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Quadrizepssehneninsuffizienzen und -rupturen

Verfahren zur Behandlung in der Knieendoprothetik

Quadriceps tendon insufficiency and rupture

Treatment options in total knee arthroplasty

Zusammenfassung

Verletzungen und Insuffizienzen der Quadrizepssehne bei liegender Knietotalendoprothese stellen eine seltene, aber schwerwiegende Verletzung dar, die unbehandelt zum weitgehenden Funktionsverlust des Kniegelenks führt. Der Übersichtsbeitrag erläutert die funktionelle Anatomie, die Risikofaktoren, die Diagnostik von Verletzungen der Quadrizepssehne sowie die möglichen Versorgungsverfahren bei Partial- und Komplettrupturen. Die Behandlungsoptionen richten sich nach dem Grad des funktionellen Verlusts (partiell, komplett) sowie dem Verletzungszeitpunkt (akut vs. chronisch). Weitergehend muss in die Wahl des Behandlungsverfahrens die Qualität und Verfügbarkeit des Primärgewebes, der allgemeine Gesundheitszustand sowie das funktionelle Anforderungspotenzial des Patienten in die Entscheidung einbezogen werden. Ein konservatives Vorgehen ist häufig bei Partialrupturen gerechtfertigt und mit guten klinischen Ergebnissen assoziiert. Die vollständige Ruptur der Quadrizepssehne erfordert die operative Intervention. Für die Versorgung von Komplettrupturen sind vielfältige operative Versorgungstechniken beschrieben. In der Erstversorgung kompletter Quadrizepssehnenrupturen nach Implantation einer Knieendoprothese ist die primäre Naht mit autologer oder synthetischer Augmentation zu präferieren. Bei chronischen Insuffizienzen sowie desolater Weichteilsituation stellen die Versorgungen mithilfe gestielter Muskellappen oder tendoossärer Allografts Behandlungsalternativen dar. Alle bisher zur Verfügung stehenden operativen Interventionsmöglichkeiten sind komplikationsbehaftet und führen nicht selten zu einem unbefriedigenden Ergebnis. Ein neuer operativer Ansatz zur Rekonstruktion und Augmentation des Streckapparats ist die Verwendung eines synthetischen Netzes, deren Technik im Detail beschrieben wird.

Abstract

Quadriceps tendon injuries and insufficiencies in total knee arthroplasty are rare, but are followed by a devastating complication that left untreated leads to a complete loss of function of the knee. This review article summarizes the functional anatomy, risk factors, and the prevalence and diagnosis of quadriceps tendon injuries, in addition to the possible management options for partial and complete ruptures. The treatment options are adapted according to the extent of the loss of function (partial, complete) and the duration of the injury (acute vs chronic). Furthermore, the choice of treatment should take into account the quality and availability of primary tissue, the patient’s general health, along with their likely functional requirements. Conservative treatment is often justified in partial ruptures with good results. Complete ruptures require surgical intervention and multiple operative techniques are described. Treatment options for acute ruptures include direct primary repair with autogenous or synthetic tissue augmentation. In the case of chronic insufficiency and a lack of soft-tissue surroundings, reconstruction with the aid of a muscle flap or allograft tissue can be considered. All surgical intervention techniques used so far have been fraught with complications and rarely lead to satisfactory results. A new surgical approach to the reconstruction and augmentation of the extensor mechanism consists of the use of a synthetic mesh. The technique is described here in detail.

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Literatur

  1. Brown NM, Murray T, Sporer SM et al (2015) Extensor mechanism allograft reconstruction for extensor mechanism failure following total knee arthroplasty. J Bone Joint Surg Am 97:279–283

    Article  PubMed  Google Scholar 

  2. Browne JA, Hanssen AD (2011) Reconstruction of patellar tendon disruption after total knee arthroplasty: results of a new technique utilizing synthetic mesh. J Bone Joint Surg Am 93:1137–1143

    Article  PubMed  Google Scholar 

  3. Brune JC, Hesselbarth U, Seifert P et al (2012) CT lesion model-based structural allografts: custom fabrication and clinical experience. Transfus Med Hemother 39:395–404

    Article  PubMed  PubMed Central  Google Scholar 

  4. Burnett RS, Berger RA, Paprosky WG et al (2004) Extensor mechanism allograft reconstruction after total knee arthroplasty. A comparison of two techniques. J Bone Joint Surg Am 86-A:2694–2699

    PubMed  Google Scholar 

  5. Busfield BT, Huffman GR, Nahai F et al (2004) Extended medial gastrocnemius rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with and without total knee arthroplasty. Clin Orthop Relat Res 428:190–197

    Article  PubMed  Google Scholar 

  6. Cadambi A, Engh GA (1992) Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty. A report of seven cases. J Bone Joint Surg Am 74:974–979

    CAS  PubMed  Google Scholar 

  7. Chandrasekhar B, Brien W (1993) Coverage strategies in total joint replacement. Orthop Clin North Am 24:523–529

    CAS  PubMed  Google Scholar 

  8. Crossett LS, Sinha RK, Sechriest VF et al (2002) Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty. J Bone Joint Surg Am 84-A:1354–1361

    PubMed  Google Scholar 

  9. Diaz-Ledezma C, Orozco FR, Delasotta LA et al (2014) Extensor mechanism reconstruction with achilles tendon allograft in TKA: results of an abbreviate rehabilitation protocol. J Arthroplasty 29:1211–1215

    Article  PubMed  Google Scholar 

  10. Dobbs RE, Hanssen AD, Lewallen DG et al (2005) Quadriceps tendon rupture after total knee arthroplasty. Prevalence, complications, and outcomes. J Bone Joint Surg Am 87:37–45

    Article  PubMed  Google Scholar 

  11. Emerson RH Jr., Head WC, Malinin TI (1990) Reconstruction of patellar tendon rupture after total knee arthroplasty with an extensor mechanism allograft. Clin Orthop Relat Res 260:154–161

    PubMed  Google Scholar 

  12. Fernandez-Baillo N, Garay EG, Ordonez JM (1993) Rupture of the quadriceps tendon after total knee arthroplasty. A case report. J Arthroplasty 8:331–333

    CAS  Article  PubMed  Google Scholar 

  13. Gerwin M, Rothaus KO, Windsor RE et al (1993) Gastrocnemius muscle flap coverage of exposed or infected knee prostheses. Clin Orthop Relat Res 286:64–70

    PubMed  Google Scholar 

  14. Gustillo RTR (1987) Quadriceps and patellar tendon ruptures following total knee arthroplasty. In: Rand JA, Dorr LD (Hrsg) Total arthroplasty of the knee: proceedings of the Knee Society. Rockville, Aspen

    Google Scholar 

  15. Hinsenkamp M, Muylle L, Eastlund T et al (2012) Adverse reactions and events related to musculoskeletal allografts: reviewed by the World Health Organisation Project NOTIFY. Int Orthop 36:633–641

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  16. Jaureguito JW, Dubois CM, Smith SR et al (1997) Medial gastrocnemius transposition flap for the treatment of disruption of the extensor mechanism after total knee arthroplasty. J Bone Joint Surg Am 79:866–873

    CAS  Article  PubMed  Google Scholar 

  17. Kim TW, Kamath AF, Israelite CL (2011) Suture anchor repair of quadriceps tendon rupture after total knee arthroplasty. J Arthroplasty 26:817–820

    Article  PubMed  Google Scholar 

  18. Kollender Y, Bender B, Weinbroum AA et al (2004) Secondary reconstruction of the extensor mechanism using part of the quadriceps tendon, patellar retinaculum, and Gore-Tex strips after proximal tibial resection. J Arthroplasty 19:354–360

    Article  PubMed  Google Scholar 

  19. Lynch AF, Rorabeck CH, Bourne RB (1987) Extensor mechanism complications following total knee arthroplasty. J Arthroplasty 2:135–140

    CAS  Article  PubMed  Google Scholar 

  20. Menderes A, Demirdover C, Yilmaz M et al (2002) Reconstruction of soft tissue defects following total knee arthroplasty. Knee 9:215–219

    Article  PubMed  Google Scholar 

  21. Morrey MC, Barlow JD, Abdel MP, Hanssen AD (2016) Synthetic Mesh Augmentation of acute and subacute quadriceps tendon repair. Orthopedics 31(1):e9–e13

    Article  PubMed  Google Scholar 

  22. Nahabedian MY, Orlando JC, Delanois RE et al (1998) Salvage procedures for complex soft tissue defects of the knee. Clin Orthop Relat Res 356:119–124

    Article  PubMed  Google Scholar 

  23. Nam D, Abdel MP, Cross MB et al (2014) The management of extensor mechanism complications in total knee arthroplasty. AAOS exhibit selection. J Bone Joint Surg Am 96:e47

    Article  PubMed  Google Scholar 

  24. Nazarian DG, Booth RE Jr. (1999) Extensor mechanism allografts in total knee arthroplasty. Clin Orthop Relat Res 367:123–129

    PubMed  Google Scholar 

  25. Panni AS, Vasso M, Cerciello S et al (2011) Wound complications in total knee arthroplasty. Which flap is to be used? With or without retention of prosthesis? Knee Surg Sports Traumatol Arthrosc 19:1060–1068

    Article  PubMed  Google Scholar 

  26. Papalia R, Vasta S, D’adamio S et al (2014) Complications involving the extensor mechanism after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 23(12):3501–3515

    Article  PubMed  Google Scholar 

  27. Parker DL, Goodrich KC, Roberts JA et al (2003) The need for phase-encoding flow compensation in high-resolution intracranial magnetic resonance angiography. J Magn Reson Imaging 18:121–127

    Article  PubMed  Google Scholar 

  28. Pfitzner T, Perka C, Matziolis G (2009) Patella height after total knee replacement: influence of the radiological setting. Orthopäde 38:616–621

    CAS  Article  PubMed  Google Scholar 

  29. Pruss A, Kalus U (2012) Current trends in tissue banking. Transfus Med Hemother 39:373–374

    Article  PubMed  PubMed Central  Google Scholar 

  30. Rust PA, Tanna N, Spicer DD (2008) Repair of ruptured quadriceps tendon with Leeds-Keio ligament following revision knee surgery. Knee Surg Sports Traumatol Arthrosc 16:370–372

    CAS  Article  PubMed  Google Scholar 

  31. Schoderbek RJ Jr., Brown TE, Mulhall KJ et al (2006) Extensor mechanism disruption after total knee arthroplasty. Clin Orthop Relat Res 446:176–185

    Article  PubMed  Google Scholar 

  32. Suda AJ, Cieslik A, Grutzner PA et al (2014) Flaps for closure of soft tissue defects in infected revision knee arthroplasty. Int Orthop 38:1387–1392

    Article  PubMed  PubMed Central  Google Scholar 

  33. Trampuz A, Hanssen AD, Osmon DR et al (2004) Synovial fluid leukocyte count and differential for the diagnosis of prosthetic knee infection. Am J Med 117:556–562

    Article  PubMed  Google Scholar 

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Correspondence to K. Thiele.

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K. Thiele, P. von Roth, T. Pfitzner, B. Preininger und C. Perka geben an, dass kein Interessenkonflikt besteht.

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

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Thiele, K., von Roth, P., Pfitzner, T. et al. Quadrizepssehneninsuffizienzen und -rupturen. Orthopäde 45, 407–415 (2016). https://doi.org/10.1007/s00132-016-3258-5

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  • DOI: https://doi.org/10.1007/s00132-016-3258-5

Schlüsselwörter

  • Allografts
  • Prothesenversagen
  • Wiederherstellende chirurgische Eingriffe
  • Sehnenverletzungen
  • Risikofaktoren

Keywords

  • Allografts
  • Arthroplasty failure
  • Reconstructive surgical procedures
  • Tendon injuries
  • Risk factors