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DOI: 10.1055/s-0030-1250691
© Georg Thieme Verlag KG Stuttgart · New York
Die Therapie der Patellaluxation: eine systematische Literaturanalyse
The Treatment of Patellar Dislocation: A Systematic ReviewPublikationsverlauf
Publikationsdatum:
03. Mai 2011 (online)
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Zusammenfassung
Studienziel: Die Diagnostik und Therapie der Patellaluxation wird immer differenzierter und komplexer. Ziel der vorliegenden Arbeit ist es, einen Überblick über biomechanische Grundlagen des Femoropatellargelenks sowie über aktuelle Trends in der Diagnostik und Therapie der Patellaluxation zu geben. Methode: Wir führten eine systematische Literaturrecherche in den elektronischen Datenbanken Medline, Cochrane und Embase durch. Dabei wurde nach Studien über die Biomechanik des Patellofemoralgelenks sowie über konservative und operative Therapieverfahren bei Patellaluxation gesucht. Ergebnisse: In der Studie werden zunächst demografische Daten sowie die Biomechanik des Femoropatellargelenks vorgestellt. Ein konservatives Vorgehen wird im Allgemeinen bei primärer Patellaluxation ohne begleitende osteochondrale Läsion und ohne wesentliche Risikofaktoren für eine Reluxation empfohlen. In der operativen Therapie werden die niedrigsten Reluxationsraten derzeit für die Augmentation des medialen patellofemoralen Ligaments (MPFL) beschrieben. Auch bei Trochleadysplasie kann eine MPFL-Augmentation erfolgreich durchgeführt werden. Die mediale Dopplung zeigt in der Literatur sehr inhomogene Ergebnisse. Möglicherweise wird dieses Verfahren nicht allen Pathologien, die zu einer Patellaluxation führen, gerecht. Eine entsprechend der Rupturlokalisation adressierte Naht des MPFLs, insbesondere bei Erstluxation mit begleitenden Risikofaktoren für eine Reluxation, scheint sinnvoller zu sein. Ein Lateral Release kann die Instabilität aggravieren, sodass die Indikation sehr zurückhaltend gestellt werden sollte. Bei Gonarthrose im höheren Lebensalter kann das Lateral Release zu einer Beschwerdelinderung führen, bei chronisch-persistierender Patellaluxation ist es unter Umständen notwendig. Bei einer Medialisierung der Tuberositas tibiae sollte der TTTG-(tibial tuberosity trochlear groove-)Abstand gemessen werden und bei pathologischen Werten für eine verbesserte Patellaführung die Tuberositas entsprechend medialisiert werden. Bei Knorpelschäden an der medialen Patellafacette ist eine Medialisierung der Tuberositas kontraindiziert. Bei Knorpelschäden an der lateralen Facette kann neben knorpelchirurgischen Maßnahmen auch eine Anteromedialisierung der Tuberositas Erfolg versprechend sein. Die Osteotomien der Tuberositas können auch mit einer MPFL-Augmentation erfolgreich kombiniert werden. Im Wachstumsalter ist aus unserer Sicht nach wie vor die mediale Dopplung das Standardverfahren. Zusätzlich kann bei Patellamaltracking ein subperiostales Weichteilrelease mit Medialisierung des Patellasehnenansatzes an der Tuberositas tibiae durchgeführt werden. Schlussfolgerung: Die Biomechanik des Femoropatellargelenks stellt die Grundlage für das Verständnis pathologischer Vorgänge der Patellaluxation dar und ist somit entscheidend bei der Wahl eines adäquaten Therapieverfahrens. Für die patellofemorale Instabilität ist ein Zusammenspiel heterogener, morphologischer Risikofaktoren in Verbindung mit individuellen, prädisponierenden Faktoren in der Anamnese des Patienten ursächlich. Patellaerstluxationen ohne wesentliche Risikofaktoren sollten konservativ behandelt werden. In der operativen Therapie lässt sich ein Trend dahingehend feststellen, die essenzielle Pathomorphologie zu identifizieren und diese gezielt operativ anzugehen.
Abstract
Aim: The diagnosis and treatment of patellar dislocation is very complex. The aim of this study is to give an overview of the biomechanics of the patellofemoral joint and to point out the latest developments in diagnosis and treatment of patellar dislocation. Method: The authors electronically searched Medline, Cochrane and Embase for studies on the biomechanics of the patellofemoral joint and for conservative and surgical treatments after patellar dislocation. We extracted baseline demographics, biomechanical, conservation and surgical details. Results: Understanding the biomechanics of the patellofemoral joint is necessary to understand the pathology of patellar dislocation. The patellofemoral joint consists of a complex system of static, active and passive stabilising factors. Patellar instability can result from osseous and soft-tissue abnormalities, such as trochlear dysplasia, patella alta, a high tibial tuberosity trochlear groove (TTTG) distance, weaknesses of the vastus medialis obliquus or a lesion of the medial retinaculum. Recent studies have focused on the medial patellofemoral ligament (MPFL) and have shown that the MPFL is the most significant passive stabiliser of the patella. Following patellar dislocation, an MRI should be standard practice to detect an MPFL rupture, osteochondral lesions or other risk factors for redislocation. An acute first-time patellar dislocation without osteochondral lesions and without severe risk factors for a redislocation should follow a conservative treatment plan. If surgical treatment is required, the best postoperative results occur when the MPFL is reconstructed, leading to a redislocation rate of 5 %, this includes cases that have a dysplastic trochlea. Duplication of the medial retinaculum show very inconsistent results in the literature, possibly due to the fact that the essential pathomorphology of patellar dislocation is not addressed. Addressing the exact location of the rupture of the MPFL with a suture is possibly more convenient, especially after first-time dislocation with associated risk factors for a redislocation. Recent literature does not encourage the use of lateral release, since this can increase patellar instability. Indications for lateral release include persistent patellar instability or pain reduction in an older arthritic subject. For correcting a patellofemoral malalignment, the TTTG distance should be measured and a medial transposition of the anterior tibial tubercle hinged on a distal periosteal attachment should be considered. Cartilage lesions on the medial facet of the patella are a contra-indication for medial tubercle transposition. For cartilage lesions of the lateral facet, antero-medialization of the tibial tubercle can be successful. A tubercle osteotomy can be efficiently combined with MPFL reconstruction. We believe that patients with open epiphyseal plates should be treated with duplication of the medial retinaculum. In the presence of patellar maltracking, an additional subperiostal soft tissue release with medialisation of the distal part of the patellar tendon can be performed. Conclusion: It seems that the predominating factors for patellar dislocation are heterogenic morphology in combination with individual predisposition. Non-surgical treatment is typically recommended for primary patellar dislocation without any osteochondral lesions and in the absence of significant risk factors for redislocation. If surgical treatment is deemed necessary, addressing the essential pathomorphology has become the primary focus.
Schlüsselwörter
Patellaluxation - patellare Instabilität - Therapie - Biomechanik - Literaturanalyse
Key words
patellar dislocation - patellar instability - therapy - biomechanics - literature analysis
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Dr. Stephan Frosch
Universitätsmedizin Göttingen
Unfallchirurgie, Plastische und Wiederherstellungschirurgie
Robert-Koch-Straße 40
37075 Göttingen
Telefon: 01 79/9 25 08 94
Fax: 05 51/39 89 81
eMail: stephan.frosch@med.uni-goettingen.de