Stellenwert des Débridements bei der Behandlung fokaler (Grad II – III) Knorpelschäden des Kniegelenks. Systematische Literaturübersicht und Empfehlungen der AG Geweberegeneration (DGOU)

Zusammenfassung

Hintergrund Bei fokalen teilschichtigen Knorpelläsionen (Grad II – III) besteht im klinischen Alltag oft noch Unsicherheit hinsichtlich des zu empfehlenden therapeutischen Vorgehens. Während bei großflächigen, arthrotischen Knorpelveränderungen das Débridement gemäß der gängigen Lehrmeinung weitgehend abzulehnen ist, so steht eine Empfehlung bei fokalen teilschichtigen Knorpelschäden noch aus.

Material und Methoden In dieser Arbeit wurden die wissenschaftlichen Hintergründe der Knorpelglättung und der Gelenkspülung aufgearbeitet und eine systematische Literaturanalyse bez. des klinischen Effekts des Knorpeldébridements bei fokalen Defekten durchgeführt. Zudem erfolgte auch eine aktuelle Beurteilung dieser Thematik durch die Mitglieder der AG Klinische Geweberegeneration der DGOU auf der Basis eines Konsensusprozesses.

Ergebnisse In therapeutischer Hinsicht sind asymptomatische Läsionen mit stabiler Reststruktur und symptomatische Defekte mit instabilen Fragmenten voneinander zu unterscheiden. Grundsätzlich ist der Nutzen einer Gelenk-Lavage und Knorpelglättung fokalen teilschichtigen Knorpelschäden (Grad II – III) nicht belegt. Das mechanische und thermische Resezieren von Knorpelgewebe führt sogar zu einer Nekrosezone der angrenzenden Knorpelschicht und damit zu einer zusätzlichen Gewebeschädigung. Daher sollte eine großflächige „Glättung“ klinisch asymptomatischer, aufgefaserter oder unregelmäßiger Knorpeldefektareale mit ansonsten stabiler Reststruktur nicht durchgeführt werden. Hingegen kann bei klinischen Symptomen das Resezieren von instabilen und delaminierten Knorpelfragmenten sinnvoll sein, um schädliche Scherspannungen im noch vorhandenen Gewebe zu verringern und damit eine Progredienz des Schadens oder die Bildung von freien Gelenkkörpern zu reduzieren.

Schlussfolgerung Die Entscheidungskriterien für ein Débridement von teilschichtigen, fokalen Knorpelläsionen sind multifaktoriell und berücksichtigen die klinische Symptomatik, die Größe und den Grad des Defektes, die Stabilität der Reststruktur, die Defektlokalisation sowie patientenindividuelle Parameter. Während das Débridement bei asymptomatischen fokalen Läsionen weitgehend abzulehnen ist, kann es bei symptomatischen, instabilen Defektsituationen gerechtfertigt sein.

Abstract

Background In clinical practice, there is still no definite treatment algorithm for focal, partial thickness cartilage lesions (grade II – III). It is well-established that debridement (shaving/lavage) of large degenerative cartilage lesions is not recommended, but there is no such recommendation in the case of focal, partial thickness cartilage defects.

Materials and Methods The scientific rationale of cartilage shaving and joint lavage was investigated and a systematic analysis was performed of the literature on the clinical effect of cartilage debridement. Furthermore, a consensus statement on this issue was developed by the working group on Clinical Tissue Regeneration of the German Society of Orthopaedics and Trauma (DGOU).

Results The therapeutic approach is different for asymptomatic lesions with biomechanical stable residual cartilage tissue and clinically symptomatic defects with unstable fragments. The benefit of a joint lavage or surface smoothening of focal partial thickness has not been proved. Even more importantly, the mechanical or thermal resection of cartilage tissue even induces a zone of necrosis in adjacent cartilage, and thus leads to additional injury. Therefore, large scale smoothening (shaving) of clinically asymptomatic, fibrillated or irregular cartilage defects should not be performed. However, if there are clinical symptoms, resection of unstable and delaminated cartilage fragments may be reasonable, as it can reduce harmful shear tension in residual tissue. This can help to brake the progression of the damage and avoid formation of free bodies.

Conclusion The decision criteria for debridement of partial thickness focal cartilage lesions are multifactorial and include the clinical symptoms, the size and the degree of the defect, the stability of remaining cartilage, localisation of the defect, and individual patient-specific parameters. Debridement is not recommended for asymptomatic lesions, but may be reasonable for symptomatic cases with unstable tissue.

Schlüsselwörter

fokaler Knorpeldefekt - Débridement - Knorpelglättung - Arthroskopie - Radiofrequenztherapie

Key words

focal cartilage defect - debridement - shaving - arthroscopy - radiofrequency

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