A.1 Achtergrond

Zie ook noot 2 - Van alle VKB-rupturen is 70% gebaseerd op een ‘non-contact’ traumamechanisme (Quatman & Hewett, 2009; Saris et al., 2011). Met non-contact wordt bedoeld dat de krachten die zorgden voor de VKB-ruptuur afkomstig waren van de beweging van de persoon zelf en er geen contact was met een andere persoon of met een object (Shultz SJ et al., 2008). De tijd die verstrijkt tussen initieel grondcontact en het ruptureren van de VKB bedraagt 17-70 milliseconden (Ireland, 2002; Krosshaug et al., 2007; Koga et al., 2010). De incidentie van VKB-rupturen is het hoogst bij jonge mensen (15-40 jaar) die een pivoterende sport beoefenen, zoals basketbal, voetbal, handbal en skiën (Prodromos et al., 2007; Moses et al., 2012). Vrouwen hebben een 2-8 keer grotere kans op een VKB-ruptuur dan mannen bij het beoefenen van dezelfde sport (Yoo et al., 2010; Myer et al., 2013). Per jaar loopt meer dan 3% van de amateursporters een VKB-ruptuur op; bij topsporters kan dit, afhankelijk van de soort sport, zelfs oplopen tot boven de 15% (Moses et al., 2012). In Nederland werden in 2012 naar schatting 8000-9000 VKB-reconstructies uitgevoerd. De meeste primaire VKB-reconstructies worden uitgevoerd met een autologe bone-patellar tendon-bone (BPTB) graft of hamstring (HS) graft. Beide methoden leiden tot goede functionele resultaten, herstel van de passieve stabiliteit en lage complicatiepercentages (Saris et al., 2011).

Recent onderzoek bij sporters laat zien dat een derde van hen niet terugkeert op het oorspronkelijke sportniveau binnen 2 jaar (Laboute et al., 2010; Shah et al., 2010; Ardern et al., 2011a). Na 3 jaar, of na een nog langere periode, loopt dit zelfs op tot 50%, omdat veel sporters alsnog besluiten op een lager niveau te gaan sporten (Ardern et al., 2012; Mascarenhas et al., 2012; McCullough et al., 2012). Ongeveer 50% van deze sporters noemt daarbij de VKB-reconstructie als primaire reden voor hun lagere sportniveau (Ardern et al., 2011a; Ardern et al., 2012; Brophy et al., 2012; Mascarenhas et al., 2012; McCullough et al., 2012). Bovendien blijkt uit onderzoek dat zich binnen 2 jaar re-rupturen voordoen bij 3-22% van de patiënten en contralaterale VKB-rupturen bij 3-24% van de patiënten (Wright et al., 2007; Swärd et al., 2010; Barber-Westin & Noyes, 2011a; Wright et al., 2011; Paterno et al., 2012). (noot 2)

Naast het fysieke herstel blijkt de psychologische respons op de VKB-ruptuur en de revalidatie na de ruptuur (o.a. angst voor recidief), van invloed te zijn op de mate waarin iemand sportactiviteiten hervat (Kvist et al., 2005; Chmielewski et al., 2008; Webster et al., 2008; Langford et al., 2009; Van Wilgen et al., 2010; Ardern et al., 2011b; Ardern et al., 2013; Flanigan et al., 2013).

Drie recente systematische reviews over klinimetrie laten zien dat bij het bepalen van het moment waarop iemand weer gaat sporten nauwelijks gebruikgemaakt wordt van objectieve criteria en dat daarnaast op dat moment de kwaliteit van bewegen niet wordt gemeten (Barber-Westin & Noyes, 2011a, 2011b; Engelen-van Melick et al., 2013). Uit eerdere studies is echter bekend dat, naast de kwantiteit, ook de kwaliteit van bewegen van invloed is op het optreden van VKB-(re)rupturen (Renstrom et al., 2008). Zo voorspellen dynamische knievalgus en verminderde neuromusculaire controle van de romp bij de landing na een sprong het risico op een VKB-ruptuur bij gezonde vrouwen (Hewett et al., 2005; Zazulak et al., 2007). Bovendien is gebleken dat deze dynamische knievalgus en een kleine knieflexiehoek bij het landen voorspellende factoren zijn voor een re-ruptuur bij het hervatten van sportactiviteiten na een reconstructie (Paterno et al., 2010). Het is dus tijdens de revalidatie al van belang om rekening te houden met deze kwalitatieve factoren.

Bij de revalidatie na een VKB-ruptuur of -reconstructie dient men zich te realiseren dat de VKB niet alleen een mechanische functie heeft. Omdat de VKB voor circa 2,5% bestaat uit mechanoreceptoren heeft deze, via de artrokinematische reflexboog, direct invloed op de neuromusculaire controle van de knie. De knie maakt deel uit van taakafhankelijke geïntegreerde gewrichtsketens, met als doel een activiteit zoals het lopen mogelijk te maken. Door een VKB-ruptuur ontstaat partiële de-afferentie met effecten op lokaal, spinaal en supra-spinaal (hersenstam en motorische cortex) niveau. Een VKB-ruptuur heeft daarom ook consequenties voor de wijze waarop gewrichtsketens geïntegreerd worden. Dit vraagt reorganisatie van het centraal zenuwstelsel, met veranderde hersenactiviteit en daarmee een veranderde motorische controlestrategie, op grond waarvan deze subtiele nieuwe rolverdeling binnen deze gewrichtsketen mogelijk wordt (Courtney & Rine, 2006; Kapreli et al., 2009). De veranderde motorische controlestrategie kan zich uiten in individueel bepaalde veranderde proprioceptie, posturale controle, spierkracht en bewegings- en spieractivatiepatronen. Als de regie van het neuromusculaire controlesysteem voldoende flexibel is, zal de uitvoering van de activiteit niet aan doeltreffendheid en kwaliteit inboeten. Die flexibiliteit maakt het immers mogelijk dat de patiënt na een VKB-ruptuur onder wisselende omstandigheden op flexibele wijze opnieuw de regie neemt bij de reorganisatie van de gewrichtsketens. Binnen de revalidatie zijn nieuwe ontwikkelingen gaande om juist de flexibiliteit van het neuromotorisch systeem te kwantificeren. Hiervoor zijn de non-lineaire analyses (o.a. ‘sample entropy’) van kinematische registraties informatief, omdat deze analyses inzicht geven in het probleemoplossend vermogen van het neuromotorisch systeem (Georgoulis et al., 2006; Decker et al., 2011).

Gezien bovenstaande moet een VKB-ruptuur niet alleen beschouwd worden als een perifere musculoskeletale aandoening, maar vooral als een potentiële neuro-fysiologische disfunctie. Het is niet vanzelfsprekend dat een VKB-reconstructie automatisch tot een doeltreffend en kwalitatief hoogwaardig activiteitenniveau leidt, temeer omdat tot op heden nog niet is aangetoond dat er ingroei van nieuwe mechanoreceptoren plaatsvindt in de VKB-graft.

Noot 2 Re-rupturen

Noot 2

Niveau van bewijs

Niveau 3. Oorzaken van een re-ruptuur kunnen zijn (Ménétrey et al., 2008; Frank et al., 2012; Morgan et al., 2012):

  • Nieuw trauma (non-contact of contact). In 70% van de gevallen is het nieuwe trauma de oorzaak van een revisie.
  • Persisterende rotatoire instabiliteit ondanks de reconstructie.
  • Extra (eerder diagnostisch gemiste) rotatoire instabiliteit, bijvoorbeeld in de posterolaterale hoek.
  • Technische fouten, zoals verkeerd geplaatste tunnels.
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