Probleme und Komplikationen chirurgischer Verfahren zur Behandlung vollschichtiger Knorpeldefekte am Kniegelenk

Zusammenfassung

Studienziel: Die Therapie vollschichtiger Knorpeldefekte hat in den letzten Jahren durch die Einführung neuer Behandlungsverfahren große Fortschritte gemacht. Dennoch weisen die zur Verfügung stehenden Verfahren spezifische Probleme und verfahrensspezifische Komplikationen auf, deren Kenntnis für den behandelnden Chirurgen von großer Bedeutung ist. Die vorliegende Arbeit gibt eine Übersicht über die charakteristischen Komplikationen nach knorpelregenerativen Eingriffen. Methode: Unter den Suchbegriffen „autologous chondrocyte implantation“, „autologous chondrocyte transplantation“, „microfracture“, „osteochondral transplantation“, „cartilage repair“, „cartilage defect“ und „complications“ erfolgte im Oktober 2009 eine Abfrage der gängigen medizinischen Datenbanken inkl. „Medline“, „Web of Science“ und „Ovid“. Die als relevant identifizierte Literatur war Basis für die vorliegende Übersicht. Ergebnisse: Für alle knorpelregenerativen operativen Techniken existieren spezifische Komplikationen. Während die offensichtlich limitierte Haltbarkeit des Regeneratknorpels und die Bildung intraläsionaler Osteophyten Hauptprobleme nach Mikrofrakturierung darstellen, scheinen bei der OATS-Plastik die Entnahmemorbidität, die Degeneration des Umgebungsknorpels sowie die fehlende knorpelige Integration der transplantierten Zylinder von Bedeutung. Charakteristische Komplikationen nach autologer Knorpelzelltransplantation stellen dagegen die Hypertrophie des Regeneratknorpels, die Delamination, die fehlende Integration in den Umgebungsknorpel sowie – ähnlich wie bei der Mikrofrakturierung – das Ausbleiben einer suffizienten Regeneratbildung dar. Schlussfolgerung: Auch wenn die Bedeutung und klinische Relevanz dieser Komplikationen nicht für alle Beobachtungen abschließend geklärt sind, ist deren Kenntnis von großer Bedeutung, da nur so Strategien entwickelt werden können, die Komplikationen suffizient zu behandeln oder zu reduzieren.

Abstract

Aim: There has been great progress concerning the surgical treatment of full-thickness cartilage defects within recent years. Surgical techniques such as arthroscopic microfracturing (MF), autologous osteochondral transplantation (OCT) and autologous chondrocyte implantation (ACI) have been introduced and, by using these techniques, reliable and satisfying clinical results can be achieved. Nevertheless, there are also technique-related problems and characteristic complications of all surgical techniques in the field of cartilage repair. Knowledge of these complications is essential for every surgeon using these techniques. The aim of the present article is to give an overview concerning technique-associated and characteristic complications of the most common cartilage repair techniques including arthroscopic microfracturing, autologous osteochondral transplantation and autologous chondrocyte implantation (ACI). Methods: In order to identify relevant literature concerning complications following cartilage repair, medical databases including “medline”, “ovid” and “web of science” were searched for the terms “autologous chondrocyte implantation“, ”autologous chondrocyte transplantation”, “microfracture“, ”osteochondral transplantation”, “cartilage repair“, ”cartilage defect” and “complications” in October 2009. The present publication represents a non-systematic review including publications which were considered relevant for describing charateristic complications and adverse events in surgical techniques used for cartilage repair. Results: Although the number of studies describing complications and adverse events following surgical cartilage repair studies is limited, for all techniques included in the present review (arthroscopic microfracturing, autologous osteochondral transplantation and autologous chondrocyte implantation) technique-associated and characteristic complications could be identified. While regenerative tissue following microfracturing seems to be limited in terms of durability, intralesional bone formation and elevation of the subchondral bone plate seem to be characteristic problems of this technique. Harvest morbidity, degeneration of the surrounding cartilage, necrosis of the transplanted cylinders and a lack of integration of the cartilage into the surrounding cartilage seem to be related to the transplantation of osteochondral cylinders (OATS/OCT), while hypertrophic regenerative cartilage, disturbed fusion into the adjacent cartilage, delamination and insufficient cartilage regeneration are associated with the autologous chondrocyte implantation (ACI). Conclusion: The present paper identifies technique-associated complications for the most common surgical techniques used for cartilage repair. Even if the clinical relevance of the complications described in the current article has not been investigated to its fullest extent, the awareness of these characteristic complications is essential in order to avoid them whenever possible or to develop standardised treatment regimes for these problems. This needs to be addressed in further investigations.

Schlüsselwörter

knorpelregenerative Eingriffe - Knorpeldefekte - Komplikationen - Kniechirurgie - autologe Knorpelzelltransplantation

Key words

cartilage repair - cartilage defect - complications - knee surgery - autologous chondrocyte implantation

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