Zusammenfassung
Der langfristige Erfolg operativer Eingriffe am Kniegelenk ist von der Qualität der Wiederherstellung eines natürlichen Bewegungsausmaßes bei moderater muskuloskelettaler Belastung abhängig. Wesentlich dafür ist die Berücksichtigung biomechanischen Wissens bei der präoperativen Planung und während der Operation. Bisher ist dieses Wissen nur in Büchern und Journalbeiträgen verfügbar und fließt lediglich in die präoperative Planung ein. Die Übertragung in die konkrete operative Situation ist jedoch vom Können und Wissen des Operateurs abhängig.
Mathematische Modelle besitzen das Potenzial, dem Operateur detaillierte, patientenspezifische Informationen zu den in vivo wirkenden Kräften und deren räumliche und zeitliche Verteilung zur Verfügung zu stellen. Ihr Einsatz in der Routine setzt jedoch eine umfangreiche Überprüfung voraus. Mit einem an Patientendaten validierten Berechnungsmodell wurde gezeigt, dass sowohl das tibiofemorale als auch das patellofemorale Gelenk infolge der Muskelaktivität bereits während Alltagsaktivitäten erheblichen Kräften ausgesetzt sind. Die Berechnungen legen nahe, dass die Kräfte bei einer Fehlstellung der anatomischen tibiofemoralen Achse von >4° deutlich ansteigen, das Ausmaß des Kraftanstiegs dabei jedoch interindividuell stark variieren kann. Um neben der Gesamtbelastung auch die genaue Verteilung der Kräfte innerhalb des Gelenks zu ermitteln, ist eine hinreichend genaue Beschreibung der Bewegung des Kniegelenks erforderlich. In Verbindung mit MR basierter In-vivo-Bildgebung bieten neue mathematische Modelle die Möglichkeit, die Kniebewegung des einzelnen Patienten genau wiederzugeben und den Einfluss der aktiven Muskulatur auf die Kinematik zu berücksichtigen.
Durch die Implementierung dieser Technologien in präoperative Planungs- und intraoperative Navigationssysteme eröffnet sich die Möglichkeit den Operateur bei seinem Vorgehen durch Vorhersagen der patientenspezifischen postoperativen Biomechanik zu unterstützen. Wir gehen davon aus, dass durch eine auf diese Weise optimierte Biomechanik auch die Funktionsparameter des künstlichen Gelenks entscheidend verbessert werden können.
Abstract
The long-term clinical outcome of surgical interventions at the knee is dependent upon the quality of the restoration of normal function, together with moderate musculoskeletal loading conditions. In order to achieve this, it is essential to consider biomechanical knowledge during the planning and execution of the procedures. Until now, such knowledge has only been available in books and journal manuscripts and is merely considered during preoperative planning. Its transfer into the specific intraoperative situation is, however, primarily dependent upon the surgeon’s skills and understanding.
Mathematical models hold the potential to provide the surgeon with detailed, patient-specific information on the in vivo forces, as well as their spatial and temporal distribution. Their application in clinical routine, however, requires a comprehensive validation. Based on a model validated against patient data, it has been shown that – mainly as a result of the action of the muscles – both the tibiofemoral as well as the patellofemoral joints experience substantial mechanical loads even during normal activities of daily living. The calculations further indicate that malalignment at the knee in the frontal plane of more than approximately 4° results in considerably increased forces across the tibiofemoral joint. The actual change in force to a given degree of malalignment might, however, vary greatly between subjects. In order to additionally determine the distribution of the forces in more detail, a sufficiently accurate model of knee joint kinematics is required. In combination with MR-based in vivo imaging techniques, new mathematical models offer the possibility to capture the individual characteristics of knee kinematics and might additionally allow the effect of muscle activity on joint kinematics to be considered.
By implementing these technologies in preoperative planning and navigation systems, up-to-date biomechanical knowledge can be made available at the surgeons’ fingertips. We propose that optimizing the biomechanical conditions through using these approaches will allow the long-term function of the replaced joint to be significantly enhanced.
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Danksagung
Diese Studie wurde u. a. durch Mittel der Deutschen Forschungsgemeinschaft (DFG, KFO 102/2 und SFB 760) ermöglicht.
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Heller, M., Matziolis, G., König, C. et al. Muskuloskelettale Biomechanik des Kniegelenks. Orthopäde 36, 628–634 (2007). https://doi.org/10.1007/s00132-007-1115-2
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DOI: https://doi.org/10.1007/s00132-007-1115-2