Repozitorij Medicinskog fakulteta Sveučilišta u Zagrebu

Ugradnja endoproteze modificiranim izravnim lateralnim pristupom u bolesnika s izrazitom displazijom kuka [Total hip arthroplasty through a modified direct lateral approach in patients with high hip dysplasia]

Bićanić, Goran (2009) Ugradnja endoproteze modificiranim izravnim lateralnim pristupom u bolesnika s izrazitom displazijom kuka [Total hip arthroplasty through a modified direct lateral approach in patients with high hip dysplasia]. PhD thesis, Sveučilište u Zagrebu.

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    Croatian 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.

    English abstract

    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.

    Item Type: Thesis (PhD)
    Mentor: Delimar, Domagoj
    Divisions: Izvan medicinskog fakulteta
    Depositing User: dr.med. Helena Markulin
    University: Sveučilište u Zagrebu
    Institution: Medicinski fakultet
    Number of Pages: 117
    Status: Unpublished
    Creators:
    CreatorsEmail
    Bićanić, Goran
    Date: 18 December 2009
    Date Deposited: 15 Nov 2012 14:34
    Last Modified: 15 Nov 2012 14:34
    Subjects: WE Musculoskeletal System > WE 800-886 Extremities > WE 850-886 Lower Extremity
    Related URLs:
      URI: http://medlib.mef.hr/id/eprint/1654

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