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Von der tibiofemoralen Instabilität zur Luxation in der Knieendoprothetik

From tibiofemoral instability to dislocation in total knee arthroplasty

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Zusammenfassung

Die tibiofemorale Instabilität wird zunehmend als Versagen einer Knietotalendoprothese (KTEP) wahrgenommen. Bei ausgeprägter Instabilität kann es in seltenen Fällen zur Luxation kommen. Die wichtigsten Ursachen einer Instabilität sind in der nicht richtigen chirurgischen Technik und der falschen Wahl des Kopplungsgrades der Prothese zu suchen. Malalignment, Malrotation und eine intraoperativ nicht korrigierte Instabilität (insbesondere in Flexion) können zu einer instabilen Prothese führen. Kreuzbanderhaltene Prothesen und mobile Inlays sollten nur bei guter Bandbalancierung verwendet werden. Kreuzbandersetzende Prothesen geben eine höhere Stabilität und gelten als insgesamt fehlerverzeihender. Dennoch können schwere Varus- und Valgusinstabilitäten und Flexionsinstabilitäten nicht kompensiert werden. Geführte ungekoppelte Prothesen können schwere beidseitige Bandinsuffizienzen nicht langfristig kompensieren. Hier sollten besser geführte gekoppelte (Rotating-hinge-)Prothesen zur Anwendung kommen. Die exakte Analyse der Ursache einer instabilen oder luxierten Knietotalendoprothese stellt die wichtigste Voraussetzung einer erfolgreichen Behandlung dar. Der Prothesenwechsel stellt die erfolgversprechendste Methode dar. Dabei sollte die Korrektur der implantationsbezogenen Ursachen der Instabilität erfolgen. Nur bei Vorliegen von Bandinsuffizienzen sollte der nächst höhere Kopplungsgrad verwendet werden. Eine Sonderform stellt die posttraumatische Instabilität oder Luxation dar.

Abstract

Tibiofemoral instability is increasingly recognized as a mode of failure in total knee arthroplasty (TKA). Severe instability may lead to dislocation. Wrong surgical technique and wrong choice of constraint of the prostheses are the main causes for instability. Malalignment, malrotation and intraoperatively uncorrected instability especially in flexion may lead to an unstable total knee arthroplasty. Cruciate-retaining designs and mobile platforms can be considered only in the presence of well-balanced ligaments. Cruciate-substituting designs give more stability and many people find them more forgiving. However, correction of varus-valgus instability and severe flexion laxity cannot be provided. Varus-valgus contrained designs cannot compensate for the absence of medial and lateral collateral ligaments. Such cases are most reliably treated with a linked implant (rotating hinge). The exact analysis of the cause of an unstable or dislocated total knee arthroplasty represents the most essential basis of a successful treatment. Exchange of the prostheses represents the most successful procedure. Correction of implantation failures should be performed. A more constrained design should be used if insufficient ligaments are found. Post-traumatic instability or dislocation represents an exception.

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung hin: Der korrespondierende Autor hat einen Beratervertrag mit der Firma Plus Orthopedics. Trotz des möglichen Interessenkonflikts ist der Beitrag unabhängig und produktneutral.

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  1. Abteilung für Orthopädie und orthopädische Chirurgie, Allgemeines und orthopädisches LKH Stolzalpe, Stolzalpe 38, A-8852, Stolzalpe, Österreich

    M. Pietsch & S. Hofmann

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  1. M. Pietsch
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  2. S. Hofmann
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Correspondence to M. Pietsch.

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Pietsch, M., Hofmann, S. Von der tibiofemoralen Instabilität zur Luxation in der Knieendoprothetik. Orthopäde 36, 917–927 (2007). https://doi.org/10.1007/s00132-007-1142-z

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