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Periprothetische Frakturen nach Knietotalendoprothetik

Periprosthetic fractures after total knee arthroplasty

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Zusammenfassung

Bei steigenden Implantationszahlen von Knieendoprothesen werden auch vermehrt Komplikationen wie periprothetische Frakturen beobachtet. Als Pathomechanismus liegt häufig ein Bagatelltrauma mit zusätzlichen patienteneigenen, implantatspezifischen oder operationsbedingten Risikofaktoren zugrunde. Nach präoperativer Diagnostik mit Beachtung von Implantatverankerung und Streckapparatintegrität ist eine Analyse mit genauer Klassifikation bei der Therapieentscheidung hilfreich. Behandlungsziele sind exakte Reposition, stabile Fixation, Wiederherstellung der Streckfunktion und frühzeitige Mobilisation. Bei operativer Revision muss das einliegende Implantat bekannt und der Operateur auch auf einen Prothesenwechsel vorbereitet sein.

Suprakondyläre Femurfrakturen können häufig durch winkelstabile Osteosynthesen stabil versorgt werden, während bei Prothesenlockerungen oft das gesamte Teilimplantat aufwändig gewechselt werden muss. Tibial bestehen häufig zusätzliche Knochendefekte, welche durch Knochenersatz oder Implantataugmentationen mitbehandelt werden müssen. Bei gelockerten Implantaten helfen langstielige Prothesen die Defekte zu überbrücken und belastungsstabile Rekonstruktionen zu erzeugen. Im Fall einer Patellafraktur sollte bei Integrität des Streckapparats und stabilem bzw. asymptomatischem Implantat die konservative Therapie erfolgen. Wird eine operative Rekonstruktion notwendig, so besitzt die Streckapparatrekonstruktion Priorität vor einem erneuten Rückflächenersatz.

Abstract

The increasing implantation rates of knee arthroplasties are associated with a growing prevalence of complications like periprosthetic fractures. Underlying patient, implant and/or operation technique-related risk factors contribute to these fractures which often occur after minor trauma. In the diagnostic process, fracture dislocation, implant stability, and integrity of the extensor mechanism have to be assessed. Valid classification systems are available to guide treatment decisions. Treatment goals are precise reposition, stable fixation, restoration of function, and early mobilization. In the case of an operative revision, the surgeon has to know the implanted device and has to be prepared for extended procedures and revision arthroplasty.

Less invasive fixation devices like retrograde nailing or LISS are often sufficient to stabilize femoral supracondylar fractures, while loosening of the implant often requires extended exchange arthroplasty. Tibial fractures are often associated with osteolysis and bone loss which has to be addressed with bone grafts or augmented revision implants. Long-stemmed implants allow bypassing of the reconstructed defect and provide a stable solution for early mobilization. Patella fractures with stable or asymptomatic implants and continuity of the extensor mechanism should be treated conservatively. If reconstruction becomes necessary, results are often associated with significant functional limitations.

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Authors and Affiliations

  1. Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität, Ismaninger Straße 22, 81675, München

    P. Diehl & R. Burgkart

  2. Abteilung für Unfall- und Wiederherstellungschirurgie, Berufsgenossenschaftliche Unfallklinik, Murnau

    T. Klier, C. Glowalla & H. Gollwitzer

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  1. P. Diehl
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Correspondence to P. Diehl.

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Diehl, P., Burgkart, R., Klier, T. et al. Periprothetische Frakturen nach Knietotalendoprothetik. Orthopäde 35, 961–974 (2006). https://doi.org/10.1007/s00132-006-0990-2

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