Frakturendoprothetik bei Schenkelhalsfrakturen

Zusammenfassung

Weltweit hat die Zahl der Hüftendoprothesenimplantationen in den letzten Jahren stetig zugenommen. Von den 200 000 in Deutschland implantierten Hüftendoprothesen erfolgte bereits jede 4. Versorgung aufgrund einer Fraktur. Aktuell ist die endoprothetische Versorgung die häufigste Therapie der Schenkelhalsfraktur in Deutschland [1] mit steigendem Anteil, obwohl es bislang keinen nachgewiesenen Vorteil der TEP-Versorgung gegenüber der Osteosynthese in Hinblick auf das Outcome gibt [2]. Die Frage, mit welcher Art von Prothese die Frakturversorgung erfolgen soll, hängt von zahlreichen Faktoren ab und sollte das numerische wie das biologische Alter des Patienten, Dislokationsgrad und Frakturmorphologie sowie Komorbiditäten und funktionellen Anspruch mit einbeziehen. Bei Patienten bis zum 60. Lebensjahr sollte in der Behandlung unabhängig vom Dislokationsgrad der Fraktur immer auf einen Gelenkerhalt abgezielt werden (pathologische Frakturen ausgeschlossen). Aber auch die nicht dislozierten und valgisch impaktierten Schenkelhalsfrakturen können in allen Altersklassen mit Vorteil gegenüber der Prothese gelenkerhaltend operiert werden. Bei dislozierten Frakturen profitieren ältere und körperlich reduzierte Patienten (> 65 Jahre) von einer Totalendoprothese. Umso mehr bei begleitend bestehender Koxarthrose. Hemiprothesen sind in aller Regel den alten multimorbiden Patienten vorbehalten, die hier v. a. von der kürzeren OP-Zeit und dem geringeren Blutverlust profitieren. Grundsätzlich wird ab dem 70. Lebensjahr die Verwendung zementierter Prothesen empfohlen [3]. Bei der Frakturendoprothetik handelt es sich, ebenso wie bei der Osteosynthese, um eine Operation von hoher Dringlichkeit, die zur Reduktion der Mortalität und sekundärer Komplikationen innerhalb von maximal 48 Stunden erfolgen muss [4], [5], [6]. Dieser Umstand verdeutlicht, dass der Operateur einer Schenkelhalsfraktur sowohl die Endoprothetik wie auch die Osteosynthese beherrschen sollte.

Abstract

The number of hip arthroplasties is increasing throughout the world. Of the total of 200,000 implanted hip endoprostheses in Germany, 25 % are due to a femoral neck fracture. This means that hip replacement is now the most common procedure for surgical treatment in femoral neck fractures in Germany [1]. This is tending to increase, although there is no evidence that the outcome is better with hip replacement than with osteosynthesis [2]. The choice of the implant depends on many factors, including the patientʼs calendar and biological ages, the fracture type and degree of dislocation as well as functional demands and comorbidities. In younger patients (up to 60 years), therapy should be focussed on joint preservation, aside from the degree of dislocation. Non-displaced and valgus impacted femoral neck fractures can be treated to preserve the joint with ostheosynthesis in all age groups and is superior to hip replacement. In displaced fractures, elder and physically unfit patients (> 60 years) benefit from total hip replacement, particularly with preexisting coxarthrosis. Hemiprosthesis is usually reserved for older and multimorbid patients, who benefit from the shorter operation time and lower blood loss in this procedure. Cemented prostheses are generally recommended for patients older than 70 years [3]. Like osteosynthesis, endoprosthetic fracture care is a surgical procedure of high priority that must take place within a maximum of 48 hours, in order to reduce mortality and secondary complications [4], [5], [6]. This makes it clear that the surgeon who is treating femoral neck fractures should master both procedures – hip replacement and osteosynthesis.

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