Zusammenfassung
Bis heute gehört die Therapie der patellofemoralen Arthrose (PFA) zu den noch nicht vollkommen erschlossenen orthopädischen Gebieten. Besonders die Ätiologie der PFA ist weniger klar definiert als arthrotische Erkrankungen anderer Gelenke. Die isolierte PFA kann auf einer Vielzahl unterschiedlicher Pathomorphologien beruhen, die einzeln oder in Kombination zum Vollbild der PFA führen. Eine primär traumatische Genese der PFA ist selten. In der Regel führt die Kombination aus akuter oder chronischer Instabilität und vorliegendem oder bereits progressivem Knorpelschaden im Patellofemoralgelenk zum Vollbild der PFA. Aus diesem Grund ist die isolierte Behandlung patellofemoraler Knorpeldefekte äußerst schwierig und führt als isolierte Behandlungsstrategie zu weniger zufrieden stellenden Ergebnissen.
Studien, die den Erfolg unterschiedlicher Therapieformen in Abhängigkeit von der Arthroseentstehung ausleuchten, fehlen. Einen „Goldstandard“ gibt es nicht. Um so mehr erscheint es notwendig und sinnvoll, die ursächliche Pathologie und nicht nur einzelne Aspekte der Pathologie zu behandeln. Diese Behandlungsstrategie kann bei jüngeren Patienten die Korrektur einer Trochleadysplasie, die Behandlung eines osteochondralen Knorpelschadens und/oder die Korrektur der proximalen ligamentären (z. B. des medialen patellofemoralen Ligaments [MPFL]) oder distalen knöchernen Aufhängung des Streckapparats, beinhalten. Aber auch ein prothetischer Oberflächenersatz muss gelegentlich bei jüngeren Patienten alternativ berücksichtigt werden.
Die Therapie der PFA muss also die Ursache berücksichtigen, was eine große Vielseitigkeit in Bezug auf die Therapieoptionen erfordert. Aus diesem Grunde ist die Behandlung der PFA auch heute noch eine große klinische Herausforderung.
Abstract
The treatment of patellofemoral arthritis (PFA) is still challenging even today. The etiology of PFA in particular is less clearly defined than arthritic diseases of other joints. Isolated PFA can be due many different pathomorphologies which can lead to the complete symptoms of PFA alone or in combination. As a rule the degeneration is caused by simple local trauma or by continuous overload or misalignment. Therefore, a targeted diagnostic concerning the localization and the etiology has to be performed. In comparison to a generalized arthrosis, isolated patellofemoral arthritis might develop in a different manner and compared to other regions of the knee joint patellofemoral degeneration has an atraumatic origin in most cases. Therefore, the variety of chondral treatments successfully used in other joints show different outcomes in the patellofemoral joint.
As there are no studies which investigated either the therapy of cartilage defects in correlation to the pathomorphology or investigated combined techniques, a gold standard for the treatment of focal arthritis and its causes has not yet been found. 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 trochlear dysplasia with permanent patellar dislocation and hyperpression, it would be justified to implant a patellofemoral prosthesis. Hereditary dysplasia of the trochlea can be rectified so that instability and degeneration can be corrected simultaneously.
In summary, the optimal treatment depends on the extent and localization of the cartilage defect. Except for direct defects of the cartilage caused by trauma, an additional intervention to treat the causing factor has to be considered to adjust the alignment and tracking of the patellofemoral joint and therefore lower a non-physiological pressure.
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Schöttle, P., Lattermann, C. Therapie der patellofemoralen Arthrose beim jungen Patienten. Arthroskopie 23, 215–223 (2010). https://doi.org/10.1007/s00142-010-0572-5
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DOI: https://doi.org/10.1007/s00142-010-0572-5
Schlüsselwörter
- Patellofemorale Arthrose
- Patellofemorale Prothese
- Patellofemorale Instabilität
- Mediales patellofemorales Ligament (MPFL)
- Osteotomie