Intraoperative mediale Seitenbandschädigung – was tun?

Zusammenfassung

Hintergrund: Die intraoperative mediale Seitenbandschädigung ist selten und findet in der Literatur nur wenig Beachtung. Die Analyse derselben ist geprägt von wenigen Kasuistiken, welche durchaus unterschiedliche Lösungsansätze aufzeigen. Patienten, Material und Methoden: In dieser Übersichtsarbeit werden die wesentlichen Publikationen zu diesem Thema ausgewertet, um einen Behandlungsalgorithmus zu erstellen. Ergebnisse: Die in der Literatur vorgeschlagenen Vorgehensweisen sind durchaus uneinheitlich. Die Lokalisation der Schädigung und die Erfahrung des Operateurs mit gekoppelten oder teilgekoppelten Prothesen spielt eine wesentliche Rolle bei der Wahl des geeigneten Therapieverfahrens. Letztendlich stehen 5 verschiedene Behandlungsoptionen zur Verfügung: 1. die alleinige konservative postoperative Behandlung im Sinne einer Orthesenbehandlung; 2. die primäre Rekonstruktion des Innenbands; 3. die Augmentation des Innenbands; 4. die Inlay-Erhöhung und Durchführung eines Releases lateralseitig; 5. die höhere Kopplung der Knieendoprothese. Schlussfolgerung: Ein Release am femoralen Innenbandansatz sollte unterbleiben. Das stadienhafte tibiale Release sollte streng subperiostal erfolgen. Eine große Kraftaufwendung bei der Spannungskontrolle verbietet sich. Die femorale Insertion kann gut und sicher rekonstruiert werden, schwieriger ist die Rekonstruktion der tibialen Insertion aufgrund des komplexen Ansatzes des Bandes. Auch die Rekonstruktion des mittleren Bandanteils ist deutlich schwieriger. Hier werden die primäre Naht oder eine Augmentation mittels Semitendinosus- oder Quadrizepssehne empfohlen. In allen Fällen ist eine zeitlich befristete Orthesenversorgung zu empfehlen. Bei jeder der beschriebenen Schädigungen sollte als Rückzugsmöglichkeit die höhere Kopplung in Betracht gezogen werden.

Abstract

Background: Intraoperative damage to the medial collateral ligament is a rather rare condition given only scant attention in the literature. Observing international medical journals (over the recent years), one finds very few case histories. What is more, these case histories vary significantly with regards to their approaches to the problem at hand. Material and Methods: This survey lists essential publications and case histories in question and – following their analysis and in light of the fairly low number of respective cases – attempts to create a ‘treatment algorithm’. Results: Approaches to treatment vary considerably throughout the medical literature. Reasons are the localisation of the actual damage, pertaining to the medial collateral ligament as well as surgeonsʼ aptitudes and preferences with regards to hinged or constraint implants. Eventually, there are five different treatment options: (i) solely conservative treatment by means of an orthesis; (ii) primary reconstruction of the medial collateral ligament; (iii) medial collateral ligament augmentation; (iv) inlay elevation and lateral release procedure; and (v) a higher degree of coupling regarding the TKA. Conclusion: It is strongly advised to refrain from conducting a release at the femoral origin of the medial collateral ligament. In stages, a tibial release should be carried out strictly subperiostally. A high expenditure of energy during tension examination needs to be utterly avoided. Reconstruction of the femoral origin/insertion can be carried out rather safely, while reconstruction of the tibial origin/insertion is more complicated due to the more complex anatomic line-up/constellation. Likewise, the reconstruction of the median ligament portion is considerably more difficult; in this case, the application of a primary suture or augmentation by use of the semitendinosus or quadriceps tendon are recommended. In addition, the temporary application of an orthesis is recommended regardless. In any case, a higher degree of coupling should be considered as a fallback. Introduced is an algorithm which differentiates the ligament damage location.

Schlüsselwörter

mediales Kollateralband - Schädigung - Knietotalendoprothese - Rekonstruktion - Naht

Key words

medial collateral ligament - damage - total knee arthroplasty - reconstruction - suture

• Literatur

• 1 Wirtz D. AE-Manual der Endoprothetik Knie. Heidelberg: Springer Medizin; 2011: 9-10 85, 196
• 2 Department of Orthopedics, Skåne University Hospital, Lund. Swedish Knee Arthroplasty Register, Annual Report 2012. Im Internet: www.knee.se Stand: 09/2013
• 3 Whiteside LA. Ligament Balancing – Weichteilmanagement in der Knieendoprothetik. Heidelberg: Springer Medizin; 2004: 5-6
• 4 Liu F, Yue B, Gadikota HR et al. Morphology of the medial collateral ligament of the knee. J Orthop Surg Res 2010; 5: 69
• 5 Wymenga AB, Kats JJ, Kooloos J et al. Surgical anatomy of the medial collateral ligament and the posteromedial capsule of the knee. Knee Surg Sports Traumatol Arthrosc 2006; 14: 229-234
• 6 Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg Am 1998; 80: 1770-1774
• 7 Luring C, Hüfner T, Perlick L et al. The effectiveness of sequential medial soft tissue release on coronal alignment in total knee arthroplasty. J Arthroplasty 2006; 21: 428-434
• 8 Koo M-H, Choi CH. Conservative treatment for the intraoperative detachment of medial collateral ligament from the tibial attachment site during primary total knee arthroplasty. J Arthroplasty 2009; 24: 1249-1253
• 9 Leopold SS, McStay C, Klafeta K et al. Primary repair of intraoperative disruption of the medial collateral ligament during total knee arthroplasty. J Bone Joint Surg Am 2001; 83?A: 86-91
• 10 Stephens S, Politi J, Backes J et al. Repair of medial collateral ligament injury during total knee arthroplasty. Orthopedics 2012; 35: e154-e159
• 11 Lee G-C, Lotke PA. Management of intraoperative medial collateral ligament injury during TKA. Clin Orthop Rel Res 2011; 469: 64-68
• 12 Jung KA, Lee SC, Hwang SH et al. Quadriceps tendon free graft augmentation for a midsubstance tear of the medial collateral ligament during total knee arthroplasty. Knee 2009; 16: 479-483
• 13 Hartford JM, Goodman SB, Schurman DJ et al. Complex primary and revision total knee arthroplasty using the condylar constrained prosthesis: an average 5-year follow-up. J Arthroplasty 1998; 13: 380-387
• 14 Lachiewicz PF, Falaty SP. Clinical and radiographic results of the Total Condylar III and Constrained Condylar total knee arthroplasty. J Arthroplasty 1996; 11: 916-922
• 15 McPherson EJ, Vince KG. Breakage of a total condylar III knee prosthesis. A case report. J Arthroplasty 1993; 8: 561-563
• 16 Naudie DDR, Rorabeck CH. Managing instability in total knee arthroplasty with constrained and linked implants. Instr Course Lect 2004; 53: 207-215
• 17 Patel PD, Potts A, Froimson MI. The dislocating hip arthroplasty: prevention and treatment. J Arthroplasty 2007; 22: 86-90
• 18 Peters CL, Hennessey R, Barden RM et al. Revision total knee arthroplasty with a cemented posterior-stabilized or constrained condylar prosthesis: A minimum 3-year and average 5-year follow-up study. J Arthroplasty 1997; 12: 896-903
• 19 Healy WI, Iori R, Lemos DW. Medial reconstruction during total knee arthroplasty for severe valgus deformity. Clin Orthop Relat Res 1998; 356: 161-169
• 20 Rand JA. Revision total knee arthroplasty using the total condylar III prosthesis. J Arthroplasty 1991; 6: 279-284
• 21 Saeki K, Mihalko WM, Patel V et al. Stability after medial collateral ligament release in total knee arthroplasty. Clin Orthop Relat Res 2001; 392: 184-189
• 22 Dimitris K, Taylor BC, Steensen RN. Excursion of oscillating saw blades in total knee arthroplasty. J Arthroplasty 2010; 25: 158-160
• 23 Ballmer PM, Jakob RP. The non operative treatment of isolated complete tears of the medial collateral ligament of the knee. A prospective study. Arch Orthop Trauma Surg 1988; 5: 273-276
• 24 Sandberg R. Knee ligament injuries [Dissertation]. Lund University; 1987
• 25 Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clin Orthop Relat Res 1990; 256: 174-177
• 26 Woo SL, Chan S, Yamaji T. Biomechanics of knee ligament healing, repair and reconstruction. J Biomech 1997; 30: 431-439
• 27 Sulco TP. Total condylar III prosthesis in ligament instability. Orthop Clin North Am 1989; 20: 221-226
• 28 Vince KG, Abdeen A, Sugimori T. The unstable total knee arthroplasty. J Arthroplasty 2006; 21: 44-49