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Therapie der patellofemoralen Arthrose

Therapy of patellofemoral arthrosis

  • Leitthema
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Arthroskopie Aims and scope

Zusammenfassung

Bis heute gehört die Therapie der patellofemoralen Arthrose (PFA) zu den noch nicht vollkommen erschlossenen orthopädischen Gebieten. Die größte Herausforderung hierbei ist im Gegensatz zu Arthrosen anderer Gelenke die Bestimmung der Ätiologie. Dazu ist eine ausführliche Diagnose bzgl. der Anamnese, Lokalisation und Begleiterkrankungen notwendig, denn die PFA kann aufgrund einer Vielzahl von Pathomorphologien entstehen. Im Gegensatz zu Degenerationen in anderen Bereichen des Kniegelenks ist die Ätiologie der PFA in den seltensten Fällen traumatisch begründet. Daher zeigen Knorpeltherapien, die in anderen Gelenkanteilen erfolgreich angewendet werden, bei der Behandlung der PFA weniger zufrieden stellende Ergebnisse.

Da bis heute keine Studien existieren, die den Erfolg verschiedener Therapieformen in Abhängigkeit der Arthroseentstehung betrachtet haben, gibt es auch keinen Behandlungsstandard. Es erscheint aber trotzdem notwendig und sinnvoll, nicht nur den Knorpelschaden, sondern wenn möglich auch die ursächliche Pathologie zu beheben. Unter diesem Gesichtspunkt ist es dann auch gerechtfertigt, bei jüngeren Patienten mit einer ausgeprägten Trochleadysplasie und in der Folge ausgebildeten instabilitätsbedingten Arthrose einen Oberflächenersatz zu implantieren. Damit wird nicht nur die Arthrose, sondern auch die Instabilität durch Schaffung einer physiologischen Trochlea behoben.

Zusammengefasst hängt der Therapieerfolg der PFA von deren Ursache ab. Während man direkte, traumatische Schäden mit einer isolierten Knorpeltherapie erfolgreich behandeln kann, muss bei der größeren Zahl der indirekt und atraumatisch entstandenen Schäden eine Kombinationstherapie mit Behandlung der auslösenden Faktoren bedacht werden.

Abstract

Even today the treatment of patellofemoral arthritis (PFA) has still not been fully developed and the greatest challenge, in contrast to arthrosis in other joints, is to define the etiology. It is most important to decide whether the degeneration is caused by a simple local trauma or by an ongoing overload or malalignment. Therefore, a comprehensive diagnostic concerning the localization and the etiology has to be performed. In contrast to degeneration in other regions of the knee joint, the etiology of PFA rarely has a traumatic origin. Therefore, chondral forms of treatment, which can be successfully used in other joint regions show less satisfactory results for PFA.

As there are no studies which have investigated the the success of various forms of therapy of cartilage defects in correlation to the pathomorphology or investigated combined techniques, there is no gold standard. However, to achieve satisfying results, it is necessary to treat not only the cartilaginous or osteochondral defects but also the underlying pathomorphology. Therefore, even in young patients with severe patellofemoral degeneration due to a trochlear dysplasia with permanent patellar dislocations and instability, it would seem justified to implant a patellofemoral prosthesis. In this way the hereditary dysplasia of the trochlea can be rectified and instability would be corrected in addition to the degeneration.

In summary, the optimal treatment depends on the extent and localization of the cartilage defect. Whereas direct defects of the cartilage caused by trauma can be successfully treated with an isolated chondral therapy, a combination therapy with treatment of the underlying cause must be considered for the majority of indirect and atraumatic injuries.

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Schöttle, P., Hensler, D. Therapie der patellofemoralen Arthrose. Arthroskopie 22, 205–216 (2009). https://doi.org/10.1007/s00142-008-0485-8

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