Der Einfluss der Kapselrekonstruktion auf die Luxationsrate nach primärer Hüftendoprothetik: eine retrospektive Analyse von 1972 Fällen

Zusammenfassung

Hintergrund: Die Luxation ist die dominierende Komplikation in der postoperativen Frühphase nach primärer Hüftendoprothetik. Der Einfluss der Kapselbehandlung auf das Luxationsrisiko wird kontrovers diskutiert. Während Charnley dringend empfahl, auf die Resektion der Gelenkkapsel zu verzichten, zweifelten andere Autoren deren Bedeutung an oder postulierten die Kapselresektion als unerlässlich. 2002 wurde in unserer Klinik eine modifizierte minderinvasive Technik der HTEP-Implantation etabliert, die durch Schonung und Rekonstruktion der Gelenkkapsel sowie Anwendung des Bauer-Zugangs geprägt ist. Im Rahmen einer Fallkontrollstudie sollte retrospektiv analysiert werden, ob die Luxationsrate nach primärer HTEP-Implantation durch diese Technik reduziert wird und ob daraus Nachteile wie kapselassoziierte Beschwerden, funktionelle Einschränkungen oder eine erhöhte Revisionsrate resultieren.
Material und Methoden: Alle in unserer Klinik in einem definierten Zeitraum von 2002 bis 2009 durchgeführten primären HTEP-Implantationen wurden eingeschlossen und nur Kappen-, Duokopf- sowie Tumorendoprothesen ausgeschlossen. Bei Rekonstruktion der Kapsel erfolgte eine Zuordnung zur Studiengruppe (SG) und bei Resektion zur Kontrollgruppe (KG). Für jedes behandelte Gelenk wurden der WOMAC-Score und ein weiterer Fragebogen zur Erfassung von Luxationen und Revisionsoperationen der betreffenden Hüfte an die Patienten versandt. Bei nicht erreichbaren Patienten erfolgte eine protokollierte Prüfung aller verfügbaren Daten (OP-Dokumentation, elektronische Krankenblätter, Röntgenarchiv), um HTEP-Luxationen oder -Revisionen zu ermitteln. Gruppierungen und Subklassifikationen durch erfahrene Operateure sollten die Auswertbarkeit der Daten optimieren. SG und KG wurden bez. der epidemiologischen sowie der implantat- und operationsspezifischen Daten verglichen. Die statistische Auswertung erfolgte mit dem Chi-Quadrat-Test sowie mit dem Mann-Whitney-U-Test.
Ergebnisse: Von den eingeschlossenen 1972 Fällen wurden 992 der SG und 980 der KG zugeordnet. Bei einem mittleren Follow-up von 33,5 (SG) und 73,4 (KG) Monaten (mindestens 12 Monate) war die Luxationsrate in der SG mit 0,3 % (n = 3) signifikant geringer als die der KG, welche 2,55 % (n = 25) betrug (p < 0,001). Bezüglich des WOMAC-Indexes (SG: 1,46 ± 1,73; KG: 1,53 ± 1,80; p > 0,05) sowie der operativen Revisionsrate (SG: 5,24 %; KG: 6,84 %; p = 0,139) gab es keine signifikanten Unterschiede.
Schlussfolgerung: Die Schonung und Rekonstruktion der Gelenkkapsel bewirkte somit in unserem Patientengut eine 88 %ige Reduktion der Luxationsrate nach primärer Hüftendoprothetik im Vergleich zur Standardtechnik mit Kapselresektion. Einige Autoren berichten über vergleichbare Effekte bei Kapsel- oder Weichteilrekonstruktion in Verbindung mit dem posterioren und posterolateralen Zugang. Unabhängig vom operativen Zugang resultiert aus der Schonung und Rekonstruktion der Gelenkkapsel offenbar eine wesentliche Reduktion der Luxationsrate, insbesondere, wenn der azetabuläre Kapselursprung unversehrt bleibt. Kapselassoziierte Beschwerden, funktionelle Nachteile oder eine erhöhte Revisionsrate fanden sich weder in der eigenen Untersuchung noch in der Literatur. Schonung und Rekonstruktion der Hüftgelenkkapsel sind daher in der primären Hüftendoprothetik zu empfehlen.

Abstract

Background: Dislocation is the second most frequently encountered complication in primary total hip arthroplasty (THA) and occurs more commonly in the early postoperative rehabilitation phase. Sir Charnley recommended the “avoidance of resection of the capsule” and emphasised its contribution to hip joint stability in THA. Several authors, however, doubted its significance and considered resection of the capsule to be essential. Since 2002, some surgeons increasingly adopted a modified, less invasive technique of THA via Bauer approach, including the preservation and repair of the hip joint capsule with focus on maintaining its acetabular origin. Another group of surgeons applied the traditional technique including the resection of the joint capsule via an anterolateral approach. In this case-control study we investigated whether the dislocation rate can be reduced through joint capsule reconstruction and whether any negative impact on patient satisfaction, functional results or revision rate is observed.
Material and Methods: All cases of primary THA performed in our institution in a timeframe between 2002 and 2009 were included with the only exceptions of resurfacing arthroplasty, dual mobility and tumour hip replacements. Joint capsule repair cases were gathered in the study group (SG), capsule resection cases in the control group (CG). Additional patient-related data were taken from the anaesthesia records. The WOMAC score and a questionnaire focusing on detection of dislocations and revision surgeries was sent out for each case. Further targeted research was conducted that included requesting records and reports from external hospitals. In the case of non-responding patients, all available data (operating room documentation, electronic files, archive, X-rays) were reviewed for incidents of dislocation and revision surgery. Groupings and classifications were exclusively performed by senior surgeons. SG and CG were compared regarding epidemiologic, implant-associated and surgery-specific data. Statistical evaluations were performed using the Chi-squared test and the Mann-Whitney U test.
Results: 1972 cases of primary THA were included: 992 in the SG and 980 in the CG. The follow-up rates were 92.7 % in the SG and 76.4 % in the CG, the mean follow-up times 33.5 months and 73.4 months, respectively, with a follow-up of at least 12 months in all cases. In the SG, the dislocation rate was 0.3 % (n = 3) and thus significantly lower than the 2.55 % in the CG (n = 25, p < 0.001). Both the WOMAC score (SG: 1.46 ± 1.73; CG: 1.53 ± 1.80; p > 0.05) and the revision rate (SG: 5.24 %; CG: 6.84 %; p = 0.139) showed no significant differences.
Conclusion: Preservation and repair of the hip joint capsule causes an 88-%-reduction of the dislocation rate in primary THA in this large series including 1972 cases, operated via the Bauer or the anterolateral approach. Several authors reported comparable results after THA using similar techniques of soft tissue and capsular repair through the posterior or posterolateral approach. Sparing and reconstructing the hip joint capsule therefore seems to reduce the dislocation rate after primary THA by one order of magnitude regardless of the surgical approach and, especially, if the acetabular origin is preserved. Capsule-related specific complications such as an increased revision rate, malfunction or pain were neither recorded in our study nor by others. Thus, careful preservation and reconstruction of the hip joint capsule may be expressly recommended in primary THA.

Schlüsselwörter

Hüftendoprothetik - Luxation - Gelenkkapsel - Kapselrekonstruktion - Kapselresektion

Key words

total hip arthroplasty - dislocation - hip joint capsule - resection of the capsule - capsular repair

• Literatur

• 1 Charnley J. Low Friction Arthroplasty of the Hip: Theory and Practice. Berlin, Heidelberg, New York: Springer; 1979: 314-319
• 2 Etienne A, Cupic Z, Charnley J. Postoperative dislocation after Charnley low-friction arthroplasty. Clin Orthop Relat Res 1978; 132: 19-23
• 3 Bottner F, Pellicci PM. Review: posterior soft tissue repair in primary total hip arthroplasty. HSS J 2006; 2: 7-11
• 4 Stucki G, Meier D, Stucki S et al. [Evaluation of a German version of WOMAC (Western Ontario and McMaster Universities) Arthrosis Index]. Z Rheumatol 1996; 1: 40-49
• 5 Bauer R, Kerschbaumer F, Poisel S et al. The transgluteal approach to the hip joint. Arch Orthop Trauma Surg 1979; 95: 47-49
• 6 Sanchez-Sotelo J, Berry DJ. Epidemiology of instability after total hip replacement. Orthop Clin North Am 2001; 4: 543-552
• 7 Morrey BF. Instability after total hip arthroplasty. Orthop Clin North Am 1992; 2: 237-248
• 8 Kohn D, Rühmann O, Wirth CJ. Die Verrenkung der Hüfttotalendoprothese unter besonderer Beachtung verschiedener Zugangswege. Z Orthop Unfall 1997; 1: 40-44
• 9 Phillips CB, Barrett JA, Losina E et al. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am 2003; 1: 20-26
• 10 Sanchez-Sotelo J, Haidukewych GJ, Boberg CJ. Hospital cost of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am 2006; 2: 290-294
• 11 Lewinnek GE, Lewis JL, Tarr R et al. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am 1978; 2: 217-220
• 12 Ali Khan MA, Brakenbury PH, Reynolds IS. Dislocation following total hip replacement. J Bone Joint Surg Br 1981; 2: 214-218
• 13 Woo RY, Morrey BF. Dislocations after total hip arthroplasty. J Bone Joint Surg Am 1982; 9: 1295-1306
• 14 Jolles BM, Zangger P, Leyvraz PF. Factors predisposing to dislocation after primary total hip arthroplasty. J Arthroplasty 2002; 3: 282-288
• 15 Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res 2002; 405: 46-53
• 16 Berry DJ, von Knoch M, Schleck CD et al. Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am 2005; 11: 2456-2463
• 17 Hedley AK, Hendren DH, Mead LP. A posterior approach to the hip joint with complete posterior capsular and muscular repair. J Arthroplasty 1990; 5: 57-66
• 18 Mallory TH, Lombardi jr. AV, Fada RA et al. Dislocation after total hip arthroplasty using the anterolateral abductor split approach. Clin Orthop Relat Res 1999; 358: 166-172
• 19 Demos HA, Rorabeck CH, Bourne RB et al. Instability in primary total hip arthroplasty with the direct lateral approach. Clin Orthop Relat Res 2001; 393: 168-180
• 20 van Stralen GM, Struben PJ, van Loon CJ. The incidence of dislocation after primary total hip arthroplasty using posterior approach with posterior soft-tissue repair. Arch Orthop Trauma Surg 2003; 5: 219-222
• 21 Weeden SH, Paprosky WG, Bowling JW. The early dislocation rate in primary total hip arthroplasty following the posterior approach with posterior soft-tissue repair. J Arthroplasty 2003; 6: 709-713
• 22 Pellicci PM, Bostrom M, Poss R. Posterior approach to total hip replacement using enhanced posterior soft tissue repair. Clin Orthop Relat Res 1998; 355: 224-228
• 23 Chiu F, Chen C, Chung T et al. The effect of posterior capsulorrhaphy in primary total hip arthroplasty: a prospective randomized study. J Arthroplasty 2000; 2: 194-199
• 24 Goldstein WM, Gleason TF, Kopplin M et al. Prevalence of dislocation after total hip arthroplasty through a posterolateral approach with partial capsulotomy and capsulorrhaphy. J Bone Joint Surg Am 2001; 83: 2-7
• 25 White jr. RE, Forness TJ, Allman JK et al. Effect of posterior capsular repair on early dislocation in primary total hip replacement. Clin Orthop Relat Res 2001; 393: 163-167
• 26 Suh KT, Park BG, Choi YJ. A posterior approach to primary total hip arthroplasty with soft tissue repair. Clin Orthop Relat Res 2004; 418: 162-167
• 27 Dixon MC, Scott RD, Schai PA et al. A simple capsulorrhaphy in a posterior approach for total hip arthroplasty. J Arthroplasty 2004; 3: 373-376
• 28 Sierra RJ, Raposo JM, Trousdale RT et al. Dislocation of primary THA done through a posterolateral approach in the elderly. Clin Orthop Relat Res 2005; 411: 262-267
• 29 Iorio R, Specht LM, Healy WL et al. The effect of EPSTR and minimal incision surgery on dislocation after THA. Clin Orthop Relat Res 2006; 447: 39-42
• 30 Kwon MS, Kuskowski M, Mulhall KJ et al. Does surgical approach affect total hip arthroplasty dislocation rates?. Clin Orthop Relat Res 2006; 447: 34-38
• 31 Pellicci PM, Potter HG, Foo LF et al. MRI shows biologic restoration of posterior soft tissue repairs after THA. Clin Orthop Relat Res 2009; 4: 940-945
• 32 Kao JT, Woolson ST. Piriformis tendon repair failure after total hip replacement. Orthop Rev 1992; 2: 171-174
• 33 DʼAngelo F, Murena L, Zatti G et al. The unstable total hip replacement. Indian J Orthop 2008; 3: 252-259
• 34 Morrey BF. Difficult complications after hip joint replacement: dislocation. Clin Orthop Relat Res 1997; 344: 172-187
• 35 Burroughs BR, Hallstrom B, Golladay GJ et al. Range of motion and stability in total hip arthroplasty with 28-, 32-, 38-, and 44-mm femoral head sizes: an in vitro study. J Arthroplasty 2005; 1: 11-19
• 36 Padgett DE, Lipman J, Robie B et al. Influence of total hip design on dislocation: a computer model and clinical analysis. Clin Orthop Relat Res 2006; 447: 48-52
• 37 Amlie E, Høvik Ø, Reikerås O. Dislocation after total hip arthroplasty with 28 and 32-mm femoral head. J Orthop Traumatol 2010; 2: 111-115
• 38 Bistolfi A, Crova M, Rosso F et al. Dislocation rate after hip arthroplasty within the first postoperative year: 36 mm versus 28 mm femoral heads. Hip Int 2011; 21: 559-564
• 39 Howie DW, Holubowycz OT, Middleton R. Large femoral heads decrease the incidence of dislocation after total hip arthroplasty: a randomized controlled trial. J Bone Joint Surg Am 2012; 12: 1095-1102
• 40 Perka C, Haschke F, Tohtz S. Luxationen nach Hüftendoprothetik. Z Orthop Unfall 2012; 150: e89-e103
• 41 Prietzel T, Richter K, Pilz D et al. [The stabilizing effect of atmospheric pressure (AP) on hip joint subject to traction force – An experimental study]. Z Orthop Unfall 2007; 4: 468-475