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Arthroskopisch gestützte Behandlung der aseptischen Hüftkopfnekrose

Arthroscopically assisted therapy of avascular necrosis of the femoral head

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Zusammenfassung

Operationsziel

Funktionserhalt des Hüftgelenks durch eine Behandlung der aseptischen Hüftkopfnekrose beim Erwachsenen oder zumindest Vermeidung einer Progression des Krankheitsbilds.

Indikationen

Aseptische Hüftkopfnekrose des Erwachsenen im Steinberg-Stadium I–III. Im Steinberg-Stadium IVa (weniger als 15% der Gelenkfläche, Abflachung < 2 mm) als Erhaltungsversuch des Hüftgelenks im Frühstadium des Hüftkopfeinbruchs.

Kontraindikationen

Manifeste Coxarthrose, Gelenkinfektion. Relative Kontraindikationen: Einbruch des Hüftkopfs > 2 mm oder > 15% der Gelenkfläche (ab Steinberg-Stadium IVb), persistierende Risikofaktoren (Alkoholabusus, Chemotherapie, lokale Bestrahlung, hochdosierte Kortisoneinnahme) sowie Adipositas permagna (BMI > 40).

Operationstechnik

Bei intraartikulären Knorpelschäden und/oder fraglichem Kopfeinbruch Hüftgelenksarthroskopie. Ohne Hüftkopfeinbruch mehrfache Anbohrung mit einer Parallelbohrhülse über einen lateralen Zugang (Steinberg II, III). Anschließend Kürettage der Nekrose über eine zentrale Bohrung und Einbringen zylinderförmiger Spongiosa-Autografts mit dem OATS-Instrumentarium (Steinberg IIb/c, IIIb/c). Als Rekonstruktionsversuch im Stadium Steinberg IVa mit Unterfütterung des abgeflachten Kopfanteils zur Wiederherstellung der Kopfkontur (radiologisch kontrolliert).

Nachbehandlung

Teilbelastung (10 kg) des operierten Beins für 6 Wochen. Bei großen subchondralen Herden (Steinberg IIIc) oder subchondraler Fraktur mit Kopfeinbruch (Steinberg IVa) Teilbelastung für 12 Wochen.

Ergebnisse

Frühergebnisse bei 53 Patienten (56 Hüftgelenke, konsekutiv versorgt im Zeitraum Juni 2004 bis Dezember 2009) nach durchschnittlich 33 ± 20 Monaten: Erfolgsrate von 86% in den präkollaptischen Stadien I–III (keine TEP-Implantation, keine Reoperation, kein radiologischer Progress in Zusammenhang mit erneuten klinischen Beschwerden). Das Versagen der kopferhaltenden Therapie nach diesen Kriterien lag im Steinberg-Stadium I bei 0 (0%), im Stadium II bei 2 (10%), im Stadium III bei 3 (25%) und im Stadium IVa bei 4 Fällen (31%).

Abstract

Objective

Preservation of the hip joint function by treatment of the avascular necrosis of the femoral head in adults or at least avoiding progression.

Indications

Avascular necrosis of the femoral head in adults in Steinberg stages I–III. In patients with Steinberg stage IVa (subchondral collapse ≤ 15% of the articular surface, depression < 2 mm) hip joint salvage therapy in early stages of femoral head collapse.

Contraindications

Manifest osteoarthritis of the hip joint. Joint infection. Relative contraindications: subchondral collapse > 15% of the articular surface or depression > 2 mm (Steinberg stage IVb and above). Persisting risk factors for a progression of avascular necrosis (e.g., alcohol abuse, chemotherapy, local irradiation, high-dose cortisone therapy) and obesity (BMI > 40).

Surgical technique

Arthroscopy of the hip joint in case of cartilage defects and/or potential collapse of the femoral head. Without collapse of the femoral head and absence of severe damage of the cartilage: core decompression using a guiding sleeve through a lateral approach (Steinberg II, III). Subsequently curettage of the necrotic area through a central drill hole and insertion of autogenic bone cylinders using an OATS harvester (Steinberg II b/c, III b/c). In Steinberg stage IVa, reconstruction of the outline of the femoral head is attempted by reduction of the impressed portion (under intraoperative fluoroscopy).

Postoperative management

Limited weight bearing (10 kg) of the operated leg for 6 weeks. In cases of large necrotic defects located directly beneath the subchondral bone (Steinberg IIIc) as well as subchondral collapse with flattening of the femoral head (Steinberg IVa) limited weight bearing (10 kg) for 12 weeks.

Results

Early results of femoral head preserving therapy in 53 patients (56 hips, consecutively treated between June 2004 and December 2009) after 33 ± 20 months: success rate (no arthroplasty, no reoperation, no radiological progress associated with clinical symptoms) 86% for patients treated with Steinberg stages I–III. Failure of the head preserving therapy with concern to the mentioned criteria depending on the initial Steinberg stage: 0 (0%) for stage I, 2 (10%) for stage II, 3 (25%) for stage III, and 4 (31%) for stage IVa.

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  1. Orthopädische Klinik und Poliklinik, Universität Rostock, Doberaner Str. 142, 18057, Rostock, Deutschland

    M. Ellenrieder, T. Tischer, P.C. Kreuz, S. Fröhlich, A. Fritsche & W. Mittelmeier

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  1. M. Ellenrieder
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  2. T. Tischer
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  3. P.C. Kreuz
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  4. S. Fröhlich
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  5. A. Fritsche
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  6. W. Mittelmeier
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Correspondence to M. Ellenrieder.

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Ellenrieder, M., Tischer, T., Kreuz, P. et al. Arthroskopisch gestützte Behandlung der aseptischen Hüftkopfnekrose. Oper Orthop Traumatol 25, 85–94 (2013). https://doi.org/10.1007/s00064-011-0072-4

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