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Kombinierte Rekonstruktion des hinteren und vorderen Kreuzbandes

Arthroskopische Versorgung mit dem GraftLink®-System

Combined posterior and anterior cruciate ligament reconstruction

Arthroscopic treatment with the GraftLink® system

  • Operative Techniken
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Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Zusammenfassung

Operationsziel

Simultane arthroskopische Rekonstruktion des hinteren (HKB) und vorderen Kreuzbandes (VKB) mit GraftLink® (Arthrex, Naples, FL, USA). Ziel sind die stabile Versorgung und ein funktionell gutes Ergebnis nach HKB-/VKB-Rekonstruktion. Die Transplantatprotektion durch das sicherheitsgurtartige biomechanische GraftLink®-Prinzip soll das intraoperativ erzielte Stabilitätsergebnis längerfristig sichern.

Indikationen

VKB-, HKB- oder kombinierte Kreuzbandruptur, insbesondere bei Multiligamentverletzung. Kreuzband-Re-Ersatzplastik.

Kontraindikationen

Präoperativ fixierte hintere Schublade. Höhergradige Bewegungseinschränkung mit Streckdefizit (Ext./Flx. 0‑0-120° als Voraussetzung). Komplexes regionales Schmerzsyndrom. Höhergradige Quadrizepsatrophie, ossäre Deformitäten.

Operationstechnik

Rückenlagerung mit frei beweglichem Bein (bei Flexion ≥ 120° antegrades Vorgehen möglich, bei Flexion < 120° Vorgehen mittels Retrocutter). Oberschenkelblutsperre. Staging-Arthroskopie. Kreuzbandersatz mit GraftLink®, idealerweise in folgender Reihenfolge der Bohrkanäle: 1. HKB tibial, 2. VKB femoral, 3. HKB femoral, 4. VKB tibial. Hybridfixierung (v. a. HKB) empfohlen. Empfohlene Portale: Hohes anteromediales, hohes anterolaterales, posteromediales, ggf. posterolaterales Portal und Subvastus-Mini-Inzision.

Weiterbehandlung

Kombinierter Kreuzbandersatz: Schrittweise Belastungs‑/Bewegungssteigerung in der PCL-Schiene, ab der 5. Woche zunehmend Übergang in die Vollbelastung sowie Extension/Flexion 90° ab der 7. Woche. Abtrainieren der PCL-Schiene ab der 13. postoperativen Woche. Freigabe für Kontaktsportarten/Wettkampfsport nach 1 Jahr.

Ergebnisse

Mit dem GraftLink®-System können stabile Kniegelenkverhältnisse hergestellt und gute funktionelle Ergebnisse erzielt werden. Gerade für komplexe Folgezustände nach Kniegelenkluxation mit VKB- und HKB-Ruptur eignet sich das Verfahren sehr gut für den ein- oder zweizeitigen Kreuzbandersatz.

Abstract

Objective

Simultaneous arthroscopic reconstruction of the anterior and/or posterior cruciate ligament (ACL/PCL) using the GraftLink® system (Arthrex) to obtain stable treatment and good functional results. The transplant is protected by the safety belt like biomechanical GraftLink® principle, which is used to secure the intraoperatively obtained stability in the long term.

Indications

ACL, PCL, or combined cruciate ligament rupture, especially multiligament injuries. Revision ACL and PCL reconstruction.

Contraindications

Preoperative fixed posterior tibial subluxation. Reduced range of motion (ROM) with an extension lag (extension/flexion 0‑0-120° preoperatively required). Complex regional pain syndrome. High-grade atrophy of the quadriceps femoris muscle and osseous deformities.

Surgical technique

Supine position with mobile leg and possible flexion of at least 120° allowing antegrade femoral bone tunnel replacement. Retrograde tunnel placement (e. g. using a retrocutter) is recommended in case of less than 120° knee flexion. Thigh tourniquet. Staging arthroscopy. Cruciate ligament reconstruction is realized by anatomic tunnel placement for the ACL/PCL using the GraftLink®. Recommended sequence of reconstruction: 1. tibial PCL tunnel, 2. femoral ACL tunnel, 3. femoral PCL tunnel, 4. tibial ACL tunnel. Hybrid fixation is recommended. Portals: High anteromedial, high anterolateral, posteromedial, posterolateral, small subvastus incision.

Postoperative management

Combined cruciate ligament replacement: Gradual load and ROM increase in the PCL track. After postoperative week 5, increasing load up to full weight bearing, with extension/flexion 0‑0-90° after week 7. Down training of the PCL track after week 13. Contact and competitive sports after 1 year.

Results

The GraftLink® system allows restoration of knee joint stability with good functional results. The procedure is especially suitable for complex situations like after knee dislocation with ACL and PCL reconstruction in 1 or 2 steps.

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Literatur

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Authors and Affiliations

  1. Sektion Sporttraumatologie und arthroskopische Chirurgie, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland

    A. Ateschrang, M. D. Ahrend, S. Ahmad, D. Körner, U. Stöckle & A. J. Schreiner

  2. BG Unfallklinik, Frankfurt, Deutschland

    T. Stein

  3. Ahmet Necdet Sezer Hospital, Afyonkarahisar, Türkei

    M. Yesil

Authors
  1. A. Ateschrang
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  2. M. D. Ahrend
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  3. S. Ahmad
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  4. D. Körner
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  5. T. Stein
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  6. M. Yesil
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  7. U. Stöckle
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  8. A. J. Schreiner
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Correspondence to A. Ateschrang.

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Interessenkonflikt

A. Ateschrang, M.D. Ahrend, S. Ahmad, D. Körner, T. Stein, M. Yesil, U. Stöckle und A.J. Schreiner geben an, dass kein Interessenkonflikt besteht.

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

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Redaktion

A.B. Imhoff, München

Zeichner

B. Brühmüller, Waghäusel

A. Ateschrang und M.D. Ahrend haben zu gleichen Teilen zur Erstellung des Manuskripts beigetragen.

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Ateschrang, A., Ahrend, M.D., Ahmad, S. et al. Kombinierte Rekonstruktion des hinteren und vorderen Kreuzbandes. Oper Orthop Traumatol 31, 20–35 (2019). https://doi.org/10.1007/s00064-018-0580-6

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  • DOI: https://doi.org/10.1007/s00064-018-0580-6

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