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Der proximale und komplette Femurersatz

Proximal and total femur replacement

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Zusammenfassung

Operationsziel

Ziel der Operation ist die Rekonstruktion segmentaler Knochensubstanzverluste des proximalen Femur nach weiter Tumorresektion oder nach Revisionseingriffen in der Hüftendoprothetik.

Indikationen

Aggressive benigne und primär maligne Knochentumoren des proximalen Femur, stabilitätsgefährdende Knochenmetastasen, ausgeprägter segmentaler Knochensubstanzverlust des proximalen Femur oder periprothetische Frakturen.

Kontraindikationen

Lokale floride Infektionen. Relative Kontraindikationen: Sehr kurze Lebenserwartung (< 3 Monate) und nicht vorhandenes azetabuläres Lager.

Operationstechnik

Anterolateraler Zugang, Darstellung und Ablösung des M. iliopsoas und des M. gluteus medius mit Sicherheitsabstand zum Knochen. Armierung der Sehnenstümpfe mit nichtresorbierbarem Nahtmaterial. Distale Durchtrennung von M. vastus lateralis, M. vastus intermedius und M. rectus femoris in Abhängigkeit der extraossären Tumorausdehnung. Distale Femurosteotomie mit Sicherheitsabstand von mindestens 3 cm zum Tumor. Bei totalem Femurersatz zusätzliche laterale Arthrotomie mit Resektion der Bänder und Menisken. Präparation des Markraums unter Schutz mit Verbrügge-Zange. Nach Probereposition mit Probekomponenten Implantation der definitiven Komponenten unter Einstellung der Antetorsion in 5°-Schritten. Vor Reposition Überstülpen und Fixieren eines Anbindungsschlauchs. Refixierung der Muskulatur am Anbindungsschlauch. Bei totalem Femurersatz Präparation des Tibiaschafts, Montage der Femurkomponenten und Kopplung mit der distalen Femurkomponente.

Weiterbehandlung

Infektionsprophylaxe, 20 kg Teilbelastung, Bewegungsschiene.

Ergebnisse

Von Juni 2007 bis Dezember 2011 erfolgte bei 20 Patienten die Implantation eines proximalen MUTARS®-Femurersatzes und bei 2 Patientinnen die Implantation eines totalen MUTARS®-Femurs. Das mittlere Alter zum Operationszeitpunkt betrug 62,0 ± 18,1 Jahre (18–82 Jahre). Die Operationsindikationen waren 3 primär maligne Knochentumore und 19 Femurmetastasen. Zum Zeitpunkt der Datenerhebung konnten 15 Patienten mit einem mittleren Nachuntersuchungszeitraum von 20,3 ± 17,2 Monaten (4–51 Monate) nachuntersucht werden. Bezogen auf alle 22 Fälle traten 3 tiefe Protheseninfektionen (13,6%) und 2 Luxationen (9,1%) auf. Von den 15 nachuntersuchten Patienten hatten 3 ein sehr gutes (20%), 4 ein gutes (26,7%), 6 ein zufriedenstellendes (40%) und 2 (13,3%) ein schlechtes funktionelles Ergebnis im MSTS-Score nach Enneking.

Abstract

Objective

Reconstruction of segmental bone defects of the proximal femur following wide tumor resection or revision arthroplasty.

Indications

Aggressive benign or primary malignant bone tumors of the proximal femur; destructive metastases; massive segmental bone defects of the proximal femur; periprosthetic fractures.

Contraindications

Local infection; very short life expectancy (< 3 months); massive deficiency of acetabular bone stock.

Operative technique

Anterolateral approach. Exposure and detachment of the iliopsoas and gluteus medius muscle from the proximal femur with a sufficient safety margin to the bone; distal transsection of the vastus lateralis/intermedius and rectus femoris muscle according to the extraosseous tumor extension; distal femur osteotomy al least 3 cm beyond the farthest point of tumor extension; in case of total femur replacement, additional lateral arthrotomy of the knee with resection of the ligaments and menisci; reaming of the medullary canal after securing the shaft with a Verbrugge clamp; trial assembly and reduction followed by the definitive implantation of the prosthesis with adjustment of the femoral neck anteversion in 5° increments; soft tissue reconstruction and fixation to an attachment tube covering the prosthesis; in case of total femur replacement, the preparation of the tibia is followed by the coupling of the tibial and femoral components.

Postoperative management

Infection prophylaxis, 20 kg partial weight bearing, continuous passive motion.

Results

A total of 20  patients with proximal femur replacement and 2 patients with total femur replacement implanted between June 2007 and December 2011 were retrospectively reviewed. Three patients had primary malignant bone tumors, while 19 patients underwent resection for metastatic disease. The mean age at surgery was 62.0 ± 18.1 years (18–82 years). Fifteen patients with a mean follow-up of 20.3 ± 17.2 months (4–51 months) were studied. Among the 22 cases, periprosthetic infection occurred in 3 patients (13.6%), dislocation in 2 patients (9.1%). Evaluation of the functional outcome in 15 patients using the MSTS score by Enneking revealed 3 very good (20%), 4 good (26.7%), 6 fair (40%), and 2 poor (13.3%) results.

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Authors and Affiliations

  1. Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Rheinische Friedrich-Wilhems-Universität Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland

    P.H. Pennekamp & D.C. Wirtz

  2. Orthopädische Klinik und Poliklinik, Schwerpunkt Tumororthopädie, LMU München, München, Deutschland

    H.R. Dürr

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  1. P.H. Pennekamp
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  2. D.C. Wirtz
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  3. H.R. Dürr
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Correspondence to P.H. Pennekamp.

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Pennekamp, P., Wirtz, D. & Dürr, H. Der proximale und komplette Femurersatz. Oper Orthop Traumatol 24, 215–226 (2012). https://doi.org/10.1007/s00064-011-0061-7

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