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Chronische patellofemorale Instabilität

Chronic patellofemoral instability

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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.

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.

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Literatur

  1. Amis AA (2007) Current concepts on anatomy and biomechanics of patellar stability. Sports Med Arthrosc 15(2):48–56

    Article  PubMed  Google Scholar 

  2. Ali S, Bhatti A (2007) Arthroscopic proximal realignment of the patella for recurrent instability: report of a new surgical technique with 1–7 years of follow-up. Arthroscopy 23(3):305–311

    Article  PubMed  Google Scholar 

  3. Barber FA, McGarry JE (2008) Elmslie-Trillat procedure for the treatment of recurrent patellar instability. Arthroscopy 24(1):77–81

    Article  PubMed  Google Scholar 

  4. Bitar AC, Demange MK, D’Elia CO, Camanho GL (2012) Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon. Am J Sports Med 40(1):114–122

    Article  PubMed  Google Scholar 

  5. Bollier M, Fulkerson J, Cosgarea A, Tanaka M (2011) Technical failure of medial patellofemoral ligament reconstruction. Arthroscopy 27(8):1153–1159

    Article  PubMed  Google Scholar 

  6. Caton JH, Dejour D (2010) Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop 34(2):305–309

    Article  PubMed  Google Scholar 

  7. Christiansen SE, Jakobsen BW, Lund B, Lind M (2008) Isolated repair of the medial patellofemoral ligament in primary dislocation of the patella: a prospective randomized study. Arthroscopy 24(8):881–887

    Article  PubMed  Google Scholar 

  8. Christiansen SE, Jacobsen BW, Lund B, Lind M (2008) Reconstruction of the medial patellofemoral ligament with gracilis tendon autograft in transverse patellar drill holes. Arthroscopy 24(1):82–87

    Article  PubMed  Google Scholar 

  9. Cowan SM, Bennell KL, Hodges PW (2002) Therapeutic patellar taping changes the timing of vasti muscle activation in people with patellofemoral pain syndrome. Clin J Sport Med 12(6):339–347

    Article  PubMed  CAS  Google Scholar 

  10. Desio SM, Burks RT, Bachus KN (1998) Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 26(1):59–65

    PubMed  CAS  Google Scholar 

  11. Donell ST, Joseph G, Hing CB, Marshall TJ (2006) Modified Dejourtrochleoplasty for severe dysplasia: operative technique and early clinical results. Knee 13(4):266–273

    Article  PubMed  Google Scholar 

  12. Dopirak R, Adamany D, Bickel B, Steensen R (2008) Reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft: a case series. Orthopedics 31(3):217

    PubMed  Google Scholar 

  13. Drez D Jr, Edwards TB, Williams CS (2001) Results of medial patellofemoral ligament reconstruction in the treatment of patellar dislocation. Arthroscopy 17(3):298–306

    Article  PubMed  Google Scholar 

  14. Ellera Gomes JL, Stigler Marczyk LR, César de César P, Jungblut CF (2004) Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: a follow-up study. Arthroscopy 20(2):147–151

    Article  Google Scholar 

  15. Elias JJ, Cosgarea AJ (2006) Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: a computational analysis. Am J Sports Med 34(9):1478–1485n

    Article  PubMed  Google Scholar 

  16. Fithian DC, Paxton EW, Cohen AB (2004) Indications in the treatment of patellar instability. J Knee Surg 17(1):47–56

    PubMed  Google Scholar 

  17. Fulkerson JP, Becker GJ, Meaney JA et al (1990) Anteromedial tibial tubercle transfer without bone graft. Am J Sports Med 18(5):490–496

    Article  PubMed  CAS  Google Scholar 

  18. Halbrecht JL (2001) Arthroscopic patella realignment: an all-inside technique. Arthroscopy 17(9):940–945

    Article  PubMed  CAS  Google Scholar 

  19. Haspl M, Cicak N, Klobucar H, Pecina M (2002) Fully arthroscopic stabilization of the patella. Arthroscopy 18(1):E2

    PubMed  Google Scholar 

  20. Koëter S, Pakvis D, Loon CJ van, Kampen A van (2007) Trochlear osteotomy for patellar instability: satisfactory minimum 2-year results in patients with dysplasia of the trochlea. Knee Surg Sports Traumatol Arthrosc 15(3):228–232

    Article  PubMed  Google Scholar 

  21. LaPrade RF, Engebretsen AH, Ly TV et al (2007) The anatomy of the medial part of the knee. J Bone Joint Surg Am 89(9):2000–2123

    Article  PubMed  Google Scholar 

  22. Lattermann C, Toth J, Bach BR Jr (2007)The role of lateral retinacular release in the treatment of patellar instability. Sports Med Arthrosc 15(2):57–60

    Article  PubMed  Google Scholar 

  23. Lippacher S, Reichel H, Nelitz M (2010) Patellar fracture after patellar stabilization. Orthopade 39(5):516–518

    Article  PubMed  CAS  Google Scholar 

  24. Merican AM, Kondo E, Amis AA (2009) The effect on patellofemoral joint stability of selective cutting of lateral retinacular and capsular structures. J Biomech 42(3):291–296

    Article  PubMed  Google Scholar 

  25. Miller JR, Adamson GJ, Pink MM et al (2007) Arthroscopically assisted medial reefing without routine lateral release for patellar instability. Am J Sports Med 35(4):622–629

    Article  PubMed  Google Scholar 

  26. Nam EK, Karzel RP (2005) Mini-open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocation: a medium-term follow-up. Am J Sports Med 33(2):220–230

    Article  PubMed  Google Scholar 

  27. Nakagawa K, Wada Y, Minamide M et al (2002) Deterioration of long-term clinical results after the Elmslie-Trillat procedure for dislocation of the patella. J Bone Joint Surg Br 84(6):861–864

    Article  PubMed  CAS  Google Scholar 

  28. Neyret P, Robinson AH, Le Coultre B et al (2002) Patellar tendon length–the factor in patellar instability? Knee 9(1):3–6

    Article  PubMed  Google Scholar 

  29. Nomura E, Inoue M (2006) Hybrid medial patellofemoral ligament reconstruction using the semitendinous tendon for recurrent patellar dislocation: minimum 3 years‘ follow-up. Arthroscopy 22(7):787–793

    Article  PubMed  Google Scholar 

  30. Nomura E, Inoue M, Kobayashi S (2007) Long-term follow-up and knee osteoarthritis change after medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 35(11):1851–1858

    Article  PubMed  Google Scholar 

  31. Ostermeier S, Stukenborg-Colsman C, Wirth CJ, Bohnsack M (2007) Reconstruction of the medial patellofemoral ligament by tunnel transfer of the semitendinosus tendon. Oper Orthop Traumatol 19(5–6):489–501

    Google Scholar 

  32. Panni AS, Alam M, Cerciello S et al (2011) Medial patellofemoral ligament reconstruction with a divergent patellar transverse 2-tunnel technique. Am J Sports Med 39(12):2647–2655

    Article  PubMed  Google Scholar 

  33. Pritsch T, Haim A, Arbel R et al (2007) Tailored tibial tubercle transfer for patellofemoral malalignment: analysis of clinical outcomes. Knee Surg Sports Traumatol Arthrosc 15(8):994–1002

    Article  PubMed  Google Scholar 

  34. 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 

  35. Schöttle PB, Fucentese SF, Romero J (2005) Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc 13(7):516–521

    Article  PubMed  Google Scholar 

  36. Schöttle 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(5):693

    Article  PubMed  Google Scholar 

  37. Schöttle PB, Schmeling A, Rosenstiel N, Weiler A (2007) Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med 35:801–804

    Article  PubMed  Google Scholar 

  38. Schöttle PB, Scheffler SU, Schwarck A, Weiler A (2006) Arthroscopic medial retinacular repair after patellar dislocation with and without underlying trochlear dysplasia: a preliminary report. Arthroscopy 22(11):1192–1198

    Article  PubMed  Google Scholar 

  39. Schöttle PB, Schell H, Duda G, Weiler A (2007) Cartilage viability after trochleoplasty. Knee Surg Sports Traumatol Arthrosc 15(2):161–167

    Article  PubMed  Google Scholar 

  40. Small NC, Glogau AI, Berezin MA (1993) Arthroscopically assisted proximal extensor mechanism realignment of the knee. Arthroscopy 9(1):63–67

    Article  PubMed  CAS  Google Scholar 

  41. Steiner TM, Torga-Spak R, Teitge RA (2006) Medial patellofemoral ligament reconstruction in patients with lateral patellar instability and trochlear dysplasia. Am J Sports Med 34(8):1254–1261

    Article  PubMed  Google Scholar 

  42. Tom A, Fulkerson JP (2007) Restoration of native medial patellofemoral ligament support after patella dislocation. Sports Med Arthrosc 15(2):68–71

    Article  PubMed  Google Scholar 

  43. Thaunat M, Erasmus PJ (2009) Management of overtight medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 17:480–483

    Article  PubMed  Google Scholar 

  44. Utting MR, Mulford JS, Eldridge JD (2008) A prospective evaluation of trochleoplasty for the treatment of patellofemoral dislocation and instability. J Bone Joint Surg Br 90(2):180–185

    Article  PubMed  CAS  Google Scholar 

  45. Knoch F von, Böhm T, Bürgi 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(10):1331–1335

    Google Scholar 

  46. Verdonk R, Jansegers E, Stuyts B (2005) Trochleoplasty in dysplastic knee trochlea. Knee Surg Sports Traumatol Arthrosc 13(7):529–533

    Article  PubMed  CAS  Google Scholar 

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Interessenkonflikt

Der korrespondierende Autor weist für sich und seine Koautoren auf folgende Beziehung/en hin: Fa. Karl Storz, Tuttlingen; Otto Bock, Duderstadt.

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  1. Klinik für Orthopädie und Unfallchirurgie, Martin Luther Krankenhaus, Berlin, Grunewald, Caspar Theyss-Straße 27–31, 14193, Berlin, Deutschland

    W. Petersen, P. Forkel & A. Achtnich

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  1. W. Petersen
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  2. P. Forkel
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  3. A. Achtnich
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Correspondence to W. Petersen.

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Petersen, W., Forkel, P. & Achtnich, A. Chronische patellofemorale Instabilität. Unfallchirurg 115, 397–409 (2012). https://doi.org/10.1007/s00113-012-2197-9

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