Mittel- bis langfristige Ergebnisse nach vorderer Kreuzbandruptur und Versorgung in Healing-Response-Technik

 

 Buy Article Permissions and Reprints

Zusammenfassung

Hintergrund: Das arthroskopische Healing-Response-Verfahren wird bei proximalen Total- oder Partialrupturen des vorderen Kreuzbands eingesetzt. Innerhalb von 6 Wochen nach Trauma werden mit einer Ahle Mikrofrakturierungen im Bereich des femoralen Kreuzbandansatz und Perforationen im Bereich des vorderen Kreuzbands gesetzt, die einen Austritt von Stammzellen und Wachstumsfaktoren bewirken. Das Kreuzband kann so an seinem nativen Ursprung einheilen. Die vorliegende Arbeit zeigt mittel- bis langfristige Ergebnisse nach Healing-Response-Operation nach einem Zeitraum von mindestens 5 Jahren. Die Hypothese der Studie ist, dass bei adäquater Indikation und Patientenselektion die Healing Response eine Behandlungsoption zur autologen Kreuzbandplastik darstellt. Methodik: Zwischen 2004 und 2007 wurden 126 Patienten in unserer Klinik in Healing-Response-Technik operiert. Einschlusskriterium für die Nachuntersuchung war eine proximale, vordere Kreuzbandruptur, die innerhalb von 6 Wochen nach Trauma in Healing-Response-Technik versorgt worden ist. Ausschlusskriterien waren Kniekomplexverletzungen mit multidirektionaler Instabilität, Kreuzbandreruptur, Kreuzbandplastik, Kreuzbandruptur oder Knieprothese auf der Gegenseite und Knorpelrekonstruktionsmaßnahmen (AMIC, MACT, OATS). 43 von 89 verfügbaren Patienten (23 Frauen/20 Männer; Durchschnittsalter zum Operationszeitpunkt: 36,6 Jahre ± 11,6 Jahre; Range: 16–66 Jahre; durchschnittliche Follow-up-Zeit: 6,3 Jahre) konnten nachuntersucht werden. Das klinisch nachuntersuchte Kollektiv wurde mithilfe des Lysholm-, Tegner-Aktivitäts-Scores, modifizierten IKDC-2000-Knieuntersuchungsbogens und eines subjektiven Bogens zur Beurteilung der Kniefunktion bewertet. Weiterhin wurden Bewegungsausmaße, Muskelumfangsmessungen der unteren Extremität und die vordere Translation mit einem KT-1000-Arthrometer bestimmt. Ergebnisse: Die primäre Insuffizienzquote nach Healing-Response-Operation lag insgesamt bei 15,1 %. Bis zum Zeitpunkt der Datenerfassung im Juli 2012 wurden 24,6 % aller 126 Healing-Response-Patienten sekundär mit einer autologen Kreuzbandplastik versorgt. Das klinisch nachuntersuchte Kollektiv von 43 Patienten zeigte einen durchschnittlichen Lysholm-Score von 92 ± 8,9 Punkten. 72 % erreichten ihr ursprüngliches Aktivitätsniveau im Tegner-Aktivitäts-Score. In der IKDC-2000-Bewertung erreichten 90,7 % der Patienten eine A-Bewertung. 93 % wiesen keine Atrophien auf. Das Kollektiv zeigte keine Einschränkungen des Bewegungsausmaßes. Die durchschnittliche, mit einem KT-1000 gemessene vordere Translation im Manual-Maximum-Displacement-Test lag im Seitenvergleich bei 1,3 mm ± 1,6 mm. 86 % der Patienten bewerteten die Gesamtbehandlung mit gut bis sehr gut. 97,7 % der Patienten gaben eine normale oder fast normale Kniefunktion an. Schlussfolgerung: Patienten mit gutem Outcome 6–12 Wochen nach Healing-Response-Operation zeigen auch nach einem Beobachtungszeitraum von durchschnittlich 6,3 Jahren gute klinische Ergebnisse sowie eine objektiv nachweisbare hohe Kniestabilität. Bei entsprechender Indikation stellt die Healing-Response-Methode unserer Meinung nach eine Behandlungsoption bei frischen, proximalen, vorderen Kreuzbandrupturen dar. Dabei muss die primäre Insuffizienzrate von bis zu 15 % im präoperativen Gespräch berücksichtigt werden.

Abstract

Background: Healing response (HR) is an all-arthroscopic technique for treatment of acute proximal anterior cruciate ligament (ACL) tears within 6 weeks after injury. By means of arthroscopically controlled microfracture holes in the native femoral attachment and perforations of the ACL itself the exit of stem cells and growth factors is induced and the ligament can heal into its native attachment zone. The purpose of the study was to document medium- to long-term results after 5 years or longer following the healing response (HR) procedure. The aim of our study was to show that HR is a treatment option for acute proximal ACL tears. Material and Methods: Between 2004 and 2007 126 patients were treated in healing response technique in our hospital. Patients with a complete proximal ACL tear and operation within 6 weeks of initial injury were included in this study. Patients who had complex knee injuries with multidirectional instability, ACL rerupture, contralateral ACL reconstruction, contralateral ACL rupture or knee replacement and cartilage repair procedures (AMIC, MACT, OATS) were excluded. 43 (23 women/20 men; mean age at time of surgery 36.6 years ± 11.6; range: 16 to 66 years) of 89 eligible patients received clinical follow-up up to 8 years after surgery (mean: 6.3 years). Lysholm score, Tegner activity score, a modified IKDC-2000 knee examination form and an individually created questionnaire were used for evaluation. Furthermore, range of motion, muscle circumference of the lower limb and the anterior tibial translation were measured with a KT-1000 arthrometer™ (MEDmetric® Corporation, San Diego, USA). Results: 15.1 % of all patients showed a primary insufficiency after HR. 24.6 % of the 126 patients required subsequent ACL reconstruction up to the time of data collection. The 43 patients who received clinical follow-up showed a mean Lysholm score of 92 ± 8.9 points. 72 % reached their original level of activity in the Tegner activity score. According to the IKDC evaluation system 90.7 % of all patients were grade A. 93 % did not show muscles atrophies of the lower limb. There were no limitations in range of motion. Mean side-to-side difference in the KT-1000 manual-maximum displacement test measurements was 1.3 mm ± 1.6 mm. 97.7 % patients had a normal or nearly normal knee function and 86 % rated the overall treatment as good to very good. Conclusion: Patients with good clinical results 6 to 12 weeks after HR show even in the medium- to long-term follow-up good clinical outcomes as well as objective stability. In selected cases HR is an alternative treatment option for acute, proximal ACL ruptures. When indicating an HR procedure, it should be taken into consideration that up to 15 % of all patients could have a primary insufficiency.

• Literatur

• 1 Csintalan RP, Inacio MCS, Funahashi TT. Incidence rate of anterior cruciate ligament reconstructions. Perm J 2008; 12: 17-21
  PubMedGoogle Scholar
• 2 Siegel L, Vandenakker-Albanese C, Siegel D. Anterior cruciate ligament injuries: anatomy, physiology, biomechanics, and management. Clin J Sports Med 2012; 22: 349-355
  CrossrefPubMedGoogle Scholar
• 3 Wild CY, Steele JR, Munro BJ. Why do girls sustain more anterior cruciate ligament injuries than boys? A review of the changes in estrogen and musculoskeletal structure and function during puberty. Sports Med 2012; 42: 733-749
  CrossrefPubMedGoogle Scholar
• 4 Bollen S. Epidemiology of knee injuries: diagnosis and triage. Br J Sports Med 2000; 34: 227-228
  CrossrefPubMedGoogle Scholar
• 5 Duquin TR, Wind WM, Fineberg MS et al. Current trends in anterior cruciate ligament reconstruction. J Knee Surg 2009; 22: 7-12
  Article in Thieme ConnectPubMedGoogle Scholar
• 6 Mihelic R, Jurdana H, Jotanovic Z et al. Long-term results of anterior cruciate ligament reconstruction: a comparison with non-operative treatment with a follow-up of 17–20 years. Int Orthop 2011; 35: 1093-1097
  CrossrefPubMedGoogle Scholar
• 7 Reinhardt KR, Hetsroni I, Marx RG. Graft selection for anterior cruciate ligament reconstruction: a level I systematic review comparing failure rates and functional outcomes. Orthop Clin North Am 2010; 41: 249-262
  CrossrefPubMedGoogle Scholar
• 8 Ahn JH, Kim JG, Wang JH et al. Long-term results of anterior cruciate ligament reconstruction using bone-patellar tendon-bone: an analysis of the factors affecting the development of osteoarthritis. Arthroscopy 2012; 28: 1114-1123
  CrossrefPubMedGoogle Scholar
• 9 Bourke HE, Gordon DJ, Salmon LJ et al. The outcome at 15 years of endoscopic anterior cruciate ligament reconstruction using hamstring tendon autograft for ‘isolated anterior cruciate ligament rupture. J Bone Joint Surg Br 2012; 94: 630-637
  PubMedGoogle Scholar
• 10 Janssen RP, du Mée AW, van Valkenburg J et al. Anterior cruciate ligament reconstruction with 4-strand hamstring autograft and accelerated rehabilitation: a 10-year prospective study on clinical results, knee osteoarthritis and its predictors. Knee Surg Sports Traumatol Arthrosc 2013; 21: 1977-1988
  CrossrefPubMedGoogle Scholar
• 11 Ng WH, Griffith JF, Hung EH et al. Imaging of anterior cruciate ligament. World J Orthop 2011; 2: 75-84
  PubMedGoogle Scholar
• 12 Tjoumakaris FP, Donegan DJ, Sekiya JK. Partial tears of the anterior cruciate ligament: diagnosis and treatment. Am J Orthop (Belle Mead NJ) 2011; 40: 92-97
  PubMedGoogle Scholar
• 13 Matsumoto T, Ingham SM, Mifune Y et al. Isolation and characterization of human anterior cruciate ligament-derived vascular stem cells. Stem Cells Dev 2012; 21: 859-872
  CrossrefPubMedGoogle Scholar
• 14 Mifune Y, Matsumoto T, Ota S et al. Therapeutic potential of anterior cruciate ligament derived stem cells for anterior cruciate ligament reconstruction. Cell Transplant 2012; 21: 1651-1665
  CrossrefPubMedGoogle Scholar
• 15 Steadmann JR, Cameron-Donaldson ML, Briggs KK et al. A minimally invasive technique (“healing response”) to treat proximal ACL injuries in skeletally immature athletes. J Knee Surg 2006; 19: 8-13
  Article in Thieme ConnectPubMedGoogle Scholar
• 16 Steadman JR, Cameron-Donaldson ML, Briggs KK et al. Healing-response treatment for ACL injuries. Orthop Technol Rev 2002; 3: 3
  PubMedGoogle Scholar
• 17 Steadman JR, Rodkey WG, Rodrigo JJ. Microfracture: surgical technique and rehabilitation to treat chondral defects. Clin Orthop Relat Res 2001; (391 Suppl.): S362-S369
  PubMedGoogle Scholar
• 18 Steadman JR, Matheny LM, Briggs KK et al. Outcomes following healing response in older, active patients: a primary anterior cruciate ligament repair technique. J Knee Surg 2012; 25: 255-260
  Article in Thieme ConnectPubMedGoogle Scholar
• 19 Steadman JR, Briggs KK, Rodrigo JJ et al. Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. Arthroscopy 2003; 19: 477-484
  CrossrefPubMedGoogle Scholar
• 20 Steinert AF, Kunz M, Prager P et al. Mesenchymal stem cell characteristics of human anterior cruciate ligament outgrowth cells. Tissue Eng Part A 2011; 17: 1375-1388
  CrossrefPubMedGoogle Scholar
• 21 Frosch KH, Preiss A, Heider S et al. Primary ligament sutures as a treatment option of knee dislocations: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2013; 21: 1502-1509
  CrossrefPubMedGoogle Scholar
• 22 Murray MM, Spindler KP, Abreu E et al. Collagen-platelet richplasma hydrogel enhances primary repair of the porcine anterior cruciate ligament. J Orthop Res 2007; 25: 81-91
  CrossrefPubMedGoogle Scholar
• 23 Murray MM. Current status and potential for primary ACL repair. Clin Sports Med 2009; 28: 51-61
  CrossrefPubMedGoogle Scholar
• 24 Murray MM, Spindler KP, Ballard P et al. Enhanced histologic repair in a central wound in the anterior cruciate ligament with a collagen-platelet-rich plasma scaffold. J Orthop Res 2007; 25: 1007-1017
  CrossrefPubMedGoogle Scholar
• 25 Murray MM, Spindler KP, Devin C et al. Use of a collagen-platelet rich plasma scaffold to stimulate healing of a central defect in the canine ACL. J Orthop Res 2006; 24: 820-830
  CrossrefPubMedGoogle Scholar
• 26 Grøntvedt T, Engebretsen L, Benum P et al. A prospective, randomized study of three operations for acute rupture of the anterior cruciate ligament. Five-year follow-up of one hundred and thirty-one patients. J Bone Joint Surg Am 1996; 78: 159-168
  PubMedGoogle Scholar
• 27 Kdolsky R, Kwasny O, Schabus R. Synthetic augmented repair of proximal ruptures of the anterior cruciate ligament. Long-term results of 66 patients. Clin Orthop Relat Res 1993; 295: 183-189
  PubMedGoogle Scholar
• 28 Kaplan N, Wickiewicz TL, Warren RF. Primary surgical treatment of anterior cruciate ligament ruptures: a long term follow-up study. Am J Sports Med 1990; 18: 254-358
  CrossrefPubMedGoogle Scholar
• 29 Sherman MF, Bonamo JR. Primary repair of the anterior cruciate ligament. Clin Sports Med 1988; 7: 739-750
  PubMedGoogle Scholar
• 30 Seiler H, Frank HR. Suture of the anterior cruciate ligament – what is the real value of this method?. Unfallchirurg 1993; 96: 443-450
  PubMedGoogle Scholar
• 31 Strehl A, Eggli S. The value of conservative treatment in rupturesof the anterior cruciate ligament (ACL). J Trauma 2007; 62: 1159-1162
  CrossrefPubMedGoogle Scholar
• 32 Dhillon MS, Balo K, Prabhakar S. Proprioception in anterior cruciate ligament deficient knees and its relevance in anterior cruciate ligament reconstruction. Indian J Orthop 2011; 45: 294-300
  CrossrefPubMedGoogle Scholar
• 33 Schutte MJ, Dabezies EJ, Zimny ML et al. Neural anatomy of the human anterior cruciate ligament. J Bone Joint Surg 1987; 69: 243-247
  PubMedGoogle Scholar
• 34 Zimny ML, Schutte M, Dabezies E. Mechanoreceptors in the human anterior cruciate ligament. Anat Rec 1986; 214: 204-209
  CrossrefPubMedGoogle Scholar
• 35 Barrack RL, Skinner HB, Buckley SL. Prorioception in the anterior cruciate deficient knee. Am Journal Sports Med 1989; 17: 1-6
  PubMedGoogle Scholar
• 36 Grigg P, Greenspan BJ. Response of primate joint afferent neurons to mechanical stimulation of knee. J Neurophysiol 1977; 40: 1-8
  PubMedGoogle Scholar
• 37 Johansson H, Sjolander P, Sojka P. Receptors in the knee joint ligaments and their role in the biomechanics of the joint. Crit Rev Biomed Eng 1991; 18: 341-368
  PubMedGoogle Scholar
• 38 Scheffler SU, Unterhauser FN, Weiler A. Graftremodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2008; 16: 834-842
  CrossrefPubMedGoogle Scholar
• 39 Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982; 10: 150-154
  CrossrefPubMedGoogle Scholar
• 40 Hefti F, Müller W, Jakob RP, Stäubli HU. Evalution of knee ligament injuries with IKDC form. Knee Surg Sport Traumatol Arthrosc 1993; 1: 226-234
  CrossrefPubMedGoogle Scholar
• 41 Tegner Y, Lysholm J. Rating systems in the evaluation on knee ligament injuries. Clin Orthop 1985; 198: 43-49
  PubMedGoogle Scholar
• 42 Balasch H, Schiller M, Friebel H et al. Evaluation of anterior knee joint instability with the Rolimeter: A test im comparison with manual assessment and measuring with the KT-1000 Arthrometer. Knee Surg Sports Traumatol Athrosc 1999; 7: 204-208
  PubMedGoogle Scholar
• 43 Bach jr. BR, Warren RF, Flynn WM et al. Arthrometric evaluation of knees that have a torn anterior cruciate ligament. J Bone Joint Surg Am 1990; 72: 1299-1306
  CrossrefPubMedGoogle Scholar
• 44 Briggs KK, Steadman JR, Hay CJ et al. Lysholm score and Tegner activity level in individuals with normal knees. Am J Sports Med 2009; 37: 898-901
  CrossrefPubMedGoogle Scholar
• 45 Wasmaier J, Kubik-Huch R, Pfirmann C et al. Proximal anterior cruciate ligament tears: the healing response technique versus conservative treatment. J Knee Surg 2013; 26: 263-271
  Article in Thieme ConnectPubMedGoogle Scholar
• 46 Rosc D, Powierza W, Zastawna E et al. Post-traumatic plasminogenesis in intraarticular exudate in the knee joint. Med Sci Monit 2002; 8: CR371-378
  PubMedGoogle Scholar
• 47 Laprade RF, Wijdicks CA. The management of injuries to the medial side of the knee. J Orthop Sports Phys Ther 2012; 42: 221-233
  CrossrefPubMedGoogle Scholar
• 48 Woo SL, Vogron TM, Abramowitch SD. Healing and repair of ligament injuries in the knee. J Am Acad Orthop Surg 2000; 8: 364-372
  PubMedGoogle Scholar
• 49 Agung M, Ochi M, Yanada S et al. Mobilization of bone marrow derived mesenchymal stem cells into the injured tissues after intraarticular injection and their contribution to tissue regeneration. Knee Surg Sports Traumatol Arthrosc 2006; 14: 1307-1314
  CrossrefPubMedGoogle Scholar
• 50 Rodkey WG, Arnoczky SP, Steadman JR. Healing of a surgically created partial detachment of the posterior cruciate ligament using marrow stimulation: an experimental study in dogs. J Knee Surg 2006; 19: 14-18
  Article in Thieme ConnectPubMedGoogle Scholar