Z Orthop Unfall 2012; 150(3): 272-279
DOI: 10.1055/s-0031-1298388
Knie
Georg Thieme Verlag KG Stuttgart · New York

Knorpelregeneration nach valgisierender Tibiakopfosteotomie. Ergebnisse einer arthroskopischen Studie

Cartilage Regeneration after High Tibial Osteotomy. Results of an Arthroscopic Study
G. Spahn
1   Unfallchirurgie und Orthopädie, Praxisklinik für Unfallchirurgie und Orthopädie, Eisenach
,
H. M. Klinger
2   Orthopädische Klinik, Georg-August-Universität, Göttingen
,
P. Harth
3   Radiologische Gemeinschaftspraxis Eisenach
,
G. O. Hofmann
4   Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena – Friedrich-Schiller-Universität Jena
5   BG Unfallklinik „Bergmannstrost“ Halle
› Author Affiliations
Further Information

Publication History

Publication Date:
22 June 2012 (online)

Zusammenfassung

Zielstellung: Die hohe Tibiakopfosteotomie (HTO) stellt ein etabliertes Verfahren bei der Behandlung unikompartimenteller medialer Gonarthrosen dar. Diese Studie wurde mit dem Ziel durchgeführt, eine mögliche Knorpelregeneration nach HTO in Beziehung zu den bei der Indexoperation angewandten arthroskopischen Knorpeltherapieverfahren zu untersuchen. Dazu wurden 1,5 Jahre nach medial öffnender HTO im Rahmen der Metallentfernung Kontrollarthroskopien durchgeführt. Material und Methode: Bei 135 Patienten (72 Männer und 63 Frauen; Altersmittelwert 48,8 Jahre) erfolgte nach knöcherner Konsolidierung einer Opening-Wedge-HTO (1,5 Jahre) die Metallentfernung mit gleichzeitiger Kontrollarthroskopie. Die Schwere der Knorpelschäden wurde durch das ICRS-Schema (International Cartilage Repair Society) bestimmt. Ergebnisse: Bei ursprünglich Grad III konnte im Bereich des medialen Femurkondyls in 40,4 % und im Bereich des medialen Tibiaplateaus in sogar 62,3 % eine verbesserte Knorpelqualität festgestellt werden. Dagegen kam es in 13,1 % im Bereich des MFC und 8,5 % im Bereich des TM zu einer Verschlechterung der ursprünglichen Grad-III-Läsionen in einen kompletten Defekt (Grad-IV-Schaden). Am besten schnitten dabei diejenigen Patienten ab, bei denen im Verlauf der Indexoperation eine Thermoablation durchgeführt wurde. Alle kompletten Defekte wurden anlässlich der Indexoperation durch Mikrofrakturierung nach Steadman behandelt. In knapp ⅔ der ehemaligen Defekte am MFC und in etwa ⅓ der ehemaligen TM-Defekte wurde dabei im Verlauf der Kontrollarthroskopie eine Auffüllung der ehemaligen Defektzone mit in der Hakenprobe stabilen Regeneraten nachgewiesen. Schlussfolgerungen: Die medial öffnende HTO in Kombination mit einer arthroskopischen Knorpeltherapie erbringt einerseits ein gutes klinisches Outcome und andererseits kommt es bei einem Teil der Patienten zu einer partiellen Regeneration der geschädigten Knorpelflächen. Ein Zusammenhang zwischen klinischem Outcome und der Knorpelregeneration konnte jedoch nicht sicher nachgewiesen werden. Nach unseren Untersuchungen ist die klinische Verbesserung in erster Linie auf die Wiederherstellung physiologischer Achsverhältnisse zurückzuführen. Inwieweit die Knorpelregeneration möglicherweise aber das Langzeitresultat beeinflusst, bleibt ungewiss.

Abstract

Aim: High tibial osteotomy (HTO) has been established as an effective method for the treatment of unicondylar knee osteoarthritis. This study was undertaken to quantify the potential for restoration of cartilage lesions or defects after HTO in relation to different cartilage treatment modalities. Control arthroscopy was undertaken to identify the cartilage lesions within the knee joint 1.5 years after medial opening wedge osteotomy. Material and Method: A total of 135 patients (72 male and 63 female) had undergone medial-opening high tibial osteotomy and arthroscopy. The mean age at operation was 48.8 (36 to 65) years. All HTO were fixed with an angle-stable, mobile spacer-containing plate (HTO-Platte, Königsee, Deutschland). All HTO were combined with a simultaneous arthroscopy. Grade III cartilage lesions had undergone either shaving or temperature-controlled chondroplasty (Paragon ArthroW Austin, TX, USA). In some case these cartilage lesions had remained untreated. Control arthroscopy and removal of the implants was performed 1.5 years after HTO. The cartilage lesions were graded accordingly to the ICRS guidelines (International Cartilage Repair Society). Results: The KOOS at HTO was 49.9 (SD 10.6) points. We observed at follow-up a mean increase from 66.1 (SD 28.8, 95 % CI: 61.2–71.1) points. The KOOS at follow-up was 16.1 (SD 29.8) points. There was no delayed union of the HTO space. Before HTO the varus angle was 10.4° (SD 3.9 range 5 to 20°). The correction angle was 13.6° (SD 4.4, 95 % CI: 12.9–14.4°). Finally we determined a valgus angle of −3.2° (SD 1.8 minimum 0° varus, maximum −6° valgus. The clinical outcome (KOOS) significantly (p < 0.001) correlated (R = 0.605) with the extension of valgisation. Patients with a valgus angle of 3° and more had the best outcome. Of the grade III lesions 40.4 % in the medial femoral condyle and 62.3 % in the medial tibial plateau increased to grade II or I lesions. In 13.1 % of the medial femoral condyle and 8.5 % of medial tibial plateau cases we found complete (grade IV) defects at control arthroscopy. The highest rate of regenerations was detected after temperature-controlled chondroplasty. The worst results were produced after mechanical debridement. Microfracturing of complete defects produced regeneration in about ⅔ in the medial femoral condyle and about ⅓ in the medial tibial plateau. No increase was observed within the lateral or patello-femoral compartment. No correlation was seen between cartilage regeneration and outcome. The extension of valgisation did not influence the cartilage regeneration. Conclusions: The main effect of the HTO is the shift of the weight-bearing line from the arthritic compartment to the opposite femorotibial healthy one. In addition, HTO also produces a partial restoration of cartilage lesions. Deep cartilage lesions (grade III) restore in about 60 % of the cases after HTO. The worst restoration is found after mechanical shaving. This method should be avoided in the future. The best restoration was found in deep lesions after thermochondroplasty. Furthermore, in about half of the patients with complete (grade IV) defects, microfracturing caused the formation of fibrocartilaginous regenerates. This procedure should always be performed if possible.

 
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