Behandlung der Patellainstabilität

Die Patellainstabilität ist für die PatientenInnen eine belastende Erkrankung mit einer in der orthopädischen Praxis häufig auftretenden Problemstellung. Die Anomalien des patellofemoralen Gelenks, die die Stabilität des Kniescheibenlaufs beeinträchtigen können, sind vielfältig, sodass für eine erfolgreiche Therapie eine strukturierte Analyse essenziell ist. Dieser Beitrag zeigt den Aufbau einer differenzierten Diagnostik und Therapie sowie Beispiele aus der Praxis.

Kernaussagen

• Bei rezidivierenden Patellaluxationen ist die Indikation zur chirurgischen Therapie aufgrund der zu erwartenden Ineffektivität konservativer Therapien gegeben.

• Die Patellainstabilität bedarf aufgrund der ursächlichen komplexen Pathologie einer strukturierten klinischen und radiologischen Analyse.

• Das mediale patellofemorale Ligament (MPFL) ist der bedeutendste passive Weichteilstabilisator der Kniescheibe.

• Die Dysplasie der femoralen Trochlea, die relative Position der Trochlearinne zur Tuberositas tibiae sowie Beinachsen- und Torsionsfehler sind bedeutende Faktoren der chronischen Patellainstabilität.

• Die chirurgische Therapieantwort bei Patellainstabilität muss entsprechend der Analyse differenziert gewählt werden.

• Als operative Therapieoptionen stehen zur Verfügung:

  • MPFL-Plastik,

  • Trochleaplastik,

  • Tuberositas-tibiae-Transfer,

  • Beinachsenkorrektur,

  • Rotationskorrektur,

  • Kombinationseingriffe.

Schlüsselwörter

Patellaluxation - Patellainstabilität - Knieoperation - Achsabweichung - Fehlstellung

Publication History

Article published online:
12 October 2023

• Literatur

• 1 Pagliazzi G, Napoli F, Prvitali D. et al. A Meta-analysis of surgical versus nonsurgical treatment of primary patella dislocation. Arthroscopy 2019; 35: 2469-2481
• 2 Fithian DC, Paxton EW, Stone ML. et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med 2004; 32: 1114-1121 DOI: 10.1177/0363546503260788. (PMID: 15262631)
• 3 Arendt EA, Askenberger M, Agel J. et al. Risk of redislocation after primary patellar dislocation: a clinical prediction model based on magnetic resonance imaging variables. Am J Sports Med 2018; 46: 3385-3390 DOI: 10.1177/0363546518803936. (PMID: 30398902)
• 4 Nha KW, Ha Y, Oh S. et al. Surgical treatment with closing-wedge distal femoral osteotomy for recurrent patellar dislocation with genu valgum. Am J Sports Med 2018; 46: 1632-1640 DOI: 10.1177/0363546518765479. (PMID: 29688749)
• 5 Dejour H, Walch G, Nove-Josserand L. et al. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc 1994; 2: 19-26 DOI: 10.1007/BF01552649. (PMID: 7584171)
• 6 Howells NR, Eldridge JD. Medial patellofemoral ligament reconstruction for patellar instability in patients with hypermobility: A case control study. J Bone Joint Surg Br 2012; 94: 1655-1659 DOI: 10.1302/0301-620X.94B12.29562. (PMID: 23188907)
• 7 Post WR. Clinical evaluation of patients with patellofemoral disorders. Arthroscopy 1999; 15: 841-851 DOI: 10.1053/ar.1999.v15.015084. (PMID: 10564862)
• 8 Best MJ, Tanaka MJ, Demehri S. et al. Accuracy and reliability of the visual assessment of patellar tracking. Am J Sports Med 2020; 48: 370-375 DOI: 10.1177/0363546519895246. (PMID: 31913663)
• 9 Kolowich PA, Paulos LE, Rosenberg TD. et al. Lateral release of the patella: indications and contraindications. Am J Sports Med 1990; 18: 359-365 DOI: 10.1177/036354659001800405. (PMID: 2403183)
• 10 Blønd L, Haugegaard M. Combined arthroscopic deepening trochleoplasty and reconstruction of the medial patellofemoral ligament for patients with recurrent patella dislocation and trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc 2014; 22: 2484-2490 DOI: 10.1007/s00167-013-2422-2. (PMID: 23370988)
• 11 Haim A, Yaniv M, Dekel S. et al. Patellofemoral pain syndrome: Validity of clinical and radiological features. Clin Orthop Relat Res 2006; 451: 223-228 DOI: 10.1097/01.blo.0000229284.45485.6c. (PMID: 16788411)
• 12 Luhmann SJ, Smith JC, Schootman M. et al. Recurrent patellar instability: Implications of preoperative patellar crepitation on the status of the patellofemoral articular cartilage. J Pediatr Orthop 2019; 39: 33-37 DOI: 10.1097/BPO.0000000000001017. (PMID: 28614283)
• 13 Caton J, Deschamps G, Chambat P. et al. Les rotules basses (Patellae inferae) – A propos de 128 observations. Rev Chir Orthop Reparatrice Appar Mot 1982; 68: 317-325
• 14 Goutallier D, Bernageau J, Lecudonnec B. Mesure de lʼécart tubérosité tibiale antérieure – gorge de la trochlée (TA-GT). Rev Chir Orthop Reparatrice Appar Mot 1978; 64: 423-428
• 15 Seitlinger G, Scheurecker G, Högler R. et al. Tibial tubercle-posterior cruciate ligament distance: A new measurement to define the position of the tibial tubercle in patients with patellar dislocation. Am J Sports Med 2012; 40: 1119-1125
• 16 Toms AP, Cahir J, Swift L. et al. Imaging the femoral sulcus with ultrasound, CT, and MRI: Reliability and generalizability in patients with patellar instability. Skeletal Radiol 2009; 38: 329-338
• 17 Blackburne JS, Peel TE. A new method of measuring patellar height. J Bone Joint Surg Br 1977; 59: 241-242 DOI: 10.1302/0301-620X.59B2.873986. (PMID: 873986)
• 18 Insall J, Salvati E. Patella position in the normal knee joint. Radiology 1971; 101: 101-104 DOI: 10.1148/101.1.101. (PMID: 5111961)
• 19 Lippacher S. et al. Observer agreement on the dejour trochlear dysplasia classification: A Comparison of true lateral radiographs and axial magnetic resonance images. Am J Sports Med 2012; 40: 837-843 DOI: 10.1177/0363546511433028. (PMID: 22238057)
• 20 Tecklenburg K, Dejour D, Hoser C. et al. Bony and cartilaginous anatomy of the patellofemoral joint. Knee Surg Sports Traumatol Arthrosc 2006; 14: 235-240 DOI: 10.1007/s00167-005-0683-0. (PMID: 16254736)
• 21 Wright RW. MARS Group. Osteoarthritis classification scales: Interobserver reliability and arthroscopic correlation. J Bone Joint Surg Am 2014; 96: 1145-1151 DOI: 10.2106/JBJS.M.00929. (PMID: 25031368)
• 22 Schoettle PB, Zanetti M, Seifert B. et al. The tibial tuberosity-trochlear groove distance; a comparative study between CT and MRI scanning. Knee 2006; 13: 26-31 DOI: 10.1016/j.knee.2005.06.003. (PMID: 16023858)
• 23 Tscholl PM, Wanivenhaus F, Fucentese SF. Conventional radiographs and magnetic resonance imaging for the analysis of trochlear dysplasia: the influence of selected levels on magnetic resonance imaging. Am J Sports Med 2017; 45: 1059-1065 DOI: 10.1177/0363546516685054. (PMID: 28177645)
• 24 Nacey NC, Fox MG, Luce BN. et al. Assessing Femoral Trochlear Morphologic Features on Cross-Sectional Imaging Before Trochleoplasty: Dejour Classification Versus Quantitative Measurement. AJR Am J Roentgenol 2020; 215: 458-464 DOI: 10.2214/AJR.19.22400. (PMID: 32507014)
• 25 Paley D, Tetsworth K. Mechanical axis deviation of the lower limbs. Preoperative planning ofmultiapical frontal plane angular and bowing deformities of the femur and tibia. Clin Orthop Relat Res 1992; (280) 65-71 (PMID: 1611765)
• 26 Kolb A, Isak V, Hobusch GM. et al. Distal femoral varus osteotomy: Results of the lateral open-wedge technique without bone grafting. Int Orthop 2019; 43: 2315-2322
• 27 Hesham K, Carry PM, Freese K. et al. Measurement of Femoral Version by MRI is as Reliable and Reproducible as CT in Children and Adolescents With Hip Disorders. J Pediatr Orthop 2017; 37: 557-562 DOI: 10.1097/BPO.0000000000000712. (PMID: 28323254)
• 28 Schmaranzer F, Lerch TD, Siebenrock KA. et al. Differences in femoral torsion among various measurement methods increase in hips with excessive femoral torsion. Clin Orthop Relat Res 2019; 477: 1073-1083 DOI: 10.1097/CORR.0000000000000610. (PMID: 30624313)
• 29 Jun Kang H, Wang F, Cheng Chen B. et al. Non-surgical treatment for acute patellar dislocation with special emphasis on the MPFL injury patterns. Knee Surg Sports Traumatol Arthrosc 2013; 21: 324-331 DOI: 10.1007/s00167-012-2020-8.
• 30 Longo UG, Ciuffreda M, Locher J. et al. Treatment of primary acute patellar dislocation: systematic review and quantitative synthesis of the literature. Clin J Sport Med 2017; 27: 511-523 DOI: 10.1097/JSM.0000000000000410. (PMID: 28107220)
• 31 Schöttle PB, Schmeling A, Rosenstiel N. et al. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med 2007; 35: 801-804 DOI: 10.1177/0363546506296415. (PMID: 17267773)
• 32 Wagner D, Pfalzer F, Hingelbaum S. et al. The influence of risk factors on clinical outcomes following anatomical medial patellofemoral ligament (MPFL) reconstruction using the gracilis tendon. Knee Surg Sports Traumatol Arthrosc 2013; 21: 318-324 DOI: 10.1007/s00167-012-2015-5. (PMID: 22538501)
• 33 Bereiter H, Gautier E. Die Trochleaplastik als chirurgische Therapie der rezidivierenden Patellaluxation bei Trochleadysplasie des Femurs. Arthroskopie 1994; 7: 281-286
• 34 Schöttle PB, Fucentese SF, Pfirrmann C. et al. Trochleaplasty for patellar instability due to trochlear dysplasia: A minimum 2-year clinical and radiological follow-up of 19 knees. Acta Orthop 2005; 76: 693-698 DOI: 10.1080/17453670510041781. (PMID: 16263617)
• 35 Longo UG, Rizzello G, Ciuffreda M. et al. Elmslie-Trillat, Maquet, Fulkerson, Roux Goldthwait, and other distal realignment procedures for themanagement of patellar dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy 2016; 32: 929-943
• 36 Brown DE, Alexander AH, Lichtman DM. The Elmslie-Trillat procedure: Evaluation in patellar dislocation and subluxation. Am J Sports Med 1984; 12: 104-109 DOI: 10.1177/036354658401200203. (PMID: 6742284)
• 37 Kraus T, Lidder S, Švehlík M. et al. Patella re-alignment in children with a modified Grammont technique. Acta Orthop 2012; 83: 504-510
• 38 Kumar S, Sonanis SV. Growth modulation for coronal deformity correction by using eight plates-systematic review. J Orthop 2018; 15: 168-172 DOI: 10.1016/j.jor.2018.01.022. (PMID: 29657461)