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Beeinflusst der Zugangsweg die intraoperativ gemessene Beinachse in der Knieendoprothetik?

Eine navigationsgestützte Studie am Kadaverknie

Influence of the surgical approach in total knee arthroplasty on ligament tension

A navigation-controlled cadaver study

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Zusammenfassung

Beim endoprothetischen Ersatz des Kniegelenks ist die Rekonstruktion der mechanischen Beinachse ein wichtiger Faktor für ein gutes Langzeitergebnis. Da der Zugangsweg nach wie vor kontrovers diskutiert wird, war es Ziel der Studie mit Hilfe eines bildfreien Navigationssystems einen möglichen Einfluss des anatomischen Zugangsweges auf die Weichteilbalancierung und damit die Achsausrichtung herauszuarbeiten.

An 5 nicht Formalin-fixierten Kniegelenken wurden der Subvastus-, Midvastus-, medial-parapatellare Zugang, der „rectus snip“ und die Tuberositasosteotomie durchgeführt und ihr Einfluss auf die Gesamtbeinachse bei der Weichteilbalancierung in Flexion und Extension mittels eines Navigationssystems (CT-free Ci-Navigation-System™) und Spreizerinstrumentarium (Balansys™) mit definiertem Kraftmoment quantifiziert.

Der Subvastuszugang hatte in Extension nur einen geringen Einfluss auf die gemessene Beinachse während bei 90° Flexion eine Valgisierung zu beobachten war. Dieser Effekt verstärkt sich um ca. 0,5–1,0° der Gesamtbeinachse bei Erweiterung des Zugangs. Eine Messung bei evertierter Patella verfälscht das Ergebnis zusätzlich um durchschnittlich 0,5°.

Bei der Wahl des Zugangs in der Knieendoprothetik sollte der Einfluss auf die Bandspannung stets berücksichtigt werden. Eine Evertierung der Patella sollte bei der Bandspannungsuntersuchung vermieden werden.

Abstract

Correct postoperative leg alignment and stability of the total knee prosthesis over the full range of movement is one critical factor for successful TKA. The anatomic approach is still the subject of controversy. The aim of our study was to elucidate the influence of the surgical approach on the ligament balancing and the anterioposterior limb axis.

On five cadaver knees we studied the influence of the subvastus, midvastus, medial parapatellar, rectus snip, and tuberosity osteotomy approaches on the anterioposterior leg axis in extension and the rotation of the femoral component in flexion. Measurements were performed and documented by CT-free Ci-Navigation-System. Ligament tension was measured with a tensor device.

We found that the subvastus approach leads to less widening of the medial compartment than all other approaches in extension. In 90° flexion we found a similar influence. The consecutive release from subvastus to midvastus to medial parapatellar approach leads to a further opening of 0.5–1° valgus in extension as well as in flexion. An everted patella amplifies this influence.

The surgeon has to be aware of the impact on the ligament situation in regard to the anatomic approach when ligament balancing and soft tissue releases are carried out. Patella eversion should be avoided when managing soft tissues.

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Authors and Affiliations

  1. Unfallchirurgische Klinik, Medizinische Hochschule, Hannover

    C. Lüring, T. Hüfner, D. Kendoff & C. Krettek

  2. Orthopädische Klinik, Universität, Regensburg

    L. Perlick, H. Bäthis & J. Grifka

  3. Unfallchirurgische Klinik, Medizinische Hochschule, Carl-Neuberger-Straße 1, 30623, Hannover

    C. Lüring

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  1. C. Lüring
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  2. T. Hüfner
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  4. L. Perlick
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Correspondence to C. Lüring.

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Lüring, C., Hüfner, T., Kendoff, D. et al. Beeinflusst der Zugangsweg die intraoperativ gemessene Beinachse in der Knieendoprothetik?. Unfallchirurg 108, 274–278 (2005). https://doi.org/10.1007/s00113-004-0887-7

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