Die posttraumatische Arthrose – eine Herausforderung?

 

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Zusammenfassung

Die endoprothetische Versorgung der posttraumatischen Gonarthrose unterscheidet sich grundsätzlich kaum von dem Vorgehen bei primärer Arthrose. Aufgrund der 10-fach höheren Infektionsrate ist jedoch neben der üblichen Operationsplanung ein nach aktuellem Kenntnisstand bestmöglicher Ausschluss einer Infektion sinnvoll. Extraartikuläre Fehlstellungen müssen präoperativ erkannt werden und individuell – sei es durch teilweisen oder vollständigen intraartikulären Ausgleich oder ein- oder zweizeitige Korrekturosteotomie – adressiert werden. Die regelhaft vorliegende Kombination aus kontraktem Kniegelenk und ligamentärer Insuffizienz kann Instabilitäten maskieren, sodass der Kopplungsgrad der Implantate erst intraoperativ sicher bestimmt werden kann. Beim Vorliegen knöcherner Defekte kann der bei der Implantation anfallende autologe Knochen verwendet werden. In Abhängigkeit der Knochendefektsituation und des Kopplungsgrads der Implantate ergibt sich die Notwendigkeit für Stiele, wobei bislang keine klare Empfehlung für eine zementierte oder zementfreie Verankerung gegeben werden kann. Der Operationszugang sollte sich, wenn möglich, an vorhandenen Narben orientieren, um Wundheilungsstörungen zu vermeiden. Auch bei optimaler Planung und Durchführung der Implantation sind die Ergebnisse bei posttraumatischer Gonarthrose erheblich schlechter als bei primärer Arthrose. Daher kommt der Bahnung einer realistischen Erwartungshaltung des häufig jungen Patientenguts eine relevante Rolle zu.

Abstract

Total knee replacement in patients with post-traumatic arthritis is not fundamentally different from total knee replacement in patients with primary arthritis. Because of a 10-times higher infection rate, ordinary surgical planning should be implemented by the best possible exclusion of site infection based on actual information. Extra-articular deformities have to be preoperatively identified and individually treated with either an incomplete or a complete intra-articular correction or a single or double correction osteotomy. The commonly found combination of a contracted knee joint and an insufficient ligament balancing can mask instabilities of the knee joint. Consequently the definitive grade of a constrained knee prosthesis can only be determined intraoperatively. Existing osseous defects can be addressed with autologous bone grafts left from the total knee arthroplasty. Depending on the osseous defective site and the grade of constraints, prosthesis stems may be necessary but so far no clear recommendation can be given for either a cemented or a cementless fixation of the stem. The approach to the knee joint should be guided according to existing scars in order to prevent wound healing disorders. Even given optimal surgical planning and an optimum procedure of total knee arthroplasty postoperative results of post-traumatic arthritis are significantly inferior to results of primary arthritis. Therefore it is important to induce the commonly younger patients to form realistic expectations.

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