Trochanterabrisse heilten ohne weitere Maßnahme knöchern ein. Der transfemorale Zugang erlaubt als erweiterter Zugang eine sichere Schonung des M. gluteus medius und der vastoglutealen Schlinge, was reproduzierbar gute klinische Ergebnisse erzielen lässt.

Abstract

For revision of hip prostheses several standard and extended approaches can be used. The goal of these approaches is a good visualisation with minimal trauma of the bone and its vascularisation as well as of the muscles. Of the extended approaches we prefer the transfemoral approach in a modified technique. This approach is indicated when the stem of the endoprosthesis is broken, when the femoral axis has shifted because of stem loosening, or when the bone has become noticeably thin, which by itself or in combination would greatly increase the risk of an intraoperative fracture or perforation. Similarly, it is indicated in cases in which the cement mantle was stable, when a periprosthetic fracture of Vancouver B2 or B3 type is present or when a loose cementless stem with a coarsely porous surface cannot be removed in an endofemoral manner. In a published study of 68 patients with hip revisions using this modified transfemoral approach, we could see a continuous increase of the Harris hip score from 41.4 points preoperatively to 85.9 points 24 months postoperatively. Healing of the bony flap was seen in 98.5 % of the cases. Two postoperative non-dislocated trochanter fractures could be treated conservatively. The transfemoral approach is an extended approach with sparing of the gluteal muscles and the vasto-gluteal sling. Reproducible good clinical results can be achieved.

Schlüsselwörter

Revision - Hüfttotalendoprothese - transfemoraler Zugang - Zugang - Muskeltrauma

Key words

revision - hip arthroplasty - extended trochanteric osteotomy - approach - muscle trauma

• Literatur

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