Femoropatellare Instabilität

Zusammenfassung

Die vorliegende Arbeit beschreibt 3-Jahres-Ergebnisse nach Elmslie-Trillat-Rekonstruktion mit einem kombinierten Weichteileingriff (mediale Kapselraffung, laterales Release) bei Patienten mit einer femoropatellaren Instabilität. Präoperativ und im Rahmen der Nachuntersuchung wurden belastete Röntgenaufnahmen des Kniegelenkes in zwei Ebenen sowie eine Merchant-View Aufnahme angefertigt. Der Insall-Salvati-Index, der Sulkus- und Kongruenzwinkel wurden zur radiologischen Auswertung herangezogen. Die klinische Evaluation wurde anhand des Knee-Society- and Tegner-Scores durchgeführt. Subjektiv konnte bei 22 von 23 Patienten eine hohe bis sehr hohe Zufriedenheit erzielt werden. Eine Reluxation der Patella nach erfolgter Operation trat lediglich bei einem der Patienten auf. Der Großteil der Patienten war postoperativ wieder in der Lage, zu ihrem sportlichen bzw. körperlichen Leistungsniveau zurückzukehren. Die dargestellte Operationstechnik versucht möglichst viele Abnormitäten einer femoropatellaren Instabilität zu korrigieren, um eine dynamische Stabilität der Patella bei freiem Bewegungsausmaß zu erzielen. Die sehr guten Ergebnisse des vorliegenden Patientenkollektivs im Vergleich mit anderen Studiengruppen sind demnach vermutlich durch den Kombinationseingriff zu erklären.

Abstract

We report a retrospective study of patients with patellar instability, all treated by operation and followed up for 3 years. Patients with recurrent dislocation of the patella, lateral displacement and primary patella dislocation were treated by a Elmslie-Trillat reconstruction combined with a soft tissue intervention. Preoperative and follow-up radiographic evaluation included weight bearing anteroposterior view and merchant view. Evaluation was done using the Insall-Salvati index, sulcus and congruence angle. The operation was performed on 23 patients. The clinical evaluation at follow-up was performed using the Knee-Society- and Tegner-Score. Subjective results of the operation were excellent or good in 22 of the 23 at three years with a redislocation rate of only 1 out of 26. Most patients were able to return to the same level of sporting activity as before the injury. The technique described in this paper tries to correct as much as possible of the abnormal parameters in patellar instability to achieve a dynamic stability of the patella through the full range of motion. The excellent results are presumable explained by the use of the combined technique.

Schlüsselwörter

Femoropatellare Instabilität - Elmslie-Trillat - Weichteileingriff - 3-Jahres Follow-up

Key words

Patellar instability - Elmslie-Trillat - soft tissue intervention - 3-year follow-up

Literatur

• 1 Fairbank J C, Pynsent P B, Poortvliet J A. et al . Mechanical factors in the incidence of knee pain in adolescents and young adults.  J Bone Joint Surg Br. 1984;  66 (5) 685-93
• 2 Dejour H van, Walch G, Nove-Josserand L, Guier C. Factors of patellar instability: an anatomic radiographic study.  Knee Surg Sports Traumatol Arthrosc. 1994;  2 (1) 19-26
• 3 Aglietti P, Insall J N, Cerulli G. Patellar pain and incongruence.  Clin Orthop Relat Res. 1983;  6 (176) 217-232
• 4 Aglietti P, Pisaneschi A, De Biase P. Recurrent dislocation of patella: Three kinds of surgical treatment.  Ital J Orthop Traumatol. 1992;  18 (1) 25-36
• 5 Rillmann P, Dutly A, Kieser C. et al . Modified Elmslie-Trillat procedure for instability of the patella.  Knee Surg Sports Traumatol Arthrosc. 1998;  6 (1) 31-35
• 6 Insall J, Salvati E. Patella position in the normal knee joint.  Radiology. 1971;  101 (1) 101-104
• 7 Trillat A, Dejour H, Couette A. Diagnosis and treatment of recurrent dislocations of the patella.  Rev Chir Orthop Reparatrice Appar Mot. 1964;  50 813-824
• 8 Blauth W, Mann M. Medial-and simultaneous anterior-transfer of the tibial tuberosity.  Z Orthop Ihre Grenzgeb. 1977;  115 (2) 252-255
• 9 Hehne H J. Biomechanics of the patellofemoral joint and its clinical relevance.  Clin Orthop Relat Res. 1990;  (258) 73-85
• 10 Aglietti P, Buzzi R, Biase P D. et al . Surgical treatment of recurrent dislocation of the patella.  Clin Orthop. 1994;  308 8-17
• 11 Arnbjornsson A, Egund N, Rydling O. et al . The natural history of recurrent dislocation of the patella. Long-term results of conservative and operative treatment.  J Bone Joint Surg Br. 1992;  172 (1) 140-142
• 12 Cash J D, Hughston J C. The treatment of acute patellar dislocation.  Am J Sports Med. 1988;  16 244-249
• 13 Chrisman O D, Snook G A, Wilson T C. A long-term prospective study of the Hauser and Roux-Goldthwait procedures for recurrent patellar dislocation.  Clin Orthop Relat Res. 1979;  10 (144) 26-30
• 14 Cofield R H, Bryan R S. Acute dislocation of the patella: results of conservative treatment.  J Trauma. 1977;  17 (7) 526-531
• 15 Cox J S. Evaluation of the Roux-Elmslie-Trillat procedure for knee extensor realignment.  Am J Sports Med. 1982;  10 (5) 303-310
• 16 Fulkerson J B, Becker G J, Maeney J A, Miranda M, Folik M A. Anteromedial tibial tubercle transfer without bone graft.  Am J Sports Med. 1990;  18 (5) 490-497
• 17 Kumar A, Jones S, Bickerstaff D R. et al . Functional evaluation of the modified Elmslie-Trillat procedure for patello-femoral dysfunction.  Knee. 2001;  8 (4) 287-292
• 18 Nakagawa K, Wada Y, Minamide M. et al . Deterioration of long-term clinical results after the Elmslie-Trillat procedure for dislocation of the patella.  J Bone Joint Surg Br. 2002;  84 (6) 861-864
• 19 Carney J R, Mologne T Z, Muldoon M. et al . Long-term evaluation of the Roux-Elmslie-Trillat procedure for patellar instability: a 26-year follow-up.  Am J Sports Med. 2005;  33 (8) 1220-1223
• 20 Shelbourne K D, Porter D A, Rozzi W. Use of a modified Elmslie-Trillat procedure to improve abnormal patellar congruence angle.  Am J Sports Med. 1994;  22 (3) 318-323
• 21 Conti C, Berruto M, Bianchi M. The Elmslie-Trillat procedure for recurrent subluxation of the patella. One to five year Ergebnisse.  Ital J Orthop Traumatol. 1992;  18 (3) 341-349
• 22 Koskinen S K, Rantanen J P, Nelimarkka O I. et al . Effect of Elmslie-Trillat and Roux-Goldthwait procedures on patellofemoral relationships and symptoms in patients with patellar dislocations.  Am J Knee Surg. 1998;  11 (3) 167-173
• 23 Kruger T, Birke A, Decker T. et al . Results of the Elmslie-Trillat procedure in cases of patella(sub)luxation related to chondral pathology.  Unfallchirurg. 1999;  102 (9) 700-707
• 24 Mirroneau A. Reultats du traitement chirugical de línstabilité femoro-patellaire. Vlems Journees Lyonnaise de Chirurgie du genu Lyon; Ameuse 1987
• 25 Deburge A, Chambat P. Transposition of the anterior tibial tuberosity.  Rev Chir Orthop Reparatrice Appar Mot. 1980;  66 (4) 218-222
• 26 Grana W A, O’Donoghue D H. Patellar-tendon transfer by the slot-block method for recurrent subluxation and dislocation of the patella.  J Bone Joint Surg Am. 1977;  59 (6) 736-741
• 27 Fielding J W, Liebler W A, Krishne Urs N D. et al . Tibial tubercle transfer: a long-range follow-up study.  Clin Orthop Relat Res. 1979;  10 (144) 43-44
• 28 Marcacci M, Zaffagnini S, Iacono F. et al . Results in the treatment of recurrent dislocation of the patella after 30 years.  Knee Surg Sports Traumatol Arthrosc. 1995;  3 (3) 163-166
• 29 Hawkins U, Bell R H, Anisette G. Acute patellar dislocation: the natural history.  Am J Sports Med. 1986;  14 (2) 117-120
• 30 Sherman O H, Fox J M, Sperling H. et al . Patellar instability: treatment by arthroscopic electrosurgical lateral release.  Arthroscopy. 1987;  3 (3) 152-160
• 31 Nam E K, Narzel R P. Mini-Open Medial Reefing and Arthroscopic Lateral Release for the Treatment of Recurrent Patellar Dislocation.  Am J Sports Med. 2005;  33 (2) 220-230
• 32 Scuderi G, Cuomo F, Scott W N. Lateral release and proximal realignment for patellar subluxation and dislocation: a long-term follow-up.  J Bone Joint Surg Am. 1988;  70 (6) 856-861
• 33 Sargent J P, Teipner W A. Medial patellar retinacular repair for acute and recurrent dislocation of the patella: a preliminary report.  J Bone Joint Surg Am. 1971;  53 386-387
• 34 Greenspan A. Skelettradiologie. Orthopädie, Traumatologie, Rheumatologie, Onkologie München, Jena; Urban & Fischer Verlag 2002 3. Aufl
• 35 Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries.  Clin Orthop Relat Res. 1985;  Sep (198) 43-49