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Biomechanik der Sagittalebene des Kniegelenks

Bedeutung des tibialen „slope“ für die Kniechirurgie

Biomechanics of the sagittal plane of the knee joint

Importance of the tibial slope for knee surgery

  • Leitthema
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Arthroskopie Aims and scope

Zusammenfassung

Veröffentlichungen über die Bedeutung des „posterior tibial slope“, die Neigung des Tibiaplateaus nach dorsal, nehmen in den letzten Jahren stetig zu. Primär trat dieses Thema als „Nebeneffekt“ der valgisierenden hohen tibialen Osteotomie (HTO) in den Fokus, als erkannt wurde, dass die Eingriffe in der Frontalebene mit Veränderungen in der Sagittalen einhergehen. Die Neigung des Tibiaplateaus kann im seitlichen Röntgen und in sagittalen MRT-Schichten gemessen werden. Es besteht jedoch bislang keine Einigkeit darüber, welche Messtechnik anzuwenden ist, und wann ein Neigungswinkel als steil bzw. zu steil bewertet werden muss. Gemäß der Darstellung im seitlichen Röntgen wurde in ersten Studien an den Knochenkonturen des medialen und lateralen Plateaus gezeigt: Ein steiler tibialer Slope führt zu vermehrter anteriorer tibialer Translation (ATT); diese Zusammenhänge gibt es sowohl im kreuzbandinsuffizienten als auch im kreuzbandintakten Knie. Selbstverständlich ist nicht der Knochen die eigentliche oder einzige formgebende Struktur: Die Gelenkoberfläche wird vom Knorpel und von den Menisken gebildet. Folglich wird in immer mehr Studien auch der sog. weichteilige Slope bestimmt. Bei Patienten mit einer Ruptur des vorderen Kreuzbands (VKB) zeigt sich nicht nur der knöcherne, sondern auch der weichteilige mediale und laterale Slope signifikant steiler als bei den gesunden Vergleichspersonen. Die v. a. durch den steilen lateralen Slope beim „Knee-in-and-toe-out“-Mechanismus vermittelte ATT zeichnet sich wahrscheinlich für mehr als 50 % aller VKB-Rupturen verantwortlich. Oft ist dieser Mechanismus mit einer abrupten intensiven Quadrizepsaktivierung und reduzierter „Hamstring“-Koaktivierung kombiniert. Die Rolle der Hamstrings in Abhängigkeit vom tibialen Slope wird jedoch noch kontrovers diskutiert.

Abstract

Publications on the importance of the posterior tibial slope, i.e. the inclination of the tibial plateau dorsally, have shown a continuous increase in recent years. Initially this topic came into focus as a side effect of valgus high tibial osteotomy (HTO), when it was recognized that surgery in the frontal plane was associated with changes in the sagittal plane. The slope of the tibial plateau can be measured in lateral X‑rays and in sagittal magnetic resonance imaging (MRI) layers; however, until now there has been no consensus as to which measurement technique should be used and when a slope angle should be regarded as steep or too steep. According to the findings in lateral X‑rays in the first studies on bone contours of the medial and lateral plateau, the following could be shown: a steeper lateral slope leads to more anterior tibial translation (ATT) and this association is found both in knees with cruciate ligament insufficiency as well as in knees with intact cruciate ligaments. Of course, the bone is not the actual or the only structure providing the shape: the joint surface is formed from cartilage and the meniscus. Accordingly, in more and more studies the so-called soft tissue slope is also measured. In patients with a rupture of the anterior cruciate ligament (ACL), not only the bony slope but also the medial and lateral soft tissue slopes are significantly steeper compared to healthy persons. Especially the steep lateral slope in the so-called knee-in and toe-out mechanism leads to ATT and is responsible for more than 50% of all ACL ruptures. Very often this mechanism is combined with an abrupt intensive quadriceps activation and a reduced hamstring co-activation; however, the role of the hamstring depending on the tibial slope is still controversially discussed.

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  1. OrthoPlus München, Lenbachplatz 2a, Alte Börse, 80333, München, Deutschland

    S. Hinterwimmer

  2. Abteilung und Poliklinik für Sportorthopädie, Klinikum rechts der Isar, München, Deutschland

    M. Feucht

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Hinterwimmer, S., Feucht, M. Biomechanik der Sagittalebene des Kniegelenks. Arthroskopie 34, 2–9 (2021). https://doi.org/10.1007/s00142-020-00407-w

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