Aktuelles Vorgehen in der Nachbehandlung gelenkerhaltender Operationen am Kniegelenk im deutschsprachigen Raum

Zusammenfassung

Einleitung Die postoperative Nachbehandlung nach gelenkerhaltenden Kniegelenkoperationen beinhaltet neben klassischer Physiotherapie weitere Ansätze und Hilfsmittel wie CPM- und CAM-Schienen, TENS-Geräte, BFR-Training, Prähabilitation und digitale Gesundheitsanwendungen. Ziel der vorliegenden Umfrage war es, aktuelle Standards, Trends und Steuerungsmöglichkeiten in der Nachbehandlung zu untersuchen, Problemfelder zu identifizieren und mit der aktuellen Literatur zu vergleichen.

Material und Methoden Es erfolgte eine strukturierte anonyme Online-Befragung gelisteter Fachärzte für Orthopädie und Unfallchirurgie der deutschsprachigen Gesellschaft für Arthroskopie und Gelenkchirurgie (AGA). Der Fragebogen umfasste 36 geschlossene Fragen zur Nachbehandlung gelenkerhaltender Operationen am Kniegelenk.

Ergebnisse Es konnten die Fragebogen von 528 Teilnehmenden mit langjähriger Berufserfahrung (86,6% mehr als 10 Jahre) analysiert werden. Standardisierte Nachbehandlungsschemata werden von 97,2% verwendet und deren Evidenz als hoch (59,1%) /sehr hoch (14,8%) eingeschätzt. Probleme der Rehabilitation werden in 10–20% der Fälle von 87,3% (persistierende Muskelatrophie 30,9%) gesehen. Nach rekonstruktiven Eingriffen werden CPM-Schienen (70,1%), CAM-Schienen (42,1%), Orthesen (85,0%) und TENS-Geräte (40,0%) verschrieben. Potentere Ansätze zur Behandlung des postoperativen Muskeldefizits werden von 89,4% gewünscht. BFR-Training ist bei 41,7% bekannt und wird von 8% regelmäßig angewendet. Es erfolgt nur ein unregelmäßiger Austausch mit behandelnden Physiotherapeuten (schriftlich: 27,5%). Eine digitale Rehabilitationssteuerung würde von 83,3% unterstützt werden, 22,7% kennen digitale Gesundheitsanwendungen nicht. 87,9% der Teilnehmenden gehen davon aus, dass Prähabilitation das postoperative Ergebnis beeinflussen kann.

Schlussfolgerung Die Nachbehandlung kniegelenkerhaltender Operationen erfolgt in der Regel standardisiert und wird regelmäßig auf Aktualität überprüft. Die Evidenz für ausgesprochene Empfehlungen wird dabei als hoch eingeschätzt. In der Regel werden Orthesen nach rekonstruktiven Eingriffen verwendet, persistierende Muskelatrophien sind ein zentrales Problemfeld, das BFR-Training ist nur begrenzt bekannt, standardisierte Trainingsprotokolle fehlen hierfür aktuell. Die Kommunikation mit Physiotherapeuten ist verbesserungswürdig. Eine digitale Rehabilitationssteuerung wird selten verwendet, würde aber von der Mehrzahl der Chirurgen unterstützt werden.

Abstract

Introduction Postoperative follow-up after joint-preserving knee surgery involves conventional physiotherapy as well as other approaches and devices such as CPM and CAM splints, TENS devices, BFR exercise, prehabilitation, and digital health applications. The aim of this survey was to investigate current standards, trends and control methods in postoperative care to identify fields of concern and to compare them with the current literature.

Material and Methods We conducted a structured anonymous online survey of specialists in orthopaedics and trauma surgery listed by the German-speaking Society for Arthroscopy and Joint Surgery (AGA). The questionnaire included 36 closed-ended questions on the follow-up of joint-preserving surgery of the knee joint.

Results Questionnaires from 528 participants with long-term professional experience (86.6% with more than 10 years) were analysed. Standardised post-treatment schemes are used by 97.2% and their evidence is estimated to be high (59.1%) / very high (14.8%). Problems of rehabilitation are seen in 10–20% of cases by 87.3% (persistent muscular atrophy 30.9%). After reconstructive surgery, CPM splints (70.1%), CAM splints (42.1%), orthoses (85.0%) and TENS devices (40.0%) are prescribed. More potent approaches for the treatment of postoperative muscle deficits are desired by 89.4%. BFR exercise is known by 41.7% and is used regularly by 8%. Communication with treating physiotherapists is infrequent (written: 27.5%). Digital rehabilitation management would be supported by 83.3%; 22.7% are not aware of digital health applications. 87.9% of participants believe that prehabilitation can affect postoperative outcomes.

Conclusion Follow-up of knee joint-preserving surgeries is usually standardised and regularly reviewed for up-to-date evidence. The evidence for recommendations made is considered high. Orthoses are usually used after reconstructive surgery, persistent muscle atrophy is a major problem, BFR training is only known to a limited extent, and there is currently a lack of standardised training protocols. Communication with physiotherapists needs to be improved. Digital rehabilitation management is rarely used but would be supported by the majority of surgeons.

Schlüsselwörter

Arthroskopie - gelenkerhaltende Operation - Kniegelenk - Nachbehandlung - Rehabilitation

Keywords

arthroscopy - joint-preserving surgery - knee joint - postoperative care - rehabilitation

Publication History

Received: 18 October 2023

Accepted after revision: 13 November 2023

Article published online:
01 February 2024

• Literatur

• 1 Destatis, Bundesamt S. Die 20 häufigsten Operationen insgesamt (OPS 5). 2021
• 2 Sherman SL, DiPaolo ZJ, Ray TE. et al. Meniscus Injuries: A Review of Rehabilitation and Return to Play. Clin Sports Med 2020; 39: 165-183 DOI: 10.1016/j.csm.2019.08.004. (PMID: 31767104)
• 3 Schulz M, Krohne B, Röder W. et al. Randomized, prospective, monocentric study to compare the outcome of continuous passive motion and controlled active motion after total knee arthroplasty. Technol Health Care 2018; 26: 499-506 DOI: 10.3233/thc-170850. (PMID: 29630570)
• 4 Jaspers T, Taeymans J, Hirschmüller A. et al. Continuous Passive Motion Does Improve Range of Motion, Pain and Swelling After ACL Reconstruction: A Systematic Review and Meta-Analysis. Z Orthop Unfall 2019; 157: 279-291 DOI: 10.1055/a-0710-5127.
• 5 Wright RW, Preston E, Fleming BC. et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg 2008; 21: 217-224 DOI: 10.1055/s-0030-1247822. (PMID: 18686484)
• 6 D’Amore T, Rao S, Corvi J. et al. The Utility of Continuous Passive Motion After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Comparative Studies. Orthop J Sports Med 2021; 9 DOI: 10.1177/23259671211013841. (PMID: 34262979)
• 7 Gatewood CT, Tran AA, Dragoo JL. The efficacy of post-operative devices following knee arthroscopic surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc 2017; 25: 501-516 DOI: 10.1007/s00167-016-4326-4. (PMID: 27695905)
• 8 Friemert B, Bach C, Schwarz W. et al. Benefits of active motion for joint position sense. Knee Surg Sports Traumatol Arthrosc 2006; 14: 564-570 DOI: 10.1007/s00167-005-0004-7. (PMID: 16328464)
• 9 Culvenor AG, Girdwood MA, Juhl CB. et al. Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus. Br J Sports Med 2022; 56: 1445-1453 DOI: 10.1136/bjsports-2022-105495. (PMID: 35768181)
• 10 Wengle L, Migliorini F, Leroux T. et al. The Effects of Blood Flow Restriction in Patients Undergoing Knee Surgery: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 50: 2824-2833 DOI: 10.1177/03635465211027296. (PMID: 34406084)
• 11 Slysz J, Stultz J, Burr JF. The efficacy of blood flow restricted exercise: A systematic review & meta-analysis. J Sci Med Sport 2016; 19: 669-675 DOI: 10.1016/j.jsams.2015.09.005. (PMID: 26463594)
• 12 DePhillipo NN, Kennedy MI, Aman ZS. et al. Blood Flow Restriction Therapy After Knee Surgery: Indications, Safety Considerations, and Postoperative Protocol. Arthrosc Tech 2018; 7: e1037-e1043 DOI: 10.1016/j.eats.2018.06.010. (PMID: 30377584)
• 13 Wright RW, Fetzer GB. Bracing after ACL reconstruction: a systematic review. Clin Orthop Relat Res 2007; 455: 162-168 DOI: 10.1097/BLO.0b013e31802c9360. (PMID: 17279043)
• 14 Calanna F, Duthon V, Menetrey J. Rehabilitation and return to sports after isolated meniscal repairs: a new evidence-based protocol. J Exp Orthop 2022; 9: 80 DOI: 10.1186/s40634-022-00521-8. (PMID: 35976500)
• 15 Herrero CP, Bloom DA, Lin CC. et al. Patient Satisfaction Is Equivalent Using Telemedicine Versus Office-Based Follow-up After Arthroscopic Meniscal Surgery: A Prospective, Randomized Controlled Trial. J Bone Joint Surg Am 2021; 103: 771-777 DOI: 10.2106/jbjs.20.01413. (PMID: 33720907)
• 16 O’Donnell K, Freedman KB, Tjoumakaris FP. Rehabilitation Protocols After Isolated Meniscal Repair: A Systematic Review. Am J Sports Med 2017; 45: 1687-1697 DOI: 10.1177/0363546516667578. (PMID: 28256906)
• 17 Thomas AC, Wojtys EM, Brandon C. et al. Muscle atrophy contributes to quadriceps weakness after anterior cruciate ligament reconstruction. J Sci Med Sport 2016; 19: 7-11 DOI: 10.1016/j.jsams.2014.12.009. (PMID: 25683732)
• 18 Lepley LK, Davi SM, Burland JP. et al. Muscle Atrophy After ACL Injury: Implications for Clinical Practice. Sports Health 2020; 12: 579-586 DOI: 10.1177/1941738120944256. (PMID: 32866081)
• 19 Williams GN, Buchanan TS, Barrance PJ. et al. Quadriceps weakness, atrophy, and activation failure in predicted noncopers after anterior cruciate ligament injury. Am J Sports Med 2005; 33: 402-407 DOI: 10.1177/0363546504268042. (PMID: 15716256)
• 20 Eckenrode BJ, Carey JL, Sennett BJ. et al. Prevention and Management of Post-operative Complications Following ACL Reconstruction. Curr Rev Musculoskelet Med 2017; 10: 315-321 DOI: 10.1007/s12178-017-9427-2. (PMID: 28710739)
• 21 Hauger AV, Reiman MP, Bjordal JM. et al. Neuromuscular electrical stimulation is effective in strengthening the quadriceps muscle after anterior cruciate ligament surgery. Knee Surg Sports Traumatol Arthrosc 2018; 26: 399-410 DOI: 10.1007/s00167-017-4669-5. (PMID: 28819679)
• 22 Wright RW, Preston E, Fleming BC. et al. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg 2008; 21: 225-234 DOI: 10.1055/s-0030-1247823. (PMID: 18686485)
• 23 Kopkow C, Lange T, Schmitt J. et al. Utilization of Physical Therapy Services in Germany from 2004 until 2014: Analysis of Statutory Health Insurance Data. Gesundheitswesen 2017; 79: 153-160 DOI: 10.1055/s-0042-116229.
• 24 Petersen W DT, Mehl J, Stöhr A. et al. Prevention of knee and ACL injuries. Guidelines of the ligament commitee of the DKG (German Knee Society). OUP 2016; DOI: 10.3238/oup.2016.0542-0550.
• 25 Lind M, Nielsen T, Faunø P. et al. Free rehabilitation is safe after isolated meniscus repair: a prospective randomized trial comparing free with restricted rehabilitation regimens. Am J Sports Med 2013; 41: 2753-2758 DOI: 10.1177/0363546513505079.
• 26 Yang XG, Feng JT, He X. et al. The effect of knee bracing on the knee function and stability following anterior cruciate ligament reconstruction: A systematic review and meta-analysis of randomized controlled trials. Orthop Traumatol Surg Res 2019; 105: 1107-1114 DOI: 10.1016/j.otsr.2019.04.015. (PMID: 31279767)
• 27 Senese M, Greenberg E, Todd Lawrence J. et al. REHABILITATION FOLLOWING ISOLATED POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A LITERATURE REVIEW OF PUBLISHED PROTOCOLS. Int J Sports Phys Ther 2018; 13: 737-751
• 28 Friemert B, Lübken FV, Schmidt R. et al. The influence of a controlled active motion splint on proprioception after anterior cruciate ligament plasty. A prospective randomized study. Unfallchirurg 2006; 109: 22-29 DOI: 10.1007/s00113-005-1006-0. (PMID: 16163508)
• 29 Carter HM, Littlewood C, Webster KE. et al. The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: a systematic review. BMC Musculoskelet Disord 2020; 21: 647 DOI: 10.1186/s12891-020-03676-6. (PMID: 33010802)
• 30 Keller M, Kurz E, Schmidtlein O. et al. Interdisciplinary Assessment Criteria for Rehabilitation after Injuries of the Lower Extremity: A Function-Based Return to Activity Algorithm. Sportverletz Sportschaden 2016; 30: 38-49 DOI: 10.1055/s-0042-100966. (PMID: 27002707)
• 31 Lutz PM, Lenz J, Achtnich A. et al. Female doctors in orthopedics and trauma surgery in Germany: a current status quo. Orthopade 2021; 50: 713-721 DOI: 10.1007/s00132-020-04048-7. (PMID: 33294942)