Gesellschaft für Orthopädisch-Traumatologische Sportmedizin

Revisionen nach Kreuzbandverletzungen

Neue Methode der offenen radikalen Ausschneidung des Fibrosegewebes bewährt sich

Derzeit werden in Deutschland ca. 50.000 Kreuzbandverletzungen des Kniegelenkes jährlich behandelt. Angesichts der komplizierten inneren Struktur des Kniegelenkes und des hohen Funktionsanspruchs unserer Patienten müssen wir davon ausgehen, dass weder operative noch nichtoperative Behandlungsmaßnahmen immer den gewünschten Erfolg bringen. So ist es natürlich, dass derzeit die Zahl der Revisionsoperationen nach Kreuzbandverletzungen immer mehr zunehmen. Eine wesentliche Ursache für Revisionsoperationen nach Kreuzbandverletzungen sind Einschränkungen der Kniebeweglichkeit vor allem nach operativen Bandrekonstruktionen. Die Häufigkeit von wesentlichen Bewegungseinschränkungen wird in der Kreuzbandchirurgie der letzten zehn Jahre mit 10 – 28 % angegeben. Dabei sprechen wir bei einem Verlust der Streckfähigkeit von über 10° und einem Verlust der Beugefähigkeit von über 10° von einer Arthrofibrose. Gemeint ist mit diesem Begriff eine in Ausmaß und eventuell Qualität unerwünschte Wucherung von Bindegewebe im Kniegelenk, welche den Bewegungsumfang einschränkt. Da erhebliche Bewegungseinschränkungen Funktionen des Kniegelenkes obligat wesentlich beeinträchtigen, werden die Patienten einer Vielzahl von Behandlungsverfahren zugeführt und es entsteht oftmals ein jahrelanger Krankheitszustand mit frustrierendem Ergebnis.

Der Autor hat sich in den letzten zehn Jahren intensiv mit diesem Problem beschäftigt. Kommt es zu einer derartigen Arthrofibrose, muss zunächst einmal die Ursache eingegrenzt werden. Finden sich mechanische Hindernisse wie Schraubenköpfe, Knochenneubildungen etc. im Gelenk, müssen diese selbstverständlich behoben werden und die Beweglichkeit wird dadurch wieder hergestellt. Bestehen keine derartigen Hindernisse, aber eine durch Kernspintomographie oder Arthroskopie abgrenzbare lokale Bindegewebsneubildung, spricht man von einer lokalisierten Arthrofibrose. Durch mechanische Irritation von Kreuzbandtransplantaten an Knochenvorsprüngen kann es beispielsweise zu einer ausgeprägten Narbenbildung mit erheblicher Bindegewebsneuformierung kommen, wobei diese schwielenartige Gewebsbildungen auf dem Kreuzbandersatz dann die Streckung behindert (Cyclops-Syndrom). Nach Eröffnung des Kniegelenkes können auch lokalisierte Verklebungen der Gleitschichten vorwiegend im oberen Gelenksabschnitt entstehen, welche die Bewegung hindern. Diese Prozesse treten im allgemeinen sechs bis acht Wochen nach Kreuzbandoperationen auf und

können, sofern sie rechtzeitig entdeckt werden, durch eine arthroskopische Revisionsoperation mit sehr guter Erfolgsquote behoben werden. In einer eigenen Serien von 24 Patienten konnte gezeigt werden, dass derartige arthroskopische Behandlungen der lokalisierten Arthrofibrose in den ersten sechs Monaten postoperativ eine sehr hohe Erfolgsrate haben.

Anders stellt sich die Situation dar, wenn die Bindegewebsneubildungen der Arthrofibrose größere Abschnitte des Gelenkes befällt. Aus bislang nicht geklärten Gründen kann es zu einer Schrumpfung des Gewebes der Kniegelenkskapsel und des unter der Kniescheibe angebrachten Fettkörpers kommen, mit der Folge einer zunehmenden Bewegungseinschränkung für Streckung und Beugung. Dieses der Lungenfibrose oder der Leberzirrhose vergleichbare Krankheitsbild ist extrem gefährlich, da Versuche der arthroskopischen Entfernung des Gewebes den Prozess meist erst stimulieren und zu einer Verschlechterung des Zustandes führen. Der Autor hat in den letzten Jahren 91 Patienten mit derartiger generalisierter Arthrofibrose operativ behandelt. Die Patienten hatten im Mittel über vier (maximal zwölf) arthroskopische Voroperationen durchgemacht, ohne dass es zu einer Besserung der Beweglichkeit gekommen war. Die Patienten wiesen eine Krankheitsdauer von bis zu sieben Jahren auf bei einem mittleren Verlust der Kniestreckung von 20°.

Durch die vom Autor entwickelte Methode der offenen radikalen Ausschneidung des Fibrosegewebes über einen kleinen vorderen Zugang, verbunden mit einer Lösung der hinteren Kniegelenkskapsel über einen kleinen Zusatzschnitt, konnte den Patienten mit hoher Sicherheit geholfen werden. Der Gewinn an Streckung betrug im Mittel 17°, kein Patient wies bei der Nachuntersuchung mehr als 5° Streckhemmung mehr auf. Funktion und Schmerzbild verbesserten sich dramatisch und 80% der Patienten beurteilten subjektiv ihr Gelenk als exzellent oder gut. Die in Zusammenarbeit mit der Medizinischen Hochschule Hannover durchgeführten Gewebsuntersuchungen zeigen, dass hier ein chronisch-entzündlicher Prozess in der Schleimhaut stattfindet, welcher sich selbst unterhält und zu immer stärkeren Kapselschrumpfungen führt. Derzeit werden Forschungsanstrengungen unternommen, um künftig möglicherweise eine medikamentöse Behandlung der Arthrofibrose zu realisieren.

Professor Dr. Philipp Lobenhoffer
Chefarzt der Klinik für Unfall- und Wiederherstellungschirurgie
Henriettenstiftung Hannover

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