Skip to main content
SpringerLink
Log in

Die Osteonekrose des Kniegelenks: Pathophysiologie, Klinik und aktuelle Therapie

  • Osteonekrose
  • Published:
Arthroskopie Aims and scope

Zusammenfassung

Erstbeschreiber der Osteonekrose des Femurkondylus war Ahlbäck 1968 [1]. Doch bereits vor ihm hatten Milgram u. Helfet 1963, Rubens-Duval et al. 1966 und Kolar et al. 1968 auf dieses Krankheitsbild hingewiesen [2, 3, 4]. Die Osteonekrose des Kniegelenks befällt meist den medialen, aber auch den lateralen Femurkondylus oder das mediale Tibiaplateau [5, 6, 7, 8, 9, 10, 11]. Man unterscheidet die spontane oder idiopathische Osteonekrose von der sekundären Osteonekrose mit bekannten exogenen oder endogenen Ursachen [12]. Die spontane Osteonekrose des Kniegelenks äußert sich mit akuten Knieschmerzen bei älteren Patienten, 3-mal häufiger bei Frauen als bei Männern. Ätiologisch werden eine traumatische und eine vaskuläre Genese diskutiert. Pathophysiologisch wird die Osteonekrose in 4 Stadien eingeteilt [12], wobei Stadium I lediglich eine umschriebene Knorpelerweichung, Stadium IV schließlich eine sekundäre Osteoarthrose bedeuten. Dazwischen kommt es zur Knorpel-Knochen-Abhebung mit Bildung eines Knochenkraters (Stadien II und III). Die klinische Untersuchung lässt lediglich differenzialdiagnostische Verdachtsdiagnosen zu. Unter den bildgebenden Verfahren sind die Röntgenuntersuchung, die Kernspintomographie und die Knochenszintigraphie geeignete Optionen. Therapeutisch reicht die Palette der Maßnahmen in Abhängigkeit vom Schweregrad der Nekrose von konservativen Maßnahmen über das arthroskopische Debridement oder Anbohren des Herdes, die Knorpel-Knochen-Transplantation, die Korrekturosteotomie am Tibiakopf bis zum teilweisen oder vollständigen Kniegelenkersatz.

Abstract

The osteonecrosis of the knee joint was first described by Ahlbäck 1968. Indications to this clinical picture were given earlier by Milgram (1963), Rubens-Duval (1966), and Kolar (1968). The spontaneous or idiopathic osteonecrosis has to be differentiate from the secondary osteonecrosis, which exogenous or endogenous causes are well known. There is a sudden onset of pain in the knee joint. Most patients are about 60 years old. The sex ratio is 3:1 for females. As etiology are discussed a vascular and a traumatic genesis. The pathology of the ostenecrosis can be divided into four stages: Stage I is the flattering of the cartilage. During stage II a osteochondral flap attached to the subchondral bone can be seen. Stage III shows a bone defect, that is filled with fibrous cartilage. The stage IV then leads to the secondary arthritis. Clinical examination is often unspecific and leads to different diagnosis. X-ray, MRI and bone scan can be helpful for the radiological examination. The treatment of an osteonecrosis of the femur condyle includes conservative treatment as well as operative treatment such as the arthroscopic debridement combined with drilling or core decompression, the autogenous or allogenous osteochondral grafting, the high tibial osteotomy, the unicompartmental or total knee arthroplasty.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1.
Abb. 2.
Abb. 3.
Abb. 4.
Abb. 5.
Abb. 6.
Abb. 7.

Literatur

  1. Ahlbäck S, Bauer GCH, Bohne WH (1968) Spontaneous osteonecrosis of the knee. Arthritis Rheum 11:705–733

    CAS  PubMed  Google Scholar 

  2. Milgram JE, Helfet AJ (1963) The management of internal derangements of the knee. In: Cortison osteochondritis dissecans. Lippincott, Philadelphia, pp 220–226

  3. Rubens-Duval A, Villaumey J, Lubetzki D, Rozenbaum (1966) L'ostéochondrite du genou du sujet agé. Intéret de la biopsie synovial. Rev Rhum 33:638–644

    Google Scholar 

  4. Kolar J, Streda A, Bek V, Babicky A, Bibr B, Janko L, Kralova M (1968) Untersuchungen bei sog. primären und sekundären Gelenknekrosen mit knochensuchenden radioaktiven Isotopen. Fortschr Röntgenstr 108:487–492

    Google Scholar 

  5. Lotke PA, Ecker ML (1983) Osteonecrosis-like syndrome of the medial tibial plateau. Clin Orthop 176:148–153

    PubMed  Google Scholar 

  6. Marmor L (1984) Osteonecrosis of the knee. Clin Orthop 185:195–196

    PubMed  Google Scholar 

  7. Houpt J, Alpert B, Lotem M, Greyson ND, Pritzker KPH, Langer F, Gross AE (1982) Spontaneous osteonecrosis of the medial plateau. J Rheumat 9:81–90

    CAS  Google Scholar 

  8. Gutowski WT, Weil UH (1985) Die spontane Osteonekrose des Knies. Orthopäde 14:58–63

    Google Scholar 

  9. Blauth W, Edelmann P (1973) Zur spontanen Osteonekrose des Kniegelenkes beim Erwachsenen. Z Orthop 111:503–507

    CAS  Google Scholar 

  10. Bohne W, Muheim G (1970) Spontane Osteonekrose des Kniegelenkes. Z Orthop 107:384–402

    CAS  Google Scholar 

  11. Sakai T, Sugano N, Nishii T, Haraguchi K, Yoshikawa H, Ohzono K (2000) Bone scintigraphy for osteonecrosis of the knee in patients with non-traumatic osteonecrosis of the femoral head: comparison with magnetic resonance imaging. Ann Rheum Dis 60:14–20

    Article  Google Scholar 

  12. Patel DV, Breazeale NM, Behr CT, Warren RF, Wickiewicz TL, O'Brien SJ (1998) Osteonecrosis of the knee: current clinical concepts. Knee Surg Sports Traumatol Arthrosc 6:2–11

    CAS  PubMed  Google Scholar 

  13. Kelman GJ, Williams GW, Colwell CW, Walker RH (1990) Steroid-related osteonecrosis of the knee: two case reports and a literature review. Clin Orthop 257:171–176

    PubMed  Google Scholar 

  14. McCarthy DJ, McCarthy G, Carrera G (1991) Intraarticular corticosteroids possibly leading to local osteonecrosis and marrow fat induced synovitis. J Rheumat 18:1091–1094

    Google Scholar 

  15. Wang GJ, Sweet DE, Reger SI, Thompson RC (1977) Fat-cell changes as a mechanism of avascular necrosis of the femoral head in cortisone-treated rabbits. J Bone Joint Surg 59-A 6:729–735

    Google Scholar 

  16. Wang GJ, Lennox DW, Reger SI, Stamp WG, Hubbard SL (1981) Cortisone-induced intrafemoral head pressure change and its response to a drilling decompression method. Clin Orthop 159:274–278

    PubMed  Google Scholar 

  17. Blauth W, Hassenpflug J, Hohmann D (1981) Das Knie. In: Die spontane Osteonekrose des Kniegelenkes. Stork, Bruchsal, S 145–158

  18. Uchio Y, Ochi M, Adachi N, Nishikori T, Kawasaki K (2001) Intraosseous hypertension and venous congestion in osteonecrosis of the knee. Clin Orthop 384:217–223

    PubMed  Google Scholar 

  19. Lotke PA, Ecker ML, Alavi A (1977) Painful knees in older patients. J Bone Joint Surg 59-A 5:617–621

    Google Scholar 

  20. Lotke PA, Ecker ML (1988) Osteonecrosis of the knee. J Bone Joint Surg 70-A 3:470–473

    Google Scholar 

  21. Yamamoto T, Bullough PG (2000) Spontaneous osteonecrosis of the knee: the result of subchondral insufficiency fracture. J Bone Joint Surg 82-A:858–866

    Google Scholar 

  22. Ahuja SC, Bullough PG (1978) Osteonecrosis of the knee. J Bone Joint Surg 60-A 2:191–197

    Google Scholar 

  23. Zippel H, Schlenzka D, Stiller D, Schwesinger G (1998) Beitrag zur Pathologie, Klinik und Therapie der spontanen Osteonekrose des Erwachsenenkniegelenkes (Morbus Ahlbäck). Orthop Traumatol 28:205–217

    Google Scholar 

  24. Hardy P, Haab F, Leparc JM, Lortat-Jacob A, Benoit J (1998) Aseptic avascular necrosis of the femoral condyles in renal transplant patients: clinical and radiological aspects on 69 knees. Knee Surg Sports Traumatol Arthrosc 6(4):209–214

    Article  CAS  PubMed  Google Scholar 

  25. Narvaez J, Narvaez JA, Rodriguez-Moreno J, Roig-Escofet D (2000) Osteonecrosis of the knee: differences among idiopathic and secondary types. Rheumatology (Oxford) 39:982–989

    Google Scholar 

  26. Aglietti P, Insall JN, Buzzi R, Dechamps G (1983) Idiopathic osteonecrosis of the knee. J Bone Joint Surg 65-B:588–597

    Google Scholar 

  27. Mont MA, Baumgarten KM, Rifai A, Bluemke DA, Jones LC, Hungerford DS (2000) Atraumatic osteonecrosis of the knee. J Bone Joint Surg 82-A:1279–1290

    Google Scholar 

  28. Lecouvet FE, van de Berg BC, Maldague BE, Lebon CJ, Jamart J, Saleh M, Noel H, Malghem J (1998) Early irreversible osteonecrosis versus transient lesions of the femoral condyles: prognostic value of subchondral bone and marrow changes on imaging. Am J Roentgenol 170:71–77

    CAS  PubMed  Google Scholar 

  29. Marmor L, Goldberg RT (1992) Failure of magnetic resonance imaging in evaluating osteonecrosis of the knee. Am J Knee Surg 5:195–201

    Google Scholar 

  30. Hipp E, Aigner R (1987) Osteonecrosis dissecans. Spez Orthop 2:59–60

    Google Scholar 

  31. Rupp N, Reiser M, Hipp H, heller H, Lukas P, Allgayer B, Hawe W (1985) Diagnostik der Knochennekrose durch magnetische Resonanz-(MR)-Tomographie. Fortschr Röntgenstr 142:131–137

    Google Scholar 

  32. Brahme SK, Fox JM, Ferkel RD, Friedman MJ, Flannigan BD, Resnick DL (1991) Osteonecrosis of the knee after arthroscopic surgery: diagnosis with MR imaging. Radiology 178:851–853

    CAS  PubMed  Google Scholar 

  33. Lanzer WL, Komenda G (1990) Changes in articular cartilage after menisectomy. Clin Orthop 252:41–48

    PubMed  Google Scholar 

  34. Muscolo DL, Costa-Paz M, Makino A, Ayerza MA (1996) Osteonecrosis of the knee following arthroscopic menisectomy in patients over 50-years old. Arthroscopy 12:273–279

    CAS  PubMed  Google Scholar 

  35. Santori N, Condello V, Adriani E, Mariani PP (1995) Osteonecrosis after arthroscopic medial menisectomy. Arthroscopy 11:361–372

    Google Scholar 

  36. Prues-Latour V, Bonvin JC, Fritschy D (1998) Nine cases of osteonecrosis in elderly patients following arthroscopic menisectomy. Knee Surg Sports Traumatol Arthrosc 6:142–147

    CAS  PubMed  Google Scholar 

  37. Johnson TC, Evans JA, Gilley JA, DeLee JC (2000) Osteonecrosis of the knee after arthroscopic surgery for meniscal tears and chondral lesions. Arthroscopy 16:254–261

    CAS  PubMed  Google Scholar 

  38. Muheim G, Bohne WH (1970) Prognosis in spontaneous osteonecrosis of the knee. J Bone Joint Surg 52-B:605–612

    Google Scholar 

  39. Al-Rowaih A, Björkengren A, Egund N, Lindstrand A, Wingstrand H, Thorngren KG (1993) Size of osteonecrosis of the knee. Clin Orthop 287:68–75

    PubMed  Google Scholar 

  40. Rozing PM, Insall JN, Bohne WH (1980) Spontaneous osteonecrosis of the knee. J Bone Joint Surg 62-A:2–7

    Google Scholar 

  41. Lotke PA, Battish R, Nelson CL (2001) Treatment of osteonecrosis of the knee. Instr Course Lect 50:483–488

    CAS  PubMed  Google Scholar 

  42. Motohashi M, Morii T, Koshino T (1991) Clinical course and roentgenographic changes of osteonecrosis in the femoral condyle under conservative treatment. Clin Orthop 266:156–161

    PubMed  Google Scholar 

  43. Valenti Nin JR, Leyes M, Schweitzer D (1998) Spontaneous osteonecrosis of the knee. Knee Surg Sports Traumatol Arthrosc 6:12–15

    PubMed  Google Scholar 

  44. Uchio Y, Ochi M, Adachi N, Shu N (2000) Effectiveness of an insole with a lateral wedge for idiopathic osteonecrosis of the knee. J Bone Joint Surg 82-B:724–727

    Google Scholar 

  45. Low K, Mont MA, Hungerford DS (1999) Steroid-associated osteonecrosis of the knee: a comprehensive review. Measurement of bone marrow blood volume in the knee by positron emission tomography. J Orthop Sci 4:216–222

    Article  PubMed  Google Scholar 

  46. Jacobs MA, Loeb PE, Hungerford DS (1989) Core decompression of the distal femur for avascular necrosis of the knee. J Bone Joint Surg 71-B:583–587

    Google Scholar 

  47. Flynn JM, Springfield DS, Mankin HJ (1994) Osteoarticular allografts to treat distal femoral osteonecrosis. Clin Orthop 303:38–43

    PubMed  Google Scholar 

  48. Gross AE, McKee NH, Pritzker KPH, Langer F (1983) Reconstruction of skeletal deficits at the knee. Clin Orthop 174:96–106

    PubMed  Google Scholar 

  49. Convery FR, Myers MH, Akeson WH (1991) Fresh osteochondral allografting of the femoral condyle. Clin Orthop 273:139–145

    PubMed  Google Scholar 

  50. Langer F, Pritzker KPH, Houpt J, Gross AE (1985) Osteochondral allografts in the treatment of osteonecrosis of the knee. Orthop Clin North Am 16(4):727–740

    Google Scholar 

  51. Wirth CJ, Stukenborg-Colsman C, Wefer A (1998) Osteonekrose des Femurkondylus. Orthopäde 27:501–507

    Google Scholar 

  52. Marmor L (1988) Unicompartimental arthroplasty of the knee with a minimum ten-year follow-up period. Clin Orthop 228:171–177

    PubMed  Google Scholar 

  53. Marmor L (1993) Unicompartimental arthroplasty for the osteonecrosis of the knee joint. Clin Orthop 294:247–253

    PubMed  Google Scholar 

  54. Mohler J, Morscher E (1980) Therapie der Femurkondylennekrose. Orthopäde 9:314–319

  55. Bergman NR, Rand JA (1991) Total knee arthroplasty in osteonecrosis. Clin Orthop 273:77–82

    PubMed  Google Scholar 

  56. Stern SH, Insall JN, Windsor RE (1988) Total knee arthroplasty in osteonecrotic knees. Orthop Trans 12:72

    Google Scholar 

  57. Seldes RM, Tan V, Duffy G, Rand JA, Lotke PA (1999) Total knee arthroplasty for steroid-induced osteonecrosis. J Arthroplasty 14:533–537

    CAS  PubMed  Google Scholar 

  58. Mont MA, Myers TH, Krackow KA, Hungerford DS (1997) Total knee arthroplasty for corticosteroid associated avascular necrosis of the knee. Clin Orthop 338:124–130

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Orthopädische Klinik, Medizinische Hochschule Hannover

    C. Stukenborg-Colsman & C. J. Wirth

  2. Orthopädische Klinik, Medizinische Hochschule Hannover, Anna-von-Borries-Str. 1–7, 30625 , Hannover

    C. Stukenborg-Colsman

Authors
  1. C. Stukenborg-Colsman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. C. J. Wirth
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to C. Stukenborg-Colsman.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Stukenborg-Colsman, C., Wirth, C.J. Die Osteonekrose des Kniegelenks: Pathophysiologie, Klinik und aktuelle Therapie. Arthroskopie 16, 8–14 (2003). https://doi.org/10.1007/s00142-003-0211-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00142-003-0211-5

Schlüsselwörter

Keywords

Search

Navigation