Knorpelersatzverfahren und Regeneration am Knie- und Hüftgelenk

Die operative Therapie von Knorpelschäden am Kniegelenk hat sich in den letzten Jahren von vorsichtigen Anfängen mit innovativen Therapieansätzen zu einem festen und etablierten Baustein der gelenkerhaltenden Therapie entwickelt. Hingegen hat sich am Hüftgelenk erst in den letzten 10 Jahren, basierend auf einem erweiterten Verständnis grundlegender mechanischer Pathomechanismen, die gelenkerhaltende Hüftchirurgie und insbesondere die Knorpeltherapie etabliert. Der Beitrag stellt die zur Verfügung stehenden Techniken vor.

Kernaussagen

• Die Indikation zu knorpelregenerativen Verfahren wird von verschiedenen Faktoren beeinflusst: Defektstadium und -lokalisation, Anzahl der Defekte, Kontraindikationen wie z. B. schwere Arthrose und rheumatologische Erkrankungen.

• Die Wahl des Verfahrens wiederum hängt vor allem von der Defektgröße, aber auch von der Defektmorphologie, dem Patientenalter, den zugrunde liegenden Ursachen und dem sportlichen Anspruch ab.

• Die Mikrofrakturierung wird immer noch eingesetzt: bei fokalen Läsionen < 2,5 cm² und bei Patienten mit niedrigerem funktionellem Anspruch. Die Mikrofrakturierung mit Matrix oder auch Matrix-augmented Bone Marrow Stimulation (mBMS) stellt die Weiterentwicklung des Verfahrens dar.

• Die autologe Chondrozytentransplantation (ACT) ist der Goldstandard für die Behandlung von fokalen Knorpelschäden > 2,5 cm² am Kniegelenk und > 2 cm² am Hüftgelenk. Als zweizeitiges Verfahren folgt auf die arthroskopische Entnahme der Knorpelzellen die In-vitro-Expansion und anschließend die Applikation der Zellen.

• Die osteochondrale Transplantation (OCT) stellt für kleine osteochondrale Defekte (< 3 cm²) insbesondere an den Femurkondylen, die mit möglichst einem Knochenzylinder zu behandeln sind, eine zuverlässige Therapieoption dar. Aufgrund der Limitationen in der Indikation und der nicht zu vernachlässigenden Entnahmemorbidität hat sie in den letzten Jahren jedoch an Bedeutung verloren.

• Nur ein geringer Anteil der Knorpelschäden kann als echter traumatischer Knorpelschaden eingestuft werden. Häufig liegt ursächlich eine Fehlstellung und/oder eine strukturelle Schwächung des Gelenks vor. Im Sinne des Prinzips der Behandlung der Ursache und nicht nur des Symptoms besteht ein steigender Bedarf an Begleitoperationen.

• Die Rehabilitation nach einer knorpelregenerativen Behandlung ist für das Behandlungsergebnis essenziell, wobei die Empfehlungen zur Rehabilitation noch auf niedrigerer Evidenz beruhen.

• Die Nachbehandlung gliedert sich in die 3 Phasen Proliferationsphase (Woche 0 – 6), Übergangsphase (Woche 6 – 12) und Remodellierungsphase (Woche 12 – 26). Die Dauer bis zur Rückkehr in den Leistungssport kann aufgrund der langen Remodellierungsphase bis zu 1 Jahr betragen.

Schlüsselwörter

fokaler Knorpelschaden - Gelenkerhalt - Mikrofrakturierung - Knochenmarkstimulation - autologe Chondrozytentransplantation - osteochondrale Transplantation

Publication History

Article published online:
11 August 2021

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