Pathophysiologie und aktuelle Behandlungskonzepte bei ausgewählten Osteonekrosen

Zusammenfassung

Osteonekrosen treten sowohl beim heranwachsenden als auch ausgewachsenem Skelett meist an prädisponierenden Lokalisationen mit Bevorzugung der Epiphysen auf. Pathophysiologisch unterscheidet man neben einer idiopathischen Form zwischen einer primär vaskulären (Thromboembolien, Hämoglobinopathien usw.) und einer toxischen (Cortison, Alkohol, Chemotherapeutika usw.) Genese. Unabhängig der Ätiologie resultiert eine Nekrose der Knochentrabekel und des angrenzenden Knochenmarks sowie eine Ödembildung. Durch avaskuläre Umbauvorgänge bildet sich eine Fibrose und mechanisch instabiler Geflechtknochen aus, sodass es im Verlauf zu einer subchrondralen Fraktur und einem Gelenkkollaps kommt. Insbesondere bei Beteiligung großer Gelenke resultieren sekundär arthrotische Deformitäten, sodass insbesondere die Hüftkopfnekrose sowie die fokale subchondrale Osteonekrose und Osteochondrosis dissecans des Knies von klinischer Bedeutung sind. Diagnostisch ist neben der nativ-radiologischen Röntgendiagnostik die Magnetresonanztomographie mit der charakteristischen Darstellung des „Sichelzeichens“ entscheidend. Therapeutisch können als konservative Maßnahmen lediglich periphere Vasodilatatoren oder Bisphosphonate als off-label use Schmerzen reduzieren und die Zeit bis zum Gelenkflächenkollaps verhindern, wohingegen die hyperbare Sauerstofftherapie, die Stoßwellentherapie, Antikoagulanzien und Statine allgemein nicht angewendet werden sollten. Die Standardtherapie in frühen Stadien ist die retrograde Anbohrung mit der Zielsetzung einer Ödementlastung und einer Unterbrechung der Sklerosezone zur Revaskularisation. Weitere operative Maßnahmen wie Umstellungsosteotomien, vaskularisierte Knochentransplantate sowie Knorpelplastiken sind möglich, wobei diese mit dem prothetischem Gelenkersatz konkurrieren.

Abstract

Osteonecrosis occurs in both children and adults with the main focus on the epiphysis as a predisposed location. Pathophysiologically, a distinction is made between primary vascular (thromboembolism, haemoglobinopathy etc.), toxic (alcohol, cortisone, chemotherapeutic agents) and idiopathic origin. Independently of the aetiology, osteonecrosis leads to necrosis of the bone trabeculae and the adjacent bone marrow as well as oedema formation. Avascular remodelling causes fibrosis and the formation of mechanically unstable woven bone, leading to a subchrondral fracture and a collapse of the joint surface. Especially if large joints are involved, secondary osteoarthritic deformities occur, so femoral head necrosis, focal subchondral osteonecrosis and osteochondrosis dissecans of the knee are of clinical significance. X-ray and MRI are crucial diagnostic procedures. The treatment of osteonecrosis is challenging. For conservative therapy, the off-label use of peripheral vasodilators and bisphosphonates may reduce pain and time to articular collapse, whereas hyperbaric oxygen therapy, shockwave therapy, anticoagulants and statins are not recommended. Standard treatment in early stages focuses on retrograde drilling aimed at reducing oedema and breaking down the sclerosis zone to establish a process of revascularisation. Further operative options such as corrective osteotomies, vascularized bone grafts and cartilage remodelling surgery are possible, but they compete with prosthetic joint replacement and are inferior, especially in progressive stages.

Schlüsselwörter

Osteonekrosen - Femurkopfnekrose - fokale subchondrale Nekrose - Osteochondrosis dissecans - Talusnekrosen

Key words

osteonecrosis - femoral head necrosis - focal subchondral necrosis - osteochondrosis dissecans - talus necrosis

• Literatur

• 1 Krenn V, Muller S, Krenn VT. et al. Pathophysiology of aseptic femoral head necrosis: Pathogenesis and histopathological differential diagnosis. Orthopade 2018; 47: 710-716
• 2 Skeletterkrankungen JF. Berlin Heidelberg; 2016
• 3 Uchio Y, Ochi M, Adachi N. et al. Intraosseous hypertension and venous congestion in osteonecrosis of the knee. Clin Orthop Relat Res 2001; DOI: 217-223.
• 4 Mont MA, Cherian JJ, Sierra RJ. et al. Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update. J Bone Joint Surg Am 2015; 97: 1604-1627
• 5 Kijowski R, Blankenbaker DG, Shinki K. et al. Juvenile vs. adult osteochondritis dissecans of the knee: appropriate MR imaging criteria for instability. Radiology 2008; 248: 571-578
• 6 Accadbled F, Vial J, Sales de Gauzy J. Osteochondritis dissecans of the knee. Orthop Traumatol Surg Res 2018; 104: S97-S105
• 7 Uozumi H, Sugita T, Aizawa T. et al. Histologic findings and possible causes of osteochondritis dissecans of the knee. Am J Sports Med 2009; 37: 2003-2008
• 8 Bohndorf K, Beckmann J, Jager M. et al. S3 Guideline. Part 1: Diagnosis and Differential Diagnosis of Non-Traumatic Adult Femoral Head Necrosis. Z Orthop Unfall 2015; 153: 375-386
• 9 Mont MA, Zywiel MG, Marker DR. et al. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am 2010; 92: 2165-2170
• 10 Arbab D, Konig DP. Atraumatic Femoral Head Necrosis in Adults. Dtsch Arztebl Int 2016; 113: 31-38
• 11 Roth A, Beckmann J, Bohndorf K. et al. Update of the German S3 guideline on atraumatic femoral head necrosis in adults. Orthopade 2018; 47: 757-769
• 12 Vardhan H, Tripathy SK, Sen RK. et al. Epidemiological Profile of Femoral Head Osteonecrosis in the North Indian Population. Indian J Orthop 2018; 52: 140-146
• 13 Maus U, Roth A, Tingart M. et al. S3 Guideline. Part 3: Non-Traumatic Avascular Necrosis in Adults – Surgical Treatment of Atraumatic Avascular Femoral Head Necrosis in Adults. Z Orthop Unfall 2015; 153: 498-507
• 14 Roth A, Beckmann J, Smolenski U. et al. S3 guideline. Part 2: Non-Traumatic Avascular Femoral Head Necrosis in Adults – Untreated Course and Conservative Treatment. Z Orthop Unfall 2015; 153: 488-497
• 15 Aigner N, Petje G, Schneider W. et al. Bone marrow edema syndrome of the femoral head: treatment with the prostacyclin analogue iloprost vs. core decompression: an MRI-controlled study. Wien Klin Wochenschr 2005; 117: 130-135
• 16 Kang P, Pei F, Shen B. et al. Are the results of multiple drilling and alendronate for osteonecrosis of the femoral head better than those of multiple drilling? A pilot study. Joint Bone Spine 2012; 79: 67-72
• 17 Mont MA, Ragland PS, Etienne G. Core decompression of the femoral head for osteonecrosis using percutaneous multiple small-diameter drilling. Clin Orthop Relat Res 2004; DOI: 131-138.
• 18 Yoo MC, Kim KI, Hahn CS. et al. Long-term followup of vascularized fibular grafting for femoral head necrosis. Clin Orthop Relat Res 2008; 466: 1133-1140
• 19 Eward WC, Rineer CA, Urbaniak JR. et al. The vascularized fibular graft in precollapse osteonecrosis: is long-term hip preservation possible?. Clin Orthop Relat Res 2012; 470: 2819-2826
• 20 Betsch M, Tingart M, Driessen A. et al. Total hip replacement in avascular femoral head necrosis. Orthopade 2018; 47: 751-756
• 21 Ahlback S, Bauer GC, Bohne WH. Spontaneous osteonecrosis of the knee. Arthritis Rheum 1968; 11: 705-733
• 22 Bhatnagar N, Sharma S, Gautam VK. et al. Characteristics, management, and outcomes of spontaneous osteonecrosis of the knee in Indian population. Int Orthop 2018; 42: 1499-1508
• 23 Pape D, Seil R, Fritsch E. et al. Prevalence of spontaneous osteonecrosis of the medial femoral condyle in elderly patients. Knee Surg Sports Traumatol Arthrosc 2002; 10: 233-240
• 24 Pape D, Hoffmann A, Kohn D. [Femoral osteonecrosis – Ahlbaeck's disease]. Radiologe 2012; 52: 1023-1029
• 25 Mont MA, Baumgarten KM, Rifai A. et al. Atraumatic osteonecrosis of the knee. J Bone Joint Surg Am 2000; 82: 1279-1290
• 26 Di Caprio F, Meringolo R, Navarra MA. et al. Postarthroscopy Osteonecrosis of the Knee: Current Concepts. Joints 2017; 5: 229-236
• 27 al-Rowaih A, Bjorkengren A, Egund N. et al. Size of osteonecrosis of the knee. Clin Orthop Relat Res 1993; DOI: 68-75.
• 28 Robertson DD, Armfield DR, Towers JD. et al. Meniscal root injury and spontaneous osteonecrosis of the knee: an observation. J Bone Joint Surg Br 2009; 91: 190-195
• 29 Muscolo DL, Costa-Paz M, Ayerza M. et al. Medial meniscal tears and spontaneous osteonecrosis of the knee. Arthroscopy 2006; 22: 457-460
• 30 Reddy AS, Frederick RW. Evaluation of the intraosseous and extraosseous blood supply to the distal femoral condyles. Am J Sports Med 1998; 26: 415-419
• 31 Yamamoto T, Bullough PG. Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg Am 2000; 82: 858-866
• 32 Akamatsu Y, Mitsugi N, Hayashi T. et al. Low bone mineral density is associated with the onset of spontaneous osteonecrosis of the knee. Acta Orthop 2012; 83: 249-255
• 33 Aglietti P, Insall JN, Buzzi R. et al. Idiopathic osteonecrosis of the knee. Aetiology, prognosis and treatment. J Bone Joint Surg Br 1983; 65: 588-597
• 34 Mont MA, Marker DR, Zywiel MG. et al. Osteonecrosis of the knee and related conditions. J Am Acad Orthop Surg 2011; 19: 482-494
• 35 Karim AR, Cherian JJ, Jauregui JJ. et al. Osteonecrosis of the knee: review. Ann Transl Med 2015; 3: 6
• 36 Yates PJ, Calder JD, Stranks GJ. et al. Early MRI diagnosis and non-surgical management of spontaneous osteonecrosis of the knee. Knee 2007; 14: 112-116
• 37 Jureus J, Lindstrand A, Geijer M. et al. Treatment of spontaneous osteonecrosis of the knee (SPONK) by a bisphosphonate. Acta Orthop 2012; 83: 511-514
• 38 Meier C, Kraenzlin C, Friederich NF. et al. Effect of ibandronate on spontaneous osteonecrosis of the knee: a randomized, double-blind, placebo-controlled trial. Osteoporos Int 2014; 25: 359-366
• 39 Ollivier M, Jacquet C, Lucet A. et al. Long-Term Results of Medial Unicompartmental Knee Arthroplasty for Knee Avascular Necrosis. J Arthroplasty 2019; 34: 465-468
• 40 Myers TG, Cui Q, Kuskowski M. et al. Outcomes of total and unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee. J Bone Joint Surg Am 2006; 88 Suppl 3 76-82
• 41 Gross CE, Sershon RA, Frank JM. et al. Treatment of Osteonecrosis of the Talus. JBJS Reviews: July 12, 2016; 4: 7 doi: 10.2106/JBJS.RVW.15.00087
• 42 Canale ST, Kelly Jr FB. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978; 60: 143-156
• 43 Ahmad J, Raikin SM. Current concepts review: talar fractures. Foot Ankle Int 2006; 27: 475-482
• 44 Dhillon MS, Rana B, Panda I. et al. Management Options in Avascular Necrosis of Talus. Indian J Orthop 2018; 52: 284-296
• 45 Hefti F, Beguiristain J, Krauspe R. et al. Osteochondritis dissecans: a multicenter study of the European Pediatric Orthopedic Society. J Pediatr Orthop B 1999; 8: 231-245
• 46 Dipaola JD, Nelson DW, Colville MR. Characterizing osteochondral lesions by magnetic resonance imaging. Arthroscopy 1991; 7: 101-104
• 47 Rath B, Eschweiler J, Betsch M. et al. Cartilage repair of the knee joint. Orthopade 2017; 46: 919-927
• 48 Bruns J, Werner M, Habermann C. Osteochondritis Dissecans: Etiology, Pathology, and Imaging with a Special Focus on the Knee Joint. Cartilage 2018; 9: 346-362
• 49 Sales de Gauzy J, Mansat C, Darodes PH. et al. Natural course of osteochondritis dissecans in children. J Pediatr Orthop B 1999; 8: 26-28
• 50 Schenker H, Wild M, Rath B. et al. Current overview of cartilage regeneration procedures. Orthopade 2017; 46: 907-913