Rotationsfehlstellungen der Komponenten als Ursache chronischer Schmerzen und vorzeitigem Prothesenversagen bei Knieendoprothesen

ZusammenfassungDie Rotation der Tibia- und Femurkomponente stellt ein zentrales Thema in der modernen Knieendoprothetik dar. Nach der exakten frontalen Achsausrichtung des Beins und der perfekten Weichteilbalancierung stellt die korrekte Rotation der Komponenten die “dritte Dimension” der Knieendoprothetik dar. Das Ziel einer verbesserten Operationstechnik mit modifizierten Instrumenten und exakter Rotationsposition ist die Optimierung des funktionellen Ergebnisses.Patienten mit schmerzhaften Knietotalendoprothesen (KTEP) oder vorzeitigem Prothesenversagen ohne erkennbare konventionelle Implantationsabweichung oder Infekt sollten auf eine Rotationsfehlstellung untersucht werden. In einer prospektiven Studie an 26 Patienten mit schmerzhaften KTEP und Rotationsabweichungen an Femur und/oder Tibia erfolgte eine Revisionsoperation mit Austausch der Komponenten. Bei 25 Patienten lag eine klinisch relevante Innenrotationsfehlstellung der Tibiakomponente (Mittel 8,4°) und/oder Femurkomponente (Mittel 5,6°) vor. Nur in 1 Fall fand sich eine klinisch relevante Außenrotationsfehlstellung der Femurkomponente von 10°. Bei insgesamt 10 Patienten (38%) fand sich eine kombinierte Fehlstellung an Femur und Tibia.Nach Systemwechsel und Korrektur der Fehlpositionierung der Komponenten zeigten nach einem durchschnittlichen Nachuntersuchungszeitraum von 18 (8–34) Monaten 20 dieser Patienten (78%) gute und sehr gute Ergebnisse. Bei Patienten mit chronisch schmerzhaften KTEP und nachgewiesener Rotationsfehlstellungen der Komponenten sollte bei entsprechendem Leidensdruck ein kompletter Systemwechsel in Erwägung gezogen werden.AbstractRotational alignment of the tibial and femoral component plays an important role in modern total knee replacement surgery. After correct frontal alignment and proper soft tissue balancing, the rotational placement of the components represents the “third dimension” in knee endoprosthetic surgery. Improved surgical techniques with modified instruments and better rotational component positioning will lead to better functional outcomes.Patients with painful total knee arthroplasties (TKA) or early failure without evident classic implantation failures or signs of infection should be evaluated for malrotation of the components. In a prospective study in 26 patients with painful TKA and malrotation of the tibia and/or femur component, revision surgery with exchange of the components was performed. Twenty-five cases showed clinically relevant internal malrotation of the tibial component (ø 8.4°) and/or femoral component (ø 5.6°). Only one patient had 10° of external malrotation of the femoral component. Combined malrotations of the tibia and femur were found in ten knees (38%).After revision surgery and correction of malrotations, 20 patients (78%) were scored with excellent and good results. Patients with painful TKA resistant to conservative therapy and evident malrotations of the component should be considered for revision surgery with change of the malrotated components.

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