Folgen einer vorderen Kreuzbandruptur – Ein systematisches Umbrella-Review

Zusammenfassung

Einleitung Die Behandlung einer vorderen Kreuzbandruptur wird nach wie vor kontrovers diskutiert. Insbesondere die Frage: Konservative oder operative Versorgung? steht dabei im Mittelpunkt. Für die Beantwortung dieser Frage werden häufig Folgeschäden wie die Entwicklung einer posttraumatischen Arthrose, Sekundärschäden am Meniskus oder Knorpel und auch die Partizipation im Sport herangezogen. Sollten zwischen den einzelnen Behandlungsoptionen bedeutsame Unterschiede bezüglich dieser Parameter bestehen, so wären die Ergebnisse für die Entwicklung evidenzbasierter Behandlungspfade von hoher Bedeutung. Ziel dieser Arbeit war es daher, die Entwicklung einer Gonarthrose nach einer Ruptur des vorderen Kreuzbandes und der entsprechenden Behandlung (konservativ oder operativ) zu evaluieren.

Material und Methoden Zur Beantwortung der Fragestellung wurde eine systematische Literaturrecherche in der Medline über Pubmed, der Cochrane Library und in CINAHL durchgeführt. Die Recherche wurde im Januar 2020 durchgeführt und im Januar 2021 wiederholt. Eingeschlossen wurden ausschließlich systematische Reviews mit einem minimalen Nachuntersuchungszeitraum von 10 Jahren. Untersuchte Kohorten umfassten Patienten mit einer entweder konservativ oder operativ versorgten Ruptur des vorderen Kreuzbandes. Die Diagnose Arthrose wurde entweder radiologisch (anerkannte Scores) oder klinisch (Schmerz und Funktionseinschränkung) gestellt. Passende Übersichtsarbeiten wurden mit dem AMSTAR-2-Fragebogen einer qualitativen Bewertung unterzogen.

Ergebnisse Die Literaturrecherche ermittelte zunächst n = 42 Übersichtsarbeiten, von denen 14 Arbeiten inkludiert werden konnten. Nach der Volltextprüfung und der qualitativen Bewertung verblieben zur Auswertung der Ergebnisse lediglich n = 2 systematische Reviews. Die Ergebnisse beider Arbeiten zeigen unpräzise Daten mit einer großen Variabilität. Es kann aber mit großer Wahrscheinlichkeit davon ausgegangen werden, dass das Risiko für die Entwicklung einer Gonarthrose nach einer Ruptur des vorderen Kreuzbandes erhöht ist. Eine Reduktion der Inzidenz der Gelenkdegeneration durch eine Rekonstruktion des vorderen Kreuzbandes ist nicht nachweisbar, genauso wenig wie ein Unterschied bei einem direkten Vergleich zwischen konservativer und operativer Versorgung.

Schlussfolgerung Patienten mit einer vorderen Kreuzbandruptur tragen mit hoher Wahrscheinlichkeit ein größeres Risiko für eine progressive Gelenkdegeneration. Ein pauschaler protektiver Effekt einer Kreuzbandplastik ist in den ausgewerteten Arbeiten nicht nachweisbar. Aus diesem Grund sollten innerhalb der Entscheidungsfindung über operative versus konservative Versorgung andere Faktoren wie die funktionelle Instabilität noch höher bewertet werden.

Abstract

Introduction The treatment of an anterior cruciate ligament rupture is still controversial. In particular, this applies to the question of conservative versus surgical treatment. The answer to this question is often based on consequential damage such as the development of posttraumatic osteoarthritis, secondary damage to the meniscus or cartilage, and participation in sports. If there are significant differences in these parameters between the individual treatment options, the results will be of great importance for the development of evidence-based treatment pathways. Therefore, the aim of this work was to evaluate the development of knee osteoarthritis after rupture of the anterior cruciate ligament and the corresponding treatment (conservative or surgical).

Material and methods To answer the above question, a systematic literature search was conducted in Medline via Pubmed, the Cochrane Library and in CINAHL. Only systematic reviews with a minimum follow-up period of 10 years were included. The search was conducted in January 2020 and updated in January 2021. Investigated cohorts included patients with a rupture of the anterior cruciate ligament who had undergone either conservative or surgical treatment. Osteoarthritis was diagnosed either radiologically (recognized scores) or clinically (pain and impaired function). Appropriate reviews were qualitatively evaluated using the AMSTAR-2 questionnaire.

Results The literature research initially identified n = 42 reviews from which 14 reviews were included. After full-text review and qualitative evaluation, only n = 2 systematic reviews remained for evaluation. The results of both papers show imprecise data with a high variability. However, it can be assumed with high probability that the development of osteoarthritis of the knee is increased after a rupture of the anterior cruciate ligament. There is no evidence that the incidence of joint degeneration may be reduced by reconstruction of the anterior cruciate ligament, nor is there a difference when comparing conservative and surgical treatment directly.

Conclusion Patients with an anterior cruciate ligament rupture are likely to be at a greater risk of developing progressive joint degeneration. A protective effect of cruciate ligament surgery has not been found in the evaluated studies. A general argument in favour of cruciate ligament surgery aiming to achieve a protective effect on hyaline articular cartilage seems obsolete based on the results and should therefore not be used in patient education in the future.

Schlüsselwörter

VKB - Arthrose - Spätfolgen - Übersichtsarbeit

Key words

ACL - osteoarthritis - prevention - review

Publikationsverlauf

Artikel online veröffentlicht:
20. September 2021

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