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Die chirurgische Hüftluxation

Derzeitiger Stellenwert in der Therapie des femoroazetabulären Impingements

Surgical hip dislocation

Current status in the treatment of femoral acetabular impingement

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Zusammenfassung

Einleitung

Die chirurgische Hüftluxation (CHL) ist als ursprüngliche Therapie des femoroazetabulären Impingements (FAI) weitestgehend durch minimalinvasive Verfahren ersetzt worden. Nichtsdestotrotz stellt sie im Falle von komplexeren FAI eine mögliche Alternative dar. Hier bietet sie aufgrund der sehr guten Gelenkexposition und damit zirkumferenten Therapieoption, einen klaren Vorteil, bei jedoch größerer operativer Invasivität. Unter der Berücksichtigung der aktuellen Literatur besteht immer noch ein Mangel an mittel- und längerfristigen Untersuchungen des Outcomes der CHL, um den Therapieerfolg bewerten zu können. Ziel ist es daher, das mittelfristige Outcome sowie Risiken und Komplikationen der CHL in der Therapie des FAI zu untersuchen und eine Beurteilung zum Stellenwert des Verfahrens abzuleiten.

Methodik

An 43 Patienten mit kombiniert ventralem und dorsalem Impingement mit erfolgter CHL und einem mittleren Follow-up von 54 Monaten wurde das Therapieoutcome objektiv anhand von Bewegungsumfang, Harris Hip Score (HHS), Hip Outcome Score (HOS), Aktivitätslevel, Schmerzen, Komplikationen, TEP-Implantation sowie subjektiv durch patientenspezifische Fragebögen beurteilt. Ebenfalls erfolgten eine detaillierte Röntgenauswertung sowie die Untersuchung des Einflusses einer präoperativ vorhandenen Arthrose.

Ergebnisse

Es zeigte sich eine signifikante Steigerung der Bewegungsumfänge, des HHS (69 auf 80 Pkt.;p < 0,05), eine Steigerung der Funktion sowie eine signifikante Reduktion der Schmerzintensität. Die Sportfähigkeit konnte zu 81 % wiederhergestellt werden, jedoch auf Kosten einer Intensitätsminderung bzw. dem Wechsel auf gelenkschonende Sportarten. Subjektiv waren 75 % der Patienten mit dem Outcome der Therapie zufrieden. Der Alphawinkel verringerte sich von 70 auf 45° (p < 0,05). Patienten mit fortgeschrittener Hüftgelenksarthrose wiesen keine Verbesserung der Hüftfunktion auf. Eine Hüft-TEP erhielten 36 % der Patienten im Verlauf. Die Komplikationsrate betrug ca. 13 %.

Schlussfolgerung

Die CHL zeigt im mittleren Follow-up akzeptable Ergebnisse in der Therapie des kombinierten ventralen und dorsalen Impingements. Sie führt zu einer Verbesserung der Hüftfunktion und Schmerzsymptomatik. Bei Vorhandensein einer manifesten Arthrose ist die Indikation zur CHL nicht mehr sinnvoll.

Abstract

Introduction

Surgical hip dislocation (SHD) in the therapy of femoral acetabular impingement (FAI) has been mostly replaced by minimally invasive techniques. Nevertheless, in the circumstances of complex FAI types and combined impingement located in inaccessible areas of the hip, SHD is an option to reach those deformities. The advantage of the complete overview of the hip joint enables the circumferential therapy of bony deformity, but at the expense of higher invasivity. In the literature there is still a lack of mid to long-term studies of SHD to determine the overall treatment outcome. Therefore, the aim of this study is to evaluate the treatment outcome, risks and complications of SHD in FAI therapy within a mid-term follow-up.

Methods

A total of 43 patients (mean follow-up 54 months.) with combined ventral and dorsal impingement who undertook SHD were retrospectively reviewed. Outcome parameters were range of motion (ROM), the Harris hip score (HHS), the hip outcome score (HOS), the activity level, pain, complications, conversion to total hip arthroplasty (THA) and patient specific surveys. Additionally, radiographs and the influence of preoperative osteoarthrosis were evaluated.

Results

We were able to demonstrate a significant increase of ROM, HHS (69 → 80 Pkt.; p < 0.05), hip function and a decrease in pain level. The return to sport rate was 81%, but in most cases the patients had to reduce the intensity or change to a low impact sport activity. Overall, 75% were satisfied with the treatment outcome. The alpha angle improved from 70 to 45° (p < 0.05). Patients with preoperatively advanced hip osteoarthrosis showed no decent improvement of hip function. Conversion to THA was necessary in 36% of cases. The complication rate was about 13%.

Conclusion

SHD is successful in the treatment of combined ventral and dorsal impingement within a mid-term follow-up. The improvement of hip function and the reduction of pain symptoms is possible. In case of a manifest arthrosis an indication for SHD is no longer reasonable.

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Authors and Affiliations

  1. Centrum für Muskuloskeletale Chirurgie, Klinik für Orthopädie, Klinik für Unfall- und Wiederherstellungschirurgie, Charité – Universitätsmedizin Berlin, Chariteplatz 1, 10117, Berlin, Deutschland

    S. Kirschbaum, C. Perka &  M. Müller

  2. Zentrum für Orthopädie und Unfallchirurgie, Helios-Klinikum Berlin-Buch, Berlin, Deutschland

    F. Sitterlee

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  1. F. Sitterlee
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Correspondence to M. Müller.

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Interessenkonflikt

F. Sitterlee, S. Kirschbaum, C. Perka und M. Müller geben an, dass kein Interessenkonflikt besteht.

Alle beschriebenen Untersuchungen am Menschen wurden mit Zustimmung der zuständigen Ethik-Kommission, im Einklang mit nationalem Recht sowie gemäß der Deklaration von Helsinki von 1975 (in der aktuellen, überarbeiteten Fassung) durchgeführt. Von allen beteiligten Patienten liegt eine Einverständniserklärung vor.

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Sitterlee, F., Kirschbaum, S., Perka, C. et al. Die chirurgische Hüftluxation. Orthopäde 46, 744–754 (2017). https://doi.org/10.1007/s00132-017-3394-6

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