Prospektive, randomisierte Studie zwischen Bauer- und ALMI-Zugang unter Berücksichtigung von MRI-Befunden und muskelspezifischen Blutparametern

Zusammenfassung

Fragestellung: Ziel der vorliegenden Studie war es zu überprüfen, inwieweit Unterschiede bei kernspintomografischen Muskelbefunden zwischen dem Standardzugang nach Bauer und ALMI-Zugang vorliegen. Material und Methode: Untersucht wurden 2 Patientenkollektive, denen über den konventionellen oder minimalinvasiven Zugang (ALMI) dieselbe Hüftendoprothese implantiert wurden. Alle Operationen erfolgten durch 2 erfahrene Operateure mit mehr als 1200 ALMI-Operationen. Es wurden 47 Patienten in die Studie aufgenommen. Beide Patientengruppen unterschieden sich präoperativ nicht in ihrer Alters- und Geschlechtsstruktur sowie hinsichtlich der operierten Seite. Die MRT-Untersuchungen wurden mit einem Philips Outlook Proview (0,23 Tesla Niederfeld) in standardisierter Technik präoperativ, innerhalb von 2 Wochen postoperativ und nach 14 Monaten durchgeführt. Die Auswertungen der MRI-Befunde erfolgten durch 2 unabhängige und verblindete Untersucher. Zur Dokumentation eines Muskelschadens wurden Myoglobin (bei Aufnahme, 6 Stunden postoperativ und am 1. Post-Operationstag) und Troponin (6 Stunden postoperativ) dokumentiert. Ergebnisse: Präoperativ zeigte sich bei den Männern ein signifikant größerer Durchmesser des M. gluteus medius. Weiterhin fand sich schon präoperativ bei vielen Patienten eine fettige Degeneration in der Muskulatur. Postoperativ zeigten sich geringe, jedoch nicht signifikante Unterschiede bezüglich des Ausmaßes der degenerativen Verfettung. Es fanden sich auch keine Unterschiede im Ausmaß der Muskelvolumenatrophie. Präoperativ vorliegende Muskelödeme waren zum Zeitpunkt der Nachuntersuchung nicht mehr nachweisbar. Zwei Patienten zeigten schon präoperativ eine Läsion der Glutaeus-medius-Sehne. Die Schwankungsbreite des postoperativen Myoglobinspiegels war sehr hoch (Range 118–5411 µg/l), in der ALMI-Gruppe beträgt die Standardabweichung 1445 µg/l, in der konventionellen Gruppe immerhin noch 738 µg/l, was eine sichere Interpretation schwierig macht. Ein statistisch signifikanter Unterschied lag nicht vor. Vergleichbare Befunde zeigten sich für den Troponinwert. Fazit und klinische Relevanz: Schon vor der Implantation einer Hüftendoprothese zeigen sich bei vielen Patienten deutliche Veränderungen in der Hüftmuskulatur im Rahmen der Kernspintomografie. Während Ödeme in den Muskeln offensichtlich rasch zurückgehen, kommt es nicht zu einer Reduktion der präoperativ schon vorliegenden fettigen Degeneration. Dieses gilt sowohl für den ALMI- als auch für den Bauer-Zugang.

Abstract

Purpose: The purpose of the present study was to evaluate the MRI of the hip musculature as well as specific blood parameters on comparison of the Bauer approach with the minimally invasive ALMI approach. Material and Methods: We compared two patient groups after total hip replacement, which were operated either via the Bauer or the ALMI approach. All 47 patients had the same cementless hip design. All surgeries were performed by two experienced hip surgeons with experience of more than 1200 ALMI approaches. The patient groups did not differ concerning age, sex or side which was operated on. All MRI were performed in a standardised technique with a Philips Outlook Proview (0.23 Tesla). Patients were scanned preoperatively, within 2 weeks after surgery and at time of follow-up 14 months after surgery. The evaluation of the MRI findings was performed by two independent and blinded examiners. In order to document the muscle damage we documented myoglobin (the day before surgery, 6 hours postoperatively and at the first postop. day) und troponin (6 hours postoperatively). Results: Preoperatively the male patients showed a significantly larger diameter of the gluteus medius muscle. We also could demonstrate in many patients a fatty degeneration even before surgery. At time of follow-up there was no significant difference between the two patient populations concerning the fatty degeneration. There was also no significant difference concerning the muscle atrophy. Muscle oedema, that was present before surgery, however, was no longer present at the time of follow-up. Two patients even preoperatively showed a lesion of the gluteus medius tendon. The range of the postoperative myoglobin level was high (118–5411 µg/L), in the ALMI group the standard deviation was 1445 µg/L, in the Bauer group it was 738 µg/L. There was no significant difference between both groups. Similar findings were documented for the troponin levels. Conclusion and Clinical Relevance: Even before THR many patients show significant degeneration in the hip muscles. Muscle oedema that was present before surgery had disappeared at the time of follow-up. The fatty degeneration was still present at the time of follow-up. There was no difference concerning the muscle atrophy between the ALMI and the Bauer groups.

Schlüsselwörter

Hüftendoprothese - minimalinvasiver Zugang - ALMI - Muskulatur - MRI

Key words

total hip replacement - minimal invasive appoach - ALMI - musculature - MRI

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