Kruisbandscheur & Sport Rob Janssen Orthopedisch Centrum Máxima

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1 Kruisbandscheur & Sport 2014 Rob Janssen Orthopedisch Centrum Máxima

2 Kruisbandscheur is de hartaanval van de knie

3 Overzicht 2014 I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message

4 I. De Knie

5 Overzicht I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message

6 II. Voorste kruisband (VKB) letsels Per jaar: 3% amateurs, 15% topsporters 2-8x vaker bij dan! NL 2012: 9000 VKB reconstructies 2/3 sporters terug naar oude sportniveau Kans ruptuur VKB andere knie na operatie 24%! Bijkomende schade: Kraakbeen Meniscus Collateraalbanden: mediaal 50%, lateraal 2-6% miskennen risico reruptuur VKB!

7 III. Het sportletsel

8 Gevolgen sportletsel knie Instabiliteit Kraakbeenletsel Meniscusletsel

9 Instabiliteit knie: 3 soorten Voor-achterwaarts Zijwaarts Exorotatie

10 Exorotatie bij zowel laterale als mediale knieletsels Beweging van tibiaplateau maakt onderscheid tussen posterolaterale en anteromediale instabiliteit posterolaterale instabiliteit anteromediale instabiliteit

11 Overzicht I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message

12 IV.Voorste kruisband with a little help from my friends 1. Kraakbeen 2. Meniscus 3. Collateraalbanden

13 1-2. Friends Kraakbeen-Meniscus 4 PUNTEN KENNISTOETS 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. 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 nummer 1 maart

14 1-2. Friends Kraakbeen-Meniscus Knee Surg Sports Traumatol Arthrosc (2013) 21: DOI /s KNEE Author's personal copy 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 Mée Juliette van Valkenburg Harm A. G. M. Sala Carroll M. Tseng Received: 13 April 2012 / Accepted: 24 September 2012 / Published online: 19 October 2012 Ó Springer-Verlag Berlin Heidelberg 2012 levels of activity (p \ 0.022). Radiological outcome: At Analysis of long-term clinical and radiological follow-up, 46 (53.5 %) patients had signs of osteoarthritis (OA). In this group, 33 patients (72 %) had chondral 54% artrose 10 jaar na vkb reconstructie: lesions (Cgrade 2) at the time of ACL reconstruction. A Abstract Purpose 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 reconstruction increased the risk of knee OA by 5.2 times Risicofactoren ten tijde van operatie: 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 Leeftijd 30 jaar 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 Ahlbäck 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, KT 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 history of medial meniscectomy before or at the time of ACL reconstruction increased the risk of knee OA 4 times (95 % CI ). An ICRS grade 3 at the time of ACL (95 % CI ). 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. Mediale meniscectomie Kraakbeenschade graad 2 Keywords Anterior cruciate ligament reconstruction Hamstring autograft Knee Osteoarthritis Accelerated rehabilitation Long term Radiological R. P. A. Janssen (&) A. W. F. du Mée J. van Valkenburg H. A. G. M. Sala Orthopaedic Center Máxima, Máxima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands r.janssen@mmc.nl URL: C. M. Tseng Department of Radiology, Máxima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands Introduction 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, % 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 123

15 3. Friends Collateraalbanden Mediale Collateraalband (MCL) instabiliteit (0/20º flexie): FM I geen FM II geen 0º / wel 20º FM III 0º en 20º Fetto-Marshall 1978

16 Acuut Mediaal Collateraalband letsel (MCL II-III): 50% van sportletsels met VKB ruptuur < 2 weken herkennen! intrinsieke genezing 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

17 Acuut Knieletsel 2014 VKB + MCL MCL I MCL II MCL III Fysiotherapie MRI Brace Functionele instabiliteit / Pivot sport: VKB reconstructie VKB + MCL II 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

18 Richtlijnen 2014 KNGF Richtlijn Behandeling Acute Knie Evidence Based Statement Revalidatie na Voorste Kruisbandreconstructie KNGF Evidence Statement Revalidatie na voorste-kruisbandreconstructie

19 Overzicht I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message

20 V. Revalidatie Succesvolle VKB reconstructie vereist kennis van:! Anatomische graft plaatsing Mechanische eigenschappen: geselecteerde graft fixatie methoden Biologische processen van graft na reconstructie

21 Verbeterde VKB operatietechnieken laatste 10 jaar Graft ruptuur 0,7-10% Menetrey 2008

22 Knee Surg Sports Traumatol Arthrosc (2011) 19: DOI /s 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 Knee Surg Sports Traumatol Arthrosc DOI /s Received: 21 July 2010 / Accepted: 24 January 2011 / Published online: 4 February 2011 Ó KNEE The Author(s) This article is published with open access at Springerlink.com Abstract collagen orientation became more regular, adapting to, but Purpose Histological analysis of the process not fully restoring, the appearance of the intact ACL. For the Intra-articular remodelling of hamstring tendon grafts of human hamstring tendon (HT) grafts after standardized first 12 months, cells were predominantly ovoid. Ensuing anterior aftercruciate anterior ligamentcruciate reconstruction ligament (ACLR) with an reconstruction cell morphology changed to spindle shaped in group 2 and accelerated rehabilitation protocol. predominantly narrow long cells over 24 months. Methods Rob P. A. Sixty-seven Janssen patients underwent retrieval of midsubstance Sven U. Scheffler Conclusion Human hamstring grafts showed typical biopsies after clinically successful hamstring autograft ACLR. Samples were allocated to one of three groups depending on the time point of retrieval: group 1 (6 12 months; n = 15), group 2 (13 24 months; n = 16) stages of graft remodelling, which was not complete up to 2 years after ACLR. The remodelling process in humans was prolonged compared with the results obtained in several 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 as Received: controls. 21Cellular February 2013 density, / Accepted: vascular 18 August density2013 and myofibroblast Ó The Author(s) density2013. and This collagen articlefibril is published alignment with open wereaccess ana-at Springerlink.com Anterior cruciate ligament reconstruction Myofibroblast Keywords Remodelling Human Hamstring autograft lysed by haematoxylin eosin, Remodelering Masson-Goldner-Trichrom van VKB graft duurt > 1 jaar and immunohistochemical staining protocols. Abstract Results Compared with native HT (330.4/mm 2 Conclusion Significant knowledge on human cruciate ), total cell Introduction Purpose A summary is provided on the existing knowledge ligament remodelling has been added in the understanding number was increased in groups 1-3 (Group 1 = 482.0/ mm 2 about the specific healing phases of (P = 0.036); group 2 = 850.9/mm 2 the intra-articular of the processes during the course of graft healing. Most (P = 0.005); and ACL ruptures are a common injury in orthopaedic practice. hamstring tendon graft group 3 = 595.6/mm 2 used for ACL reconstruction. Differences between human and animal in vivo studies are longed compared to animal studies. While todaýs rehabil- importantly, the remodelling process in humans is pro- (P = 0.043). There were no significant differences between the groups for vessel density. allograft to restore normal knee laxity and to prevent the The ACL is frequently replaced by a tendon autograft or explained, and implications for the postoperative time Myofibroblast density was higher in group 2 (199.6/mm 2 ) development of early osteoarthritis induced by persistent period are laid out. compared with native HT (1.9/mm 2 animal in vivo healing studies, current findings of human, P = 0.014). Collagen abnormal laxity [2]. Reconstruction techniques were Methods A systematic review of the existing literature in vivo healing studies might require new post-operative orientation was irregular up to 12 months. Thereafter, improved over the last 10 years, but graft failure is not was performed on the topic of tendon remodelling of regimens following hamstring ACL reconstruction. uncommon: % [12]. Even though substantial research hamstring grafts in ACL reconstruction using Medline efforts have been presented on various aspects of ACL database. Publications between 1982 and 2012 were Keywords Graft remodelling ACL Hamstring R. P. A. Janssen (&) J. van der Wijk H. A. G. M. Sala reconstruction [2, 3, 10, 13, 15, 27, 28, 32 34], little is known Orthopaedic included. Special Center Máxima, focus was Máxima directed Medical oncenter, in vivo human and tendon Accelerated rehabilitation Ligamentization about the remodelling process of human ACL grafts. Postbus animal90052, studies 5600analysing PD Eindhoven, intra-articular The Netherlands free tendon graft Current studies evaluating human biopsies pose inherent remodelling. r.janssen@mmc.nl URL: limits: often sample size was small and only a limited Results Animal and human in vitro and vivo researches Introduction number of time points were evaluated postoperatively [6, A. have Fiedler demonstrated T. Schmidt S. three U. Scheffler characteristic stages of graft 11, 18, 19, 21, 35]. Furthermore, use of different types of Department healing after of Orthopaedic ACL reconstruction: Surgery and Traumatology, an early graft healing Anterior cruciate ligament (ACL) reconstruction techniques have been improved over the last 10 years, but grafts limits comparability [6, 11]. Studies in humans Center phasefor with Musculoskeletal central graftsurgery, necrosis Charité, and hypocellularity and no Campus Mitte, University Medicine Berlin, describe a prolonged remodelling process compared with detectable revascularization of the graft tissue, followed by graft failure is not uncommon: % [24, 35]. Successful ACL reconstruction requires understanding of Charité Platz 1, Berlin, Germany animal studies [6, 11, 18, 19, 21, 35]. Most animal studies a phase of proliferation, the time of most intensive remodelling and revascularization and finally, a ligamentization phase with characteristic restructuring of the graft properties of the selected graft tissue, 123 mechanical several factors: anatomical graft placement, mechanical towards the properties of the intact ACL. However, a full restoration of either the biological or biomechanical properties of the intact ACL is not achieved. VKB autografts tonen 3 typische stadia van remodelering Remodelering bij mensen duurt langer dan bij dierstudies (waarop huidige revalidatieprotocollen zijn gebaseerd) behaviour and fixation strength of fixation materials as well as the biological processes that occur during graft 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

23 Knee Surg Sports Traumatol Arthrosc (2013) 21: DOI /s 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 2 weken na operatie 1 jaar na operatie Received: 25 January 2012 / Accepted: 21 June 2012 / Published online: 5 July 2012 Ó The Author(s) 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 Máxima, Máxima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands r.janssen@mmc.nl URL: H. L. M. Pasmans Department of Radiology, Máxima Medical Center, Postbus 90052, 5600 PD Eindhoven, The Netherlands 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 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]. 123

24 Overzicht I. De Knie II. Voorste Kruisband III. Het Sportletsel IV. Voorste Kruisband & Friends V. Revalidatie VI. Take Home Message

25 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

26 Take Home Message -2 Voorste kruisbandoperatie beschermt NIET tegen artrose Remodelering van VKB graft duurt > 1 jaar Hamstring pezen groeien weer aan na verwijdering uit bovenbeen Multidisciplinaire revalidatie essentieel

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