Ist der distale Femurersatz als extremitätenerhaltendes Verfahren nach komplexen Frakturen am distalen Femur geeignet?

Zusammenfassung

Hintergrund: Der modulare distale Femurersatz wurde ursprünglich entwickelt, um eine belastbare und funktionelle untere Extremität nach Resektion gelenknaher primärer Knochentumoren mit großen knöchernen Defekten wiederherzustellen. Ziel der vorliegenden Untersuchung war es, die Indikationsstellung, Komplikationen und Funktion des distalen Femurersatzes nach komplexen Frakturen oder Frakturfolgen am distalen Femur zu erfassen und im Kontext vergleichbarer Studien zu bewerten. Patienten und Methode: 14 Patienten wurden retrospektiv untersucht, die aufgrund einer Fraktur oder Frakturfolgen mit ausgedehnten posttraumatischen Defekten des distalen Femurs mit einer Megaendoprothese versorgt wurden. Das Alter der Patienten zum Zeitpunkt der Operation betrug im Median 77,0 (IQB 70,0–81,5) Jahre (IQB: Interquartilbereich). Der mediane Nachuntersuchungszeitraum betrug 27,0 (IQB 13,5–37,5) Monate (Schwankungsbereich 10–49 Monate). Ergebnisse: Die Indikation zum distalen Femurersatz wurde in 3 Fällen nach periprothetischer Fraktur gestellt. In 3 Fällen war die Indikation eine Komplikation nach Osteosynthese einer periprothetischen Fraktur, in 8 Fällen waren Komplikationen nach Osteosynthese distaler Femurfrakturen der Grund für einen distalen Femurersatz. Die Implantation des distalen Femurersatzes erfolgte bei 5 Patienten zweizeitig, nachdem eine implantatassoziierte Infektion saniert wurde. Der Knee Society Score verbesserte sich im Median von präoperativ 20,0 (IQB 7,5–30,0) signifikant auf 80,0 (IQB 62,3–89,0) zum Zeitpunkt der Nachuntersuchung (p < 0,001). Komplikationen, die eine operative Revision erforderten, waren bei 7 der 14 Patienten (50 %) aufgetreten. Bei 2 Patienten traten Wundheilungsstörungen oder oberflächliche Infektionen auf, die chirurgisch behandelt werden mussten. Eine Ruptur des Streckapparats trat bei 1 Patientin auf, die sich im weiteren Verlauf auch eine periprothetische Fraktur zuzog. Bei 1 Patienten wurde eine frühzeitige Lockerung der femoralen Prothesenkomponente festgestellt. Die häufigste Komplikation war eine periprothetische Fraktur bei 4 Patienten. Drei Patienten verstarben ohne Zusammenhang zur Prothesenimplantation. Schlussfolgerung: Der distale Femurersatz ist eine wichtige Behandlungsoption zur Wiederherstellung einer funktionell belastbaren unteren Extremität bei ausgedehnten traumatischen und posttraumatischen Defekten. Insbesondere ältere Patienten erreichen dadurch in der überwiegenden Mehrzahl wieder ihre Gehfähigkeit. Die relativ hohe Komplikationsrate erfordert eine sehr sorgfältige Indikationsstellung.

Abstract

Background: Modular distal femur replacements originally were developed for reconstructing a full weight-bearing and functional extremity after resection of primary bone tumours with large bony defects located in proximity to joints. The aim of this study was to examine the use of the modular distal femur replacements for complex fractures and severe post-traumatic sequelae of the distal femur in context to comparable studies. Patients and Methods: Fourteen patients with complex fractures or post-traumatic sequelae and extensive bone defects requiring distal femur replacement were analysed retrospectively. Median age of the patients at the time of distal femoral replacement was 77 years and median follow-up interval was 27 months. Median follow-up was 27.0 (IQB 13.5–37.5) months (range 10–49 months). Results: The indication for distal femur replacement was a periprosthetic fracture in three cases. Three further periprosthetic fractures were treated with a megaendoprosthesis after failure of osteosynthesis. In eight patients a megaendoprosthesis was implanted due to complications following ostheosynthesis for distal femoral fractures. Distal femoral arthroplasty was performed as a two-stage procedure in five patients with implant-associated infections. A lateral approach was used in six patients and a medial arthrotomy was conducted in eight patients. The median Knee Society score (KSS) improved significantly from 20.0 (IQB 7.5–30.0) points preoperatively to 80.0 (IQB 62.3–89.0) points at follow-up (p < 0.001). Complications requiring surgical intervention were documented in seven of 14 patients (50 %). In two patients wound-healing disorders and superficial infections necessitated surgery. In one patient a rupture of the patellar tendon was diagnosed. This patient subsequently also sustained a periprosthetic fracture. Another patient developed early aseptic loosening of the femoral component. The most common complication was a periprosthetic fracture in four patients. Three patients died for reasons not related to distal femoral replacement. Conclusion: Distal femoral replacement is an important option in reconstituting a full weight-bearing and functional lower extremity after complex fractures and post-traumatic sequelae with massive bone destruction. Particularly elderly patients regain ambulatory ability in the vast majority of cases. The relatively high complication rate demands very thorough preoperative planning as well as prompt allocation of extensive surgical procedures in the case of an adverse event.

Schlüsselwörter

distaler Femurersatz - Megaendoprothese - Tumorendoprothese - posttraumatischer Defekt - Knochendefekt - Kniegelenksendoprothese

Key words

distal femoral replacement - megaendoprosthesis - tumor endoprosthesis - posttraumatic sequelae - bone defect - knee arthroplasty

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