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Patellarekonstruktion bei defizientem knöchernen Lager

Patellar bone deficiency in revision total knee arthroplasty

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Zusammenfassung

Hintergrund

Knöcherne Verluste der Patella bestimmen die chirurgische Rekonstruktion bei Wechseloperationen nach Knietotalendoprothesen (KTEP). In einem, je nach Knochenverlust abgestuftem Vorgehen, werden unterschiedliche OP-Techniken und deren Ergebnisse beschrieben.

Indikation

Primäre Patellaimplantate können in bis zu 50 % der Revisionsoperationen belassen werden. Gründe für einen Wechsel sind: aseptische und septische Lockerungen, Implantatversagen, ausgedehnte Osteolysen, insuffizientes Patellagleiten und Metal-backed-Prothesen.

Die Ziele der Rekonstruktion sind eine stabile Verankerung, ein orthogrades Gleiten des neuen Implantats und die Erhaltung einer suffizienten Streckfunktion.

Operatives Vorgehen

Je nach Ausmaß des Knochenverlustes und Vorhandenseins des patellaren Knochenrandes wird folgendes chirurgisches Vorgehen empfohlen. Bei Knochendicke über 10 mm: Implantation einer Polyethylen-onlay-type-Patella; bei 6–9 mm und erhaltenem Knochenrand: Rekonstruktion mit bikonvexem „inlay-type“-Patellaimplantat; bei stark defizientem Knochenlager (< 6 mm) oder ohne knöchernen Rand: Augmentationsverfahren mit autologer Spongiosa (Impaction Bone Grafting), Trabecular-metal-Prothese (der trabekuläre Teil des Implantates dient als Fundament für einen zementierten Polyethylenknopf), „Gull-Wing“-Osteotomie (ein adaptives und konfigurierendes Osteotomieverfahren) oder im Ausnahmefall eine Patelloplastik oder Patellektomie.

Schlussfolgerung

Da die patellare Komponente einer KTEP einen hohen Stellenwert in der Biomechanik des Gelenks und der Streckfunktion hat, sind rekonstruktive Verfahren anzustreben. Die Patelloplastik oder Patellektomie sollte vermieden werden.

Abstract

Background

Patellar bone deficiency in revision total knee arthroplasty (TKA) determines the surgical procedure. Different reconstructive and ablative techniques, dependent on the remaining bone stock, are described.

Indication

The primary patella implant can be retained in up to 50 % of revision situations. Reasons for replacement are aseptic and septic loosening, implant failure, expanding osteolysis, maltracking of the patella and “metal-backed” prosthesis.

The aim of the reconstruction is the stable fixation and proper tracking of the implant by restoring the extensor mechanism.

Surgical procedure

Dependent on the extent of bone loss and the availability of a patellar rim, the following surgical procedures are recommended. When the remaining bone thickness is 10 mm or more: implantation of a polyethylene “onlay-type” patella; when it is between 6–9 mm and there is an intact patellar rim: reconstruction with a biconvex “inlay-type” patella implant, where the biconvex shape replaces the bone defect partially. When there is deficient bone stock (less than 6 mm) or no cortical patellar rim then augmenting procedures with autologous spongiosa and procedures such as “impaction bone grafting”, “trabecular metal” prosthesis, where the trabecular part of the implant serves as the base for the cemented polyethylene button, “gull-wing” osteotomy, which is an adapting and configuring technique of osteotomy; and in exceptional cases patelloplasty or patellectomy are used.

Conclusion

Regarding the importance of the patellar component in biomechanics of the joint and function of the extensor mechanism, the reconstruction of the patella should be the primary aim. Patelloplasty or patellectomy should be avoided.

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Authors and Affiliations

  1. Orthopädisches Krankenhaus Gersthof, Wielemansgasse 28, 1180, Wien, Österreich

    J. Kloiber, E. Goldenitsch &  P. Ritschl

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  1. J. Kloiber
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  2. E. Goldenitsch
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  3. P. Ritschl
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Correspondence to P. Ritschl.

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Interessenkonflikt

P. Ritschl ist als Konsultant für die Firma Smith & Nephew® tätig. Für diese Arbeit hat der Autor keine Zuwendung bekommen. J. Kloiber und E. Goldenitsch geben an, dass kein Interessenkonflikt besteht.

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

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Kloiber, J., Goldenitsch, E. & Ritschl, P. Patellarekonstruktion bei defizientem knöchernen Lager. Orthopäde 45, 433–438 (2016). https://doi.org/10.1007/s00132-016-3253-x

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