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Das schmerzhafte Patellofemoralgelenk

Biomechanik, Diagnostik und Therapie

The painful patellofemoral joint

Biomechanics, diagnosis and therapy

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Zusammenfassung

Neue Erkenntnisse über die Pathophysiologie und Biomechanik des patellofemoralen Gelenks (PFG) schaffen ein besseres Verständnis und erlauben neue therapeutische Ansätze. Entscheidend für eine erfolgreiche Behandlung ist die Analyse der zugrunde liegenden Pathologie. Im vorliegenden Beitrag werden die biomechanischen Grundlagen der statischen, passiven und aktiven Faktoren und ihr Einfluss auf das PFG beschrieben. Die Patienten werden klinisch und bildgebend mit einer Basisdiagnostik in die 3 Krankheitsbilder Schmerz, Instabilität und Arthrose eingeteilt. Bei Vorliegen einer PFG-Instabilität erfolgt eine weiterführende Diagnostik mit der Magnetresonanztomographie (MRT). Ziel dieses zusätzlichen MRT-Einsatzes ist die Analyse der biomechanischen Ursachen für die Instabilität. Auf Basis eines pathophysiologischen Konzepts wird ein neuer therapeutischer Algorithmus zur Behandlung der 3 Krankheitsbilder vorgestellt.

Abstract

New knowledge about the pathophysiology and biomechanics of the patellofemoral joint (PFJ) has led to a better understanding and new treatment options. To recognise the main pathology is the most important and difficult part. This article describes the basic principles of biomechanics (static, passive and active factors) and their influence on the PFJ. Patients are classified into three groups (pain, instability and arthritis). This is achieved by a clinical evaluation and standard X-rays. The instability group is analysed additionally with MRI. The aim of this evaluation is to analyse the biomechanical cause of the instability. Based on a pathophysiological concept a new therapeutic algorithm is introduced.

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Literatur

  1. Ackroyd CE, Newman JH, Evans R et al (2007) The Avon patellofemoral arthroplasty: five-year survivorship and functional results. J Bone Joint Surg Br 89:310–315

    PubMed  CAS  Google Scholar 

  2. Amis AA, Firer P, Mountney J et al (2003) Anatomy and biomechanics of the medial patellofemoral ligament. Knee 10:215–220

    Article  PubMed  CAS  Google Scholar 

  3. Amis AA, Senavongse W, Bull AM (2006) Patellofemoral kinematics during knee flexion-extension: an in vitro study. J Orthop Res 24:2201–2211

    Article  PubMed  Google Scholar 

  4. Arendt EA, Fithian DC, Cohen E (2002) Current concepts of lateral patella dislocation. Clin Sports Med 21:499–519

    Article  PubMed  Google Scholar 

  5. Baldini A, Anderson JA, Cerulli-Mariani P et al (2007) Patellofemoral evaluation after total knee arthroplasty. Validation of a new weight-bearing axial radiographic view. J Bone Joint Surg Am 89:1810–1817

    Article  PubMed  Google Scholar 

  6. Biedert RM (2008) Osteotomien. Orthopade 37:872, 874–872, 880

    Article  PubMed  CAS  Google Scholar 

  7. Biedert RM (2010) Lengthening of the lateral retinaculum in arthroscopic surgery. Arthroskopie 23:191–194

    Article  Google Scholar 

  8. Blackburn JS, Peel TE (1977) A new method of measuring patellar height. J Bone Joint Surg Br 59(2):241–242

    Google Scholar 

  9. Bohnsack M, Borner C, Ruhmann O et al (2005) Patellofemorales Schmerzsyndrom. Orthopade 34:668–676

    Article  PubMed  CAS  Google Scholar 

  10. Brattsroem H (1964) Shape of the intercondylar groove normally and in recurrent dislocation of patella. A clinical and x-ray-anatomical investigation. Acta Orthop Scand Suppl 68:148

    Google Scholar 

  11. Caton J (1989) Method of measuring the height of the patella. Acta Orthop Belg 55:385–386

    PubMed  CAS  Google Scholar 

  12. Chung CY, Lee KM, Park MS et al (2010) Validity and reliability of measuring femoral anteversion and neck-shaft angle in patients with cerebral palsy. J Bone Joint Surg Am 92:1195–1205

    Article  PubMed  Google Scholar 

  13. Cofield RH, Bryan RS (1977) Acute dislocation of the patella: results of conservative treatment. J Trauma 17:526–531

    Article  PubMed  CAS  Google Scholar 

  14. Conlan T, Garth WP Jr, Lemons JE (1993) Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am 75:682–693

    PubMed  CAS  Google Scholar 

  15. Cox JS (1976) An evaluation of the Elmslie-Trillat procedure for management of patellar dislocations and subluxations: a preliminary report. Am J Sports Med 4:72–77

    Article  PubMed  CAS  Google Scholar 

  16. Dejour D, Saggin P (2010) The sulcus deepening trochleoplasty – the Lyon’s procedure. Int Orthop 34:311–316

    Article  PubMed  Google Scholar 

  17. Dejour H, Walch G, Neyret P et al (1990) Dysplasia of the femoral trochlea. Rev Chir Orthop Reparatrice Appar Mot 76:45–54

    PubMed  CAS  Google Scholar 

  18. Dejour H, Walch G, Nove-Josserand L et al (1994) Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 2:19–26

    Article  PubMed  CAS  Google Scholar 

  19. Derasari A, Brindle TJ, Alter KE et al (2010) McConnell taping shifts the patella inferiorly in patients with patellofemoral pain: a dynamic magnetic resonance imaging study. Phys Ther 90:411–419

    Article  PubMed  Google Scholar 

  20. Dye SF, Vaupel GL, Dye CC (1998) Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med 26:773–777

    PubMed  CAS  Google Scholar 

  21. Ellera Gomes JL, Stigler Marczyk LR, Cesar de Cesar P et al (2004) Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: a follow-up study. Arthroscopy 20:147–151

    Article  Google Scholar 

  22. Farahmand F, Naghi TM, Amis A (2004) The contribution of the medial retinaculum and quadriceps muscles to patellar lateral stability – an in-vitro study. Knee 11:89–94

    Article  PubMed  Google Scholar 

  23. Farr J, Schepsis A, Cole B et al (2007) Anteromedialization: review and technique. J Knee Surg 20:120–128

    PubMed  Google Scholar 

  24. Feller JA, Amis AA, Andrish JT et al (2007) Surgical biomechanics of the patellofemoral joint. Arthroscopy 23:542–553

    Article  PubMed  Google Scholar 

  25. Fithian DC, Paxton EW, Stone ML et al (2004) Epidemiology and natural history of acute patellar dislocation. Am J Sports Med 32:1114–1121

    Article  PubMed  Google Scholar 

  26. Fulkerson JP (1983) Anteromedialization of the tibial tuberosity for patellofemoral malalignment. Clin Orthop Relat Res 176–181

  27. Galland O, Walch G, Dejour H et al (1990) An anatomical and radiological study of the femoropatellar articulation. Surg Radiol Anat 12:119–125

    Article  PubMed  CAS  Google Scholar 

  28. Goldthwait JE (1899) V. Permanent dislocation of the patella. The report of a case of twenty years‘ duration, successfully treated by transplantation of the patella tendons with the tubercle of the tibia. Ann Surg 29:62–68

    PubMed  CAS  Google Scholar 

  29. Goutallier D, Bernageau J, Lecudonnec B (1978) The measurement of the tibial tuberosity. Patella groove distanced technique and results (author’s transl). Rev Chir Orthop Reparatrice Appar Mot 64:423–428

    PubMed  CAS  Google Scholar 

  30. Green JP, Waugh W, Wood H (1968) Congenital lateral dislocation of the patella. J Bone Joint Surg Br 50(2):285–289

    PubMed  CAS  Google Scholar 

  31. Grelsamer RP, Bazos AN, Proctor CS (1993) Radiographic analysis of patellar tilt. J Bone Joint Surg Br 75:822–824

    PubMed  CAS  Google Scholar 

  32. Hauser ED (2006) Total tendon transplant for slipping patella: a new operation for recurrent dislocation of the patella. 1938. Clin Orthop Relat Res 452:7–16

    Article  PubMed  Google Scholar 

  33. Hofmann S, Kramer J, Vakil-Adli A et al (2004) Painful bone marrow edema of the knee: differential diagnosis and therapeutic concepts. Orthop Clin North Am 35:321–333, ix

    Article  PubMed  Google Scholar 

  34. Insall J (1979) Chondromalacia patellae: patellar malalignment syndrome. Orthop Clin North Am 10:117–127

    PubMed  CAS  Google Scholar 

  35. Insall J, Salvati E (1971) Patella position in the normal knee joint. Radiology 101(1):101–104

    PubMed  CAS  Google Scholar 

  36. Iranpour F, Merican AM, Baena FR et al (2010) Patellofemoral joint kinematics: the circular path of the patella around the trochlear axis. J Orthop Res 28:589–594

    PubMed  Google Scholar 

  37. Ireland ML, Willson JD, Ballantyne BT et al (2003) Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther 33:671–676

    PubMed  Google Scholar 

  38. Iwano T, Kurosawa H, Tokuyama H et al (1990) Roentgenographic and clinical findings of patellofemoral osteoarthrosis. With special reference to its relationship to femorotibial osteoarthrosis and etiologic factors. Clin Orthop Relat Res 190–197

  39. Knoch F von, Bohm T, Burgi ML et al (2006) Trochleaplasty for recurrent patellar dislocation in association with trochlear dysplasia. A 4- to 14-year follow-up study. J Bone Joint Surg Br 88:1331–1335

    Google Scholar 

  40. Kuroda R, Kambic H, Valdevit A et al (2001) Articular cartilage contact pressure after tibial tuberosity transfer. A cadaveric study. Am J Sports Med 29:403–409

    PubMed  CAS  Google Scholar 

  41. Lee TQ, Sandusky MD, Adeli A et al (2002) Effects of simulated vastus medialis strength variation on patellofemoral joint biomechanics in human cadaver knees. J Rehabil Res Dev 39:429–438

    PubMed  Google Scholar 

  42. Mariani PP, Caruso I (1979) An electromyographic investigation of subluxation of the patella. J Bone Joint Surg Br 61-B:169–171

    Google Scholar 

  43. Mehta VM, Inoue M, Nomura E et al (2007) An algorithm guiding the evaluation and treatment of acute primary patellar dislocations. Sports Med Arthrosc 15:78–81

    Article  PubMed  Google Scholar 

  44. Merican AM, Iranpour F, Amis AA (2008) Iliotibial band tension reduces patellar lateral stability. J Orthop Res 42:1539–1546

    Google Scholar 

  45. Mihalko WM, Boachie-Adjei Y, Spang JT et al (2008) Controversies and techniques in the surgical management of patellofemoral arthritis. Instr Course Lect 57:365–380

    PubMed  Google Scholar 

  46. Mulford JS, Wakeley CJ, Eldridge JD (2007) Assessment and management of chronic patellofemoral instability. J Bone Joint Surg Br 89:709–716

    Article  PubMed  CAS  Google Scholar 

  47. Natri A, Kannus P, Jarvinen M (1998) Which factors predict the long-term outcome in chronic patellofemoral pain syndrome? A 7-yr prospective follow-up study. Med Sci Sports Exerc 30:1572–1577

    Article  PubMed  CAS  Google Scholar 

  48. Nomura E, Inoue M, Kurimura M (2003) Chondral and osteochondral injuries associated with acute patellar dislocation. Arthroscopy 19:717–721

    Article  PubMed  Google Scholar 

  49. Ostermeier S, Becher C (2010) Einfluss des Tuberositastransfers auf das patellofemorale Gelenk. Arthroskopie 23:208–214

    Article  Google Scholar 

  50. Pagenstert GI, Bachmann M (2008) Klinische Untersuchung bei patellofemoralen Problemen. Orthopade 37:890–903

    Article  PubMed  CAS  Google Scholar 

  51. Paulos L, Swanson SC, Stoddard GJ et al (2009) Surgical correction of limb malalignment for instability of the patella: a comparison of 2 techniques. Am J Sports Med 37:1288–1300

    Article  PubMed  Google Scholar 

  52. Phillips CL, Silver DA, Schranz PJ et al (2010) The measurement of patellar height: a review of the methods of imaging. J Bone Joint Surg Br 92:1045–1053

    Article  PubMed  CAS  Google Scholar 

  53. Powers CM (2003) The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther 33:639–646

    PubMed  Google Scholar 

  54. Rebmann K, Grasshoff H, Brendel U (1989) [Results of the surgical treatment of habitual and recurrent patella dislocation using Ali Krogius‘ method]. Beitr Orthop Traumatol 36(12):571–575

    PubMed  CAS  Google Scholar 

  55. Ronga M, Oliva F, Longo UG et al (2009) Isolated medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 37(9):1735–1742

    Article  PubMed  Google Scholar 

  56. Sanchis-Alfonso V (2008) Patellofemorale Schmerzen. Orthopade 37:835–840

    Article  PubMed  CAS  Google Scholar 

  57. Sanchis-Alfonso V, Rosello-Sastre E (2003) Anterior knee pain in the young patient – what causes the pain? „Neural model“. Acta Orthop Scand 74:697–703

    Article  PubMed  Google Scholar 

  58. Schneider B, Laubenberger J, Jemlich S et al (1997) Measurement of femoral antetorsion and tibial torsion by magnetic resonance imaging. Br J Radiol 70:575–579

    PubMed  CAS  Google Scholar 

  59. Schoettle PB, Zanetti M, Seifert B et al (2006) The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. Knee 13:26–31

    Article  PubMed  Google Scholar 

  60. Schottle PB, Fucentese SF, Pfirrmann C et al (2005) Trochleaplasty for patellar instability due to trochlear dysplasia: a minimum 2-year clinical and radiological follow-up of 19 knees. Acta Orthop 76:693–698

    Article  PubMed  Google Scholar 

  61. Schottle PB, Romero J, Schmeling A et al (2008) Technical note: anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft. Arch Orthop Trauma Surg 128:479–484

    Article  PubMed  Google Scholar 

  62. Seitlinger G, Scheurecker A, Högler R et al (2010) Medialisierung der Tuberositas – der Goldstandard oder obsolet. 27. AGA Kongress, 9.–11.11.1010, Wien, V40:44–44

  63. Seitlinger G, Scheurecker G, Högler R et al (2010) Die dynamische TT-TG-Abstand-Messung im offenen MRT bei Patienten mit Patella-Instabilität und gesunden Probanden. Sport Orthop Sport Traumatol 2:108–109

    Article  Google Scholar 

  64. Sillanpaa PJ, Mattila VM, Maenpaa H et al (2009) Treatment with and without initial stabilizing surgery for primary traumatic patellar dislocation. A prospective randomized study. J Bone Joint Surg Am 91:263–273

    Article  PubMed  Google Scholar 

  65. Singer BJ, Silbert PL, Song S et al (2010) Treatment of refractory anterior knee pain using botulinum toxin type A (Dysport) injection to the distal vastus lateralis muscle: a randomised placebo controlled crossover trial. Br J Sports Med Aug 5. [Epub ahead of print]

  66. Smith TO, Hunt NJ, Donell ST (2008) The reliability and validity of the Q-angle: a systematic review. Knee Surg Sports Traumatol Arthrosc 16:1068–1079

    Article  PubMed  Google Scholar 

  67. Smith TO, Bowyer D, Dixon J et al (2009) Can vastus medialis oblique be preferentially activated? A systematic review of electromyographic studies. Physiother Theory Pract 25:69–98

    Article  PubMed  Google Scholar 

  68. Urch SE, Tritle BA, Shelbourne KD et al (2009) Axial linear patellar displacement: a new measurement of patellofemoral congruence. Am J Sports Med 37:970–973

    Article  PubMed  Google Scholar 

  69. Van Tiggelen D, Cowan S, Coorevits P et al (2009) Delayed vastus medialis obliquus to vastus lateralis onset timing contributes to the development of patellofemoral pain in previously healthy men: a prospective study. Am J Sports Med 37:1099–1105

    Article  Google Scholar 

  70. Verdonk P, Bonte F, Verdonk R (2008) Die laterale Retinaculumspaltung. Orthopade 37:884–889

    Article  PubMed  CAS  Google Scholar 

  71. Warden SJ, Hinman RS, Watson MA Jr et al (2008) Patellar taping and bracing for the treatment of chronic knee pain: a systematic review and meta-analysis. Arthritis Rheum 59:73–83

    Article  PubMed  Google Scholar 

  72. Weiner DS, Cook AJ, Hoyt WA Jr et al (1978) Computed tomography in the measurement of femoral anteversion. Orthopedics 1:299–306

    PubMed  CAS  Google Scholar 

  73. Wiberg G (1941) Roentgenographic and anatomic studies on the patellofemoral joint with special reference to chondromalacia patella. Acta Orthop Scand 12:319

    Article  Google Scholar 

  74. Yamada Y, Toritsuka Y, Horibe S et al (2007) In vivo movement analysis of the patella using a three-dimensional computer model. J Bone Joint Surg Br 89:752–760

    Article  PubMed  CAS  Google Scholar 

  75. Yercan HS, Ait Si, Selmi T, Neyret P (2005) The treatment of patellofemoral osteoarthritis with partial lateral facetectomy. Clin Orthop Relat Res 14–19

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung hin: Der korrespondierende Autor ist als Berater für die Firma Zimmer und Stryker tätig.

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Authors and Affiliations

  1. Abteilung für Orthopädie, Krankenhaus Oberndorf, Paracelsusstraße 37, A-5110 , Oberndorf, Österreich

    G. Seitlinger

  2. Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland

    K. Beitzel & A. Imhoff

  3. Röntgeninstitut am Schillerplatz, Linz, Österreich

    G. Scheurecker

  4. Allgemeines und Orthopädisches Krankenhaus Stolzalpe, Stolzalpe, Österreich

    S. Hofmann

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  1. G. Seitlinger
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  3. G. Scheurecker
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  4. A. Imhoff
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  5. S. Hofmann
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Correspondence to G. Seitlinger.

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Seitlinger, G., Beitzel, K., Scheurecker, G. et al. Das schmerzhafte Patellofemoralgelenk . Orthopäde 40, 353–370 (2011). https://doi.org/10.1007/s00132-011-1752-3

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