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Sportverletz Sportschaden 2012; 26(2): 91-99
DOI: 10.1055/s-0032-1312815
Übersichtsarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Die Osteochondrosis dissecans und osteochondrale Läsionen des Talus: klinische und biomechanische Aspekte

Osteochondrosis Dissecans and Osteochondral Lesions of the Talus: Clinical and Biochemical Aspects
A. Suckel
1   Katharinenhospital, Klinikum Stuttgart
,
M. Hoyer
1   Katharinenhospital, Klinikum Stuttgart
,
C. Raab
1   Katharinenhospital, Klinikum Stuttgart
,
M. Wünschel
2   Orthopädische Universitätsklinik Tübingen
› Author Affiliations
Further Information

Publication History

Publication Date:
25 May 2012 (online)

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Zusammenfassung

Hintergrund: Osteochondrale Läsionen am Talus weisen unterschiedliche Verläufe auf, das Krankheitsbild ist unscharf definiert. Klinisch und in der Begutachtung wird inkohärent diskutiert.

Methode: In einem Übersichtsartikel sollen relevante Studien analysiert werden zu Pathologie, zu Langzeitverläufen und verschiedenen Behandlungsmethoden. Vor dem Hintergrund des aktuellen biomechanischen Verständnisses wird unter illustrativer Darstellung eigener Ergebnisse ein Erklärungsversuch zur kontrovers diskutierten Problematik des Krankheits-/Verletzungsbilds unternommen.

Ergebnisse: Es liegen Langzeitstudien zum Spontanverlauf der Erkrankung und konservativer Therapie vor, Beobachtungen nach Debridement und direkter Anbohrung, dem retrograden Anbohren, der Knorpel-Knochentransplantationen und autologen Chondrozytentransplantation. Biomechanische Untersuchungen beschreiben eine hohe Belastung in anterolateralen Gelenkabschnitten. In den meisten Studien liegt das Patientenalter bei hoher Streubreite um 28 Jahre, jüngere Patienten weisen günstigere Behandlungsresultate auf als ältere. Bei Kindern ist die höchste Rate spontan günstiger Verläufe zu erwarten. Etwa drei Viertel der operativen Verläufe sind als günstig zu beschreiben, bei jedem zehnten Patienten ist langfristig mit der Ausbildung einer Arthrose zu rechnen.

Schlussfolgerung: Die Erkrankung zeigt histologisch eine subkortikale Knochennekrose bei unklarer Pathogenese. In 90 % der Fälle lässt sich ein Distorsionstrauma in der Anamnese nachweisen, ein direkter Unfallzusammenhang als alleinige Ätiologie ist nicht ableitbar. Ein möglicher Erklärungsansatz stellt eine osteochondrale Fraktur auf dem Boden einer schon vorbestehenden Osteonekrose dar. Es wird ein stadienabhängiges Behandlungsregime vorgeschlagen. Asymptomatische und gering symptomatische Befunde aller Stadien können konservativ behandelt werden, symptomatische Stadien Hepple I, II und V mit intaktem Knorpel können nach konservativ erfolgloser Therapie indirekt angebohrt werden und mittels subchondraler Spongiosaplastik stabilisiert werde, bei aufgebrochenem Knorpel in den Stadien III, IV und V stellt die Mosaikplastik eine sinnvolle Behandlungsstrategie dar. Nur bei Knorpelläsionen über 2,5 cm2 kann die Nekrosenexzision und die Spongiosaplastik in Verbindung mit einer ACT erwogen werden. Das alleinige Anbohren sollte nach eigener Einschätzung Ausnahmeindikationen vorbehalten sein.

Abstract

Background: The natural course of osteochondral lesions of the talus are varied and the disease pattern is not clearly defined. There is an ongoing discussion among clinicians concerning the aethiopathology and the correct treatment.

Methods: In this article all relevant studies are analysed with regard to aetiology, long-term outcome and the different established treatment options. Against the background of the current biomechanical understanding, an approach is made to this controversially discussed disease pattern utilising our own biomechanical laboratory results.

Results: The available literature deals with longitudinal analyses regarding the natural history of the disease, conservative treatment, surgical options like debridement and anterograde drilling, retrograde drilling, osteochondral transplantation and autologous chondrocyte transplantation (ACT). Biomechanical trials describe high loads in the anterolateral parts of the joint. In most of the published studies the average age of the patients is around 28 years, younger patients have more favourable outcomes compared to older ones. In children the highest rate of spontaneous and advantageous course of the disease can be expected. Around 75 % of the published outcomes relating to surgical therapy are satisfactory while 10 % of the patients will suffer from osteoarthritis in the long term.

Conclusion: While the aetiopathology of the disease remains unclear, histopathological studies reveal subcortical bone necrosis. In 90 % of the cases there is an ankle sprain in the past medical history although a direct correlation with trauma as exclusive trigger is not obvious. A possible approach is an osteochondral fracture in combination with an already existing osteonecrosis. A staged treatment regime is advised. In asymptomatic cases conservative treatment is advocated independent of the stage. Symptomatic patients with Hepple stages I, II and V and intact cartilage surface should undergo retrograde drilling in combination with a subchondral filling with cancelleous bone. If a cartilage defect is present (Hepple stages III, IV, V), an osteochondral transplantation is reasonable. Only if the defect zone is > 2.5 cm2 should a debridement combined with a transplantation of cancellous bone and an ACT be considered. The sole anterograde drilling in our opinion should only be performed as an exception.

Schlüsselwörter

Osteochondrosis dissecans tali - Knorpelschaden Sprunggelenk - osteochondrale Läsion - osteochondrale Fraktur - Flakefraktur

Key words

Osteochondrosis dissecans - cartilage lesion of the talus - osteochondral lesion - osteochondral fracture - flake fracture
 

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