Azetabuläre Osteolysen bei Hüfttotalendoprothese – wann kann die Pfanne belassen werden?

 

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Zusammenfassung

Die Entscheidung, eine Hüftendoprothesenpfanne bei vorliegenden Osteolysen zu belassen oder auszutauschen, stellt eine Herausforderung dar. Sowohl der Entschluss zum nicht operativen Vorgehen mit regelmäßigen Kontrollen als auch zur operativen Vorgehensweise mit einem Gleitpaarungswechsel und ggf. Osteolyseauffüllung erfordert eine sorgfältige Diagnostik mit Anamnese, körperlicher Untersuchung und Bildgebung. Im Zweifelsfall ist eine Computertomografie empfehlenswert, um das Ausmaß und die Bedeutung der Osteolysen besser einschätzen zu können. Eine engmaschige klinisch-radiologische Verlaufskontrolle kann bei radiologisch fester Pfanne, asymptomatischen Patienten, nicht progredienten Osteolysen, regelrechter Implantatlage sowie Fehlen von Implantatdefekten, höhergradigem PE-Verschleiß und Infektionszeichen erfolgen. Wird in der Bildgebung eine Lockerung oder Malposition der Pfanne, die Lokalisation der Osteolyse im lasttragenden Bereich, eine drohende oder bereits vorliegende Fraktur, eine rasche Progression der Osteolyse, ein Implantatdefekt oder ein ausgeprägter Inlay-Verschleiß sichtbar, ist ein operatives Vorgehen zu präferieren. In diesen Fällen erfolgt zumeist der Pfannenwechsel. Im Falle einer korrekt positionierten und radiologisch festen Pfanne muss die Situation mit dem Patienten diskutiert werden. Dabei ist neben patientenspezifischen Faktoren das Risiko, welches mit weiterem Abwarten einhergeht, abzuschätzen. Wird operiert, kann beim asymptomatischen Patienten und intraoperativ stabiler Pfanne ein Gleitpaarungswechsel, ggf. mit Auffüllung der Osteolysen, durchgeführt werden. Ob die Auffüllung der vorhandenen Osteolysen einen Vorteil im weiteren Verlauf bringt, ist bisher nicht abschließend geklärt. Für generelle Aussagen sind weitere Studien im Umgang mit Osteolysen bei korrekt positionierten und radiologisch festen Pfannen notwendig.

Abstract

Periacetabular osteolysis is a frequent long-term complication of cementless total hip arthroplasty. The decision whether to retain or to revise a cup in the presence of osteolysis remains a challenge. The options are regular clinical and radiological check-ups, isolated liner exchange with and without bone grafting, and complete cup revision. Thorough preoperative diagnostics, including a medical history, examination and imaging, are mandatory for correct decision making. In most patients, computed tomography is useful to assess periacetabular osteolysis. If the cup is well-fixed and positioned in an asymptomatic patient without progressive osteolysis and no implant defect or higher grade polyethylene wear and no signs of infection, continuous clinical and radiological monitoring is preferred. If imaging reveals cup loosening, malposition, osteolysis localised in a weight-bearing area, imminent or present periprosthetic fractures, rapid progressive osteolysis, implant defects or massive inlay wear, surgical treatment may be preferred. Cup revision is usually performed in such patients. If the cup is well-positioned and well-fixed in the X-ray, the procedure has to be discussed with the patient individually. Apart from patient-specific risk factors, the risk of further progression has to be assessed. Isolated liner exchange can be performed if the patient is asymptomatic and the cup proves to be stable intraoperatively. It is still unclear whether filling osteolyses through screw holes or osseous windows is of long-term benefit.

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