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Revisionen nach MPFL-Rekonstruktion

Revision surgery following MPFL reconstruction

  • Leitthema
  • Published:
Arthroskopie Aims and scope

Zusammenfassung

Hintergrund

Mit zunehmender Verbreitung der Rekonstruktion des medialen patellofemoralen Ligaments (MPFL) zur Behandlung der patellofemoralen Instabilität steigt auch die Anzahl der Revisionsoperationen. Aufgrund der Komplexität der Pathologie und mit zunehmendem Wissen über die Biomechanik des patellofemoralen Gelenks zeigt sich, dass die Hauptfehlerquellen nach fehlgeschlagener MPFL-Rekonstruktion die Indikationsstellung und operationstechnische Fehler sind.

Ziel der Arbeit

Ziel des Artikels ist, Fehler in der Indikationsstellung sowie intraoperative Fehlerquellen exemplarisch darzustellen und Lösungsmöglichkeiten aufzuzeigen.

Methoden

In diesem Beitrag soll diese Thematik aufgegriffen und auf Basis der Literatur und eigenen Beobachtungen diskutiert werden.

Ergebnisse

Im Rahmen der Indikationsstellung wird häufig die zugrunde liegende Pathologie nicht adäquat analysiert und somit auch nicht adressiert. So kann sich bei Problemen nach MPFL-Rekonstruktion häufig das Vorliegen einer nicht adressierten höhergradigen Trochleadysplasie oder ausgeprägten knöchernen Valgus- und Rotationsdeformität zeigen. Im Vordergrund stehen jedoch technische Operationsfehler, insbesondere die zu weit proximale bzw. ventrale femorale Transplantatverankerung. Dies kann zu einer vermehrten Druckbelastung des patellofemoralen Knorpels und somit zu einer progredienten Schädigung mit Arthroseentwicklung führen.

Schlussfolgerung

Die MPFL-Rekonstruktion ist eine effektive Methode zur Behandlung der patellofemoralen Instabilität. Nach fehlgeschlagener MPFL-Rekonstruktion ist die Indikationsstellung und somit die zugrundeliegende Pathologie genau zu analysieren. Signifikante Kopathologien sollten zusätzlich adressiert werden (u. a. Trochleaplastik, Valgus- und Rotationskorrektur). Bei operationstechnischen Fehlern sind individuelle Lösungsstrategien, wie z. B. partielles Release, MPFL-Reinsertion, MPFL-Revisionsersatz u. a. erforderlich. Die femorale Transplantatinsertion sollte grundsätzlich intraoperativ röntgenologisch kontrolliert werden (Bildwandler). Sämtliche Maßnahmen sollten darauf abzielen, die physiologische Anatomie wiederherzustellen und die patellofemorale Druckbelastung zu minimieren.

Abstract

Background

With increasing application of the medial patellofemoral ligament (MPFL) reconstruction technique for the treatment of patellofemoral instability, the number of revision surgeries also increases. Due to the complex pathology and increasing knowledge of the biomechanics of the patellofemoral joint, the main reasons for failure are the imprecise indication for surgery and specific technical surgical errors.

Aim

This article discusses the indication for MPFL reconstruction and presents options for resolution of technical surgical errors.

Methods

Discussion based on a review of the literature and personal observations.

Results

In cases of failure after MPFL reconstruction the underlying pathology is often not adequately analyzed and thus not addressed. Specifically, the existence of a high-grade trochlear dysplasia and significant bony valgus and rotational deformities are often overlooked. The main focus, however, is on technical surgical errors, particularly the femoral malpositioning of the graft (i. e. proximal or ventral placement). This can lead to increased pressure load on the patellofemoral compartment, thus inducing progressive cartilage damage and osteoarthritis.

Conclusion

Reconstruction of the MPFL is an effective method for the treatment of patellofemoral instability. After failed MPFL reconstruction, the indications and thus the underlying pathology have to be accurately analyzed. Significant copathologies should be addressed (e.g. trochleoplasty, valgus and rotational corrections). In cases of technical surgical errors, individual solution strategies, such as partial graft-release, MPFL reinsertion and MPFL re-replacement have to be discussed. The femoral graft insertion should be generally checked intraoperatively by fluoroscopy. Operative interventions should restore the physiological anatomy and minimize the patellofemoral compressive load.

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Authors and Affiliations

  1. Sporthopaedicum Berlin, Bismarckstraße 45-47, 10627, Berlin, Deutschland

    A. Schmeling

  2. Isar Klinikum, München, Deutschland

    P. Schöttle

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Correspondence to A. Schmeling.

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Interessenkonflikt

A. Schmeling und P. Schöttle geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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F. Dirisamer, Linz-Puchenau

A. Schmeling, Berlin

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Schmeling, A., Schöttle, P. Revisionen nach MPFL-Rekonstruktion. Arthroskopie 28, 202–212 (2015). https://doi.org/10.1007/s00142-015-0028-z

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  • DOI: https://doi.org/10.1007/s00142-015-0028-z

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