Aktuelle diagnostische und therapeutische Vorgehensweise bei der primären und rezidivierenden Patellaluxation – Analyse einer bundesweiten Umfrage und der aktuellen Literatur

Zusammenfassung

Studienziel: Patellaluxationen sind eine häufige Verletzungsart des Kniegelenks. Bei der Erstluxation können Begleitschäden auftreten, die im Verlauf zu einer rezidivierenden Luxation führen können. Zudem gibt es kongenitale Pathologien, die eine Patellaluxation prädisponieren. In der aktuellen Literatur werden die Diagnostik und die Therapie bei Patellaluxationen zunehmend diskutiert. Ziel unserer Umfrage an deutschen Kliniken war es daher, die aktuellen Versorgungsstrategien in Deutschland zu erfassen und mit der aktuellen Literatur zu diskutieren. Methode: 735 orthopädische und/oder unfallchirurgische Kliniken wurden eingeladen, an einer anonymen Umfrage zur Diagnostik und Therapie bei primärer und rezidivierender Patellaluxation teilzunehmen. Der Fragebogen bestand aus Multiple-Choice-Fragen und war in 3 Abschnitte unterteilt. Ein systematisches Literaturreview wurde zudem durchgeführt. Ergebnisse: 245 Kliniken (33,3 %) nahmen an der Umfrage teil. Sowohl bei Erst- als auch bei Reluxationen der Patella war die klinische Untersuchung für die Teilnehmer von großer Bedeutung. Zudem wurde eine MRT-Untersuchung in über 80 % bei der primären und rezidivierenden Patellaluxation durchgeführt. Konventionelle Röntgenaufnahmen wurden in über 50 % initiiert. Bei der primären Patellaluxation war die konservative Therapie die häufigste genannte Maßnahme, gefolgt von der Raffung des medialen Retinaculums und der MPFL-Plastik (MPFL: mediales patellofemorales Ligament). Bei rezidivierenden Patellaluxationen war die MPFL-Plastik an erster Stelle der gewählten Therapieformen. Zudem wurde ein Versatz der Tuberositas tibiae ebenfalls häufig durchgeführt. Schlussfolgerung: In Übereinstimmung mit der aktuellen Literatur konnte die klinische Bedeutung der MPFL-Plastik bei primären und besonders bei rezidivierenden Patellaluxationen aufgezeigt werden. Zudem ist die konservative Therapie weiterhin die häufigste Therapieform bei der primären Patellaluxation.

Abstract

Aim: Patellar dislocations are a common injury of the knee joint. During patella dislocations injuries of soft-tissue structures can occur that can destabilise the patella and lead to recurrent dislocations. There are also congenital pathologies that predispose to patella dislocations. In the current literature, diagnostics and treatment of patellar dislocations are frequently discussed. Therefore the aim of our survey was to analyse and summarise actual diagnostic and therapeutic strategies regarding primary and recurrent patella dislocations. Methods: An online questionnaire form was sent to 735 orthopaedic and/or trauma departments in Germany. The departments were invited to participate in an anonymous survey concerning diagnostics and treatment of primary and recurrent patellar dislocations. The questionnaire consisted of multiple choice questions and was divided into three sections. The first section included questions concerning the department structure. The second part contained questions regarding diagnostics and treatment of primary patella dislocations. The third part involved diagnostic and treatment strategies for recurrent patella dislocations. A systematic review of outcome after treatment of patellar dislocation was performed and discussed with the results of the survey. Results: 245 hospitals (33.3 %) returned the questionnaire. Among the participants were 23 % orthopaedic surgery departments, 32 % trauma surgery departments and 45 % combined departments. 12 % were university hospitals and 53 % academic teaching hospitals. Clinical examination was performed by nearly all participants after primary and recurrent patella dislocations. MRI was used as diagnostic tool in 81 % after primary patella dislocation and in 85 % after recurrent patella dislocation. Conventional X-rays were performed in 58 % (primary) and 51 % (recurrent patella dislocations). Computed tomography scans for measurement of the tuberositas tibiae–trochlea groove distance were used in 35 % after recurrent dislocations and in 20 % after primary patella dislocations. 69 % of the participating departments performed non-operative therapies after primary patella dislocations, especially when no associated injuries and no congenital pathologies were observed. Reconstruction of the medial retinaculum was the most frequent surgical therapy (52 %) followed by the reconstruction of the medial patellofemoral ligament (36 %) after primary patella dislocation. Following recurrent patella dislocations reconstruction of the medial patellofemoral ligament (58.5 %) was the most performed surgery and a tuberositas transfer was done in 58 % of participating departments after recurrent patella dislocation. Conclusion: The results of our survey showed diagnostic and therapeutic procedures in the participating departments which are in accordance with recommendations in recent publications. The clinical importance of the MPFL reconstruction was observed for primary and recurrent patella dislocation. In addition, conservative treatment is still the most common treatment after primary dislocation of the patella.

Schlüsselwörter

primäre Patellaluxation - sekundäre Patellaluxation - Umfrage - Reviews

Key words

primary patella dislocation - recurrent patella dislocation - survey - review

• Literatur

• 1 White BJ, Shermann OH. Patellofemoral Instability. Bull NYU Hosp Jt Dis 2009; 1: 22-29
• 2 Fithian DC, Paxton EW, Stone ML. Epidemiology and natural history of acute patella dislocation. Am J Sports Med 2004; 32 (5) 1114-1121
• 3 Aglietti P, Buzzi R, Insall JN. Surgery of the Knee. 3rd. ed. Kapitel: Diseases of the Patellofemoral Joint. Philadelphia: Churchill Livingstone; 2001: 913-1042
• 4 Fulkerson JP. Disorders of the Patellofemoral Joint. 3rd. ed. Baltimore: Wiliams and Wilkins; 1996
• 5 Donell S. Patellofemoral dysfunction-extensor mechanisms malalignment. Curr Orthop 2006; 20: 103-111
• 6 Dejour H, Walch G, Nove-Josserand L et al. Factors of patellar instability: An anatomic radiographic study. Knee Surg Sports Trauma Arthroscopy 1994; 2: 19-26
• 7 Ostermeier S, Becher C. Vorderes Knieschmerzsyndrom, Patellofemoraler Schmerz – Patellare Instabilität. Köln: Deutscher Ärzte-Verlag; 2011
• 8 Senavongse W, Farahmand F, Jones J et al. Quantitative measurement of patellofemoral joint stability: force-displacement behaviour of the human patella in vitro. J Orthop Res 2003; 21: 780-786
• 9 Stefancin JJ, Parker RD. First-time traumatic patellar dislocation: a systematic review. Clin Orthop Relat 2007; 455: 93-101
• 10 Smith TO, Walker J, Russel N. Outcomes of medial patellofemoral ligament reconstruction for patellar instability: a systematic review. Knee Surg Sports Traumatol Arthrosc 2007; 15: 1301-1314
• 11 Sillanpää PJ, Mattila VM, Visuri T et al. Patellofemoral osteoarthritis in patients with operative treatment for patellar dislocation: a magnetic resonance-based analysis. Knee Surg Traumatol Arthrosc 2011; 19: 230-235
• 12 Deutsche Krankenhausgesellschaft. Deutsches Krankenhausverzeichnis. Im Internet:. http://www.deutsches-krankenhaus-verzeichnis.de Stand: 04.11.2011
• 13 Carney JR, Mologne TS, Muldoon M et al. Long-term evaluation of the Roux-Elmslie-Trillat procedure for patellar instability. Am J Sports Med 2005; 33: 1220-1223
• 14 Schöttle PB, Fucentese SF, Pfirrmann C et al. Trochleaplasty for patellar instability due to trochlear dysplasia. Acta Orthopaedica 2005; 76: 693-698
• 15 Baier C, Springorum HR, Beckmann J et al. Therapie der patellaren Instabilität bei Kindern und Jugendlichen. Orthopäde 2011; 40: 868-876
• 16 Oestern S, Varoga D, Lippross S et al. Patellaluxation. Unfallchirurg 2011; 114: 345-359
• 17 Salzmann GM, Weber T, Spang JT et al. Comparison of native axial radiographs with axial MR imaging for determination of the trochlear morphology in patients with trochlear dysplasia. Arch Orthop Trauma Surg 2010; 130: 335-340
• 18 Guerrero P, Li X, Patel K et al. Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study. Sports Med Arthrosc Rehabil Ther Technol 2009; 1: 17
• 19 Sillanpää PJ, Peltola E, Mattila VM et al. Femoral avulsion of the medial patellofemoral ligament after primary traumatic patellar dislocation predicts subsequent instability in men: a mean 7-year nonoperative follow-up study. Am J Sports Med 2009; 37: 1513-1521
• 20 Schöttle 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
• 21 Kang HJ, Wang F, Chen BC et al. Non-surgical treatment for acute patellar dislocation with special emphasis on the MPFL injury patterns. Knee Surg Sports Traumatol Arthrosc 2013; 21: 325-331
• 22 Palmu S, Kallio PE, Donell ST et al. Acute patellar dislocation in children and adolescents: a randomized clinical trial. J Bone Joint Surg [Am] 2008; 90: 463-470
• 23 Sillanpää PJ, Mäenpää HM, Mattila VM et al. Arthroscopic surgery for primary traumatic patellar dislocation: a prospective, nonrandomized study comparing patients treated with and without acute arthroscopic stabilization with a median 7-year follow-up. Am J Sports Med 2008; 36: 2301-2309
• 24 Nikku R, Nietosyaara Y, Aalto K et al. Operative treatment of primary patellar dislocation does not improve medium-term outcome. Acta Orthop 2005; 76: 699-704
• 25 Baudendistel B. Akute traumatische primäre Patellaluxation – Langzeitergebnisse von operativer und konservativer Behandlung im Vergleich [Dissertation]. Medizinische Fakultät der Universität Heidelberg; 2009 Kurzfassung im Internet: http://www.ub.uni-heidelberg.de/archiv/9866
• 26 Lattermann C, Toth J, Bach Jr BR. The role of lateral retinacular realease in the treatment of patellar instability. Sports Med Arthrosc 2007; 15: 57-60
• 27 Schöttle PB, Scheffler SU, Schwarck A et al. Arthroscopic medial retinacular repair after patellar dislocation with and without underlying trochleardysplasia: a preliminary report. Arthroscopy 2006; 22: 1192-1198
• 28 Lee JJ, Lee SJ, Won YG et al. Lateral release and medial plication for recurrent patella dislocation. Knee Surg Sports Traumatol Arthrosc 2012; 20: 2438-2444
• 29 Miller JR, Adamson GJ, Pink MM et al. Arthroscopically assisted medial reefing without routine lateral release for patellar instability. Am J Sports Med 2007; 35: 622-629
• 30 Coons DA, Barber FA. Thermal medial retinaculum shrinkage and lateral release for the treatment of recurrent patellar instability. Arthroscopy 2006; 22: 166-171
• 31 Nam EK, Karzel RP. Mini-open medial reefing and arthroscopic lateral release for the treatment of recurrent patellar dislocation. Am J Sports Med 2005; 33: 220-230
• 32 Zhao J, Huangfu X, He Y et al. Recurrent patellar dislocation in adolescents: medial retinaculum plication versus vastus medialis plasty. Am J Sports Med 2012; 40: 123-132
• 33 Krause F, Kolling C, Brantschen R et al. [Medium-term results after m. vastus medialis obliquus-plasty for lateral patellar dislocation]. Orthopade 2006; 35: 94-101
• 34 Biglieni L, Fiore M, Coviello M et al. Patellar instability: combined treatment with Goldthwait technique and arthroscopic lateral release. Musculoskelet Surg 2011; 95: 95-99
• 35 Nelitz M, Dreyhaupt J, Reichel H et al. Anatomic reconstruction of the medial patellofemoral ligament in children and adolescents with open growth plates. Am J Sports Med 2013; 41: 58-63
• 36 Wang C, Ma L, Zhou J et al. Double-bundle anatomical versus single-bundle isometric medial patellofemoral ligament reconstruction for patellar dislocation. Int Orthop 2013; 37: 617-624
• 37 Wang JL, Li HP, Liu YJ et al. Reconstruction of the medial patellofemoral ligament with a suture-tie technique of patellar side fixation. Chin Med J 2012; 125: 1884-1888
• 38 Xie G, Zhao J, Huangfu X et al. Medial patellofemoral ligament reconstruction using semitendinosus tendons: polyester suture augmentation versus nonaugmentation. Am J Sports Med 2012; 40: 1365-1374
• 39 Zhao J, Huangfu X, He Y. The role of medial retinaculum plication versus medial patellofemoral ligament reconstruction in combined procedures for recurrent patellar instability in adults. Am J Sports Med 2012; 40: 1355-1364
• 40 Bitar AC, Demange MF, DʼElia CO et al. Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon. Am J Sports Med 2012; 40: 114-122
• 41 Panni AS, Alam M, Cerciello S et al. Medial patellofemoral ligament reconstruction with a divergent patellar transverse 2-tunnel technique. Am J Sports Med 2011; 39: 2647-2655
• 42 Han H, Xia Y, Yun X et al. Anatomical transverse patella double tunnel reconstruction of medial patellofemoral ligament with a harmstring tendon autograft for recurrent patellar dislocation. Arch Orthop Trauma Surg 2011; 131: 343-351
• 43 Deie M, Ochi M, Adachi N et al. Medial patellofemoral ligament reconstruction fixed with a cylindrical bone plug and a grafted semitendinosus tendon at the original femoral site for recurrent patellar dislocation. Am J Sports Med 2011; 39: 140-145
• 44 Ahmad CS, Brown GD, Stein BS. The docking technique for medial patellofemoral ligament reconstruction: surgical technique and clinical outcome. Am J Sports Med 2009; 37: 2021-2027
• 45 Ronga M, Oliva F, Longo UG et al. Isolated medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 2009; 37: 1735-1742
• 46 Nomura E, Inoue M, Kobayashi S. Long-term follow-up and knee osteoarthritis change after medial patellofemoral ligament reconstruction for recurrent patella dislocation. Am J Sports Med 2007; 35: 1851-1858
• 47 Deie M, Ochi M, Sumen Y et al. A long-term follow-up study after medial patellofemoral ligament reconstruction using the trandferred semitendinosus tendon for patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2005; 13: 522-528
• 48 Utting MR, Mulford JS, Eldridge JD. A prospective evaluation of trochleoplasty for the treatment of patellofemoral dislocation and instability. J Bone Joint Surg Br 2008; 90: 180-185
• 49 von Knoch F, Böhm T, Bürgi ML et al. Trochleaplasty for recurrent patellar dislocation in association with trochlear dysplasia. J Bone Joint Surg Br 2006; 88: 1331-1335
• 50 Steensen RN, Dopirak RM, Maurus PB. A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft. Arthroscopy 2005; 21: 365-370
• 51 Quirbach S, Smekal V, Rosenberger RE et al. Anatomical double-bundle reconstruction of the medial patellofemoral ligament with a gracilis autograft. Oper Orthop Traumatol 2012; 24: 131-139
• 52 Tsuda E, Ishibashi Y, Yamamoto Y et al. Incidence and radiologic predictor of postoperative patellar instability after Fulkerson procedure of the tibial tuberosity for recurrent patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2012; 20: 2062-2070
• 53 Tecklenburg K, Feller JA, Whitehead TS et al. Outcome of surgery for recurrent patellar dislocation based on the distance of the tibial tuberosity to the trochlear groove. J Bone Joint Surg Br 2010; 92: 1376-1380
• 54 Barber FA, McGarry JE. Elmslie-Trillat procedure for the treatment of recurrent patellar instability. Arthroscopy 2008; 24: 77-81
• 55 Endres S, Endres N, Lappas K et al. Femoropatellare Instabilität. Sportverl Sportschaden 2006; 20: 184-191
• 56 Carney JR, Mologne TS, 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: 1220-1223