| Abstract | Ugradnja totalne endoproteze displastičnog kuka odraslih je zahtjevan ortopedski zahvat.
Brojni članci objavljeni na tu temi još i danas upućuju na nepostojanje takozvanog zlatnog
standarda u operativnom liječenju displazija. Osobito su raznolike tehnike za operaciju displazija
visokog stupnja (3 i 4 po Crowe-u). Opisane tehnike pokazuju i različite ishode liječenja.
S tim u vezi, cilj ovog rada je vrednovati novi operacijski pristup razvijen u Klinici za
ortopediju Medicinskog fakulteta Sveučilišta u Zagrebu i Kliničkog bolničkog centra Zagreb. Taj
pristup ima prednost u odnosu na ostale u tome što osigurava odličnu preglednost operacijskog
polja, čuva abduktornu muskulaturu i omogućuje dodatno skraćenje femura ukoliko je to
potrebno radi balansa mekih tkiva i postizanja jednake duljine ekstremiteta. Ovim pristupom je
također olakšana rekonstrukcija centra rotacije kuka uz implantaciju acetabularnog dijela
endoproteze kuka u pravi acetabulum sve uz očuvanje snage muskulature što bitno pridonosi
kasnijem funkcionalnom statusu bolesnika.
Nakon odobrenja nadležnih etičkih povjerenstava, uspješnost novog operacijskog pristupa
provjerena je prospektivno na 28 odraslih bolesnika s displazijom kuka (starijih od 18 godina)
kojima je predviđena ugradnja totalne endoproteze zbog sekundarne artroze displastičnog kuka.
U istraživanje su uključivani nakon što su upoznati sa svrhom i protokolom istraživanja te nakon
što su potpisali informirani pristanak. Bolesnici su podijeljeni u ispitivanu (visoki stupanj
displazije, 3. i 4. po Crowe-u, 14 bolesnika) i kontrolnu skupinu (blagi stupanj displazije, 1. i 2.
po Crowe-u, 14 bolesnika) te su testirani prije operacije i minimalno 6 mjeseci nakon operacije.
Novi modificirani lateralni pristup vrednovan je u odnosu na rezultate uobičajenog lateralnog
pristupa po Baueru i Hardinge-u, ali kod bolesnika s nižim (blažim) stupnjevima displazije
(Crowe 1 i 2). Analiza rezultata je pokazala da ne postoje značajne razlike u rezultatima
dobivenim poslijeoperacijskim testiranjem bolesnika. Testiranje je obuhvatilo različite čimbenike
poput vrednovanja općeg i funkcionalnog statusa bolesnika, mjerenja opsega pokreta, snage i
stabilnosti bolesnika. U obje skupine, ispitivanoj (Crowe 3 i 4) i kontrolnoj (Crowe 1 i 2) dolazi
87
do značajnog poboljšanja u odnosu na vrednovanje izvršeno prije operacije, te nema razlike u
poslijeoperacijskim rezultatima između ispitivanih skupina.
Iz toga proizlazi da je novi modificirani lateralni pristup jednako dobar za bolesnike s
visokim stupnjem displazije (Crowe 3 i 4) kao i uobičajeni lateralni pristup za bolesnike s nižim
stupnjem displazije (Crowe 1 i 2). S obzirom na podatke iz literature proizlazi i da je novi
modificirani lateralni pristup bolji za bolesnike s visokim stupnjem displazije (Crowe 3 i 4) od
uobičajenog lateralnog pristupa.
Procijenjene su prednosti i nedostatci novog operacijskog pristupa za bolesnike s teškim
stupnjevima displazije (Crowe 3 i 4), te je utvrđeno da se korištenjem novog pristupa u bolesnika
s teškim stupnjevima displazije (Crowe 3 i 4) postižu razultati kao i kod bolesnika s blažim
stupnjevima displazije (Crowe 1 i 2) što do sada nije bio slučaj jer su rezultati nakon ugradnje
totalne endoproteze kuka u bolesnika s teškim stupnjevima displazije (Crowe 3 i 4) bili značajno
lošiji (što se objašnjavalo velikim anatomskim promjenama kod visokih displazija i zahtjevnim
operacijskim tehnikama). Nadalje, kao smjernice u operacijskom liječenju odraslih bolesnika s
displazijom kuka predlaže se korištenje uobičajenog lateralnog pristupa po Baueru ili Hardinge-u
za bolesnike s blažim stupnjevima displazije (Crowe 1 i 2), te korištenje novog modificiranog
lateralnog pristupa za liječenje bolesnika s teškim stupnjevima displazije (Crowe 3 i 4). Također se
za bolesnike s teškim stupnjevima displazije (Crowe 3 i 4) preporuča fizikalna terapija koja bi
obuhvatila vježbe jačanja natkoljene i pelvitrohanterne muskulature, te rad na posturalnoj
stabilnosti bolesnika čak i više od 6 mjeseci nakon operacije kako bi se u potpunosti postigla
snaga i opseg pokreta usporediv sa zdravom (neoperiranom) nogom. |
| Abstract (english) | Total hip arthroplasty in patients with high hip dysplasia is a demanding procedure. There is
still no golden standard for operative treatment of patients with high hip dysplasia, although the
topic is often discussed in the literature. A significant number of different techniques are
proposed for operative treatment of patients with secondary osteoarthritis due to high hip
dysplasia (Crowe 3 and 4). Described techniques offer various treatment outcomes.
Therefore, the aim of this study is to evaluate new operative approach which was developed
at Department of Orthopaedic Surgery, School of Medicine, University of Zagreb, and Clinical
Hospital Centre Zagreb. This approach has advantage over others because it allows for excellent
view of the operative field, it protects hip abductors and it allows additional femoral shortening if
it is necessary for soft tissue balance and leg length equalization. With this approach
reconstruction of the hip rotation centre is much easier and implantation of the acetabular cup in
the level of the true acetabulum is possible. All that is possible while preserving strength of the
muscles (especially abductors) which considerably contribute to later better functional status of
the patients.
After approval of the relevant Ethical Committees, new approach was prospectively analyzed
in a group of 28 patients with secondary hip arthritis due to hip dysplasia which were scheduled
for the total hip arthroplasty. They were included in the study after they were informed about the
study protocol and after they signed informed consent. Patients were divided in two groups; test
group (patients with severe hip dysplasia, Crowe 3 and 4, 14 patients) and control group (patients
with mild hip dysplasia, Crowe 1 and 2, 14 patients) and were tested before the operation and at
least 6 months after the operation. New modified direct lateral approach was evaluated and
compared to standard lateral approach according to Bauer and Hardinge which was used in
89
patients with secondary arthritis due to mild dysplasia (Crowe 1 and 2). Analysis of the results
showed that there is no significant difference between the groups after the operation. Various test
were performed, evaluation of the functional status and general health status, range of motion,
strength and stability. Results for both groups, test group (Crowe 3 and 4) and control group
(Crowe 1 and 2) were significantly better after the operation and there were no difference
between the groups in the postoperative results.
Therefore, the conclusion is that the new modified direct lateral approach is suitable for
patients with secondary hip arthritis due to severe hip dysplasia (Crowe 3 and 4), and standard
direct lateral approaches are suitable for patients with secondary hip arthritis due to mild hip
dysplasia (Crowe 1 and 2). When compared with the published data new approach is much better
for patients with severe dysplasia than standard lateral approaches.
The study evaluated advantages and disadvantages of the new operative approach for total hip
arthroplasty in patients with secondary hip arthritis due to hip dysplasia. The conclusion is that
with new operative approach in patients with severe dysplasia (Crowe 3 and 4) postoperative
results are comparable with postoperative results in patients with mild dysplasia (Crowe 1 and 2)
operated with standard lateral approaches, which until now was not the case since postoperative
results after total hip arthroplasty in patients with severe dysplasia (Crowe 3 and 4) were much
worse (it was believed that this is due to gross anatomical changes in severe dysplasia and because
of demanding operative techniques). Furthermore, new algorithm is proposed for operative
treatment of patients with secondary hip arthritis due to hip dysplasia. Standard lateral
approaches such as Bauer or Hardinge approach should be used for the treatment of patients with
mild dysplasia (Crowe 1 and 2) and new modification of direct lateral approach should be used
for the treatment of the patients with severe hip dysplasia (Crowe 3 and 4). Finally, for patients
with severe hip dysplasia (Crowe 3 and 4) prolonged physical therapy, which should include
strengthening of the muscles of the thigh and pelvis and postural balance exercises, is proposed
even 6 months after the operation in order to fully restore strength and range of motion
comparable to the healthy (nonoperated) leg. |
