Diagnostischer Algorithmus der schmerzhaften Hüfttotalendoprothese

 

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Zusammenfassung

Hintergrund: Die Implantation von Hüfttotalendoprothesen (HTEP) gehört zu den häufigsten und erfolgreichsten Operationen in der Orthopädie und Unfallchirurgie. Der klinische Erfolg dieser Operationen kann anhand der Standzeiten der Endoprothesen, der Funktionsverbesserung, aber natürlich auch über die Zufriedenheit der Patienten und deren Schmerzen gemessen werden. Trotz des klinischen Erfolgs der Hüfttotalendoprothetik mit 10-Jahres-Überlebensraten von bis zu 96 % (Schwedisches Endoprothesenregister 2011) beträgt die Prävalenz von Leistenschmerzen nach Versorgung mit konventionellen HTEPs zwischen 0,4 und 18,3 % und von aktivitätslimitierenden Oberschenkelschmerzen nach zementfreier Prothesenversorgung in einigen Studien 1,9 bis zu 40,9 %. Eindeutige Ursachen für ein Implantatversagen sind meist mithilfe der klinischen Untersuchung und einem Standardröntgen zu identifizieren, wogegen die unklare schmerzhafte Hüfttotalendoprothese nach wie vor eine Herausforderung für den Chirurgen darstellt. Hierbei ist zwischen extra- und intraartikulären Schmerzen zu differenzieren, wobei die Letzteren eine biologische oder eine mechanische Ursache haben können. Um zwischen mechanisch und nicht mechanisch bedingten Schmerzen zu unterscheiden, sind der Beginn der Schmerzen nach der Operation und das Auftreten bei Bewegung oder in Ruhe wegweisend. Grundsätzlich gilt ein schmerzhaftes Hüftgelenk bis zum Beweis des Gegenteils verdächtig für einen periprothetischen Infekt. Es ist wichtig zu betonen, dass schmerzhafte Hüfttotalendoprothesen, bei denen keine Ursache identifiziert werden kann, nicht einer Revisionsoperation zugeführt werden sollten.

Methode: In der folgenden Übersichtsarbeit wird ein diagnostischer Algorithmus beschrieben, welcher eine detaillierte Analyse von schmerzhaften Hüfttotalendoprothesen erlaubt. Die Analyse beinhaltet eine genaue Anamnese mit einer ausführlichen Schmerzanamnese, eine sorgfältige klinische Untersuchung der betroffenen Hüfte und der angrenzenden Gelenke, wie der Wirbelsäule und der Kniegelenke, eine Labor- und radiologische Analyse sowie weiterführende invasive Untersuchungsmethoden, wie Gelenkpunktionen und Biopsien.

Schlussfolgerung: Diese Übersichtsarbeit bietet dem Leser mithilfe eines diagnostischen Algorithmus eine wichtige Unterstützung zur Abklärung der Ursache von schmerzhaften Hüfttotalendoprothesen.

Abstract

Background: Total hip arthroplasty (THA) is one of the most common and successful surgical procedures in orthopedic surgery and clinical success can be characterized by the revision rate and improvement of function, as well as the patientʼs satisfaction and pain. Despite the clinical success of primary THA with 10-year survival rates as high as 96 % (Swedish Hip Arthroplasty Register, 2011), the prevalence of groin pain after conventional total hip replacement ranges from 0.4 to 18.3 % and activity-limiting thigh pain is still an existing problem linked to the femoral component of uncemented hip replacement in up to 1.9 to 40.9 % of cases in some series. Obvious causes of failure might be identified with clinical examinations and standard radiographs only, whereas the unexplained painful THA still remains a challenge for the surgeon. They can be classified into extra- and intraarticular disorders, the latter being divided into biological and mechanical origins. The onset of the pain after the operation and the differentiation between pain in motion and at rest are helpful to distinguish between mechanical and non-mechanical problems. An infection should be the first diagnosis to be ruled out in a painful THA. It is generally accepted that a clear understanding of the failure mechanism in each case is required prior considering revision surgery.

Method: In this review a practical diagnostic algorithm is described for failure analysis in more detail. The evaluation of a painful THA includes a detailed history with an extended analysis of the type of pain, thorough clinical examination including the spine and knee joints, radiographic and laboratory analysis, as well as invasive examinations like joint aspiration and biopsies.

Conclusion: This diagnostic algorithm offers an important tool for a sufficient failure analysis in almost all patients with painful THA.

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