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Therapie degenerativer Meniskusläsionen

Von der eminenz- zur evidenzbasierten Medizin

Treatment of degenerative meniscal lesions

From eminence to evidence-based medicine

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Zusammenfassung

Hintergrund

Der Behandlung degenerativer Meniskusläsionen wurde nach Veröffentlichung mehrere Level-1-Studien in den vergangenen Jahren größere Aufmerksamkeit zuteil. Die folgende Arbeit analysiert die Literatur und berichtet über die Konsensusarbeit der European Society of Sports Medicine Knee Surgery and Arthroscopy (ESSKA), ein Behandlungskonzept für diese Patienten zusammenzufassen.

Material und Methode

Für die Analyse wurden die Level-1- bis -4-Studien, Reviewarbeiten und die Konsensusarbeit der ESSKA einbezogen, die über die operative und konservative Behandlung von Meniskusläsionen berichten.

Ergebnisse

Meniskusschäden verursachen eine Progression der Arthrose. Patienten, die neben dem Meniskusschaden bereits eine Arthrose haben, zeigen schlechtere postoperative Ergebnisse. Patienten nach operativer Behandlung von degenerativen Meniskusläsionen erreichen über 70 Punkte im Lysholm-Score. Die Level-1-Studien zeigten vergleichbare klinische Ergebnisse nach konservativer und operativer Behandlung. Über 30 % der initial konservativ behandelten Patienten benötigten nach ca. 3–6 Monaten eine Arthroskopie. Patienten mit Lappenrissen oder mechanischen Symptomen reagieren schlechter auf eine konservative Therapie.

Diskussion

Die Level-1-Studien untersuchten ein sehr selektiertes Patientenklientel, welches nicht dem klinischen Alltag entspricht. Aus diesem Grunde ist eine Verallgemeinerung der Ergebnisse nur eingeschränkt möglich. Entsprechend der Konsensusarbeit der ESSKA sollten Patienten, die eine degenerative Meniskusläsion haben, über einen Zeitraum von 3 Monaten konservativ behandelt werden. Im Fall von mechanischen Symptomen empfiehlt sich eher eine zeitnahe operative Versorgung. Eine Arthroskopie sollte nicht empfohlen werden, wenn die Patienten bereits eine fortgeschrittene Arthrose zeigen.

Abstract

Background

The treatment of degenerative meniscal lesions has received increased attention since the publication of several Level 1 studies over the last few years. The following review of literature including the consensus statement given by ESSKA reports on the management of patients with degenerative meniscal lesions.

Material and methods

The analysis includes the literature of Level 1 to 4 studies and the statement of the consensus group of ESSKA concerning the surgical or conservative management of these patients.

Results

Meniscal lesions cause progression in osteoarthritis. Patients presenting a combination of degenerative meniscal lesion and osteoarthritis show inferior clinical outcome. The average clinical outcome after surgical treatment was 70 points based on the Lysholm score. Level 1 studies show no difference in clinical outcome. However, over 30% of these patients require arthroscopy at the second stage after an interval of 3 to 6 months. Patients presenting a flap tear or complaining about mechanical symptoms show poor outcome after conservative treatment.

Discussion

Level 1 studies have focused on very selected patients. These patients do not represent the daily practice of orthopaedic surgeons. The findings of the level 1 studies should, therefore, not be generalized. According to the consensus statement of ESSKA, the treatment of degenerative meniscal lesions should start with conservative management. In the case of persistent symptoms, surgery should be considered after 3 months. In the case of mechanical symptoms, arthroscopy might be indicated earlier. Arthroscopy in advanced osteoarthritic knees is not indicated due to inferior clinical outcome.

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Abb. 1

Abbreviations

ASK:

Arthroskopie

BMI:

Body-Mass-Index

ESSKA:

European Society of Sports Medicine Knee Surgery and Arthroscopy

IKDC:

International Knee Documentation Committee

K/L:

Kellgren-Lawrence-Grad

KOOS:

Knee Injury and Osteoarthritis Outcome Scale

MID:

minimal important difference

NSAR:

nichtsteroidalen Antirheumatika

TEP:

Totalendoprothese

UKA:

unikondyläre Knieendoprothetik

VKB:

vorderes Kreuzband

WOMAC:

Western Ontario und McMaster Universities Osteoarthritis Index

WOMET:

Western Ontario Meniskus Evaluationsinstrument

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Authors and Affiliations

  1. Zentrum für Orthopädie und Unfallchirurgie, Hochschulklinikum Brandenburg, Medizinische Hochschule Theodor Fontane, Hochstraße 26, 14770, Brandenburg an der Havel, Deutschland

    R. Becker & S. Kopf

  2. Klinik Sanssouci, Helene Lange Straße 13, 14469, Potsdam, Deutschland

    M. Bernard

  3. Sporthopaedicum Berlin, Bismarckstraße 45–47, 10627, Berlin, Deutschland

    S. Scheffler

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Correspondence to R. Becker.

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R. Becker, M. Bernard, S. Scheffler und S. Kopf geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Becker, R., Bernard, M., Scheffler, S. et al. Therapie degenerativer Meniskusläsionen. Orthopäde 46, 808–821 (2017). https://doi.org/10.1007/s00132-017-3465-8

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