Kruisbandscheur & Sport 2014 Rob Janssen Orthopedisch Centrum Máxima
„Kruisbandscheur is de hartaanval van de knie”
Overzicht 2014 I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message
I. De Knie
Overzicht I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message
II. Voorste kruisband (VKB) letsels • •
Per jaar: 3% amateurs, 15% topsporters 2-8x vaker bij ♀ dan ♂
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NL 2012: 9000 VKB reconstructies • 2/3 sporters terug naar oude sportniveau • Kans ruptuur VKB andere knie na operatie 24%!
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Bijkomende schade: • Kraakbeen • Meniscus • Collateraalbanden: • mediaal 50%, lateraal 2-6% • miskennen risico reruptuur VKB!
!
III. Het sportletsel
Gevolgen sportletsel knie Instabiliteit
Kraakbeenletsel
Meniscusletsel
Instabiliteit knie: 3 soorten Voor-achterwaarts
Zijwaarts
Exorotatie ↑
Exorotatie ↑ bij zowel laterale als mediale knieletsels Beweging van tibiaplateau maakt onderscheid tussen posterolaterale en anteromediale instabiliteit posterolaterale instabiliteit
anteromediale instabiliteit
Overzicht I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message
IV.Voorste kruisband
“with a little help from my friends”
1. Kraakbeen 2. Meniscus 3. Collateraalbanden
.NL KE IOS
4 PU
ISTOETS NN
WWW.PHYS
1-2. „Friends” Kraakbeen-Meniscus NTEN
Bindweefsel in herstel
Beschermt een voorstekruisbandreconstructie tegen artrose van de knie? Rob Janssen R.P.A. Janssen, orthopedisch chirurg, Orthopedisch Centrum Máxima, Máxima Medisch Centrum Eindhoven-Veldhoven. www.rpajanssen.nl
Samenvatting Letsels van de voorste kruisband (VKB) komen meestal voor bij pivoterende sporten zoals voetbal, hockey, korfbal en zaalsporten. Patiënten krijgen vaak het advies om de VKB te laten reconstrueren omdat ze anders slijtage van de knie krijgen. Het ontstaan van knie-artrose (gonartrose) na een VKB-ruptuur is echter een multifactorieel proces. Wetenschappelijk onderzoek toont aan dat het risico op röntgenologische artrose van de knie gelijk is bij patiënten met en zonder reconstructie van de VKB. De in de praktijk vaak gemaakte opmerking ‘U moet uw voorste kruisband laten reconstrueren, anders krijgt u slijtage van de knie’ is onjuist. Indicaties voor een VKB-reconstructie van de knie zijn klachten van invaliderende functionele instabiliteit, bij het hechten van een meniscusruptuur en de wens tot pivoterende (sport)activiteiten.
Leerdoelen Na het lezen van dit artikel: heeft u inzicht in de huidige hypothesen over het ontstaan van gonartrose na VKB-letsels; kent u de risicofactoren voor gonartrose na een VKB-ruptuur; kent u het risicopercentage van gonartrose na VKBreconstructies; kent u de huidige indicaties voor een VKB-reconstructie; kunt u beargumenteren of een VKB-reconstructie de knie beschermt tegen artrose.
Inleiding Een scheur van de voorste kruisband (VKB) is het meest voorkomend kniebandletsel. Een VKB-letsel komt vaak voor bij pivoterende sportactiviteiten, zoals
voetbal, hockey, korfbal, ski, tennis en zaalsporten.1,2,3 De jaarlijkse incidentie is 0,8 per 1000 inwoners in leeftijd van 10 tot 64 jaar.4 Jongere kinderen zijn helaas geen uitzondering. De jongste patiënt in mijn eigen praktijk is 5 jaar oud.5 ‘U moet uw voorste kruisband laten opereren, anders krijgt u artrose.’ Zegt u dit wel eens tegen uw patiënten? Klopt dat wel? Helpt een VKB-operatie tegen slijtage van de knie op lange termijn? Is sport of zware activiteit na een VKB-reconstructie verstandig of leidt dit tot meer slijtage op langere termijn? Ter beantwoording van deze vragen zal ik de meest recente inzichten presenteren over gonartrose in relatie tot de VKB. Dit artikel heeft tot doel een overzicht te geven van de huidige wetenschap over de relatie tussen VKB en gonartrose. Achtereenvolgens komen aan bod: de anatomie van de VKB, het ontstaan van gonartrose na VKB-letsel, gonartrose bij conservatief beleid na VKB-letsel, de relatie tussen VKB-reconstructie en gonartrose, de invloed van de operatietechniek op gonartrose, indicaties voor VKB-reconstructies.
Anatomie van de voorste kruisband De VKB bevindt zich centraal in het kniegewricht, tussen het tibiaplateau en de binnenzijde van de laterale femurcondyl. De VKB bestaat uit twee mechanische entiteiten, benoemd naar de insertieplaats op de tibia: een anteromediale en een posterolaterale bundel (zie
www.physios.nl | nummer 1 | maart 2011 | 23
1-2. „Friends” Kraakbeen-Meniscus Author's personal copy
Knee Surg Sports Traumatol Arthrosc (2013) 21:1977–1988 DOI 10.1007/s00167-012-2234-9
KNEE
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 Rob P. A. Janssen • Arthur W. F. du Me´e • Juliette van Valkenburg • Harm A. G. M. Sala Carroll M. Tseng
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Received: 13 April 2012 / Accepted: 24 September 2012 / Published online: 19 October 2012 ! Springer-Verlag Berlin Heidelberg 2012
Abstract Purpose Analysis of long-term clinical and radiological outcomes after anterior cruciate ligament (ACL) reconstruction with special attention to knee osteoarthritis and its predictors. Methods A prospective, consecutive case series of 100 patients. Arthroscopic transtibial ACL reconstruction was performed using 4-strand hamstring tendon autografts with a standardized accelerated rehabilitation protocol. Analysis was performed preoperatively and 10 years postoperatively. Clinical examination included Lysholm and Tegner scores, IKDC, KT-1000 testing (MEDmetric Co., San Diego, CA, USA) and leg circumference measurements. Radiological evaluation included AP weight bearing, lateral knee, Rosenberg and sky view X-rays. Radiological classifications were according to Ahlba¨ck and Kellgren & Lawrence. Statistical analysis included univariate and multivariate logistic regressions. Results Clinical outcome A significant improvement (p \ 0.001) between preoperative and postoperative measurements could be demonstrated for the Lysholm and Tegner scores, IKDC patient subjective assessment, KT1000 measurements, pivot shift test, IKDC score and oneleg hop test. A pivot shift phenomenon (glide) was still present in 43 (50 %) patients and correlated with lower
levels of activity (p \ 0.022). Radiological outcome: At follow-up, 46 (53.5 %) patients had signs of osteoarthritis (OA). In this group, 33 patients (72 %) had chondral lesions (Cgrade 2) at the time of ACL reconstruction. A history of medial meniscectomy before or at the time of ACL reconstruction increased the risk of knee OA 4 times (95 % CI 1.41–11.5). An ICRS grade 3 at the time of ACL reconstruction increased the risk of knee OA by 5.2 times (95 % CI 1.09–24.8). There was no correlation between OA and activity level (Tegner score C6) nor between OA and a positive pivot shift test. Conclusion Transtibial ACL reconstruction with 4-strand hamstring autograft and accelerated rehabilitation restored anteroposterior knee stability. Clinical parameters and patient satisfaction improved significantly. At 10-year follow-up, radiological signs of OA were present in 53.5 % of the subjects. Risk factors for OA were meniscectomy prior to or at the time of ACL reconstruction and chondral lesions at the time of ACL reconstruction. Level of evidence II.
54% artrose 10 jaar na vkb reconstructie: •
Risicofactoren ten tijde van operatie:
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Leeftijd ≥ 30 jaar
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Mediale meniscectomie
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Kraakbeenschade ≥ graad 2
Keywords Anterior cruciate ligament reconstruction ! Hamstring autograft ! Knee ! Osteoarthritis ! Accelerated rehabilitation ! Long term ! Radiological Introduction
R. P. A. Janssen (&) ! A. W. F. du Me´e ! J. van Valkenburg ! H. A. G. M. Sala Orthopaedic Center Ma´xima, Ma´xima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands e-mail:
[email protected] URL: www.rpajanssen.com C. M. Tseng Department of Radiology, Ma´xima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands
Injuries of the anterior cruciate ligament (ACL) frequently occur in cutting and pivoting sports such as soccer, field hockey, indoor sports, alpine skiing and tennis [8, 13, 32, 52, 55]. In Scandinavia, 40–50 % of all ACL ruptures occur during soccer [20]. Women suffer ACL ruptures more frequently than men [2]. The overall incidence of ACL injury is 78 per 100,000 persons [50]. The group
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3. „Friends” Collateraalbanden
Mediale Collateraalband (MCL) instabiliteit (0/20º flexie): FM I FM II FM III
geen
geen 0º / wel 20º
0º en 20º
Fetto-Marshall 1978
Acuut Mediaal Collateraalband letsel (MCL II-III): •
50% van sportletsels met VKB ruptuur
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< 2 weken herkennen!
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intrinsieke genezing
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snelle functionele revalidatie beter dan operatie/gips
Kniebrace: FROM / 24 uur per dag / 6 weken Sandberg 1987, Ballmer 1988, Petermann 1993, Robins 1993, Reider 1994, Indelicato 1995 Wijdicks 2010, Marchant 2011, Bonasia 2012, LaPrade 2013
Acuut Knieletsel 2014
VKB + MCL
MCL I
Fysiotherapie
MCL II
MRI
MCL III
Brace
VKB + MCL II Functionele instabiliteit / Pivot sport: VKB reconstructie
VKB + MCL III
Reconstructie VKB Reconstructie VKB + MCL
Shelbourne 1992, Shierl 1994, Hillard-Sembell 1996, Millet-Steadman 2004 LaPrade 2007, Wijdicks 2010, Marchant 2011, Brown 2013, ISAKOS 2013
Richtlijnen 2014 KNGF • Richtlijn Behandeling Acute Knie
• Evidence Based Statement Revalidatie na
Voorste Kruisbandreconstructie KNGF Evidence Statement Revalidatie na voorste-kruisbandreconstructie
Overzicht I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message
V. Revalidatie Succesvolle VKB reconstructie vereist kennis van: ! •
Anatomische graft plaatsing
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Mechanische eigenschappen:
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geselecteerde graft
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fixatie methoden
Biologische processen van graft na reconstructie
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Verbeterde VKB operatietechnieken laatste 10 jaar
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Graft ruptuur 0,7-10% Menetrey 2008
Knee Surg Sports Traumatol Arthrosc (2011) 19:1299–1306 DOI 10.1007/s00167-011-1419-y
KNEE
Remodelling of human hamstring autografts after anterior cruciate ligament reconstruction Rob P. A. Janssen • Jasper van der Wijk • Anja Fiedler • Tanja Schmidt • Harm A. G. M. Sala Sven U. Scheffler
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Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-013-2634-5 Received: 21 July 2010 / Accepted: 24 January 2011 / Published online: 4 February 2011 !K The Author(s) 2011. This article is published with open access at Springerlink.com NE E
Abstract collagen orientation became more regular, adapting to, but Purpose Histological analysis of the remodelling process not fully restoring, the appearance of the intact ACL. For the of human hamstring tendon (HT) grafts after standardized first 12 months, cells were predominantly ovoid. Ensuing anterior cruciate ligament reconstruction (ACLR) with an cell morphology changed to spindle shaped in group 2 and accelerated rehabilitation protocol. predominantly narrow long cells over 24 months. Methods patients Conclusion Human hamstring grafts showed typical Rob P. A.Sixty-seven Janssen • Sven U. underwent Scheffler retrieval of midsubstance biopsies after clinically successful hamstring stages of graft remodelling, which was not complete up to autograft ACLR. Samples were allocated to one of three 2 years after ACLR. The remodelling process in humans groups depending on the time point of retrieval: group 1 was prolonged compared with the results obtained in sev(6–12 months; n = 15), group 2 (13–24 months; n = 16) eral animal studies. and group 3 ([24 months; n = 11). Level of evidence Case–control study, Level III. Biopsies from native HT (n = 17) and ACL (n = 8) served asReceived: controls. density, vascular density2013 and myofiKeywords Remodelling ! Human ! Hamstring autograft ! 21 Cellular February 2013 / Accepted: 18 August broblast density2013. and This collagen alignment wereaccess ana-at Springerlink.com Anterior cruciate ligament reconstruction ! Myofibroblast ! The Author(s) article fibril is published with open lysed by haematoxylin–eosin, Masson-Goldner-Trichrom and immunohistochemical staining protocols. Conclusion Significant knowledge on human cruciate Abstract Results Compared with native HT (330.4/mm2), total cell Introduction ligament remodelling has been added in the understanding Purpose A summary is provided on the existing knowlnumber was increased in groups 1-3 (Group 1 = 482.0/ of the processes during the course of graft healing. Most edge about the specific healing phases of the intra-articular ACL ruptures are a common injury in orthopaedic practice. mm2 (P = 0.036); group 2 = 850.9/mm2 (P = 0.005); and importantly, the remodelling process in humans is prohamstring tendon graft 2 used for ACL reconstruction. Difgroup 3 = 595.6/mm (P = 0.043). There were no sigThe ACL is frequently replaced by a tendon autograft or longed compared to animal studies. While today´s rehabilferences between human and animal in vivo studies are nificant differences between the groups for vessel density. allograft to restore normal knee laxity and to prevent the itation protocols are often extrapolated from findings of explained, and implications for the postoperative time 2 Myofibroblast density was higher in group 2 (199.6/mm ) development of early osteoarthritis induced by persistent animal in vivo healing studies, current findings of human period are laid out. 2 compared with native HT (1.9/mm , P = 0.014). Collagen abnormal laxity [2]. Reconstruction techniques were in vivo healing studies might require new post-operative Methods A systematic review of the existing literature improved over the last 10 years, but graft failure is not orientation was irregular up to 12 months. Thereafter, regimens following hamstring ACL reconstruction. was performed on the topic of tendon remodelling of uncommon: 0.7–10% [12]. Even though substantial research hamstring grafts in ACL reconstruction using Medline efforts have been presented on various aspects of ACL Keywords Graft remodelling ! ACL ! Hamstring database. Publications between 1982 and 2012 were reconstruction [2, 3, 10, 13, 15, 27, 28, 32–34], little is known R. P. A. Janssen (&) ! J. van der Wijk ! H. A. G. M. Sala tendon ! Accelerated rehabilitation ! Ligamentization included. Special focus directed on Center, in vivo human and ´ xima, was Orthopaedic Center Ma Ma´xima Medical about the remodelling process of human ACL grafts. animal90052, studies intra-articular free tendon graft Postbus 5600analysing PD Eindhoven, The Netherlands Current studies evaluating human biopsies pose inherent e-mail:
[email protected] remodelling. limits: often sample size was small and only a limited URL: www.rpajanssen.com Results Animal and human in vitro and vivo researches Introduction number of time points were evaluated postoperatively [6, have demonstrated three characteristic stages of graft A. Fiedler ! T. Schmidt ! S. U. Scheffler 11, 18, 19, 21, 35]. Furthermore, use of different types of healing after ACL reconstruction: an early graft healing Anterior cruciate ligament (ACL) reconstruction techDepartment of Orthopaedic Surgery and Traumatology, grafts limits comparability [6, 11]. Studies in humans ´ Center for Musculoskeletal Surgery, Charite , phase with central graft necrosis and hypocellularity and no niques have been improved over the last 10 years, but describe a prolonged remodelling process compared with Campus Mitte, University Medicine Berlin, graft failure is not uncommon: 0.7–10 % [24, 35]. Sucdetectable revascularization of the graft tissue, followed by animal studies [6, 11, 18, 19, 21, 35]. Most animal studies Charite´ Platz 1, 10117 Berlin, Germany a phase of proliferation, the time of most intensive cessful ACL reconstruction requires understanding of remodelling and revascularization and finally, a ligamenseveral factors: anatomical graft placement, mechanical tization phase with characteristic restructuring of the graft properties of the selected graft tissue, 123 mechanical towards the properties of the intact ACL. However, a full behaviour and fixation strength of fixation materials as well as the biological processes that occur during graft restoration of either the biological or biomechanical properties of the intact ACL is not achieved. remodelling, maturation and incorporation. They influence directly the mechanical properties of the knee joint after ACL reconstruction and, therefore, determine the rehabilitation and time course until normal function of
Intra-articular remodelling of hamstring tendon grafts after anterior cruciate ligament reconstruction
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VKB autografts tonen 3 typische stadia van remodelering
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Remodelering van VKB graft duurt > 1 jaar
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Remodelering bij mensen duurt langer dan bij dierstudies (waarop huidige revalidatieprotocollen zijn gebaseerd)
Knee Surg Sports Traumatol Arthrosc (2013) 21:898–905 DOI 10.1007/s00167-012-2125-0
KNEE
Regeneration of hamstring tendons after anterior cruciate ligament reconstruction Rob P. A. Janssen • Maria J. F. van der Velden Huub L. M. Pasmans • Harm A. G. M. Sala
Pre-operatief
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2 weken na operatie
1 jaar na operatie
Received: 25 January 2012 / Accepted: 21 June 2012 / Published online: 5 July 2012 ! The Author(s) 2012. This article is published with open access at Springerlink.com
Abstract Purpose Primary aim of the study was analysis of hamstring tendon regeneration after anterior cruciate ligament reconstruction (ACLR). Secondary aim was analysis of isokinetic muscle strength in relation to hamstring regeneration. The hypothesis was that regeneration of hamstring tendons after ACLR occurs and that regenerated hamstring tendons contribute to isokinetic hamstring strength with regeneration distal to the knee joint line. Methods Twenty-two patients scheduled for ACLR underwent prospective MRI analysis of both legs. MRI parameters were tendon regeneration and morphology, muscle retraction and muscle cross-sectional area. A double-blind, prospective analysis of isokinetic quadriceps and hamstrings strength was performed. Results Regeneration of the gracilis tendon after ACLR occurred in all patients. Regeneration of the semitendinosus tendon occurred in 14 patients. At 1 year, the surface area of the semitendinosus and gracilis muscle decreased compared to both preoperatively (P \ 0.01) and the contralateral leg (P \ 0.01). The cross-sectional area of the semitendinosus muscle decreased in the absence of tendon regeneration (P = 0.05). The cross-sectional area of the gracilis muscle was greater in case of regeneration distal to the joint line (P = 0.01). Muscle retraction of the semitendinosus muscle
R. P. A. Janssen (&) ! M. J. F. van der Velden ! H. A. G. M. Sala Orthopaedic Center Ma´xima, Ma´xima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands e-mail:
[email protected] URL: www.rpajanssen.com H. L. M. Pasmans Department of Radiology, Ma´xima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands
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was increased in case of nonregeneration (P = 0.02). There was no significant relationship between isokinetic flexion strength and tendon regeneration. Conclusion Hamstring tendons regenerated after harvest of both semitendinosus and gracilis tendons for ACLR. There was no relation between isokinetic flexion strength and tendon regeneration. Level of evidence Prognostic study, Level II. Keywords Anterior cruciate ligament reconstruction ! Hamstring ! Semitendinosus ! Gracilis ! Regeneration ! MRI
Introduction Hamstring tendons are frequently used as autograft for single- and double-bundle anterior cruciate ligament (ACL) reconstruction. Regeneration of hamstring tendons, to various extends, has previously been reported [4–7, 14, 16, 20–22, 27]. In 1982, Lipscomb et al. [12] reported results of hamstring muscle strength after ACL reconstruction using autograft hamstring tendons. Regeneration of hamstring tendons after ACL reconstruction was first described by Cross et al. in 1992. Part of their study was analysis of upper leg flexion and extension muscle strength in analogy of the work of Lipscomb et al. [12]. In addition to hamstring regeneration and muscle strength after ACL reconstruction, Simonian et al. [21] examined the crosssectional area of individual hamstring muscles as well as the insertion site of the regenerated tendons. Later, mostly, retrospective research on regeneration of hamstring tendons after ACL reconstruction focused on muscle cross-sectional area [5, 6, 20, 22, 27], retraction of hamstring muscle [5, 14, 27] and muscle strength [5, 14, 22, 23].
Overzicht I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message
VI. Take Home Message -1 •
3 soorten (klinisch relevante) knie-instabiliteit: Voorachterwaarts / Zijwaarts / Exorotatie ↑
Lichamelijk onderzoek ➤ oorzaak Exorotatie ↑ ! •
VKB & friends belangrijk voor „return to sports"
MCL snel herkennen en brace behandeling
Take Home Message -2 •
Voorste kruisbandoperatie beschermt NIET tegen artrose
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Remodelering van VKB graft duurt > 1 jaar
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Hamstring pezen groeien weer aan na verwijdering uit bovenbeen
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Multidisciplinaire revalidatie essentieel
