Revisionsendoprothetik des Kniegelenks

Zusammenfassung

Die Kombination aus steigender Lebenserwartung, Zunahme der Risikofaktoren für eine Gonarthrose gepaart mit hohem funktionellem Anspruch bis ins hohe Lebensalter führt zu einer Zunahme der Implantationszahlen primärer Knieendoprothesen. Folglich nimmt auch die Häufigkeit von Revisionseingriffen drastisch zu. Klare Konzepte sind notwendig, um gute Ergebnisse zu erzielen. Dieser Artikel gibt einen Überblick über die aktuellen Strategien der Revisionsendoprothetik des Kniegelenks.

Abstract

In addition to periprosthetic infections (PJI), the reconstruction of bony defects is the major challenge of revision total knee arthroplasty (TKA). Infection should be ruled out in all cases prior to operation. Revision TKA requires intensive planning with regard to the needed augmentation possibilities and the stems to be used. The sole biological reconstruction of major defects (AORI II and III) shows high failure rates. Large defects must be augmented by metal (wedges/sleeves/cones). The concept of zonal anchorage (3-zone model) with a stable anchorage in 2 out of 3 zones as close to the joint as possible is currently the standard. According to the model, metaphysis (zone 2) is an increasingly important factor for long-term stable anchoring. The use of cones or sleeves seems to significantly improve the results of revision TKA. The anchorage in zone 3 via stems is still mandatory. Cemented metaphysary anchoring and cement-free diaphysary anchoring stems are available, whereby no clear recommendation for a principle can be given.

Kernaussagen

• Die präoperative Differenzierung zwischen septischer und aseptischer Lockerung sollte standardisiert erfolgen.

• Die Rekonstruktion knöcherner Defekte ist neben periprothetischen Infekten die größte Herausforderung der Knierevisionsendoprothetik.

• Prothesenwechsel bedürfen einer intensiven Planung in Hinblick auf die benötigten Augmentationsmöglichkeiten und die zu verwendenden Schäfte.

• Der alleinige biologische Aufbau bei größeren Defekten (AORI II und III) zeigt hohe Versagensraten.

• Große Defekte müssen metallisch augmentiert werden (Wedges, Sleeves, Cones).

• Das Konzept der zonalen Verankerung (3-Zonen-Modell) mit einer möglichst gelenknahen, stabilen Verankerung in 2 von 3 Zonen stellt aktuell den Standard dar.

• Entsprechend dem Modell ist die Metaphyse (Zone 2) ein zunehmend wichtigerer Faktor für eine langfristige stabile Verankerung. Die Verwendung von Cones oder Sleeves scheint die Resultate der Knierevisionsendoprothetik signifikant verbessern zu können.

• Die Verwendung von Stielverlängerungen ist aktuell der Goldstandard. Hier stehen zementierte metaphysär verankernde und vorwiegend zementfreie diaphysär verankernde Stems zur Verfügung, wobei keine klare Empfehlung für ein Prinzip gegeben werden kann.

• Ob unter Verwendung eines Sleeves ganz auf eine diaphysäre (Stem-)Verankerung verzichtet werden kann, ist aktuell noch in der Diskussion.

Schlüsselwörter

Revisionsendoprothetik - Knie - Defektaufbau

Key words

revision total knee arthroplasty - bony defects - reconstruction

Publication History

Article published online:
30 September 2020

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