Mini-open-Verfahren zeigt gute Ergebnisse in der Therapie des femoroazetabulären Impingements

Zusammenfassung

Hintergrund In der Therapie des femoroazetabulären Impingements (FAI) hat die Arthroskopie als minimalinvasives Verfahren mit geringem Weichteilschaden in den letzten Jahren einen deutlichen Aufschwung erfahren. Nachteile der Arthroskopie sind bekanntlich die lange Operationsdauer und flache Lernkurve des Operateurs. Das Mini-open-Verfahren stellt demgegenüber eine mögliche Alternative dar. Kritisch diskutiert werden der Einfluss des größeren Weichteileingriffs der Mini-open-Technik auf das Outcome sowie das noch ungenügende Follow-up der vorliegenden Ergebnisse. Ziel dieser Studie war daher die Evaluation des Outcomes nach Mini-open-Verfahren im mittleren Follow-up und die Gegenüberstellung desselben mit den Ergebnissen des arthroskopischen Verfahrens in der Literatur.

Patienten, Material und Methodik Es erfolgte eine retrospektive Nachuntersuchung (Follow-up 40,5 Monate) von 99 Patienten (105 Hüften, 40 Frauen, 59 Männer), die sich aufgrund eines klinisch und radiologisch gesicherten FAI zwischen 2005 und 2012 einer Mini-open-Operation unterzogen. Im Fokus der Untersuchung standen die prä- und postoperative Schmerzintensität (NRS: numerische Rating-Skala), das klinische und funktionelle Outcome sowie die Änderung des sportlichen Verhaltens und die Zufriedenheit der Patienten. Die radiologische Auswertung (HNO [Head-Neck-Offset], Alphawinkel, Arthrosegrad) erfolgte anhand präoperativer, direkt postoperativer und zum Follow-up vorliegender Röntgenbilder.

Ergebnisse Der präoperative NRS konnte von 6,5 ± 2,3 auf durchschnittlich 2,3 ± 2,6 gesenkt werden (p < 0,001). Der modifizierte Harris Hip Score (mHHS) stieg von 69,2 auf 85,2 Punkte. Der HOS-ADL (HOS: Hip Outcome Score, ADL: „Activities of Daily Life“) betrug zum Follow-up 82,2 %, der HOS-Sport 69,7 %. Die Rückkehrrate zur sportlichen Aktivität betrug 93 % jedoch war ein deutlicher Rückgang der High-Impact-Sportarten und eine Zunahme der Low-Impact-Sportarten zu verzeichnen. Der Alphawinkel konnte in physiologische Bereiche korrigiert werden). In 17,6 % der Fälle konnte zum Follow-up eine Arthroseprogredienz festgestellt werden. Patienten mit bereits manifester Koxarthrose (Kellgren-Lawrence-Grad ≥ 2) hatten ein signifikant schlechteres Outcome als Patienten ohne manifeste Arthrose (Kellgren-Lawrence ≤ 1).

Schlussfolgerung Die Mini-open-Technik stellt ein effektives und sicheres Verfahren in der Therapie des femoroazetabulären Impingements dar. Es weist im mittelfristigen Follow-up gute Ergebnisse auf, äquivalent dem arthroskopischen Verfahren und ermöglicht die Rückkehr zur sportlichen- und Alltagsaktivität. Da Patienten mit manifester Koxarthrose nur unzureichend von diesem Vorgehen profitieren, sollte die Indikation zur Mini-open-Operation in diesen Fällen zurückhaltend gestellt werden.

Abstract

Background Femoroacetabular impingement (FAI) describes a painful, abnormal (bony) contact between the femoral neck and acetabulum, which, if left untreated, contributes to early osteoarthritis (OA) of the hip. Despite its flat learning curve and long operation times, hip arthroscopy has been used increasingly often in recent years in the surgery of femoroacetabular impingement. The mini-open technique (MOT) offers a possible alternative that addresses the abnormal morphological prominence and allows minimally invasive clearance of hip motion. There is still a lack of information on the influence of the greater degree of soft tissue intrusion inherent to the mini-open approach. Therefore we decided to evaluate the medium-term outcome of the mini-open technique and to compare the results to those of the arthroscopic technique reported in the literature.

Patients, Material und Methods 99 patients (105 hips, 40 women, 59 men) underwent mini-open surgical treatment for FAI between 2005 and 2012 and were followed-up for an average of 40.5 months. The evaluation focused on the pre- and postoperative pain intensity (NRS: numeric rating scale), the clinical and functional outcomes such as ROM (range of motion), HOS (Hip Outcome Score) and mHHS (modified Harris Hip Score), changes in athletic behaviour and the satisfaction of the patients. Radiological analysis (α-angle, anterior head-neck-offset (HNO), head-neck-offset ratio, ossification, grade of OA) was performed using preoperative, immediate postoperative as well as follow-up radiographs. Finally our results were compared to those reported for the arthroscopic technique in the literature.

Results The average pain level decreased from 6.5 ± 2.3 to 2.3 ± 2.6 (p < 0.001). 80 % (84) confirmed a mean postoperative pain-free period of 29.5 months (2–103 months), and 52.4 % (55) were still almost pain-free by the time of the final follow-up. The mHHS increased from 68.2 ± 13.5 to 85.2 ± 18.2 (p < 0.001). The HOS-ADL (ADL: activities of daily life) was 82.2 % ± 19.7 and the HOS-sport was 69.7 % ± 27.9 at the final follow-up. At the time of the last follow-up, 93 % of the preoperatively active patients (n = 84) returned to athletic activities (n = 78). In a comparison of athletic behaviour, significantly fewer patients were performing high-impact and more patients were performing low-impact sports after surgery. Flexion (113°±16 to 117°±16) and internal rotation (12°±8 to 25°±12) improved significantly. α-angle reduction from 62°±11 to 42°± 9 (p < 0.01) was observed. The HNO increased from 3.8 mm ± 3.2 to 10.7 mm ± 3.2. In 17.6 % of the cases, progression of OA was noticed. Patients with initial OA Kellgren ≥ 2 showed significantly worse outcome than those without OA.

Conclusion MOT is a safe and effective alternative for treating FAI. It leads to recovery of pain-free hip function in short- and medium-term follow-up and allows a return to practicing sports in most cases. Patients with preoperative OA ≥ 2 seem to experience insufficient gains from MO surgery, so surgeons should be reluctant to apply the technique under these circumstances.

Schlüsselwörter

Hüftgelenk - femoroazetabuläres Impingement - FAI - Mini-open-Zugang - Koxarthrose - Outcome

Key words

hip joint - femoroacetabular impingement - FAI - mini-open approach - osteoarthritis - outcome

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