Knorpelschaden und Gonarthrose, Teil IV

Zusammenfassung

Die gelenkerhaltenden operativen Therapiemaßnahmen bei Knorpelschäden oder Gonarthrose können kurz- und mittelfristig effektiv zur Verminderung der Beschwerden führen. Dabei haben arthroskopische Techniken einen hohen Stellenwert. Lavage, Knorpelglättung, Meniskusresektion, Entfernen freier Körper und Osteophytenabtragung sind Maßnahmen des Gelenkdébridements. Die Behandlung isolierter Knorpeldefekte durch knochenmarkstimulierende Techniken (Bohrung, Abrasion, Mikrofrakturierung) führt zur Ausbildung fibrokartilaginärer Regenerate. Dabei können zum Teil sehr gute und gute klinische Ergebnisse erzielt werden. Dies ist ebenso durch die osteochondrale Transplantation möglich. Dieses Verfahren wird jedoch durch begrenzte Kapazität geeigneter Spenderareale und Probleme im Bereich der Defektzonen (Inkongruenz, fehlende intakte Knorpelschulter) limitiert. Innovative Techniken des Tissue Engineerings wie autologe Chondrozytentransplantation mit Periostlappen bzw. als matrix-gekoppelte Verfahren sind zukunftsweisende Methoden. Diese müssen ebenso wie die Behandlung mit Stammzellen und die Gentherapie jedoch ihre Effektivität in langfristigen kontrollierten Studien unter Beweis stellen. Wesentlich für die gelenkerhaltende Therapie bei Knorpelschäden ist die stadienabhängige Auswahl des Verfahrens ebenso wie die Beachtung individueller patientenabhängiger Faktoren.

Abstract

Joint-sparing operative treatment of cartilage lesions and in gonarthritis mostly affects a significant decrease of complaints in short- and middle-term follow-up. Arthroscopic treatments have a high priority. Arthroscopic housecleaning includes joint lavage, chondral debridement, and removal of loose bodies as well as resection of osteophytes. Local deep cartilage defects can be treated by bone-marrow-stimulating techniques. Drilling, abrasion or microfracturing produces fibro-cartilaginous regenerate's mostly excellent or good clinical outcome. Also the transplantation of osteochondral cylinders effects good results. This method limited by limits in the donor capacity, incongruence within the repaired defect zones and large defects without intact cartilage margins. Innovative techniques of tissue engineering (autologous chondrocyte implantation with periostal flaps or matrix-associated) surely are forward-looking methods. But these modern techniques inclusive stem cell implementation or genetic therapies have to demonstrate their effectiveness in controlled long-term clinical trials. The stage-dependent therapy and a carefully patient's selection are essential for the successfully joint-sparing operative therapy.

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