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Ligament bracing – Augmentierte Primärnaht bei multiligamentären Verletzungen des Kniegelenks

Ligament bracing—augmented primary suture repair in multiligamentous knee injuries

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Zusammenfassung

Operationsziel

Wiederherstellung der Kniegelenksstabilität durch primäre Kreuzbandnähte und Fadenaugmentationen im Rahmen einer Kniegelenksluxation.

Indikation

Kniegelenksluxationen Typ III und IV nach Schenck im Akutstadium. Die operative Versorgung sollte wenn möglich innerhalb der ersten 7 Tage nach Trauma erfolgen.

Kontraindikationen

Chronische Instabilitäten nach Kniegelenksluxation, refixierbare knöcherne Ausrisse, kritische Weichteilverhältnisse, akute Infektsituationen, mangelnde Compliance.

Operationstechnik

Rückenlagerung in elektrischem Beinhalter. Kurzer arthroskopischer Rundgang mit wenig Wasserdruck. Schenck Typ III medial und Typ IV: anteromediale parapatellare Arthrotomie; Schenck Typ III lateral: anteromediane Arthrotomie. Armierung der Bandstümpfe für die transossäre Ausziehnaht. Platzierung der VKB- und HKB-Bohrkanäle unter Zuhilfenahme arthroskopischer Zielgeräte. Extrakortikale Ausleitung der Fadenarmierungen und Einbringen der Fadenaugmentationssysteme. Einstellung der a.-p.-Translation über die Augmentationsfäden. Fixation der HKB-Augmentation in 70°- bis 90°-Flexion. Fixation der VKB-Augmentation in 20°- bis 30°-Flexion. Spannungsfreies Verknoten der transossären Ausziehnähte. Anschließend ggf. (postero)laterale und/oder mediale Stabilisierung.

Nachbehandlung

Teilbelastung mit 20 kg für 6 Wochen. Stabilisierende Orthesenbehandlung (z. B. Hypex-Lite®, Albrecht) in der Regel für 12 Wochen. Mobilisation des Kniegelenks unter aktiver Quadrizepsanspannung in den ersten 6 Wochen.

Ergebnisse

Insgesamt wurden 20 Patienten nach dem Prinzip des „ligament bracing“ operiert. Nachuntersucht wurden bisher 8 Patienten im Alter von 18–60 Jahren (Median 33 Jahre) nach 10–15 Monaten (Median 12 Monate). Subjektiv und objektiv stabile Bandverhältnisse mit sehr guten Ergebnissen zeigten 6 Patienten. Eine VKB-Rezidivinsuffizienz boten 2 Patienten; die Seitenbänder und das HKB waren dabei jeweils stabil. Die Evaluierung erfolgte mittels IKDC-, Tegner- und Lysholm-Score. Zur Objektivierung dienten neben der klinischen Untersuchung gehaltene Röntgenaufnahmen im Seitenvergleich. Komplikationen traten bei der vorgestellten Operationstechnik nicht auf. Im Rahmen der Nachbehandlung kam es bei 2 Patienten zu einem beginnenden Beugedefizit.

Abstract

Objective

Reconstruction of knee stability by primary ligament sutures and additional augmentation after knee dislocation.

Indications

Acute knee dislocation Schenck type III and IV. Operative treatment should be performed within 7 days after injury.

Contraindications

Chronic instability after knee dislocation, refixable bony avulsions, critical soft tissue, infection, lack of compliance.

Surgical technique

Supine position with electric leg holder. Short arthroscopic assessment of concomitant injuries. Schenck type III medial injuries and Schenck IV injuries: anteromedial parapatellar arthrotomy. Injuries type Schenck III lateral: anteromedian arthrotomy. Armoring of ligament stumps for transosseus sutures. Placement of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) drill tunnels. Extracortical diversion of the suture armorings and insertion of augmentation systems. Fixation of the PCL augmentation in 70–90° flexion. Fixation of the ACL augmentation in 20–30° flexion. Knotting of the transosseus ligament sutures. If necessary (postero-)lateral and/or medial stabilization.

Postoperative management

Limited weight bearing with 20 kg for 6 weeks. Stabilizing brace (e.g., Hypex-Lite®, Albrecht) generally for 12 weeks. Mobilization under tension of the quadriceps muscle for 6 weeks.

Results

In total, 20 patients have been treated using the principle of “ligament bracing”. So far 8 patients (aged 18–60 years, median 33 years) have been assessed with a follow-up of 10–15 months (median 12 months) postoperatively. In all, 6 patients showed stable knees with good results. Recurrent instability of the ACL was observed in 2 patients; the collateral ligaments and PCL were stable. For the evaluation the following scores were used: IKDC score, Tegner score, and Lysholm score. To objectify the data, stress radiography and physical examination were performed. Using the operative technique mentioned above, no complications occurred. During follow-up 2 patients reported a deficiency of flexion.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. K.-H. Frosch, M. Heitmann, M. Gerau, J. Hötzel, A. Giannakos und A. Preiss geben an, dass kein Interessenkonflikt besteht. Alle angewandten Verfahren stehen im Einklang mit den ethischen Normen der verantwortlichen Kommission für Forschung am Menschen (institutionell und national) und mit der Deklaration von Helsinki von 1975 in der revidierten Fassung von 2008. Alle Patienten wurden erst nach erfolgter Aufklärung und Einwilligung in die Studie eingeschlossen.

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Authors and Affiliations

  1. Chirurgisch-Traumatologisches Zentrum, Asklepios Klinik St.Georg, Lohmühlenstr. 5, 20099, Hamburg, Deutschland

    M. Heitmann, M. Gerau, J. Hötzel, A. Giannakos,  K.-H. Frosch & A. Preiss

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  1. M. Heitmann
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  2. M. Gerau
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  3. J. Hötzel
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  4. A. Giannakos
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  5. K.-H. Frosch
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  6. A. Preiss
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Corresponding author

Correspondence to K.-H. Frosch.

Zusatzmaterial online

64_2013_263_MO1_ESM.mov

Video 1. Untersuchung der Kreuzbänder in 90° und 30° Flexion. Es zeigt sich eine vermehrte anteriore und posteriore Translation als Zeichen einer VKB- und HKB-Insuffizienz bei einer Luxation Typ III nach Schenck. (MOV 42,4MB)

64_2013_263_MO2_ESM.mov

Video 2.Nach erfolgtem ligament bracing und medialer Stabilisierung zeigen sich im Stresstest stabile Bandverhältnisse (MOV 47,1MB)

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Heitmann, M., Gerau, M., Hötzel, J. et al. Ligament bracing – Augmentierte Primärnaht bei multiligamentären Verletzungen des Kniegelenks. Oper Orthop Traumatol 26, 19–29 (2014). https://doi.org/10.1007/s00064-013-0263-2

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  • DOI: https://doi.org/10.1007/s00064-013-0263-2

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