Osteochondrosis dissecans tali – eine kritische Übersicht

Zusammenfassung

Die Osteochondrosis dissecans (OD) tritt in Europa nach dem Kniegelenk am Sprunggelenk am zweithäufigsten auf. Ihre Ätiologie ist weiterhin nicht eindeutig geklärt. Es werden verschiedene Faktoren diskutiert. Am wahrscheinlichsten ist eine traumatische oder repetitive mikrotraumatische Genese. Die Pathogenese ist relativ eindeutig: Die Läsion beginnt im subchondralen Knochen, erst sekundär wird der über der knöchernen Läsion liegende Knorpel mit betroffen und kann zur Bildung eines freien Gelenkkörpers führen. Diagnostisch stellt die Erstellung eines Röntgenbilds des oberen Sprunggelenks in 2 Ebenen die erste Maßnahme dar. Das MRT gilt heute als Methode der Wahl zur erweiterten Diagnostik. Therapeutisch gibt es auf der konservativen Seite keine einheitlichen Protokolle. Die Reduktion der Last mit oder ohne Immobilisation des oberen Sprunggelenks und/oder Sportkarenz sind die wesentlichen Maßnahmen. Bei erfolgloser konservativer Therapie und bei fortgeschrittenen Läsionen kommen verschiedene operative Behandlungsmöglichkeiten infrage. Bei intaktem Knorpel werden verschiedene Techniken der Anbohrung der subchondralen Läsion verwendet. Bei lädiertem Knorpel gibt es Methoden zur Refixation, Rekonstruktion oder Maßnahmen, die den Knorpel-Knochen-Defekt lediglich débridieren und den subchondralen Knochen anbohren. Leider existiert bis heute nur eine Level-I-Untersuchung, in der nicht nur Fälle von Osteochondrosis dissecans tali, sondern auch von osteochondralen Läsionen des Talus gemeinsam untersucht wurden. In dieser Arbeit zeigte der Vergleich zwischen einer Chondroplastik und einer Mikrofrakturierung keine wesentlichen Unterschiede, Patienten mit einer osteochondralen Transplantation wiesen dagegen signifikant bessere Ergebnisse auf. Langfristig ist nur eine geringe Arthrose zu erwarten.

Abstract

The etiology remains unclear. Mechanical factors seem to play an important role. Most histologies report clefts between the cartilage and bone and necrotic areas. Several classifications have been published based on observations from imaging techniques or on intraoperative findings. Clinical symptoms are unspecific. Imaging techniques are of great importance: X-rays of the ankle joint enable a quick diagnostic overview. MRT is the imaging-technique of choice for diagnosing OCDT-lesions. Regarding treatment, a tremendous number of retrospective publications exist. Only a few are classified as level I or II papers. Patients with open physes and low-grade lesions have good results with conservative therapy. Adults do not profit from a longer conservative procedure. Where surgery is necessary, the procedure depends on the stage of the lesion and on the state of the cartilage. With intact cartilage, retrograde procedures or transchondral drilling are to be favoured. Where the cartilage is damaged, several techniques can be used: while techniques such as drilling and microfracturing, or matrix-associated microfracturing produces repair cartilage, other techniques reconstruct the defect with osteochondral grafts or cell-based procedures such as chondrocyte transplantation. Regarding the outcome, it is difficult to make a precise, scientifically-based recommendation which has been confirmed by more than one prospective study. Only limited recommendations are possible: In juveniles with intact cartilage, initially conservative treatment is indicated. If there is no improvement, conservative invasive techniques such as drilling may help. In adults conservative therapy should be limited to a few weeks. Regarding the surgical treatment options, there is a tendency towards better results with procedures which reconstruct the bone and the cartilage and there is also a trend towards better long-term results when co-morbidities are treated. Severe grades of osteoarthrosis are rare.

Key words

Osteochondrosis dissecans tali - Sprunggelenk - Talus - Arthrose

Key words

Osteochondritis dissecans - ankle joint - talus - osteoarthritis

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