Stellenwert minimalinvasiver Zugangswege bei der primären Hüftendoprothetik – ein Update

Zusammenfassung

Einleitung: Minimalinvasive Zugangswege zum Hüftgelenk bei der primären Endoprothetik stehen seit einigen Jahren im Fokus einer kontroversen Diskussion. Minimalinvasive Zugänge versprechen eine weichteilschonende Implantation mit Vorteilen in den postoperativen funktionellen Ergebnissen und reduziertem intraoperativem Blutverlust. Methodik: Auf Grundlage einer umfassenden Literatursuche (Einschlusskriterien: Prospektiv randomisierte klinische Studien, systematische Reviews, Metaanalysen) wird die verfügbare Primär- und Sekundärliteratur beurteilt, Vor- und Nachteile minimalinvasiver Zugänge zum Hüftgelenk werden im Vergleich zu traditionellen Zugängen diskutiert. Ergebnisse: Die verfügbare Primär- und Sekundärliteratur belegt Vorteile minimalinvasiver Zugänge zum Hüftgelenk im funktionellen Outcome in der frühen postoperativen Phase. Nach 1 Jahr postoperativ bestehen keine funktionellen Unterschiede mehr zum Standardzugang. Des Weiteren werden eine verminderte Operationsdauer, ein verminderter Blutverlust und ein kürzerer stationärer Aufenthalt belegt. Studien der Evidenzgrade I und II zu mittel- und langfristigen Ergebnissen minimalinvasiver Zugänge im Vergleich zu den etablierten Standardzugängen sind nicht verfügbar. Die verfügbaren Systematic Reviews und Metaanalysen lassen lediglich eine globale Beurteilung der Primärliteratur zu minimalinvasiven Zugangswegen zu, ohne dabei zwischen den etablierten Standardzugängen und dem nach minimalinvasiven Kriterien modifizierten Pendant zu differenzieren. Es existieren zurzeit wenig bildmorphologische In-vivo-Hinweise (MRT) für eine Reduktion des muskulären Traumas durch Verwendung von MIS-Zugängen. Fazit: Die verfügbare Literatur erlaubt derzeit kein abschließendes Urteil zur Wertigkeit minimalinvasiver Zugangswege zum Hüftgelenk. Weiterführende prospektiv randomisierte kontrollierte Studien sind notwendig, um die sehr guten (Langzeit-)Ergebnisse der etablieren Standardzugänge mit den nach minimalinvasiven Kriterien modifizierten Hüftzugängen zu vergleichen. Solange keine ausreichenden Langzeitergebnisse zu Komplikations- und Revisionsraten minimalinvasiver Zugangswege vorliegen, können minimalinvasive Zugangswege nicht als Goldstandard empfohlen werden.

Abstract

Introduction: Minimally invasive approaches to the hip joint during primary endoprosthetics have been for many years the focus of controversial discussion. Minimally invasive approaches offer soft tissue protecting implantations clear advantages regarding early postoperative functional results and reduced intraoperative blood loss. Method: On the basis of comprising literary research the available primary and secondary literature is evaluated – the advantages and disadvantages of minimally invasive approaches at the hip joint are discussed in relation to traditional approaches. Results: The available primary and secondary literature verifies that the advantages of minimally invasive approaches at the hip joint include functional outcome in the early postoperative phase. In comparison to standard approaches there are no differences in the functional outcome after 12 months follow-up. Additionally, reduced length of operation, reduced blood loss and shorter stationary stay are confirmed. Studies relating to degrees of evidence I and II, which concern the medium- and long-term results of minimally invasive approaches in comparison to the established standard approaches, are not available. The available systematic reviews and meta-analyses merely allow a global evaluation of the primary literature on minimally invasive approaches, without thereby differentiating between the established standard approaches and the modified pendant according to minimally invasive criteria. There is a lack of knowledge with regard to in-vivo imaging data (MRI) as a potential evidence for reduction of muscular trauma by using minimally invasive approaches. Conclusion: Presently, the available literature does not allow definitive assessment regarding the significance of minimally invasive approaches at the hip joint. Future, random-controlled studies are necessary in order to compare the reliable (long-term) results of the established standard approaches with the hip approaches according to minimally invasive criteria. As long as sufficient long-term results regarding the complication and revision rates of minimally invasive approaches are not available, the method cannot be recommended as “gold standard.”

Schlüsselwörter

künstlicher Hüftgelenksersatz - Zugang - minimalinvasiv - Hüfte

Key words

primary hip arthroplasty - approaches - minimally-invasive surgery - hip

^* Beide Autoren haben zu gleichen Teilen zur Entstehung dieser Arbeit beigetragen.

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