Bei einer Meniskusteilentfernung bleibt die Sportfähigkeit völlig erhalten
Eine isolierte Meniskusverletzung ist typisch für den Fußballspieler, die Kombinationsverletzung für den Skifahrer
Braucht das Knie einen Meniskus? Die Frage ist einfach zu beantworten: Ja. Die Menisken sind Lastverteiler, Stoßdämpfer und Bremsklötze des Kniegelenks. Ihr Fehlen führt zu Instabilität und innerhalb von zehn bis zwölf Jahren zu Arthrose. Folgende Fragen sind in diesem Zusammenhang zu stellen:
- Ist ein zerstörter Meniskus besser als kein Meniskus?
- Ist ein Meniskustransplantat besser als kein Meniskus?
- Gibt es etwas Neues oder Besseres als das humane Meniskustransplantat?
Ein beschädigter Meniskus stört und macht Symptome wie Schmerz, Bewegungsbehinderung und Schwellung des Kniegelenks. Nach Entfernung der beschädigten Anteile, also so genannter Teilentfernung, verschwinden diese Symptome und das Knie ist wieder gebrauchsfähig. Leider steigt jedoch das Arthroserisiko mit dem Volumen an Meniskussubstanz, das entfernt werden musste. Der Eingriff der partiellen Meniskusentfernung an sich beinhaltet nur ein sehr geringes Risiko für den Patienten. Er wird heute durchweg arthroskopisch durchgeführt.
Meniskusverletzungen entstehen, wenn das Kniegelenk verdreht oder gewaltsam überbeugt wird. Prädestiniert hierzu ist zu allererst der Fußballspieler, wobei die Fixierung des Fußes durch den Stollenschuh eine besonders ungünstige Auswirkung hat. Beim alpinen Skilauf kommt es seltener zur alleinigen Meniskusverletzung. Sie ist aber gerade bei diesem Sport recht häufig mit dem Riss des vorderen Kniekreuzbandes in Form einer Kombinationsverletzung zu sehen. Sicher in Bezug auf den Meniskus sind Sportarten, bei denen das Kniegelenk zwar belastet und bewegt, aber nicht verdreht wird. Musterbeispiele hierfür sind der Radsport, aber auch der Schwimmsport, bei dem die fehlende Belastung des Beines eine erhebliche Krafteinwirkung auf das Kniegelenk nicht erlaubt. Generell sind alle Sportarten, die mit häufigen raschen Richtungswechseln und Sprüngen verbunden sind, potenziell gefährlich fürs Kniegelenk und damit für den Meniskus. Dies wären auch Handball, Volleyball, Basketball, Squash und Beach-Volleyball. Die isolierte Meniskusverletzung ist eher typisch für den Fußballspieler, die Kombinationsverletzung für den Skifahrer.
Bei einem günstig, das heisst weit am Rand gelegenen, glatten Riss des Meniskus kann dieser repariert werden. Seine schlechte Durchblutung verbunden mit der hohen mechanischen Belastung erlaubt eine Heilung und damit eine Reparatur nur in diesen Ausnahmefällen. Großes Interesse gilt in den letzten Jahren einer Vereinfachung der Rekonstruktion durch Ergänzung oder Ersatz der alten Nahttechniken durch andere Verfahren. Der Riss wird dabei mit kleinen Kunststoffpfeilen, Schrauben, Klammern und anderem adaptiert. Generelles Problem dieser Methoden ist einerseits die geringere Stabilität im Vergleich zur Naht, andererseits Schäden durch die verwendeten Implantate, die zum Beispiel Kratzspuren am Gelenkknorpel hinterlassen können. Momentan verfahren die meisten Operateure so, dass an günstig gelegenen Stellen die sicheren und unbedenklichen Nähte bevorzugt werden, dass aber an schwer zugänglichen Arealen eine Rekonstruktion mit den neuen Implantaten vorgezogen wird.
Wir wissen bis heute nicht, ob der Ersatz des Meniskus durch ein Meniskustransplantat die Arthroseentwicklung verhindern kann. Es gibt diesbezüglich widersprüchliche Resultate. Mit der Verwendung von humanen Meniskustransplantaten ist nach wie vor ein geringes Infektionsrisiko verbunden. Wir wissen jedoch, dass Schmerzen, die nach völligem Meniskusverlust auftreten können, für mindestens fünf Jahre nach Einbau eines Meniskustransplantates gemildert werden. In Europa haben sich viele der mit der Meniskustransplantation befassten Operateure zur European Meniscal Transplantation Group zusammengeschlossen, um ihre Resultate auszutauschen und ihre Methoden zu vereinheitlichen. Während es nach Verlust des Innenmeniskus auch ohne Meniskustransplantation erfolgreiche Behandlungsmethoden gibt, ist dies nach Verlust des Außenmeniskus nicht der Fall. Es erscheint daher besonders dringlich, das Verfahren des Außenmeniskusersatzes zu perfektionieren.
Nach wie vor gibt es nichts Besseres als das humane Meniskustransplantat. Es existiert kein wissenschaftlicher Beweis in Form einer Evidenz basierten Studie auf hohem Niveau, das ein derzeit von manchen Operateuren verwendetes Kollagenmeniskusimplantat einen Vorteil gegenüber der Meniskusteilentfernung bringt. Dieses Kollagenmeniskusimplantat ist sowieso nur für einen Teilersatz des Meniskus geeignet und nach völligem Meniskusverlust überfordert.
In der Phase nach einer Meniskusoperation geht es bei der Teilresektion um die möglichst rasche Wiedergewinnung der Muskelkraft und die Vermeidung von Schwellungszuständen am Kniegelenk. Damit ist zunächst isometrisches Training für die Oberschenkelmuskulatur und Kühlung des Kniegelenks für einige Tage erforderlich und sind in der Folge Bewegungsübungen mit zunehmendem bzw. gegen zunehmenden Widerstand sinnvoll. Sportartspezifisches Training kann nach etwa vier bis sechs Wochen wieder aufgenommen werden. Problematisch ist die Rehabilitation nach Meniskusrekonstruktion, da die Heilung des Gewebes drei bis sechs Monate dauert und das Knie für diese Zeitdauer nicht für erhebliche Belastungen geeignet ist. In den ersten sechs Wochen nach einer Meniskusrekonstruktion kann nur isometrisch geübt werden. Der Patient muss eine Schiene tragen. Damit ist die Rehabilitation nach Meniskusnaht aufwändiger als die nach alleiniger Rekonstruktion des Kreuzbandes.
Erfreulicherweise führt eine Meniskusteilentfernung nicht zu einer Einschränkung der Sportfähigkeit. Auch nach Ausheilung einer Meniskusnaht sollte die Sportfähigkeit nicht eingeschränkt bleiben.
Es wäre wünschenswert, das Verfahren der Meniskusrekonstruktion weiter zu verbessern und zu vereinfachen, so dass es auch in der Hand des weniger erfahrenen Operateurs standardmäßig eingesetzt werden kann. Der Außenmeniskusersatz müsste technisch perfektioniert werden. Auch in Europa müssten die Möglichkeiten geschaffen werden, dass eine gute Logistik die Versorgung mit Transplantaten gewährleistet und andererseits die Finanzierung dieses Eingriffs durch die Kostenträger sichergestellt wird.
Professor Dr. Dieter Kohn, Homburg/Saar, 8. August 2005
Der Autor wurde in Ulm, Ruit, München und Hannover zum Arzt und Orthopäden ausgebildet; seit 1996 ist Dieter Kohn Professor und Leiter der Orthopädie der Universität des Saarlandes; der Gesellschaft für Orthopädisch-Traumatologische Sportmedizin gehört er als Vizepräsident Deutschland an.
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