Stellenwert der matrixaugmentierten Knochenmarkstimulation in der Behandlung von Knorpelschäden des Kniegelenks: Konsensusempfehlungen der AG Klinische Geweberegeneration der DGOU

Zusammenfassung

Für die operative Sanierung lokalisiert vollschichtiger Knorpelschäden der großen Gelenke stehen mit den Transplantationstechniken (autologe Knorpelzelltransplantation, autologe osteochondrale Transplantation) und knochenmarkstimulierenden Techniken unterschiedliche Therapieoptionen zur Verfügung. Vor allem für das Kniegelenk konnte aufgrund der verbesserten Studienlage das jeweils geeignete Anwendungsspektrum dieser Verfahren in letzter Zeit weiter präzisiert werden. Für die matrixaugmentierte Mikrofrakturierung als einzeitige Methode besteht jedoch noch keine genauere Indikationsabgrenzung, insbesondere auch nicht gegenüber den bereits etablierten Verfahren. In der vorliegenden Arbeit werden die derzeit für diese Methode zur Verfügung stehenden Biomaterialien und Anwendungsvarianten beschrieben und ihre präklinische und klinische Evidenz zusammengefasst. Grundsätzlich kann dabei festgestellt werden, dass sich die verschiedenen in diesem Bereich angebotenen Produkte hinsichtlich der Zahl und Qualität zugehöriger Studien (Evidenzlevel) noch erheblich voneinander unterscheiden. Um die matrixaugmentierte Mikrofrakturierung im Sinne einer ersten Indikationsempfehlung als Methode in den therapeutischen Algorithmus der knorpelrekonstruktiven Verfahren im Knie einzuordnen, wurde durch die Mitglieder der Arbeitsgemeinschaft (AG) Klinische Geweberegeneration der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU) im Rahmen eines Konsensusprozesses eine Bewertung der verfügbaren Evidenz vorgenommen. Vor dem Hintergrund der aktuellen Datenlage wird ihre Anwendung derzeit im Grenzbereich zwischen Zelltransplantations- und knochenmarkstimulierenden Techniken sowie als Verbesserung der klassischen Mikrofrakturierung und überwiegend im Indikationsbereich der Mikrofrakturierung gesehen. Die Empfehlungen der AG haben vorläufigen und orientierenden Charakter und bedürfen einer erneuten Überprüfung nach Verbesserung der Studienlage.

Abstract

Surgical principles for treatment of full-thickness cartilage defects of the knee include bone marrow stimulation techniques (i.e. arthroscopic microfracturing) and transplantation techniques (i.e. autologous chondrocyte implantation and osteochondral transplantation). On the basis of increasing scientific evidence, indications for these established therapeutical concepts have been specified and clear recommendations for practical use have been given. Within recent years, matrix-augmented bone marrow stimulation has been established as a new treatment concept for chondral lesions. To date, scientific evidence is limited and specific indications are still unclear. The present paper gives an overview of available products as well as preclinical and clinical scientific evidence. On the basis of the present evidence and an expert consensus from the “Working Group on Tissue Regeneration” of the German Orthopaedic and Trauma Society (DGOU), indications are specified and recommendations for the use of matrix-augmented bone marrow stimulation are given. In principle, it can be stated that the various products offered in this field differ considerably in terms of the number and quality of related studies (evidence level). Against the background of the current data situation, their application is currently seen in the border area between cell transplantation and bone marrow stimulation techniques, but also as an improvement on traditional bone marrow stimulation within the indication range of microfracturing. The recommendations of the Working Group have preliminary character and require re-evaluation after improvement of the study situation.

Schlüsselwörter

Knorpel - Kniegelenk - Knochenmarkstimulation - Mikrofrakturierung - Biomaterial

Key words

cartilage - cartilage defect - microfracture - knee - biomaterial

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