Skip to main content
SpringerLink
Log in

Diagnostik und Therapie der Luxation nach Hüfttotalprothesenimplantation

Diagnostics and therapy of luxation after total hip arthroplasty

  • Leitthema
  • Published:
Der Orthopäde Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Die Luxation nach endoprothetischem Hüftgelenkersatz stellt eine häufige und schwerwiegende Komplikation dar und ist die Ursache für eine relevante Zahl an hüftendoprothetischen Revisionseingriffen. Die Wahrscheinlichkeit des Auftretens einer Hüfttotalendoprothesen(HTEP)-Luxation ist mit indikations-, patienten- und operationsspezifischen Risikofaktoren assoziiert. Rund die Hälfte der HTEP-Luxationen tritt innerhalb der ersten 3 Monate postoperativ auf (Frühluxation).

Diagnostik

Die Diagnostik der HTEP-Luxation erfolgt klinisch und radiologisch. Die ursächliche Zuordnung wird anhand der Beurteilung der Gelenkstabilität, der knöchernen Situation (Lockerung, periprothetische Fraktur, Defekt) und der Weichteile (pelvitrochantäre Muskulatur) vorgenommen. Bei klinisch oder paraklinisch positiven Infektzeichen bzw. bei Spätluxationen ist die Gelenkpunktion indiziert.

Therapie

Die Festlegung der Therapie erfolgt nach der Ursache (Implantatfehlstellung, pelvitrochantäre Insuffizienz, Impingement, Inkongruenz zwischen Kopf und Inlay, kombinierte Ursachen). Die Therapie der akuten HTEP-Luxation besteht zunächst in der bildwandlerkontrollierten Reposition unter ausreichender Analgesie und Relaxation. Die konservative Therapie erfolgt mit der Ruhigstellung durch eine Hüftgelenkorthese oder einen Becken-Bein-Gips für 6 Wochen. Operative Therapiestrategien bei rezidivierenden Luxationen sind die Herstellung der korrekten Implantatposition sowie einer suffizienten Weichteilspannung. Größere Hüftköpfe, bipolare Köpfe und tripolare Pfannen finden aufgrund der geometrisch geringeren Ausrenkungswahrscheinlichkeit (höhere „jumping distance“) häufig Anwendung. Infektassoziierte HTEP-Luxationen werden nach den Prinzipien der periprothetischen Infekttherapie behandelt. Die Reluxationsrate ist mit bis zu 30 % hoch, daher sollte beim Ausbleiben des Therapieerfolgs die Versorgung in einem Zentrum für Revisionsendoprothetik angestrebt werden.

Schlussfolgerungen

Die Fahndung nach der genauen Ursache einer HTEP-Luxation ist eminent wichtig. Nur deren Kenntnis und die patienten- und implantatspezifischen Details ermöglichen eine Klassifizierung und zeigen Wege bzgl. des therapeutischen Vorgehens. Bei einer Revisionsoperation muss die intraoperative Funktionsdiagnostik exakt dokumentiert werden. Als Gründe für Spätluxationen sind Protheseninfekte, -abrieb und -lockerungen zu hinterfragen.

Abstract

Background

Luxation following endoprosthetic hip replacement represents a frequent and severe complication and is the reason for a relevant number of hip arthroplasty revision interventions. The probability of occurrence of luxation of a total hip arthroplasty is associated with the indications, patient and operation-specific risk factors. Approximately 50 % of luxations after total hip arthroplasty occur within 3 months of the operation (early luxation).

Diagnostics

The diagnostics of luxation of total hip arthroplasty are carried out by clinical and radiological methods. The causative assignment is made by assessment of joint stability, the bony situation (e.g. loosening, periprosthetic fracture and defects) and the soft tissue (e.g. pelvitrochanterian musculature). In cases of clinical and paraclinical signs of infection and of late luxations, a joint puncture is indicated.

Therapy

Therapy decisions are made depending on the cause (e.g. implant malpositioning, pelvitrochanterian insufficiency, impingement, incongruence between head and inlay and combinations of causes). Therapy of acute total hip prosthesis luxation begins with imaging controlled repositioning carried out with the patient under adequate analgesia and sedation. Conservative therapy is carried out by immobilization with a hip joint orthesis or pelvis-leg cast for 6 weeks. Operative therapy strategies for recurrent luxation are restoration of the correct implant position and sufficient soft tissue tension. Larger hip heads, bipolar heads and tripolar cups are more commonly used due to the geometrically lower probability of dislocation (higher jumping distance). Luxation of total hip prostheses due to infection is treated according to the principles of periprosthetic infection therapy. The rate of recurrence of luxation of 30 % is high so that in cases of unsuccessful therapy treatment should best be carried out in a center for revision arthroplasty.

Conclusions

The search for the exact cause of total hip prosthesis luxation is extremely important. A classification is only possible when the exact cause is known and together with patient and implant-specific details the therapeutic approach can be ascertained. In revision operations the intraoperative functional diagnostics must be exactly documented. The reasons for delayed luxations could be prosthesis infections, abrasion and loosening.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7
Abb. 8

Literatur

  1. Barrack RL, Butler RA, Laster DR et al (2001) Stem design and dislocation after revision total hip arthroplasty: clinical results and computer modeling. J Arthroplasty 16:8–12

    Article  CAS  PubMed  Google Scholar 

  2. Bartz RL, Nobel PC, Kadakia NR et al (2000) The effect of femoral component head size on posterior dislocation of the artificial hip joint. J Bone Joint Surg [Am] 82:1300–1307

    Google Scholar 

  3. Biedermann R, Tonin A, Krismer M et al (2005) Reducing the risk of dislocation after total hip arthroplasty: the effect of orientation of the acetabular component. J Bone Joint Surg [Br] 87:762–769

    Google Scholar 

  4. Bolland BJ, Whitehouse SL, Timperley AJ (2012) Indications for early hip revision surgery in the UK – a re-analysis of NJR data. Hip Int 22:145–152

    Article  PubMed  Google Scholar 

  5. Bozic KJ, Ong K, Lau E et al (2010) Risk of complication and revision total hip arthroplasty among Medicare patients with different bearing surfaces. Clin Orthop Relat Res 468:2357–2362

    Article  PubMed  Google Scholar 

  6. Bystrom S, Espehaug B, Furnes O et al (2003) Femoral head size is a risk factor for total hip luxation: a study of 42,987 primary hip arthroplasties from the Norwegian Arthroplasty Register. Acta Orthop Scand 74:514–524

    Article  PubMed  Google Scholar 

  7. D’lima DD, Urquhart AG, Buehler KO et al (2000) The effect of the orientation of the acetabular and femoral components on the range of motion of the hip at different head-neck ratios. J Bone Joint Surg [Am] 82:315–321

    Google Scholar 

  8. Daly PJ, Morrey BF (1992) Operative correction of an unstable total hip arthroplasty. J Bone Joint Surg [Am] 74:1334–1343

    Google Scholar 

  9. Giulieri SG, Graber P, Ochsner PE et al (2004) Management of infection associated with total hip arthroplasty according to a treatment algorithm. Infection 32:222–228

    Article  CAS  PubMed  Google Scholar 

  10. Jolles BM, Zangger P, Leyvraz PF (2002) Factors predisposing to dislocation after primary total hip arthroplasty: a multivariate analysis. J Arthroplasty 17:282–288

    Article  CAS  PubMed  Google Scholar 

  11. Kelley SS, Lachiewicz PF, Hickman JM et al (1998) Relationship of femoral head and acetabular size to the prevalence of dislocation. Clin Orthop Relat Res 163–170

  12. Kim YH, Choi Y, Kim JS (2009) Influence of patient-, design-, and surgery-related factors on rate of dislocation after primary cementless total hip arthroplasty. J Arthroplasty 24:1258–1263

    Article  PubMed  Google Scholar 

  13. Lewinnek GE, Lewis JL, Tarr R et al (1978) Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg [Am] 60:217–220

    Google Scholar 

  14. Mahoney CR, Pellicci PM (2003) Complications in primary total hip arthroplasty: avoidance and management of dislocations. Instr Course Lect 52:247–255

    PubMed  Google Scholar 

  15. Malik A, Maheshwari A, Dorr LD (2007) Impingement with total hip replacement. J Bone Joint Surg [Am] 89:1832–1842

    Google Scholar 

  16. Masonis JL, Bourne RB (2002) Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res:405:46–53

    Google Scholar 

  17. Morrey BF (1992) Instability after total hip arthroplasty. Orthop Clin North Am 23:237–248

    CAS  PubMed  Google Scholar 

  18. Muller M, Crucius D, Perka C et al (2011) The association between the sagittal femoral stem alignment and the resulting femoral head centre in total hip arthroplasty. Int Orthop 35:981–987

    Article  PubMed Central  PubMed  Google Scholar 

  19. Muller M, Tohtz S, Springer I et al (2011) Randomized controlled trial of abductor muscle damage in relation to the surgical approach for primary total hip replacement: minimally invasive anterolateral versus modified direct lateral approach. Arch Orthop Trauma Surg 131:179–189

    Article  PubMed  Google Scholar 

  20. Murray TG, Wetters NG, Moric M et al (2012) The use of abduction bracing for the prevention of early postoperative dislocation after revision total hip arthroplasty. J Arthroplasty 27:126–129

    Article  PubMed  Google Scholar 

  21. Nishii T, Sugano N, Miki H et al (2004) Influence of component positions on dislocation: computed tomographic evaluations in a consecutive series of total hip arthroplasty. J Arthroplasty 19:162–166

    Article  PubMed  Google Scholar 

  22. Orozco F, Hozack WJ (2000) Late dislocations after cementless total hip arthroplasty resulting from polyethylene wear. J Arthroplasty 15:1059–1063

    Article  CAS  PubMed  Google Scholar 

  23. Padgett DE, Warashina H (2004) The unstable total hip replacement. Clin Orthop Relat Res 447:72–79

    Article  Google Scholar 

  24. Parvizi J, Morrey BF (2000) Bipolar hip arthroplasty as a salvage treatment for instability of the hip. J Bone Joint Surg [Am] 82-A:1132–1139

    Google Scholar 

  25. Patel PD, Potts A, Froimson MI (2007) The dislocating hip arthroplasty: prevention and treatment. J Arthroplasty 22:86–90

    Article  PubMed  Google Scholar 

  26. Perka C, Haschke F, Tohtz S (2012) Dislocation after total hip arthroplasty. Z Orthop Unfall 150:e89–e103, quiz e104–e105

    CAS  PubMed  Google Scholar 

  27. Preininger B, Schmorl K, Von Roth P et al (2011) A formula to predict patients‘ gluteus medius muscle volume from hip joint geometry. Man Ther 16:447–451

    Article  PubMed  Google Scholar 

  28. Robbins GM, Masri BA, Garbuz DS et al (2001) Treatment of hip instability. Orthop Clin North Am 32:593–610, viii

    Article  CAS  PubMed  Google Scholar 

  29. Stulberg SD (2011) Dual poly liner mobility optimizes wear and stability in THA: affirms. Orthopedics 34:e445–e448

    PubMed  Google Scholar 

  30. Tohtz SW, Sassy D, Matziolis G et al (2010) CT evaluation of native acetabular orientation and localization: sex-specific data comparison on 336 hip joints. Technol Health Care 18:129–136

    PubMed  Google Scholar 

  31. Turner RS (1994) Postoperative total hip prosthetic femoral head dislocations. Incidence, etiologic factors, and management. Clin Orthop Relat Res 301:196–204

    PubMed  Google Scholar 

  32. Wera GD, Ting NT, Moric M et al (2012) Classification and management of the unstable total hip arthroplasty. J Arthroplasty 27:710–715

    Article  PubMed  Google Scholar 

  33. Wetters NG, Murray TG, Moric M et al (2013) Risk factors for dislocation after revision total hip arthroplasty. Clin Orthop Relat Res 471:410–416

    Article  PubMed  Google Scholar 

  34. Widmer KH, Zurfluh B (2004) Compliant positioning of total hip components for optimal range of motion. J Orthop Res 22:815–821

    Article  PubMed  Google Scholar 

Download references

Einhaltung ethischer Richtlinien

Interessenkonflikt. C. Perka weist auf folgende Beziehungen hin: Berater für Smith & Nephew GmbH, Aesculap, DePuy und Zimmer. B. Preininger und F. Haschke geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Author information

Authors and Affiliations

  1. Centrum für Muskuloskeletale Chirurgie, Klinik für Orthopädie und Klinik für Unfall- und Wiederherstellungschirurgie, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland

    B. Preininger, F. Haschke &  C. Perka

Authors
  1. B. Preininger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. F. Haschke
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. Perka
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to C. Perka.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Preininger, B., Haschke, F. & Perka, C. Diagnostik und Therapie der Luxation nach Hüfttotalprothesenimplantation. Orthopäde 43, 54–63 (2014). https://doi.org/10.1007/s00132-013-2125-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00132-013-2125-x

Schlüsselwörter

Keywords

Search

Navigation