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Indikation und Ergebnisse hüftnaher Osteotomien bei Dysplasie

Indications and results of corrective pelvic osteotomies in developmental dysplasia of the hip

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Zusammenfassung

Hintergrund

Rekonstruierende Eingriffe am wachsenden Skelett stellen sowohl in der Indikationsstellung als auch aus operationstechnischer Sicht eine große Herausforderung für den behandelnden Orthopäden dar. Neben der Skelettreife und Gewebequalität zum Operationszeitpunkt müssen die Art und das Ausmaß einer Fehlstellung, die zugrunde liegende Erkrankung sowie die Gesamtprognose in die Entscheidungsfindung für oder gegen ein Operationsverfahren eingeschlossen werden. Die Hüftgelenkdysplasie ist die häufigste Deformität, welche reorientierende Operationen am Hüftgelenk im Kindes- und Jugendalter indiziert. Dabei werden prophylaktische Operationen durchgeführt, um einer frühzeitigen sekundären Hüftarthrose vorzubeugen. Für Patienten und Familien aber auch für den Orthopäden ist die Nutzen-Risiko-Abwägung von großer Bedeutung.

Methoden

Es werden Techniken und Besonderheiten der einzelnen rekonstruktiven Operationstechniken am Hüfgelenk beschrieben, deren Ergebnisse anhand einer Literaturübersicht dargestellt und kritisch mit den eigenen Erfahrungen verglichen und diskutiert.

Ergebnisse

Es liegen nur wenige Langzeitstudien zum klinischen Ergebnis nach definierten, rekonstruierenden Operationen am Hüftgelenk im Kindes- und Jugendalter vor. Das Ausmaß der Deformität, die Grunderkrankung, das Patientenalter und die operative Erfahrung des orthopädischen Chirurgen sind wichtige Entscheidungshilfen bei der Wahl eines Operationsverfahrens. Im frühen Kindesalter hat sich bei der operativen Therapie der Hüftgelenkdysplasie insbesondere die Azetabuloplastik und die Salter-Osteotomie durchgesetzt, während im fortgeschrittenen Jugendalter die Dreifachbeckenosteotomie gute Ergebnisse zeigt. Bei geschlossenen Wachstumsfugen kann mit der periazatabulären Osteotomie nach Ganz ebenfalls ein gutes Korrekturergebnis erzielt werden. Intertrochantäre varisierende und derotierende Osteotomien am Femur dienen insbesondere als additive Verfahren zur Beckenosteotomie und werden heute kaum mehr als Einzelverfahren zur Gelenkreorientierung bei Hüftgelenkdysplasie durchgeführt.

Schlussfolgerung

Rekonstruierende Eingriffe am Hüfgelenk führen bei sachgemäßer Indikationsstellung und technisch korrekter Durchführung in den meisten Fällen zur Funktionsverbesserung am Hüftgelenk und können die Entstehung einer frühzeitigen Koxarthrose verzögern oder verhindern.

Abstract

Background

Joint-preserving reconstructive surgeries in children and adolescents remain challenging for orthopaedists with regard to indication and surgical technique. Besides skeletal maturity and tissue quality at the time of surgery, the kind and degree of deformity, the causative pathologies in secondary dysplasias, and the prognosis have to be considered when deciding for or against a surgical procedure. Developmental dysplasia of the hip (DDH) is the most frequent deformity that indicates reorienting surgery on the hip joint in children and adolescents. The aim of these procedures is to prevent early secondary osteoarthritis. For patients and families as well as for the orthopaedist, risk–benefit analysis is of major interest.

Methods

In this study, the surgical techniques and specialities of different reconstructive operations are presented. Based on a review of the literature, the results of defined surgical methods are discussed and compared with own experiences.

Results

Only limited information is available about the clinical long-term outcome after defined reconstructing surgery on the hip joint in children and adolescents. The degree of the deformity, the age of onset, and the surgical experience of the orthopaedist are crucial factors in decision making for or against a surgical treatment. In early childhood, acetabuloplasty and Salter osteotomy are widely accepted to correct DDH. Triple and periacetabular osteotomies are preferred and have shown promising results in late adolescence and young adults. When the triradiate cartilage (growth plate) is closed, good outcomes can be achieved by the Ganz osteotomy. Intertrochanteric varus and derotation osteotomies of the femur may serve as additional procedures for pelvic osteotomies and are rarely indicated as a single procedure today.

Conclusion

Reconstructive surgery on the hip joint improves function and may prevent early osteoarthritis and delay progression of cartilage degeneration in most patients when the indication and surgical technique are appropriate.

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  1. Klinik und Poliklinik für Orthopädie und Orthopädische Chirurgie, Universitätsklinikum, Heinrich-Heine-Universität, Moorenstraße 5, 40225, Düsseldorf, Deutschland

    M. Jäger, B. Westhoff, C. Zilkens, K. Weimann-Stahlschmidt &  R. Krauspe

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Jäger, M., Westhoff, B., Zilkens, C. et al. Indikation und Ergebnisse hüftnaher Osteotomien bei Dysplasie. Orthopäde 37, 556–576 (2008). https://doi.org/10.1007/s00132-008-1240-6

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