Indikationen und Grenzindikationen zum medialen unikondylären Gelenkersatz mit mobiler Inlay-Komponente

Zusammenfassung

Bei Patienten mit isolierter anteromedialer Gonarthrose besteht, neben der Möglichkeit zur Implantation einer bikondylären Oberflächenersatzprothese, die Möglichkeit zum unikondylären Gelenkersatz. Voraussetzungen hierfür sind funktionell intakte Kreuz- sowie Kollateralbänder, intakte Knorpelverhältnisse im lateralen Kompartiment sowie eine intraoperative Beugefähigkeit von min. 100°. Als Kontraindikationen gelten eine Instabilität oder Kontraktur der Kollateral- sowie der Kreuzbänder, eine Varusabweichung, je nach Autor > 10° oder 15°, ein Streckdefizit > 15°, eine intraoperative Beugefähigkeit < 100° sowie ein Z. n. valgisierender Umstellungsosteotomie. Ebenso gelten aufgrund der zu erwartenden progressiven Gelenkdestruktion eine entzündliche Arthropathie sowie ein viertgradiger Knorpelschaden im lasttragenden zentralen Anteil des lateralen Kompartiments als Kontraindikationen. Unter Einhaltung dieser Kriterien konnten exzellente funktionelle Langzeitergebnisse sowie Implantatüberlebensraten erreicht werden. Eine Ausweitung dieser Kriterien, insbesondere bei Kreuzbandinsuffizienz oder vorbestehender valgisierender Umstellungsosteotomie, sollte Einzelfällen vorbehalten bleiben unter sorgfältiger Nutzen- und Risikoabwägung sowie ausführlicher Aufklärung des Patienten über die fehlenden Langzeitdaten und möglicherweise erhöhten Komplikationsraten. Wurden zur Indikationsstellung zusätzlich lange Zeit die Kriterien nach Kozinn und Scott angewandt, welche sich jedoch ursprünglich auf Prothesen mit fixierter Inlay-Komponente beschränkten, können diese bei Prothesen mit mobiler Inlay-Komponente weitestgehend vernachlässigt werden. Kriterien wie Alter, Aktivität, Gewicht, das Vorliegen einer Chondrokalzinose sowie das Vorhandensein eines vorderen Knieschmerzes haben keinen Einfluss auf das klinische Outcome sowie die Langzeitüberlebensrate der Prothese.

Abstract

Beside the possibility of bicondylar knee replacement, patients with isolated anteromedial osteoarthritis also have the possibility of unicondylar knee replacement. Therefore some requirements are essential such as functionally intact cruciate and collateral ligaments, intact cartilage in the lateral compartment and an intraoperative flexion of more than 100°. An instability or contracture of the cruciate or collateral ligaments, a varus deformity more than 15°, a flexion deformity of more than 15°, an intraoperative flexion less than 100° as well as failed upper tibial osteotomy are seen as contraindications. In addition, a rheumatoid arthritis and a full thickness cartilage defect in the central part of the lateral compartment are seen as a contraindication because of the risk of a progression of the disease. With respect to these contraindications, excellent functional outcome and survival rates could be demonstrated in the long term. An expansion of these criteria, especially in patients with an insufficiency of the cruciate ligaments or after failed upper tibial osteotomy should only be done in certain cases after careful assessment of the benefits and risks. These patients should be informed about the lack of long-term results and the higher risk of complications. Quite commonly, the criteria of Kozinn and Scott are used for patient selection. These criteria were originally established for fixed-bearing prosthesis and have no relevance on mobile-bearing prosthesis. Criteria such as age, level of activity, weight, chondrocalcinosis and anterior knee pain have no effect on the clinical outcome or the long-term survival of a mobile-bearing prosthesis.

Schlüsselwörter

unikondylärer Gelenkersatz - Endoprothetik - Knie - Oxford-Schlittenprothese - Schlittenprothese

Key words

unicondylar knee replacement - arthroplasty - knee - Oxford prosthesis - mobile bearing

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