髌股关节稳定机制的解剖学及生物力学研究现状

临床上常见的膝前痛、髌骨软骨软化症及全膝关节置换术后出现的髌骨不稳等多与髌股关节的失稳或者轨迹异常有关，治疗此类疾病的关键就是要维持髌股关节的稳定性。近年来，国内外对髌股关节的稳定机制做了一些研究，从大体解剖学观测及髌股接触面积和髌骨运动轨迹的生物力学等方面做了一些探讨，本文主要从解剖学及生物力学方面对近年来髌股关节稳定机制的研究进展作一综述。     

髌股关节生物力学研究及其意义

本文综述了国外近年来采用压敏片及压力传感器对髌股关节接触力、接触面、运动力学、病理力学以及手术方法等进行生物力学实验研究的进展，指出关节接触面压力过高是髌股关节病发生的重要病因，胫骨结节前移术显著地降低了髌股关节接触力，是治疗髌股关节疾病有效的手术方法。     

髌股关节置换术进展

髌股关节置换术（PFA）早期随访失败率高，临床应用一直存在争议。髌股关节解剖形态、生物力学机制研究及人工膝关节置换临床实践，促进了现代PFA假体设计和技术发展。将髌股关节视为膝关节整体一部分的Onlay假体设计理念，取代了单纯置换病变区域的第一代Inlay假体；病例选择严格限定为单纯髌股关节疾患，进展性胫股关节炎成为术前甄别重点；手术更注重原发疾患对PFA术后髌股关节功能的影响；手术技术进步保障了假体正确安放。现代PFA呈现高疗效、低并发症趋势，已被认定为髌股关节骨关节炎的推荐治疗方案。该文就上述几方面研究进展作一综述。     

第四届全国《髌股关节紊乱诊治进展》学习班通知

由上海交通大学附属第六人民医院运动医学/关节镜外科主办的第四届全国《髌股关节紊乱诊治进展》学习班将于2015年4月24日(周五)至4月25日(周六)举行。本次学习班主要内容包括髌股关节的解剖,髌股关节疾患影像学诊断,髌股关节不稳定的治疗,髌股关节炎的处理以及髌股关节术后的康复,有国际前沿学者讲授有关髌股关节紊乱治疗的最新理念与手术技巧。具体内容包括理论授课、尸体模拟操作与手术示教。     

髌骨内静脉造影及钻孔减压在髌股关节病中的诊断与治疗价值

目的 :介绍了髌股内静脉造影及髌骨钻孔减压的方法及其在辅助诊断与治疗髌股关节病中的意义。方法 :髌骨穿刺注入 60 %泛影葡胺 4ml后 ,不同时间拍片观察造影剂排空情况。结果 :临床诊断为髌股关节病病人 ,造影剂排空时间最长者达 19h ,最短者达 3 6min ,平均 3 .9h。髌骨钻孔减压后随访 6个月～ 3年 ,平均 2年 8个月 ,休息痛组优良率为 83 .4% ;活动痛组优良率为 5 1.8%。结论 :髌骨内静脉造影可进一步明确诊断髌股关节病 ,该方法简单 ,可选择性使用。髌骨钻孔减压是一种治疗髌股关节病的简单有效方法。     

髌股关节排列异常

髌股关节排列异常柴卫兵马忠泰高淑能前膝痛是膝关节疼痛中最为常见的症状之一，其病因包括髌股关节排列异常，髌骨软骨软化症，骨关节病，滑膜病，髌周肌肉及肌腱劳损，脂肪垫肥大和损伤以及外伤后的骨软骨损伤等。其中髌股关节排列异常是在诊断上易于混淆和忽视、处理上...     

髌骨稳定性的解剖学与生物力学研究进展

正常髌股关节的骨性结构(关节形态和下肢力线)和软组织结构(静力装置和动力装置)组成髌股关节的解剖结构,有利于维持髌骨的稳定性.股骨滑车凹软骨的深度及两侧滑坡的坡度在抑制非平衡力诱发髌骨半脱位或脱位时扮演着重要角色,Q角偏大时增大髌骨的外向牵拉力.膝关节屈曲O.～20.时内侧髌股韧带在阻止髌骨脱位的软组织中发挥50%～60%的作用,股内侧斜肌纤维不是经由股四头肌腱而是直接附着于髌骨内侧缘.并独立于其他肌肉.由独立的神经支配.股内侧斜肌完全松解后,髌骨稳定性将降低30%.髌股关节的解剖出现异常.可直接导致髌骨不稳定.或成为其他不稳定因素作用的基础.详细了解髌股关节的解剖学与生物力学.时髌骨不稳定的诊断及治疗方案的选择有重要的指导意义.     

髂骨内静脉造影及钻孔减压在髌股关节病中的诊断与治疗价值

目的：介绍了髌股内静脉造影及髌骨钻孔减压的方法及其在辅助诊断与治疗髌股关节病中的意义。方法：髌骨穿刺注入６０％泛影葡胺４ｍｌ后，不同时间拍片观察造影剂排空情况。结果：临床诊断为髌股关节病病人，造影剂排空时间最长者达１９ｈ，最短者达３６ｍｉｎ平均３．９ｈ。髌骨钻孔减压后随访６个月～３年，平均２年８个月，休息痛组优良率为８３．４％；活动痛组优良率为５１．８％。结论：髌骨内静脉造影可进一步明确诊断髌股关节病，该方法简单，可选择性使用。髌骨钻孔减压是一种治疗髌股关节病的简单有效方法。     

髌股关节骨性关节炎的病因探讨及关节镜诊治

目的：探讨髌股关节骨性关节炎的发生原因及关节镜诊治效果。方法：回顾总结1998年以来本院行关节镜诊治的：192例膝关节骨性关节炎资料，分析髌股关节骨性关节炎的发生率、发生原因及关节镜诊治效果。结果：192例212膝中，有髌股关节骨性关节炎者177例189膝，占89．15％，发生原因包括髌股关节生物力学关系紊乱、滑膜皱襞挤夹磨损、髌髁骨赘阻挡干扰及细胞因子等生化原因，关节镜治疗优良率为86．77％。结论：髌股关节是膝关节骨性关节炎最好发部位，其病因是多方面的，关节镜诊治由于能直观准确地反映病变的部位和程度，有助于病因的判定并进行相应的治疗，故比传统的诊治方法效果好，值得优先选用。     

全膝关节置换术中髌股轨迹的研究现状

髌股关节并发症是全膝关节置换术后翻修最常见的原因[1],多数表现为髌前痛及髌骨外侧半脱位[2-3],少数表现为髌骨骨折[4]、髌骨撞击综合征[5]、髌骨假体松动等。笔者就全膝关节置换术中髌股轨迹的研究现状综述如下。1解剖与生物力学髌股关节由髌骨关节面与股骨滑车沟及内外侧髁     

Anatomy and malalignment of the patellofemoral joint: its relation to patellofemoral arthrosis

Patellofemoral joint function involves a complex orchestration of a number of dynamic, static, and neuromuscular factors. I will discuss the components of patellofemoral anatomy and whether the presence of certain anatomic variables may increase the risk of patellofemoral arthrosis. The patellofemoral surgeon is faced with several clinical challenges: the semantics of the language used to discuss these problems, the correlation of clinical symptoms and radiographic imaging to help diagnose a problem, and surgical challenges in optimizing extensor mechanism function.     

Modern management of patellar instability

Recurrent patellofemoral instability is a disabling condition, attributed to a variety of anatomical aetiologies. Trochlear dysplasia, patella alta, an increased tibial tubercle trochlear groove distance of greater than 20 mm and soft tissue abnormalities such as a torn medial patellofemoral ligament and inadequate vastus medialis obliquus are all factors to be considered. Management of this condition remains difficult and controversial and knowledge of the functional anatomy and biomechanics of the patellofemoral joint, a detailed history and clinical examination, and an accurate patient assessment are all imperative to formulate an appropriate management plan. Surgical treatment is based on the underlying anatomical pathology with an aim to restore normal patellofemoral kinematics. We summarise aspects of assessment, treatment and outcome of patellofemoral instability and propose an algorithm of treatment.     

Anatomy and surface geometry of the patellofemoral joint in the axial plane

We studied the anatomy of the patellofemoral joint in the axial plane on cryosections from a cadaver knee and on MR arthrotomograms from 30 patients. The cryosections revealed differences in the geometry and anatomy of the surface of the articular cartilage and corresponding subchondral osseous contours of the patellofemoral joint. On the MR arthrotomograms the surface geometry of the cartilage matched the osseous contour of the patella in only four of the 30 knees. The articular cartilaginous surface of the intercondylar sulcus and corresponding osseous contour of the femoral trochlea matched in only seven knees. Since MR arthrotomography can distinguish between the surface geometry of the articular cartilage and subchondral osseous anatomy of the patellofemoral joint, it allows the surgeon and the radiologist to appraise the true articulating surfaces. We therefore recommend MR arthrotomography as the imaging technique of choice.     

Anterior knee pain: diagnosis and treatment

Anterior knee pain is a frequent clinical problem. It provides a common challenge to diagnose and manage. Basic science studies have provided insight into the origin of anterior knee pain and refined understanding of the anatomy. Clinical evaluation has progressively focused on the contribution of the entire lower extremity to patellofemoral function. Nonsurgical management has been refined by the concept of the "envelope of function" and by increased understanding of the neuromuscular control of the knee. Indications for lateral release have been clarified and narrowed. Although anteromedial transfer of the tibial tuberosity is helpful in certain circumstances, reports of postoperative fracture have led to less aggressive rehabilitation protocols. Chondral resurfacing of the patellofemoral joint and patellofemoral arthroplasty are evolving. Emphasis should remain on nonsurgical management, which is sufficient in most patients.     

复发性髌骨脱位治疗中内侧髌股韧带重建术的研究进展

复发性髌骨脱位是引起青少年膝关节功能障碍的常见疾病,其定义为髌骨脱位发生两次及两次以上,是一种骨科及运动医学临床常见的疾病。复发性髌骨脱位的病因有很多,但归根结底,髌骨在活动中所处的异常力学环境是引起不稳的根本原因。研究发现内侧髌股韧带被认为是限制髌骨向外脱位最重要的软组织结构,因而重建内侧髌股韧带对成功治疗复发性髌骨脱位起着重要的作用。但复发性髌骨脱位往往是一个多因素引起的临床问题,除了纠正软组织的异常外,骨性结构的异常也是一个不容忽视的问题。本文对近年来对内侧髌股韧带的解剖、生物力学、手术技巧、治疗结果及术后并发症的研究情况进行了综述。     

Editorial Commentary: When It Comes to Patient Outcome,Femoral Tunnel Vision May Miss the ‘Point’ in Knee Medial Patellofemoral Ligament Reconstruction

Surgeons care deeply about optimizing femoral tunnel position in medial patellofemoral ligament reconstruction. We use a combination of anatomy, isometry, and fluoroscopy to determine the appropriate position of our graft. Although malposition does increase the risk of surgical complication, it is unclear whether femoral tunnel position actually matters for clinical outcome. Surgeons should avoid “tunnel vision” in medial patellofemoral ligament reconstruction by recognizing the combination of anatomic, biomechanical, patient-specific, and technique-dependent variables that may drive patient satisfaction and subjective outcome.     

Assessment and management of chronic patellofemoral instability

Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.     

Surgical Biomechanics of the Patellofemoral Joint

This review presents objective data, as far as possible, about the current understanding of the biomechanics of the patellofemoral joint as it pertains to the management of patellofemoral problems. When faced with a patellofemoral malfunction, it is important to check all the soft-tissue and articular geometry factors relating to the patella locally and not to neglect the overall lower limb alignment and function. It is important to remember that small alterations in alignment can result in significant alterations in patellofemoral joint stresses and that changes in the mechanics of the patellofemoral joint can also result in changes in the tibiofemoral compartments. Surgical intervention for patellofemoral problems needs to be planned carefully and take into account an individual’s anatomy.