Der Unfallchirurg

, Volume 115, Issue 5, pp 397–409 | Cite as

Chronische patellofemorale Instabilität

Leitthema

Zusammenfassung

Die chronische patellofemorale Instabilität kann zu Beschwerden und degenerativen Schäden des Femoropatellargelenks führen. Unter diesem Oberbegriff werden rezidivierende Patellaluxationen, laterale Subluxationen und chronische Luxationen zusammengefasst. Die chronische patellofemorale Instabilität kann durch 5 verschiedene Faktoren bedingt sein: 1. Elongation des medialen patellofemoralen Bandes, 2. Patella alta, 3. erhöhter Abstand der Tuberositas tibiae zur „trochlea groove“ (TTTG), 4. Trochleadysplasie und 5. pathologische Torsionswerte. Diese Faktoren müssen gezielt diagnostiziert werden. Dabei spielen die klinische Untersuchung, die radiologische Diagnostik (Luxation, Subluxation in den Defilée-Aufnahmen, Gleitlagermorphologie, Patella alta) und die Magnetresonanztomographie (MRT, TTTG-Abstand, Gleitlagermorphologie) eine wichtige Rolle.

Die Indikation zur operativen Therapie besteht bei chronischen Schmerzen mit Subluxation und Lateralisation der Patella oder rezidivierenden Luxationen. Unter den chirurgischen Techniken werden proximale und distale Realignmentoperationen unterschieden. Das früher häufig durchgeführte „lateral release“ hat heute nur bei kontraktem lateralen Retinaculum mit lateraler Subluxation und positivem Tilt oder bei chronischer Luxation eine Berechtigung. Biomechanische Studien haben gezeigt, dass ein „lateral release“ die femoropatellare Instabilität ansonsten eher erhöht.

Die Wahl des geeigneten Operationsverfahrens richtet sich nach der zugrunde liegenden Pathologie der patellofemoralen Instabilität. Noch offene Wachstumsfugen und mögliche Knorpelschäden müssen ebenfalls berücksichtigt werden. Beim Vorliegen eines elongiertem medialen patellofemoralen Ligaments (MPFL) und geringer passiver Instabilität kann eine mediale Raffung erfolgreich sein. Bei MPFL-Elongation, hoher passiver Instabilität bis zu einer Beugung von 30° und ggf. zusätzlicher geringgradiger Gleitlagerdysplasie kommt der Ersatz des MPFL mit einem autologen Sehnentransplantat in Frage. Eine Trochleaplastik ist eher selten indiziert. Sie kommt bei hochgradiger Gleitlagerdysplasie und passiver Instabilität ab einer Beugung von 30° in Frage. Bei erhöhtem TTTG-Abstand (>20 mm) oder Patella alta sollte an ein distales Realignment mit Versetzung der Tuberositas tibiae gedacht werden. Als Anteromedialisation kann diese Operation auch bei degenerativen lateralen Gelenkschäden bei Patellalateralisation sinnvoll sein.

Schlüsselwörter

Trochleadysplasie Tuberositas tibiae Mediales patellofemorales Ligament Trochleaplastik Distales Realignement 

Chronic patellofemoral instability

Abstract

Chronic patellofemoral instability may lead to pain and early osteoarthrosis. Recurrent dislocations of the patella, lateral subluxation and chronic dislocation are summarized under this generic term. There are five different factors which may be responsible of the development of chronic patellofemoral instability: 1) elongation of the medial patellofemoral ligament (MPFL), 2) patella alta, 3) increased distance between tibial tuberosity and trochlea groove (TTTG) distance, 4) trochlea dysplasia and 5) torsional malalignment. To rule out these factors clinical examination, radiological diagnostics (luxation, subluxation in the Defilée view, trochlea morphology, patella alta) and magnetic resonance imaging (MRI) of TTTG distance and trochlea morphology are crucial. The indications of operative treatment are chronic pain with subluxation, chronic dislocation and recurrent dislocation.

Currently the former frequently and universally used lateral release is only indicated in cases of subluxation and positive tilt. Biomechanical studies have shown that a lateral release will otherwise increase patellofemoral instability. The choice of the surgical technique depends on the factors underlying patellofemoral instability, the conditions of growth plate and cartilage damage. Among the different surgical options proximal and distal realignment procedures are differentiated.

In cases of MPFL elongation and mild passive instability a medial reefing might be successful. In cases of MPFL elongation, high passive instability up to 30° of flexion (with or without trochlear dysplasia) MPFL reconstruction may be the treatment of choice. A trochleoplasty is rarely indicated. This treatment may be considered in cases of high grade trochlea dysplasia and passive instability at more than 30° of flexion. If the TTTG distance is increased (>20 mm) or in cases of patella alta distal realignment with tibial tubercle transfer should be considered. This operation might also be useful in the presence of lateral cartilage damage as an anteromedialization of the patella.

Keywords

Trochleadysplasia Tibial tuberosity to trochlea distance Medial patellofemoral ligament Trochleaplasty Distal realignement 

Supplementary material

113_2012_2197_MO1_ESM.mov (9.3 mb)
Video: Dynamische Untersuchung des Partellalaufs (QuickTime 9,5 MB)

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Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  1. 1.Klinik für Orthopädie und UnfallchirurgieMartin Luther Krankenhaus, Berlin, GrunewaldBerlinDeutschland

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