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Therapie der Arthrofibrose nach Kniegelenkendoprothetik

Therapy of arthrofibrosis after total knee arthroplasty

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Zusammenfassung

Die Arthrofibrose ist mit einer Inzidenz von ca. 10% eine der häufigsten Komplikationen nach Knietotalendoprothesenimplantation. Dessen ungeachtet hat sie in der Literatur bisher viel zu wenig Augenmerk gefunden. Die vorliegenden Daten sind meist inhomogen, basieren auf nicht ausreichenden Fallzahlen und auf unkontrollierten Studien mit z. T. widersprüchlichen Therapieempfehlungen.

Klinisch wird die Arthrofibrose nach Knietotalendoprothese (Knie-TEP) durch eine (schmerzhafte) Bewegungseinschränkung mit narbiger Bindegewebevermehrung definiert. Von therapeutischer Relevanz ist die Differenzierung zwischen lokaler (peripatellarer) und generalisierter Fibrose. Histologisch zeigt sich typischerweise eine subsynoviale Fibrose mit Hyperplasie der Synovialis, chronisch inflammatorischer Infiltration und pathologischer Proliferation von Kollagen und Fibroblasten.

Diagnostisch wesentlich ist zunächst der Ausschluss anderer Ursachen der schmerzhaften Bewegungseinschränkung und insbesondere der Ausschluss einer „Low-grade-Infektion“ stellt häufig eine diagnostische Herausforderung dar. Therapeutisch sollte eine frühzeitige Physiotherapie unter großzügiger und suffizienter Analgesie erfolgen. Die nächsten Therapieschritte bei persistierender Arthrofibrose stellen die Narkosemobilisation und die offene Arthrolyse dar. Die arthroskopische Arthrolyse sollte nur bei lokalisierter Fibrose durchgeführt werden. Bei Persistenz kann sogar ein Endoprothesenwechsel indiziert sein, der allerdings häufig zu Rezidiven führt. Wesentliche Bedeutung besitzt die Prävention der Arthrofibrose durch primäre Physiotherapie und konsequente Analgesie.

Abstract

Arthrofibrosis is one of the most common complications after total knee arthroplasty with an overall incidence of approximately 10%. Nevertheless, published data are rare and clinical trials mostly include small and heterogeneous patient series resulting in controversial conclusions.

Clinically, arthrofibrosis after knee arthroplasty is defined as (painful) stiffness with scarring and soft tissue proliferation. Differentiation between local (peripatellar) and generalized fibrosis is therapeutically relevant. Histopathology typically shows subsynovial fibrosis with synovial hyperplasia, chronic inflammatory infiltration, and excessive and unregulated proliferation of collagen and fibroblasts.

Diagnostic strategies are based on the exclusion of differential causes for painful knee stiffness, and especially the exclusion of low-grade infections represents a diagnostic challenge. Early and intensive physiotherapy combined with sufficient analgesia should be initiated as a basic therapy. The next therapeutic steps for persisting arthrofibrosis include closed manipulation and open arthrolysis. Arthroscopic interventions should be limited to local fibrosis. Revision arthroplasty represents a rescue surgery, often associated with recurrence of fibrosis. Prevention of arthrofibrosis by sufficient analgesia and early physiotherapy remains the best treatment option for painful stiffness after knee arthroplasty.

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Authors and Affiliations

  1. Abteilung für Unfall- und Wiederherstellungschirurgie, Berufsgenossenschaftliche Unfallklinik, Murnau

    H. Gollwitzer & V. Bühren

  2. Klinik für Orthopädie und Unfallchirurgie, Technische Universität, München

    R. Burgkart, P. Diehl & R. Gradinger

  3. Abteilung für Unfall- und Wiederherstellungschirurgie, Berufsgenossenschaftliche Unfallklinik, Prof.-Küntscher-Straße 8, 82418, Murnau/Staffelsee

    H. Gollwitzer

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Correspondence to H. Gollwitzer.

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Gollwitzer, H., Burgkart, R., Diehl, P. et al. Therapie der Arthrofibrose nach Kniegelenkendoprothetik. Orthopäde 35, 143–152 (2006). https://doi.org/10.1007/s00132-005-0915-5

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