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Operative Orthopädie und Traumatologie

, Volume 31, Issue 1, pp 36–44 | Cite as

Anterolaterale Stabilisierung mittels modifizierter Lemaire-Plastik bei insuffizientem vorderem Kreuzband

  • M. Wurm
  • E. Herbst
  • P. Forkel
  • A. B. ImhoffEmail author
  • M. Herbort
Operative Techniken
  • 209 Downloads

Zusammenfassung

Operationsziel

Behandlung einer persistierenden anterolateralen Kniegelenksinstabilität.

Indikationen

Subjektive/objektive (Rotations‑)Instabilität des Kniegelenks nach erfolgter (anatomischer) Rekonstruktion des vorderen Kreuzbandes (VKB). VKB-Reruptur inklusive spezieller Anforderungen (z. B. Hochleistungssport, Hyperlaxität)

Relative Kontraindikationen

Gonarthrose, Achsfehlstellungen oder additive Instabilitäten, die zusätzlich adressiert werden müssen; nichtanatomische VKB-Rekonstruktion (VKBR) mit persistierender Instabilität (zuerst anatomische VKBR).

Absolute Kontraindikationen

Allgemeine Kontraindikationen (z. B. Infektionen), Reizzustand des Kniegelenks.

Operationstechnik

Rückenlagerung. Leicht bogenförmige Schnittführung im Bereich posterior und proximal des lateralen femoralen Epikondylus. Darstellung/Anzeichnen des Tractus iliotibialis. Proximales Ablösen und Armieren des Traktusstreifens. Unterminieren des lateralen Kollateralbands. Markieren des Isometriezentrums femoralseitig. Fixieren des Transplantats. Schichtweiser Verschluss.

Weiterbehandlung

Hartrahmen-Kniegelenkorthese mind. 6 Wochen. Bewegungsumfang ab 1. postoperativem Tag: Flexion-Extension 90-0-0; 20-kg-Teilbelastung für 2 Wochen postoperativ.

Ergebnisse

Die aktuelle Literatur liefert Hinweise, dass eine anterolaterale Stabilisierung den Pivot-shift-Test sowie die Rerupturrate reduziert. Basierend auf biomechanischen Arbeiten ist dabei eine Tenodese nach Lemaire der Rekonstruktion des anterolateralen Ligaments vorzuziehen. Entscheidend ist jedoch die isometrische Bohrkanalplatzierung bzw. die Fixation in tibialer Neutralrotation mit geringer Transplantatspannung. Indikationen einer anterolateralen Stabilisierung sind VKB-Rupturen mit einem drittgradigen Pivot-shift bzw. Revisionsfälle oder persistierende anterolaterale Instabilitäten nach anatomischer VKBR.

Schlüsselwörter

Rotation Gelenkinstabilität Knie Anterolateral Extraartikuläre 

Abkürzungen

A.

Arterie/Arteria

ACL

„anterior cruciate ligament“/vorderes Kreuzband

ALL

anterolaterales Ligament

ALLR

Rekonstruktion des anterolateralen Ligaments

LCL

Ligamentum collaterale laterale

N.

Nerv/Nervus

VKB

vorderes Kreuzband

VKBR

Rekonstruktion des vorderen Kreuzbandes

Anterolateral stabilization using the modified Lemaire technique for ACL deficiency

Abstract

Objective

Treatment of persistent anterolateral knee instability.

Indications

Subjective/objective (rotational) instability of the knee after anatomic anterior cruciate ligament (ACL) reconstruction. ACL re-rupture including special demands (e.g., high-performance athletes, hyperlaxity)

Relative contraindications

Osteoarthritis, additional instability of the knee, which should be treated independently; non-anatomic ACL reconstruction with persisting instability should be treated first with anatomic ACL reconstruction.

Absolute contraindications

General contraindications for surgery (e. g. septic arthritis), acute irritation of the affected knee.

Surgical technique

Supine position. Incision along the proximal lateral femoral epicondyle. Marking of the needed width and length of the iliotibial band (ITB) graft. Passing the ITB graft underneath the lateral collateral ligament. Find and mark the isometric point for fixation next to the lateral femoral epicondyle. Fixation of the ITB graft. Layered wound closure.

Postoperative management

Knee brace for at least 6 weeks. Range of motion (RoM): from postoperative day 1: flexion–extension 90-0-0°; first 2 weeks after surgery: partial weight bearing (20 kg).

Results

An anterolateral extra-articular reconstruction may reduce a persistent anterolateral rotatory instability as well as the re-rupture rate following ACL reconstruction with good patient-reported short-term outcomes. Based on current (biomechanical) data, anterolateral tenodesis seems to be superior to a reconstruction of the anterolateral ligament. If a tenodesis is performed, the graft should be fixed in an isometric position, with neutral rotation of the knee and low graft tension to avoid extraphysiologic load within the lateral compartment. Indications for such a procedure may include a high-grade pivot shift or revision ACL reconstruction as well as a persistent anterolateral rotatory instability following anatomic ACL reconstruction.

Keywords

Rotation Joint Instability Knee Anterolateral Extraarticular 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

A.B. Imhoff ist Berater für Arthrex. M. Wurm, E. Herbst, P. Forkel und M. Herbort geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Achtnich A, Ranuccio F, Willinger L et al (2018) High incidence of partially anatomic tunnel placement in primary single-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 26:462–467CrossRefGoogle Scholar
  2. 2.
    Ahlden M, Sernert N, Karlsson J et al (2013) A prospective randomized study comparing double- and single-bundle techniques for anterior cruciate ligament reconstruction. Am J Sports Med 41:2484–2491CrossRefGoogle Scholar
  3. 3.
    Arneja S, Leith J (2009) Review article: Validity of the KT-1000 knee ligament arthrometer. J Orthop Surg (Hong Kong) 17:77–79CrossRefGoogle Scholar
  4. 4.
    Ayeni OR, Chahal M, Tran MN et al (2012) Pivot shift as an outcome measure for ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 20:767–777CrossRefGoogle Scholar
  5. 5.
    Buller LT, Best MJ, Baraga MG et al (2015) Trends in anterior cruciate ligament reconstruction in the United States. Orthop J Sports Med 3:2325967114563664PubMedGoogle Scholar
  6. 6.
    Claes S, Vereecke E, Maes M et al (2013) Anatomy of the anterolateral ligament of the knee. J Anat 223:321–328CrossRefGoogle Scholar
  7. 7.
    Hauser ED (1947) Extra-articular repair for ruptured collateral and cruciate ligaments. Surg Gynecol Obstet 84:339–345PubMedGoogle Scholar
  8. 8.
    Helito CP, Camargo DB, Sobrado MF et al (2018) Combined reconstruction of the anterolateral ligament in chronic ACL injuries leads to better clinical outcomes than isolated ACL reconstruction. Knee Surg Sports Traumatol Arthrosc.  https://doi.org/10.1007/s00167-018-4934-2 CrossRefPubMedGoogle Scholar
  9. 9.
    Herbst E, Arilla FV, Guenther D et al (2018) Lateral extra-articular tenodesis has no effect in knees with isolated anterior cruciate ligament injury. Arthroscopy 34:251–260CrossRefGoogle Scholar
  10. 10.
    Hoshino Y, Araujo P, Ahlden M et al (2013) Quantitative evaluation of the pivot shift by image analysis using the iPad. Knee Surg Sports Traumatol Arthrosc 21:975–980CrossRefGoogle Scholar
  11. 11.
    Inderhaug E, Stephen JM, Williams A et al (2017) Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med 45:347–354CrossRefGoogle Scholar
  12. 12.
    Kaplan EB (1958) The iliotibial tract; clinical and morphological significance. J Bone Joint Surg Am 40-A:817–832CrossRefGoogle Scholar
  13. 13.
    Kittl C, El-Daou H, Athwal KK et al (2016) The role of the anterolateral structures and the ACL in controlling laxity of the intact and ACL-deficient knee. Am J Sports Med 44:345–354CrossRefGoogle Scholar
  14. 14.
    Lemaire M (1975) Chronic knee instability. Technics and results of ligament plasty in sports injuries. J Chir (Paris) 110:281–294Google Scholar
  15. 15.
    Lemaire M, Combelles F (1980) Plastic repair with fascia lata for old tears of the anterior cruciate ligament (author’s transl). Rev Chir Orthop Reparatrice Appar Mot 66:523–525PubMedGoogle Scholar
  16. 16.
    Lemaire M, Miremad C (1983) Chronic anterior and internal instabilities of the knee. Treatment. Rev Chir Orthop Reparatrice Appar Mot 69:591–601PubMedGoogle Scholar
  17. 17.
    Lopomo N, Signorelli C, Rahnemai-Azar AA et al (2017) Analysis of the influence of anaesthesia on the clinical and quantitative assessment of the pivot shift: a multicenter international study. Knee Surg Sports Traumatol Arthrosc 25:3004–3011CrossRefGoogle Scholar
  18. 18.
    Musahl V, Herbst E, Burnham JM et al (2018) The anterolateral complex and anterolateral ligament of the knee. J Am Acad Orthop Surg 26:261–267CrossRefGoogle Scholar
  19. 19.
    Parkinson B, Gogna R, Robb C et al (2017) Anatomic ACL reconstruction: the normal central tibial footprint position and a standardised technique for measuring tibial tunnel location on 3D CT. Knee Surg Sports Traumatol Arthrosc 25:1568–1575CrossRefGoogle Scholar
  20. 20.
    Ramaniraka NA, Saunier P, Siegrist O et al (2007) Biomechanical evaluation of intra-articular and extra-articular procedures in anterior cruciate ligament reconstruction: a finite element analysis. Clin Biomech (Bristol, Avon) 22:336–343CrossRefGoogle Scholar
  21. 21.
    Rupp S, Kohn D (2002) The anterior cruciate ligament as focus of interest. Orthopade 31:701CrossRefGoogle Scholar
  22. 22.
    Schon JM, Moatshe G, Brady AW et al (2016) Anatomic anterolateral ligament reconstruction of the knee leads to overconstraint at any fixation angle. Am J Sports Med 44:2546–2556CrossRefGoogle Scholar
  23. 23.
    Slette EL, Mikula JD, Schon JM et al (2016) Biomechanical results of lateral extra-articular tenodesis procedures of the knee: a systematic review. Arthroscopy 32:2592–2611CrossRefGoogle Scholar
  24. 24.
    Sonnery-Cottet B, Barbosa NC, Vieira TD et al (2018) Clinical outcomes of extra-articular tenodesis/anterolateral reconstruction in the ACL injured knee. Knee Surg Sports Traumatol Arthrosc 26:596–604CrossRefGoogle Scholar
  25. 25.
    Sonnery-Cottet B, Saithna A, Blakeney WG et al (2018) Anterolateral ligament reconstruction protects the repaired medial meniscus: a comparative study of 383 anterior cruciate ligament reconstructions from the SANTI study group with a minimum follow-up of 2 years. Am J Sports Med 46:1819–1826CrossRefGoogle Scholar
  26. 26.
    Sonnery-Cottet B, Saithna A, Cavalier M et al (2017) Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI study group. Am J Sports Med 45:1547–1557CrossRefGoogle Scholar
  27. 27.
    Sonnery-Cottet B, Thaunat M, Freychet B et al (2015) Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2‑year follow-up. Am J Sports Med 43:1598–1605CrossRefGoogle Scholar
  28. 28.
    Thaunat M, Clowez G, Saithna A et al (2017) Reoperation rates after combined anterior cruciate ligament and anterolateral ligament reconstruction: a series of 548 patients from the SANTI study group with a minimum follow-up of 2 years. Am J Sports Med 45:2569–2577CrossRefGoogle Scholar
  29. 29.
    Thein R, Boorman-Padgett J, Stone K et al (2016) Biomechanical assessment of the anterolateral ligament of the knee: a secondary restraint in simulated tests of the pivot shift and of anterior stability. J Bone Joint Surg Am 98:937–943CrossRefGoogle Scholar
  30. 30.
    Williams A, Ball S, Stephen J et al (2017) The scientific rationale for lateral tenodesis augmentation of intra-articular ACL reconstruction using a modified „Lemaire“ procedure. Knee Surg Sports Traumatol Arthrosc 25:1339–1344CrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  • M. Wurm
    • 1
  • E. Herbst
    • 1
  • P. Forkel
    • 1
  • A. B. Imhoff
    • 1
    Email author
  • M. Herbort
    • 2
  1. 1.Abteilung und Poliklinik für SportorthopädieKlinikum rechts der Isar, Technische Universität MünchenMünchenDeutschland
  2. 2.Klinik für Unfall‑, Hand und WiederherstellungschirurgieUniversitätsklinikum MünsterMünsterDeutschland

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