Achskorrektur am wachsenden Skelett – therapeutisches Vorgehen

Die Korrektur von Achsdeformitäten basiert auf einer genauen Diagnostik und erfolgt immer chirurgisch. Ziel der operativen Achskorrektur ist die Wiederherstellung einer geraden mechanischen Beinachse, um einer frühzeitigen Arthrose vorzubeugen. Dieser Beitrag stellt die verschiedenen Techniken vor.

Kernaussagen

• Ziel der operativen Achskorrektur ist die Wiederherstellung einer geraden mechanischen Beinachse.

• Die Therapie der Achsdeformitäten am wachsenden kindlichen Skelett besteht in der chirurgischen Achskorrektur.

• Besteht eine frontale Achsabweichung des Kniegelenks (varus/valgus) bei offenen Wachstumsfugen, kann mittels Hemiepiphysiodese (HED) eine Achskorrektur durch Wachstumslenkung (engl. „guided growth“) erzielt werden. Die direkte Manipulation der Wachstumsfuge (Physe) erlaubt eine graduelle Achskorrektur durch einen minimalinvasiven Eingriff. Der derzeitige Goldstandard ist die temporäre HED mit einer 2-Loch-Platte nach Zuggurtungsprinzip. Eine adäquate Planung sowie die Wachstums- und Korrekturprognose sind essenziell für die Wahl des Operationszeitpunkts und den Erfolg der Operation. Unter den Voraussetzungen der korrekten Deformitätenanalyse und Wachstumsprognose können ausgezeichnete klinische Ergebnisse erzielt werden.

• Bei Rotationsfehlstellungen, sagittalen oder multiplanaren Deformitäten müssen invasivere Operationsverfahren angewandt werden. Hier stehen Osteotomien mit gradueller oder akuter Deformitätenkorrektur im Vordergrund. Die Osteosynthese wird je nach chirurgischem Verfahren ausgewählt. Bei graduellen Korrekturen werden externe Fixateure verwendet, bei akuten Korrekturen kann von gekreuzten K-Drähten bis hin zur winkelstabilen Platte oder dem intramedullären Nagel jegliche Osteosynthese verwendet werden.

• Die Osteosynthesetechnik ist ebenfalls abhängig von der Lokalisation der Osteotomie.

• Besondere Acht muss auf die nahe liegende Wachstumsfuge gegeben werden, um keine iatrogenen Verletzungen mit einer resultierenden Beinlängendifferenz (BLD) oder sekundären Deformität zu kreieren.

• Neue Implantate machen minimalinvasive Operationstechniken möglich.

• Forschungsprojekte beschäftigen sich derzeit noch mit experimentellen Techniken zur biologischen Manipulation der Wachstumsfuge.

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