Behandlung der Strecksehnenruptur bei liegender Knietotalendoprothese^[*]

Zusammenfassung

Rupturen des Strecksehnenapparats gehören zu den schwerwiegendsten Komplikationen der primären und der Knierevisionsendoprothetik. Aufgrund der relativ geringen Inzidenz von 0,17–2,5 % ist das Evidenzniveau der zur Verfügung stehenden Behandlungsstrategien gering. Insgesamt sind die Ergebnisse nach periprothetischen Rupturen des Streckapparats schlechter als nach Sehnenrupturen des nativen Kniegelenks. Bei der Behandlung der selteneren Quadrizepssehnenruptur sind akute von chronischen sowie komplette von inkompletten Rupturen zu unterscheiden. Die konservative Therapie hat ihren Stellenwert bei inkompletten Rupturen mit einem aktiven Streckdefizit kleiner als 20°. Komplette Quadrizepssehnenrupturen und Rupturen der Patellarsehne werden überwiegend operativ behandelt. Je nach Ausmaß des Defekts können direkte Nahttechniken, Sehnentransfers, Muskellappenaugmentationen, Allografts oder synthetische Ersatzmaterialien Anwendung finden. Die Spätergebnisse sind häufig mit einem persistierenden Funktionsdefizit behaftet. Oberste Priorität hat daher die Prävention einer Streckapparatschädigung bei der Knieprothesenimplantation.

Abstract

Disruption of the extensor mechanism is one of the most devastating complications in knee arthroplasty with a reported incidence between 0.17 and 2.5 %. Due to a high rate of subsequent complications and poor clinical results, every effort should be made to avoid extensor mechanism disruption. In cases of disruption however, the orthopaedic surgeons must be aware of non-operative and surgical treatment options and their indications, timing, outcome and limitations. Non-operative treatment is feasible in cases of incomplete disruption of the quadriceps tendon with an extension deficit of less than 20°. Complete disruption of the quadriceps tendon or rupture of the patellar tendon should be treated operatively. Therapeutic strategies include direct repair of the tendon in acute disruption without retraction. Retraction as well as soft tissue damage necessitates augmentation of the tendon. Frequently used endogenous augments are the semitendinosus tendon as well as the gastrocnemius muscle. Exogenous options are allografts of the Achilles tendon or structured extensor mechanism grafts and synthetic augments to support endogenous tendon repair. The clinical results after extensor mechanism failure following total knee arthroplasty are less favourable compared to ruptures in native knee joints. The most common complications are postoperative stretching and the maintenance of an active extensor lag.

Schlüsselwörter

Knie - Endoprothetik - Revision - Streckapparat

Key words

knee - arthroplasty - revision - extensor mechanism

^* Nach einem Vortrag vom Sektionstag der Arbeitsgemeinschaft für Endoprothetik DKOU 2012.

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