Zusammenfassung
Hintergrund
Die Methode des Gap-Balancing ist für die Einstellung der Femurkomponentenrotation und Beugestabilität in der Primärendoprothetik des Kniegelenkes ein etabliertes und häufig angewendetes Verfahren. Allerdings ist es durch die in der Regel evertierte oder luxierte Patella und durchgeführte Weichteilreleases ungenau und fehleranfällig. Hier wird die Alternativtechnik eines Patella-in-Place-Balancers (PIPB) vorgestellt.
Methode
Zunächst erfolgt die Resektion der Tibia und das Aufbringen einer Basisplatte. Anschließend werden 2 transkondylär verlaufende Pins in sagittaler Richtung in die Femurkondylen eingedreht. Nach Reposition des Streckapparates in die anatomisch Position kann durch sukzessives Eindrehen der Pins der Flexionsspalt aufgespannt werden. An diesem Status erfolgt dann die Ausrichtung der femoralen Schnitte, parallel zur Tibia. Es wird dabei keinerlei Weichteilrelease durchgeführt. Klinische Erfahrungen von über 3000 derart versorgter Patienten werden retrospektiv dargestellt, sowie von einer prospektiven Beobachtungsstudie berichtet.
Ergebnisse
Die Technik des PIPB war für alle primären und sekundären Gonarthrosen – bei erhaltenem Bandapparat – anwendbar. Die ermittelte Revisionsrate lag bei 1,21 %. Nur 2 % der Patienten stellten sich 1 Jahr postoperativ mit einem unbefriedigenden Ergebnis neuerlich vor. In der prospektiven Betrachtung kann nach 6 Monaten eine signifikante Steigerung im KOOS dokumentiert werden (29,3 auf 63,5 Punkte, p < 0,05).
Diskussion
Der Patella-in-Place-Balancer überwindet die wesentliche Limitation der Gap-Balancing Technik hinsichtlich ihrer Ungenauigkeit durch den luxierten Streckapparat. Nach absolvierter Lernkurve erscheint die Technik sicher und reproduzierbar. Die vorläufigen Daten zeigen vielversprechende Ergebnisse.
Abstract
Background
The gap-balancing technique is well established in primary total knee arthroplasty to determine femoral rotation and flexion gap stability. However, it has been reported that the everted or luxated extensor mechanism during this procedure in addition to soft tissue releases performed may cause inaccurate flexion-gap determination and thus result in malpositioning of the femur or instability. In this article the alternative technique of a Patella in Place Balancer (PIPB) with a no tissue release philosophy is introduced.
Method
In this procedure, at first, the tibia resection is performed and a tibia baseplate inserted. Then, two pins are drilled into the sagittal profile of the femoral condyles. After anatomical repositioning of the extensor apparatus the pins are screwed in until the flexion gap is spanned. In this position femoral component orientation is determined parallel to the tibia. We describe the current clinical experience based on a retrospective review of 3,000 patients. Moreover, initial results of a prospective study are outlined.
Results
The PIPB technique was suitable for the treatment of primary and secondary gonarthrosis if the collateral ligaments were intact. The detected revision rate was about 1.21 %. Only 2 % of the treated patients reported back with an unsatisfactory outcome 1 year after surgery. In the prospective survey of 33 patients a significant improvement in the KOOS Score could be documented (29.3 points preoperatively vs. 63.5 postoperatively (p < 0.05)).
Discussion
The PIPB overcomes the major limitation of the gap balancing technique with regard to the inaccuracy caused by the dislocated extensor mechanism. After a learning curve, the technique appears to be safe and reliable. Preliminary data show promising results.
Literatur
Abdel MP, Parratte S, Blanc G, Ollivier M, Pomero V, Viehweger E, Argenson JN (2014) No benefit of patient-specific instrumentation in TKA on functional and gait outcomes: a randomized clinical trial. Clin Orthop Relat Res 472(8):2468–2476
Babazadeh S, Dowsey MM, Stoney JD, Choong PF (2014) Gap balancing sacrifices joint-line maintenance to improve gap symmetry: a randomized controlled trial comparing gap balancing and measured resection. J Arthroplasty 29(5):950–954
Berger RA, Rubash HE, Seel MJ, Thompson WH, Crossett LS (1993) Determining the rotational alignment of the femoral component in total knee arthroplasty using the epicondylar axis. Clin Orthop Relat Res 286:40–47
Berger RA, Crossett LS, Jacobs JJ, Rubash HE (1998) Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res 356:144–153
Boldt JG, Stiehl JB, Hodler J, Zanetti M, Munzinger U (2006) Femoral component rotation and arthrofibrosis following mobile-bearing total knee arthroplasty. Int Orthop 30(5):420–425
Daines BK, Dennis DA (2014) Gap balancing vs. measured resection technique in total knee arthroplasty. Clin Orthop Surg 6(1):1–8
Dennis DA (2008) Measured resection: an outdated technique in total knee arthroplasty. Orthopedics 31(9):940, 943–944
Dennis DA, Komistek RD, Kim RH, Sharma A (2010) Gap balancing versus measured resection technique for total knee arthroplasty. Clin Orthop Relat Res 468(1):102–107
Incavo SJ, Wild JJ, Coughlin KM, Beynnon BD (2007) Early revision for component malrotation in total knee arthroplasty. Clin Orthop Relat Res 458:131–136
van Jonbergen HP, Reuver JM, Mutsaerts EL, Poolman RW (2014) Determinants of anterior knee pain following total knee replacement: a systematic review. Knee Surg Sports Traumatol Arthrosc 22(3):478–499
Katz MA, Beck TD, Silber JS, Seldes RM, Lotke PA (2001) Determining femoral rotational alignment in total knee arthroplasty: reliability of techniques. J Arthroplasty 16(3):301–305
Mantas JP, Bloebaum RD, Skedros JG, Hofmann AA (1992) Implications of reference axes used for rotational alignment of the femoral component in primary and revision knee arthroplasty. J Arthroplasty 7(4):531–535
Poilvache PL, Insall JN, Scuderi GR, Font-Rodriguez DE (1996) Rotational landmarks and sizing of the distal femur in total knee arthroplasty. Clin Orthop Relat Res 331:35–46
Romero J, Stahelin T, Binkert C, Pfirrmann C, Hodler J, Kessler O (2007) The clinical consequences of flexion gap asymmetry in total knee arthroplasty. J Arthroplasty 22(2):235–240
Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD (1998) Knee Injury and Osteoarthritis Outcome Score (KOOS) – development of a self-administered outcome measure. J Orthop Sports Phys Ther 28(2):88–96
Schnurr C, Nessler J, Konig DP (2009) Is referencing the posterior condyles sufficient to achieve a rectangular flexion gap in total knee arthroplasty? Int Orthop 33(6):1561–1565
Scuderi GR, Komistek RD, Dennis DA, Insall JN (2003) The impact of femoral component rotational alignment on condylar lift-off. Clin Orthop Relat Res 410:148–154
Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM (2002) Insall Award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res 404:7–13
Siston RA, Patel JJ, Goodman SB, Delp SL, Giori NJ (2005) The variability of femoral rotational alignment in total knee arthroplasty. J Bone Joint Surg Am 87(10):2276–2280
Suzuki K, Hara N, Mikami S et al (2014) In vivo kinematic analysis of posterior-stabilized total knee arthroplasty for the valgus knee operated by the gap-balancing technique. Knee 21(6):1124–1128
Whiteside LA, Arima J (1995) The anteroposterior axis for femoral rotational alignment in valgus total knee arthroplasty. Clin Orthop Relat Res 321:168–172
Yoon JR, Oh KJ, Wang JH, Yang JH (2014) Does patella position influence ligament balancing in total knee arthroplasty? Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-014-2879-7
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M. Ettinger, T. Callies, A. Demurie, H. Van den Wyngaert und I. Ghijselings sind Berater von Stryker.
Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Ettinger, M., Calliess, T., Demurie, A. et al. Patella-in-Place-Balancing. Orthopäde 44, 269–274 (2015). https://doi.org/10.1007/s00132-015-3105-0
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DOI: https://doi.org/10.1007/s00132-015-3105-0