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DOI: 10.1055/s-2003-43125
Georg Thieme Verlag Stuttgart · New York
Defektrekonstruktion bei Tumoren des Knochens und der Gelenke
Reconstruction of Osseous Defects in Tumours of the Bone and JointsPublication History
Publication Date:
24 October 2003 (online)
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Zusammenfassung
Im Rahmen der Behandlung von Knochentumoren entstehen häufig Defekte, die einer Rekonstruktion bedürfen, da sie aufgrund ihrer Größe nicht spontan überbrückt werden. Dabei sind rekonstruktive Überlegungen nachrangig gegenüber den onkologischen Erfordernissen, die sich aus der histologischen Artdiagnose des Tumors, dessen Größe und Lokalisation ergeben. Für einen biologischen Defektaufbau werden autogene oder allogene Knochentransplantate eingesetzt, erstere bei langstreckigem Ersatz auch mit der Option einer vaskulären Anastomosierung. Bei diaphysärer Lokalisation stellt die Kallusdistraktion eine Alternative dar. Knochenersatzmaterialien gewinnen in den letzten Jahren an Bedeutung, erreichen aber noch nicht die biologische Wertigkeit von Transplantaten. Osteoinduktive Proteine befinden sich im Stadium der klinischen Erprobung. Ist eine biologische Wiederherstellung nicht zu erreichen, kommen Endoprothesen, Arthrodesen oder Gelenkresektionen ohne Ersatz in Betracht. Die Abwägung zwischen Extremitätenerhalt und Amputation wird weniger aufgrund der Größe des knöchernen Defektes, sondern abhängig von der Aggressivität und der Ausdehnung der Weichteilkomponente getroffen, da bei malignen Tumoren die Erzielung tumorfreier Absetzungsränder das entscheidende prognostische Kriterium darstellt. Besondere Therapiekonzepte gelten für die Wirbelsäule und das Becken sowie für die Metastasenchirurgie. Eine verantwortungsvolle Indikationsstellung zu einem bestimmten Rekonstruktionsverfahren ist nicht ohne Kenntnis des onkologischen Gesamtkonzeptes möglich.
Abstract
Operative therapy of skeletal neoplasms frequently includes reconstructive measures, since resulting major osseous defects are not bridged spontaneously. However, restoring skeletal integrity has to be compatible with oncological requirements based on histology, size and location of the tumour. For biological reconstruction, autografts and allografts are preferred including vascularised intercalary autografts. In diaphyseal defects distraction osteogenesis has been employed successfully. Bone substitute materials have gained increasing interest. However, so far their potential does not match that of bone grafts. Osteoinductive, morphogenetic proteins are still under clinical investigation. In cases where biological reconstruction is not feasible, alternative methods are joint replacement, arthrodesis or joint resection. Limb salvage depends less on defect size than on aggressiveness of the lesion and soft tissue involvement since in malignant tumours safe surgical margins are crucial for patient survival. Special therapeutic approaches apply for spinal and pelvic tumours as well as for metastatic lesions. Skeletal reconstruction in tumour surgery depends on a thorough knowledge of the underlying oncological therapy concepts.
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OA Dr. M. R. Sarkar
Abteilung für Unfall-, Hand- und Wiederherstellungschirurgie
Universitätsklinikum Ulm
89070 Ulm
Phone: 0731/500-0
Fax: 0731/500-27349
Email: michael.sarkar@medizin.uni-ulm.de