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Anterolaterale Stabilisierung mittels modifizierter Lemaire-Plastik bei insuffizientem vorderem Kreuzband

Anterolateral stabilization using the modified Lemaire technique for ACL deficiency

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Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Zusammenfassung

Operationsziel

Behandlung einer persistierenden anterolateralen Kniegelenksinstabilität.

Indikationen

Subjektive/objektive (Rotations‑)Instabilität des Kniegelenks nach erfolgter (anatomischer) Rekonstruktion des vorderen Kreuzbandes (VKB). VKB-Reruptur inklusive spezieller Anforderungen (z. B. Hochleistungssport, Hyperlaxität)

Relative Kontraindikationen

Gonarthrose, Achsfehlstellungen oder additive Instabilitäten, die zusätzlich adressiert werden müssen; nichtanatomische VKB-Rekonstruktion (VKBR) mit persistierender Instabilität (zuerst anatomische VKBR).

Absolute Kontraindikationen

Allgemeine Kontraindikationen (z. B. Infektionen), Reizzustand des Kniegelenks.

Operationstechnik

Rückenlagerung. Leicht bogenförmige Schnittführung im Bereich posterior und proximal des lateralen femoralen Epikondylus. Darstellung/Anzeichnen des Tractus iliotibialis. Proximales Ablösen und Armieren des Traktusstreifens. Unterminieren des lateralen Kollateralbands. Markieren des Isometriezentrums femoralseitig. Fixieren des Transplantats. Schichtweiser Verschluss.

Weiterbehandlung

Hartrahmen-Kniegelenkorthese mind. 6 Wochen. Bewegungsumfang ab 1. postoperativem Tag: Flexion-Extension 90-0-0; 20-kg-Teilbelastung für 2 Wochen postoperativ.

Ergebnisse

Die aktuelle Literatur liefert Hinweise, dass eine anterolaterale Stabilisierung den Pivot-shift-Test sowie die Rerupturrate reduziert. Basierend auf biomechanischen Arbeiten ist dabei eine Tenodese nach Lemaire der Rekonstruktion des anterolateralen Ligaments vorzuziehen. Entscheidend ist jedoch die isometrische Bohrkanalplatzierung bzw. die Fixation in tibialer Neutralrotation mit geringer Transplantatspannung. Indikationen einer anterolateralen Stabilisierung sind VKB-Rupturen mit einem drittgradigen Pivot-shift bzw. Revisionsfälle oder persistierende anterolaterale Instabilitäten nach anatomischer VKBR.

Abstract

Objective

Treatment of persistent anterolateral knee instability.

Indications

Subjective/objective (rotational) instability of the knee after anatomic anterior cruciate ligament (ACL) reconstruction. ACL re-rupture including special demands (e.g., high-performance athletes, hyperlaxity)

Relative contraindications

Osteoarthritis, additional instability of the knee, which should be treated independently; non-anatomic ACL reconstruction with persisting instability should be treated first with anatomic ACL reconstruction.

Absolute contraindications

General contraindications for surgery (e. g. septic arthritis), acute irritation of the affected knee.

Surgical technique

Supine position. Incision along the proximal lateral femoral epicondyle. Marking of the needed width and length of the iliotibial band (ITB) graft. Passing the ITB graft underneath the lateral collateral ligament. Find and mark the isometric point for fixation next to the lateral femoral epicondyle. Fixation of the ITB graft. Layered wound closure.

Postoperative management

Knee brace for at least 6 weeks. Range of motion (RoM): from postoperative day 1: flexion–extension 90-0-0°; first 2 weeks after surgery: partial weight bearing (20 kg).

Results

An anterolateral extra-articular reconstruction may reduce a persistent anterolateral rotatory instability as well as the re-rupture rate following ACL reconstruction with good patient-reported short-term outcomes. Based on current (biomechanical) data, anterolateral tenodesis seems to be superior to a reconstruction of the anterolateral ligament. If a tenodesis is performed, the graft should be fixed in an isometric position, with neutral rotation of the knee and low graft tension to avoid extraphysiologic load within the lateral compartment. Indications for such a procedure may include a high-grade pivot shift or revision ACL reconstruction as well as a persistent anterolateral rotatory instability following anatomic ACL reconstruction.

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Abbreviations

A.:

Arterie/Arteria

ACL:

„anterior cruciate ligament“/vorderes Kreuzband

ALL:

anterolaterales Ligament

ALLR:

Rekonstruktion des anterolateralen Ligaments

LCL:

Ligamentum collaterale laterale

N.:

Nerv/Nervus

VKB:

vorderes Kreuzband

VKBR:

Rekonstruktion des vorderen Kreuzbandes

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Authors and Affiliations

  1. Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81679, München, Deutschland

    M. Wurm, E. Herbst, P. Forkel &  A. B. Imhoff

  2. Klinik für Unfall‑, Hand und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland

    M. Herbort

Authors
  1. M. Wurm
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  2. E. Herbst
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  3. P. Forkel
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  4. A. B. Imhoff
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Corresponding author

Correspondence to A. B. Imhoff.

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Interessenkonflikt

A.B. Imhoff ist Berater für Arthrex. M. Wurm, E. Herbst, P. Forkel und M. Herbort geben an, dass kein Interessenkonflikt besteht.

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

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A.B. Imhoff, München

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R. Himmelhan, Mannheim

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Wurm, M., Herbst, E., Forkel, P. et al. Anterolaterale Stabilisierung mittels modifizierter Lemaire-Plastik bei insuffizientem vorderem Kreuzband. Oper Orthop Traumatol 31, 36–44 (2019). https://doi.org/10.1007/s00064-018-0579-z

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