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Intraoperative Qualitätskontrolle bei der Bohrkanalplatzierung zum vorderen Kreuzbandersatz

Intraoperative quality control of the placement of bone tunnels for reconstruction of the anterior cruciate ligament

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Zusammenfassung

Der Ersatz des vorderen Kreuzbands ist eine häufige, aber technisch anspruchsvolle Operation mit einer Revisionsrate von etwa 10%. Die Platzierung der Bohrkanäle ist die wichtigste intraoperative Variable für den Operationserfolg. Kenntnisse der anatomischen Insertionsareale an Femur und Tibia sind Voraussetzung für die erfolgreiche Operation. Als ideale Lokalisation des femoralen Bohrkanals gilt, dass dessen dorsale Begrenzung etwa 1–2 mm vor der Over-the-top-Position und bei ca. 10 Uhr (für rechte Kniegelenke) bzw. 14 Uhr (links) in der Frontalebene liegen sollte. Der femorale Bohrkanal kann transtibial oder durch ein anteromediales Arthroskopieportal angelegt werden, dabei kann die Nutzung des anteromedialen Portals nach aktuellen Studien die Gefahr einer Fehlpositionierung reduzieren.

Das Zentrum des tibialen Bohrkanals sollte auf einer gedachten Linie zwischen innerem Rand des Außenmeniskusvorderhorns und medialem Kreuzbandhöcker liegen. In Bezug zum Interkondylendach muss die Bohrkanalposition weit genug dorsal gewählt werden, um ein Anstoßen des Transplantats am Interkondylendach zu verhindern. Maßnahmen zur intraoperativen Qualitätskontrolle sind die Verwendung eines Bildverstärkers zur Kontrolle der Zieldrahtposition, die Messung der Tibiatranslation und eine postoperative Röntgenaufnahme in 2 Ebenen. Die Verwendung von computerassistierten Platzierungshilfen kann zum derzeitigen Zeitpunkt nicht routinemäßig empfohlen werden.

Abstract

The reconstruction of a ruptured anterior cruciate ligament (ACL) is a frequently performed operation, however technically demanding with a revision rate of approximately 10%. The correct placement of bone tunnels in femur and tibia is the most important variable to achieve a successful outcome. A destinct knowledge of the anatomic insertion sites is crucial. The ideal location for the femoral bone tunnel is achieved when a 1–2 mm posterior wall is left to the over-the-top position and when the entry to the bone tunnel is at 10 o’clock (right knees) or 14 o’cloc k (left knees) in the frontal plane. The femoral bone tunnel can be drilled through the tibial bone tunnel (transtibial technique) or through an anteromedial arthroscopic portal. According to recent studies the use of an anteromedial portal helps to reduce the risk of misplacement of the bone tunnel. The center of the tibial bone tunnel should be located on an imaginary line between medial border of the anterior horn of the lateral meniscus and the medial tibial spine. The position of the tibial guide wire has to be far enough posterior to avoid impingement of the graft with the roof of the intercondylar notch.

Measures for quality control include the intraoperative use of an image intensifier (fluoroscopy), instrumented laxity measurements and a postoperative radiograph in 2 planes. The use of computer assisted surgery cannot routinely be recommended at present.

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Authors and Affiliations

  1. ATOS Klinik Heidelberg

    H. H. Pässler

  2. Klinik am Ring, Köln

    J. Höher

  3. ATOS Praxisklinik Heidelberg, Bismarckstraße 9-15, 69115, Heidelberg

    H. H. Pässler

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  2. J. Höher
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Correspondence to H. H. Pässler.

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Pässler, H.H., Höher, J. Intraoperative Qualitätskontrolle bei der Bohrkanalplatzierung zum vorderen Kreuzbandersatz. Unfallchirurg 107, 263–272 (2004). https://doi.org/10.1007/s00113-004-0745-7

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