Neben der herausragenden Stellung im Bereich der Tumororthopädie erlangen Megaprothesen zunehmend Bedeutung für die Revisionsendoprothetik. Trotz der breiten Anwendung bleiben die berichteten Komplikations- und Versagensraten jedoch hoch. Die Analyse der Versagensursachen lässt grob eine Unterteilung in mechanische und nicht mechanische Versagensursachen zu, unter diesen nimmt einerseits das Weichteilversagen (Funktionsverlust) und die Lockerung, andererseits der Infekt eine herausragende Bedeutung ein. Dabei kann jedem Versagenstyp ein spezifisches Prothesenbauteil zugeordnet werden. Die technisch korrekt durchgeführte Operation vorausgesetzt, ist für das Weichteilversagen die muskuläre Anbindung an die Prothese, für die Lockerung die Verankerungstechnik über den Stem und für den Infekt die Oberflächenbeschaffenheit bzw. ggf. die Beschichtung der Prothese entscheidend. Bis heute haben sich einige vollwertige Systeme für den Ersatz des proximalen Femurs auf dem Markt etabliert, deren klinische Resultate in etwa vergleichbar sind. Im Detail sind deutliche Unterschiede hinsichtlich Verankerungstechniken, Modularität bzw. Modulverbindungen und Weichteilanbindung erkennbar, die spezifische Vor- und Nachteile mit sich bringen. In jedem Fall belegen die hohen Versagensraten ein großes Potenzial für zukünftige Entwicklungen. Innovative Verbesserungsvorschläge für jedes Bauteil sind durch Quervernetzungen zu bereits funktionierenden Systemen gut möglich. Zusammen mit neuen Erkenntnissen der Grundlagenforschung sollte es bei zukünftigen Systemen möglich sein, den Anteil der Prothesenversager deutlich zu reduzieren.
Abstract
In addition to their outstanding significance in the field of tumor orthopaedics, megaprostheses are becoming increasingly important for revision arthroplasty. Despite their wide application, the reported complication and failure rates remain high. The analysis of failure mechanisms roughly allows a breakdown into mechanical and non-mechanical causes; soft-tissue failure, loosening and periprosthetic infection play outstanding roles. Each type of failure can be associated to a specific prosthetic component: To avoid soft tissue failure, muscular connection to the prosthesis is essential; to avoid loosening, the anchoring technique on the stem is crucial; to prevent infection, the surface condition or possibly the coating of the prosthesis seem to play major roles. Some fully-fledged proximal femoral replacement systems have become established on the market and have similar clinical outcomes. However, there are significant differences in anchoring techniques, modularity or module connections and soft tissue connection. In any case, the high failure rates show that there is great potential for future developments. Innovative suggestions for each component are certainly possible through cross-linking to already functioning systems. Together with new findings from basic research, future systems should be able to significantly reduce the rate of prosthetic failures.
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