Aktuelle Trends. Deutsche Kniegesellschaft, Hamburg Proximales oder distales Alignment
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1 Deutsche Kniegesellschaft, Hamburg Aktuelle Trends Proximales oder distales Alignment PD Dr. Geert Pagenstert Stv. Chefarzt Orthopädische Klinik Universitätsspital
2 Insalls Proximales Realignment Insall et al. CORR laterale Retinakulum Spaltung - Medial und Distalisierung VMO Scuderi et al. JBJS Am Patellaluxationen FU 42m, 81% zufrieden, 1 Relux!
3 Biomechanik ligamentäre Patellastabilisation MPFL = Mediales Patello Femorales Ligament Wichtigster Stabilisator nahe Extension! Senavogse et al. JBJS Br 2005
4 Biomechanik ligamentäre Patellastabilisation Senavogse & Amis JBJS Br 2005
5 Biomechanik ligamentäre Patellastabilisation F Dirisamer
6 Resultate isolierte MPFL Plastik 50 Patellalux mit MPFL Gracilis anatomic DB Min FU 12m, Kujala & Tegner - 1x Relux - Signifikant schlechtere Ergebnisse bei Trochleadysplasie Typ 3 - Kein Unterschied Insall Salvati Index >/< 1,2 - Kein Unterschied für TTTG Distanz >/< 15mm, Trend bei >20mm
7 MPFL Plastik = Proximales Alignment
8 Retinakulum Spaltung Destabilisiert! Laterale Dekompression Nötig für Reposition der Patella?
9 Laterale Retinakulum Verlängerung bei Instabilität Patella RelocationTest Bachmann & Pagenstert, Arthroskopie 2010; Pagenstert & Attal AGA Komitee Heft 2016
10 Fixed lateral subluxation in patellar instability Grading of Patella Relocation Test 1. Reduction leads to lateral hypercompression 2. Reduction prevented by tight lateral retinaculum
11 Retinakulum Verlängerung statt Spaltung Arthroscopy 2012 Je 14 Fälle, FU 2y - Signifikant mehr Quad Atrophie & med Instabilität bei Release
12 Trend zur lateralen Retinakulum Rekonstruktion
13
14 Distales Realignment bei Patella Instabilität Tuberositas tibiae Transfer medial & distal Mechanisches Konzept 1. Quad auf Linie 2. Trochlea Abstützung nutzen
15 Distales Realignment bei Patella Instabilität Outcome Hauser TTT medial & distal 67 to 74 % Gutes Outcome 17 to 20% Redislokation 68 to 71% Progression zur Arthrose nach 7-18 y Juliusson & Markehde AOTS 1984 Chrisman Snook CORR 1979 DeCesare CORR 1979 from Pattison et al. Knee 1996
16 Pathomechanik Überkorrektur OVERMEDIALIZATION Kuroda et al. AJSM mm medialization significant increases pressure
17 Pathomechanik Überkorrektur OVERMEDIALIZATION lead to medial OA TTTG -12mm Courtesy of E. Servien
18 JBJS Br 2009 Tuberositas Distalisierung bei Patella alta Normalisiert den PF Druck!
19 Distales Realignment bei Patella Instabilität Menu à la carte Lyon School Lateral tibial tubercle Patella alta Patellotibiale Relation 22 TT-TG distance > 20mm Caton Deschamps Index > 1,3 <0,6/ >1,2 pathologisch Dejour et al. KSSTA 2: 19-26, 1994
20 Distales Realignment bei Patella Instabilität Lyon School Korrektur TT-TG auf mm Korrektur Caton-Deschamps auf cm Servien et al. SMA 2001
21 Limitationen der Normwerte Insall-Salvati-Index TTT Planung unmöglich
22 Caton Deschamps Index zur TTT Planung Patellotibial Relation <0,6/ >1,3 pathologic
23 Limitationen der Normwerte TT-TG Distance secondary to tibial torsion Dickschass et al. AOTS 2012, Saandeep et al. AJSM 2011 Teitge 40
24 Limitationen der Normwerte TT-TG Distance secondary to trochlea dysplasia Fucentese et al. KSSTA 2007 Shin et al. CORR 2006 Courtesy of P Schöttle KSSTA 2007
25 Limitationen der Normwerte TT-TG Distance Variable with body size Seitlinger et al. AJSM 2012 Seitlinger et al. AJSM 2012
26 Distales Realignment bei Patella Instabilität Outcome nach Normalisierung TTTG und Caton Index TTT combined with medial reefing & lateral release Keine Progression Arthrose 87% good outcomes (n=116) 7% Redislokation Cox AJSM 1982 Brown & Alexander AJSM 1984 Shelbourne & Porter AJSM 1994 Caton 1.4
27 Distales Realignment bei Patella Instabilität Arthroscopy 2006 TT Transfer hat keinen Einfluss auf Stabilität in Extension
28 Distales Realignment bei Patella Instabilität Evidence Senavogse & Amis JBJS Br 2005
29 Pathomechanik MPFL bei Patella alta Rotation bei Stabilisation Auslockerung durch Quad Aktivität Erasmus Orthopäde 2009
30 Pathomechanik MPFL bei Patella alta KSSTA 2016 Nicht Ansatz Proximalisieren sondern Patella alta korrigieren!
31 Fazit: Trends Proximales UND Distales Alignment 1. MPFL Plastik Standard der proximalen Patella Stabilisierung! potentiell mit ossären Korrekturen 2. Laterale Retinakulum Verlängerung nur bei fixierter Sub/-luxation OBLIGATORISCH mit Stabilisierungsoperation 3. Tuberositas Transfer medial-distal in den Normbereich KEINE Überkorrektur idr. In Kombination mit MPFL Plastik
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