Zusammenfassung
Operationsziel
Stabile Rezentrierung der Patella durch die kombinierte Rekonstruktion des MPFL und vertiefende Trochleaplastik.
Indikationen
Nachgewiesene patellofemorale Instabilität bei Vorliegen einer hochgradigen Trochleadysplasie.
Kontraindikationen
Offene Wachstumsfugen am distalen Femur, höhergradige Knorpelschäden an der Trochlea femoris (ICRS III und IV).
Operationstechnik
Untersuchung der Patellastabilität in Narkose, diagnostische Arthroskopie, anterolateraler Hautschnitt, laterale Arthrotomie, Darstellen der Trochlea femoris, Präparation einer subchondralen Lamelle bis knapp oberhalb der Fossa intercondylaris. Modellierung der trochlearen Rinne unter gleichzeitiger Vertiefung und Rezentrierung des Sulcus trochleae. Einpassen der Lamelle in die geschaffene Rinne. Fixation mit Vicrylband und Knochenankern. Verschluss der Kapsel. Darstellung der Quadrizepssehne, Präparation eines 12-15 mm breiten Sehnenstreifens aus dem ventralen Blatt, Länge des Transplantates 8-9 cm. Das Transplantat bleibt distal gestielt, Armierung und Durchziehen der Sehne im Intervall zwischen der 2. und 3. Kapselschicht zum femoralen Insertionspunkt, Fixation in ca. 30 Grad Knieflexion unter radiologischer Kontrolle mit einer Interferenzschraube. Verschluss der Entnahmestelle als auch der Kapselinzision.
Postoperatives Management
. Postoperativ Teilbelastung mit 20 kg. Physiotherapie mit Mobilisation des Kniegelenkes und Kräftigung der Quadrizepsmuskulatur. Vollbelastung 6 Wochen postoperativ erlaubt. Return to Sports frühestens drei Monate postoperativ.
Ergebnisse
Seit 2006 wurde bei insgesamt 86 Patienten mit patellofemoraler Instabilität eine vertiefende Trochleaplastik durchgeführt. Bei 26 Patienten erfolgte eine kombinierte Trochleaplastik und Rekonstruktion des MPFL mit distal gestieltem Quadrizepssehnentransplantat. Reluxationen der Patella traten während des Nachuntersuchungszeitraumes nicht auf. Alle untersuchten Knie-Scores verbesserten sich signifikant. 95 % der Patienten waren zufrieden oder sehr zufrieden mit dem Operationsergebnis.
Abstract
Objective
Combined anatomical reconstruction of the MPFL and deepening trochleoplasty to improve the stability of the patellofemoral joint in patients with severe trochlear dysplasia.
Indications
Confirmed patellofemoral instability with recurrent dislocations and high-grade trochlear dysplasia.
Contraindications
Open distal femoral physis, degenerative changes of the patellofemoral joint grade ICRS III–IV.
Surgical technique
Diagnostic arthroscopy, exposure of the femoral trochlea through a lateral parapatellar arthrotomy and preparation of an osteochondral flake were carried out. The aim was to create a recentralized, deepened groove. Fixation of the flake in the newly formed groove was achieved with a Vicryl band and bone anchors. Closure of the capsule followed. Via the same skin incision the quadriceps tendon was exposed. The most superficial layer of the quadriceps tendon with a width of 12 to 15 mm was elevated from the deeper tendon. The graft was dissected superiorly at a length of 8–9 cm. The pedicled slip of the tendon remained distally, leaving the patellar attachment intact. The interval between the capsule and the vastus medialis obliquus was developed to the femoral insertion of the MPFL. The graft was then secured with an interference screw under fluoroscopic control with the knee flexed to 30°. Closure of the aponeurosis of the tendon and the capsule concluded the procedure.
Postoperative management
Partial weight-bearing of 20 kg, using crutches, is allowed. Physical therapy with flexion and extension exercises of the knee, and strengthening of the vastus medialis muscle follow. Full weight-bearing is permitted at 6 weeks and earliest return to sport is 3 months postoperatively.
Results
Since 2006 a total of 86 patients with patellofemoral instability have undergone trochleoplasty. In 26 patients combined trochleoplasty and anatomical reconstruction of the MPFL with a distal pedicled quadriceps tendon graft was performed. No recurrent dislocation occurred postoperatively, knee scores improved statistically significantly. Ninety-five percent of the patients were satisfied or very satisfied with the result.
Literatur
Amis AA, Firer P, Mountney J, Senavongse W, Thomas NP (2003) Anatomy and biomechanics of the medial patellofemoral ligament. Knee 10:215–220
Bereiter H, Gautier E (1994) The trochleaplasty as a surgical therapy of recurrent dislocation of the patella in dysplastic trochlea of the femur. Arthroskopie 7:281–286
Dejour H, Walch G, Nove-Josserand L, Guier CH (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26
Masse Y (1978) Trochleoplasty. Restoration of the intercondylar groove in subluxations and dislocations of the patella. Rev Chir Orthop Reparatrice Appar Mot 64:3–17
Nelitz M, Dreyhaupt J, Lippacher S (2013) Combined trochleoplasty and patellofemoral ligament reconstruction for recurrent patellar dislocation in severe trochlear dysplasia. A minimum two years follow-up study. Am J Sports Med 41:1005–1012
Nelitz M, Williams SR (2014) Anatomical reconstruction of the medial patello-femoral ligament in children and adolescents using a pedicled quadriceps tendon graft. Arthrosc Tech 28(3):e303–e308
Nelitz M, Lippacher S (2013) Arthroscopic evaluation of trochlear dysplasia as an aid in decision making for the treatment of patellofemoral instability. Knee Surg Sports Traumatol Arthrosc 22:2788–2794
Ntagiopoulos PG, Byn P, Dejour D (2013) Midterm results of comprehensive surgical reconstruction including sulcus-deepening trochleoplasty in recurrent patellar dislocations with high-grade trochlear dysplasia. Am J Sports Med 41:998–1004
Schöttle PB, Fucentese SF, Pfirrmann C, Bereiter H, Romero J (2005) Trochleaplasty for patellar instability due to trochlear dysplasia: a minimum 2 year clinical and radiological follow-up of 19 knees. Acta Orthop 76:693–698
Utting MR, Mulford JS, Eldridge JD (2008) A prospective evaluation of trochleoplasty for the treatment of patellofemoral dislocation and instability. J Bone Joint Surg Br 90:180–185
Von Knoch F, Böhm T, Bürgi ML, Von Knoch M, Bereiter H (2006) Trochleaplasty for recurrent patellar dislocation in association with trochlear dysplasia. J Bone Joint Surg Br 88:1331–1335
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M. Nelitz und S. R. M. Williams geben an, dass kein Interessenkonflikt besteht.
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M. Rudert, Würzburg
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R. Himmelhan, Mannheim
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Nelitz, M., Williams, S.R.M. Kombinierte Trochleaplastik und Rekonstruktion des medialen patellofemoralen Ligaments zur Behandlung der patellofemoralen Instabilität. Oper Orthop Traumatol 27, 495–504 (2015). https://doi.org/10.1007/s00064-015-0420-x
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DOI: https://doi.org/10.1007/s00064-015-0420-x