胫骨扭转畸形与髌骨不稳

目的 通过分析髌股关节退变性关节病患者的径骨扭转畸形与髌骨关节排列紊乱的关系,揭示胫骨扭转畸形诱发ＰＦＤＡ的可能机制。     

髌股关节紊乱与胫骨扭转畸形的相关性分析

目的 :通过分析髌股关节退变性骨关节病(patello-femoral degenerative arthrosis,PFDA)患者的胫骨扭转畸形与髌股关节在静力及动力条件下排列紊乱的关系,揭示胫骨扭转畸形诱发PFDA的可能机制。方法:自2009年10月至2010年10月,选取PFDA患者50例86膝,男24膝,女62膝;对照组16例23膝,男7膝,女16膝。分别在CT扫描片上测量胫骨扭转角,并测量屈膝30°位时,分别在静力和动力条件下的髌股和谐角及外侧髌股角,经统计学对比分析后,评价PFDA患者的胫骨扭转畸形与髌股关节排列紊乱的关系。进而将PFDA患者按胫骨扭转角大小分为胫骨扭转角过大组(胫骨扭转角≥30°)、胫骨扭转角过小组(胫骨扭转角<15°)和胫骨扭转角正常组(15°≤胫骨扭转角<30°),测量屈膝30°位时,分别在静力和动力条件下髌股和谐角和外侧髌股角,进行统计学处理,分析PFDA患者胫骨扭转畸形与髌股关节排列紊乱的关系,尤其在动力条件下的关系。结果:PFDA患者的胫骨扭转角(30.30±7.11)°,大于对照组(23.10±4.73)°;与对照组比较,PFDA患者有较大的髌股和谐角(13.20±3.94)°及较小的外侧髌股角(12.30±3.04)°。胫骨扭转角过小组和胫骨扭转角过大组在静力及动力条件下的髌股和谐角和外侧髌股角比较,差异有统计学意义(P<0.05)。而胫骨扭转角正常组的髌股和谐角在静力和动力条件下比较,差异无统计学意义;外侧髌股角在静力和动力条件下比较,差异亦无统计学意义。结论:胫骨扭转畸形者多伴有髌股关节不稳,尤其是动力状态下的匹配关系紊乱,是造成PFDA患者髌股关节紊乱的主要原因。CT检测髌股关节及胫骨扭转角,既能提供髌股关节排列的信息和髌股关节的退变状况,又能通过对两者对应关系的分析为临床更好地预防和早期治疗退变性骨关节病提供指导。     

股骨远端内翻截骨治疗膝关节骨关节／WANG Jun-wen…／／J Bone Joint Surg Am

胫骨近端截骨治疗外翻性膝关节病效果不如治疗内翻性膝关节病。作者分析了30例(30膝)股骨远端截骨治疗膝外侧骨关节炎合并膝外翻畸形，其中12例为单纯外侧间隙骨关节炎，10例合并有另外两间隙轻至中度的退变性改变，8例合并有严重的髌股关节炎。行内侧入路，截除基部为5～10cm的楔行骨块，90°角状板内固定。外侧剥脱的软骨下骨行钻孔。6例凶合并严重的髌股关节炎和髌骨外侧半脱位行外侧支持带松解及髌股关节剥脱的软骨下骨钻孔。2例髌骨完全脱位分别行近端移位及近端远端同时移位恢复力线。     

股骨远端内翻截骨治疗膝关节骨关节炎

胫骨近端截骨治疗外翻性膝关节病效果不如治疗内翻性膝关节病。作者分析了 30例 (30膝)股骨远端截骨治疗膝外侧骨关节炎合并膝外翻畸形,其中 12例为单纯外侧间隙骨关节炎, 10例合并有另外两间隙轻至中度的退变性改变, 8例合并有严重的髌股关节炎。行内侧入路,截除基部为 5 ~10cm的楔行骨块,90°角状板内固定。外侧剥脱的软骨下骨行钻孔。6例因合并严重的髌股关节炎和髌骨外侧半脱位行外侧支持带松解及髌股关节剥脱的软骨下骨钻孔。2例髌骨完全脱位分别行近端移位及近端远端同时移位恢复力线。结果 25例获得满意效果, 2例一般。另 3例转…     

胫骨高位截骨术对髌股关节软骨病变的影响

目的研究胫骨内侧高位截骨术对髌股关节软骨病变的影响。方法回顾性分析自2014年1月至2018年12月诊断为膝骨关节炎合并髌股关节Iwano分级Ⅰ～Ⅲ级的86例患者,行关节镜及胫骨内侧高位截骨术,比较术后髌股关节的软骨改变。所有患者术前查体均为膝内侧疼痛,无髌股关节疼痛,膝正位X线片示内侧间室骨关节炎,髌骨轴位、侧位X线片可见髌股间隙变窄。术中使用关节镜探查髌股关节时,根据国际软骨修复协会软骨损伤分级(international cartilage repair society, ICRS)将患者分为A组35例(ICRS 0～Ⅰ级),其中男性9例,女性26例,平均年龄(55.66±4.66)岁;B组51例(ICRSⅡ～Ⅲ级),其中男性21例,女性30例,平均年龄(55.90±4.44)岁。所有患者均进行胫骨内侧高位截骨矫正力线,建议截骨处愈合后再次手术取出内固定钢板。比较两组患者在初次截骨手术和再次取出内固定手术时视觉模拟评分(visual analogue scale, VAS)、西大略湖麦克马斯特大学(Western Ontario and McMaster universities, WOMAC)骨关节炎指数评分和髌股关节Kujala评分差异;比较每组患者在截骨前后的Iwano分级和镜下ICRS分级差异。结果两组患者在初次截骨术和再次取出内固定手术时VAS评分、WOMAC评分骨关节炎指数评分和Kujala评分比较,差异均有统计学意义(P0.05);每组患者截骨手术前后对比,术后髌股关节ICRS分级较术前有增长趋势,但Iwano分级和镜下ICRS分级比较差异无统计学意义(P0.05)。非劣性检验Kujala评分结果表明B组术后评分并不比A组差。结论对于内翻膝骨关节炎无髌股关节症状的患者,如果髌股关节软骨分级为ICRS 0～Ⅲ级,仍然可采取胫骨内侧高位截骨术,短期不会加重髌股关节炎的临床症状,且功能评分得到改善。     

髌骨倾斜导致髌软骨软化超微结构观察

目的：探讨低应力环境下髌软骨软化的发病机制。方法：２８只新西兰兔，随机分成４组。右膝髌骨采用手术方法造成倾斜状态为实验侧，左膝实施假手术为对照侧，定期处死动物后进行生物力学测试、软骨组织学观察及电镜观察。结果：实验膝髌骨倾斜后髌骨内侧面接触应力明显降低，软骨发生变性；髌骨外侧面软骨接触压力无明显变化，软骨无明显变性。透射电镜下，髌内侧面软骨术后６周时深层软骨细胞代谢与分泌功能障碍；１２周时深层软骨细胞变性加剧，累及周围基质并向中层蔓延；１８～２４周时中层与深层软骨细胞变性坏死，胶原纤维破坏并异常聚合，逐渐向表层发展；髌外侧面软骨细胞则代谢活跃，胶原纤维增粗排列致密。扫描电镜下，髌骨内侧面软骨表面形成裂隙；外侧面软骨表面粗糙呈“割草地样”。结论：髌骨倾斜导致髌内侧面软骨应力减低，致使深层软骨细胞首先变性，继之周围基质变性，软骨变性逐渐由深层向表层发展。     

下肢去旋转截骨术治疗髌股关节紊乱研究进展

下肢异常旋转是髌股关节紊乱发生的重要危险因素。单纯去旋转截骨术或与其他手术联合是针对由股骨和/或胫骨旋转畸形导致的髌股关节紊乱最主要的治疗方法。其中,股骨截骨平面多数位于股骨远端的股骨髁上,治疗效果较满意;胫骨截骨平面通常位于胫骨近端,治疗后可有效稳定髌骨并缓解膝前疼痛。由于截骨范围较大,此类手术的术后并发症发生概率较高,术者在实施手术时应谨慎细致。该文就下肢旋转畸形在髌股关节紊乱中的作用,以及下肢去旋转截骨术治疗髌股关节紊乱的研究进展作一综述。     

膝内翻伴胫骨旋转的治疗

目的 观察胫骨高位截骨，胫骨结节旋转抬高治疗膝内翻伴胫骨旋转畸形的效果。方法 通过膝关节生物力学研究。简化了胫骨高位截骨的测量方法，在胫骨高位截骨的同时进行胫骨结节旋转抬高，恢复胫股关节，髌股关节的生理功能。结果 随访1-8年，通过X线，CT检查及膝关节功能评定，其优良率为88%。结论 胫骨高位截骨，胫骨结节旋转抬高治疗膝关节内侧间隔退行性关节炎，胫骨旋转所致髌股关节炎，符合生物力学要求，长期随访效果满意。     

髌骨倾斜对兔髌骨关节软骨损害的实验研究

目的建立兔髌骨倾斜的模型并观察髌股关节软骨损害的变化,为临床治疗髌股关节疾病提供实验依据。方法新西兰大白兔24只,随机分3组,每组8只,行右膝髌骨内侧支持带松解和外侧支持带紧缩术,术后不固定右膝关节。左膝髌骨为对照组。分别于术后第2周、4周、8周处死取材,分别进行髌骨倾斜角CT测量、髌骨关节面软骨大体观察、软骨组织Mankin评分。结果（1）实验侧髌骨倾斜角明显大于对照侧;（2）术后4周可见关节软骨软化,色泽晦暗,裂隙形成;术后8周关节软骨粗糙,有大的裂隙且色泽晦暗;对照组无软骨退变;（3）HE染色光镜下观察关节软骨,术后4周时,关节软骨轻度变性,可见软骨细胞变扁,表面不规则,术后8周时,软骨明显变性,可见软骨细胞增殖,排列紊乱,基质减少,潮线不完整。根据软骨Mankin评分,术后4、8周时右膝实验组得分明显高于左膝空白对照组,相比较有显著的统计学意义（P〈0.05）。结论兔髌骨倾斜后4周,髌骨外侧关节面软骨出现软骨软化,随着时间的延长软骨退变进一步加重,为治疗髌股关节软骨疾病提供实验依据。     

胫骨扭转角与髌股关节不稳定

胫骨扭转角异常增大（胫骨外旋）作为髌股关节不稳定的危险因素之一,在髌股关节疾病的诊治过程中很容易被忽视。随着电子计算机等技术的日新月异,胫骨扭转角的测量方法也在与时俱进。CT检查虽然已经成为测量的金标准,但是目前仍然缺乏规范的测量方法,测量结果也不尽相同。胫骨扭转角异常增大会影响患者步态及下肢肌力平衡,导致髌股关节不稳定。而胫骨扭转角偏大尚缺乏明确统一的手术指征。若要行胫骨旋转截骨术,应考虑胫骨扭转发生的部位。该文对胫骨扭转角与髌股关节不稳定研究进展进行综述,为该病的诊断及治疗方案选择提供参考。     

Osteotomien

Skeletal geometry, soft tissues, and neuromuscular control influence the patellofemoral gliding mechanism. Abnormal skeletal geometry – such as increased femoral anteversion, trochlear dysplasia, patella alta, increased tibial external torsion, increased tibial tubercle lateralization, and variations of combined deformities – may lead to patellofemoral complaints. Altered vectors and forces acting on the patellofemoral joint can cause cartilage failure with later arthrosis, instability, and musculotendinous insufficiency. Osteotomy with soft tissue repair might be the best treatment, depending on the primary pathology. Surgery aims to eliminate the underlying pathomorphology.     

Osteotomies

Skeletal geometry, soft tissues, and neuromuscular control influence the patellofemoral gliding mechanism. Abnormal skeletal geometry - such as increased femoral anteversion, trochlear dysplasia, patella alta, increased tibial external torsion, increased tibial tubercle lateralization, and variations of combined deformities - may lead to patellofemoral complaints. Altered vectors and forces acting on the patellofemoral joint can cause cartilage failure with later arthrosis, instability, and musculotendinous insufficiency. Osteotomy with soft tissue repair might be the best treatment, depending on the primary pathology. Surgery aims to eliminate the underlying pathomorphology.     

半月板不同切除术对髌股关节影响的生物力学研究

目的探讨半月板不同部位,不同程度切除后对膝关节髌股关节的影响,为半月板不同切除术的比较提供生物力学依据。方法采用6具人膝关节新鲜标本,保留内、外侧副韧带、关节囊及膝关市伸膝装置,Staubli机器人模拟生理状态下膝关节站立至下蹲屈膝过程,采用超低压型压敏片测量完整膝关节和半月板不同部化及程度切除术后不同屈膝角度下髌股关节接触面积、接触压,并用SPSS 12．0进行双因素方差分析。结果1．无论何种状念的半月板切除,其髌股关节接触的总体趋势没有改变,即膝火节心曲0°～90°髌股关节的接触面积会逐渐增加;2．半月板部分切除与正常膝关节在髌股接触面积、髌股平均接触从压力间的差异无统计学意义;3．外侧半月板全切除与正常膝关节在髌股接触面积之间的差异有统计学意义,其骸股接触面积在各个屈曲角度均小于正常膝关节,其髌股接触平均压力存各个屈曲角度均大于正常膝关节的髌股接触平均压力;4．内侧十月板全切除与正常膝关节在髌股接触面积间的差异无统计学意义,内侧半月板全切其在膝关节屈曲0°～30°之间其髌股关节平均压力均大于正常膝关节髌股关节间平均压力;60°～90°之间与正常膝关节髌股关节间平均压力间的差异无统计学意义。结论外侧半月板全切除术后髌股关节高接触压力、内侧半月板全切除术后髌股关节低接触压力及半月板部分切除术后髌股关节压力分布小均是术后髌股关节炎发生不可忽视的原因。     

Editorial Commentary: Does Patellofemoral Degenerative Progression After Open-Wedge High Tibial Osteotomy Adversely Affect Clinical Outcomes?

Open-wedge high tibial osteotomy causes deterioration of the patellofemoral cartilage status. However, whether patellofemoral degenerative progression adversely affects clinical outcomes remains unclear, thereby necessitating a comprehensive long-term follow-up study.     

Editorial Commentary: Trochlear Dysplasia: Can We Change its Natural History or Degenerative Prognosis?

Trochlear dysplasia may be asymptomatic and benign, or could engender patellar instability and degenerative arthritis. Autologous chondrocyte implantation is demonstrating promising outcomes for the treatment of patellofemoral cartilage lesions, but may not suffice for knees with underlying mechanical anomalies as trochlear dysplasia, where adjuvant trochleoplasty or tibial tubercle osteotomy may be required to prevent patellofemoral instability and to protect the graft from wear and damage. Rigorous radiographic assessment is important to discern the type of dysplasia, notably the presence of a potentially pathogenic supra-trochlear spur. Trochleoplasty or other realignment procedures such as tibial tubercle osteotomy should be considered where necessary to correct underlying trochlear deformities and thereby avoid iatrogenic complications or failure.     

Posterior cruciate ligament rupture alters in vitro knee kinematics

Isolated posterior cruciate ligament injuries usually are treated nonoperatively, although some patients remain symptomatic, and degenerative changes within the patellofemoral joint and the medial compartment of the tibiofemoral joint have been seen in followup studies. In vitro simulation of knee squatting was done to quantify the influence of the posterior cruciate ligament on tibiofemoral and patellofemoral kinematics. For five knee specimens, knee kinematics were measured before and after sectioning the posterior cruciate ligament, and compared using a Wilcoxon signed rank test. The only kinematic parameters that changed significantly after sectioning the posterior cruciate ligament were the tibial posterior translation and patellar flexion. The posterior translation of the tibia increased significantly between 25 degrees and 90 degrees flexion. The average increase in the posterior translation exceeded 10 mm at 90 degrees flexion. The patellar flexion increased significantly from 30 degrees to 90 degrees flexion. The average patellar flexion increase peaked at 4.4 degrees at 45 degrees flexion. Increased tibial translation could adversely influence joint stability. Increased patellar flexion could increase the patellofemoral joint pressure, especially at the inferior pole, leading to degenerative changes within the patellofemoral joint.     

Results of intramuscular injection of glycosamino-glycanpolysulfate (GAGPS) in experimental arthrosis of the knee in dogs (author's transl)]

Report on the action of GAGPS injected intramuscularly on experimental arthrosis of the knee-joint in dogs. In both hind-legs the lateral tibial joint-surface and the lateral meniscus were resected. This produces arthrotic changes similar to human arthrosis within 2 months. Of 27 dogs 13 received i.m. injections into the glutei of GAGPS (25 mg/kg). 14 dogs were not untreated controls. After the 7th postoperative day the injections were given on every third day on 10 occasions, thereafter every fourth day for another 10 occasions. The animals were killed 3 months after the start of the experiment. Loss of cartilage on the lateral condyle proved to be clearly less pronounced in the treated animals than in the controls, macroscopically, radiologically and histolocally. GAGPS, injected, intragluteally, limits loss of cartilage in experimental arthrosis of the knee in dogs.     

Site-specific immunostaining for type X collagen in noncalcified articular cartilage of canine stifle knee joint

Type X collagen is a short-chain collagen that is strongly expressed in hypertrophic chondrocytes. In this study, we used an immunohistochemical technique exploiting a prolonged hyaluronidase unmasking of type X collagen epitopes to show that type X collagen is not restricted to calcified cartilage, but is also present in normal canine noncalcified articular cartilage. A 30° valgus angulation procedure of the right tibia was performed in 15 dogs at the age of 3 months, whereas their nonoperated sister dogs served as controls. Samples were collected 7 and 18 months after the surgery and immunostained for type X collagen. The deposition of type X collagen increased during maturation from age 43 weeks to 91 weeks. In the patella, most of the noncalcified cartilage stained for type X collagen, whereas, in the patellar surface of the femur, it was present mainly in the femoral groove close to cartilage surface. In femoral condyles, the staining localized mostly in the superficial cartilage on the lateral and medial sides, but not in the central weight-bearing area. In tibial condyles, type X collagen was often observed close to the cartilage surface in medial parts of the condyles, although staining could also be seen in the deep zone of the cartilage. Staining for type X collagen appeared strongest at sites where the birefringence of polarized light was lowest, suggesting a colocalization of type X collagen with the collagen fibril arcades in the intermediate zone. No significant difference in type X collagen immunostaining was observed in lesion-free articular cartilage between controls and dogs that underwent a 30° valgus osteotomy. In osteoarthritic lesions, however, there was strong immunostaining for both type X collagen and collagenase-induced collagen cleavage products. The presence of type X collagen in the transitional zone of cartilage in the patella, femoropatellar groove, and in tibial cartilage uncovered by menisci suggests that it may involve a modification of collagen fibril arrangement at the site of collagen fibril arcades, perhaps providing additional support to the collagen network.     

Anterior Displacement of the Tibial Tuberosity in Chondromalacia Patellae

Sixty-eight knees in 62 patients with degenerative changes of the patellar joint surface, chondromalacia or arthrosis, were operated on with anterior displacement of the tibial tuberosity. Complications were encountered in no less than 22 joints and the results appeared to be somewhat related to these complications, particularly in women, even if a direct relationship between complications and remaining symptoms could not be demonstrated. in a follow-up examination an average of 13 months after operation, approximately 90 per cent of the patients had improved, men as well as women. in an additional follow-up, 30 months after operation, the men had maintained or even somewhat improved their good results whereas in women only about 70 per cent could now be classified as improved or free from symptoms. When those patients, who were not as regards all variables improved by surgery, were analysed separately, there was in this group a preponderance of women, and particularly older women. Also, the patients with complications belonged to this group. Modifications of the surgical procedure did not seem to change the results nor were the results different in those patients in whom a superficial shaving of the articular cartilage of the patella had been added. the conclusion of the study is that anterior displacement of the tibial tuberosity has a lasting beneficial effect on patients with degenerative changes of the patello-femoral joint.     

关节镜下内侧紧缩及外侧松解加半髌腱止点移位术治疗复发性髌骨脱位

目的 评价微创关节镜下外侧松解、内侧紧缩、半髌腱止点移位术的三联手术方案治疗复发性髌骨脱位的临床疗效.方法 以1998～2008年收治的71例（77膝）复发性髌骨脱位患者为研究对象,入选标准为：胫骨骨骺已经闭合,且股骨滑车沟无严重发育不良和严重膝外翻畸形.男11例,女60例;平均年龄19.5岁,67例有明确外伤史.术前测量Q角.Merchant位X片上测量股骨滑车沟角、髌骨-股骨滑车适合角,髌股外侧角.CT平扫测量股骨髁滑车凹中心与胫骨结节水平距离（TT TG）.术中采用外侧松解、内侧紧缩和半髌腱止点移位三联手术方案.结果 2例（2膝）失访,69例（75膝）术后随访2～12年,平均5.2年.除早期1例患者在术后2个月再次发生髌骨脱位外,其余病例术后髌骨脱位未见复发.术前髌骨-股骨滑车适合角（24.2°±6.8°）,术后为（-2.1°±5.8°）（P〈0.05）;术前髌股外侧角（-2.0°±5.2°）,术后为（10.9°±4.0°）（P〈0.05）;术前TT TG平均为（19.8±2.1） mm,术后为（13.6±1.8） mm （P〈0.01）.术前Lysholm评分和IKDC评分分别由术前的（45.6±4.8）、（48.3±6.8）分,提高到术后的（92.3±10.8）分 （P〈0.05）和（94.3±8.4）分（P〈0.05）;术前测量Q角男性平均为（13.2°±3.1°）,术后平均为（9.2°±2.8°）（P〈0.05）;女性平均为（21.0°±5.2°）,术后平均为（15.4°±4.4°）（P〈0.05）.结论 关节镜下外侧松解、内侧紧缩缝合、半髌腱移位术的综合手术方案治疗复发性髌骨脱位创伤较小,疗效确切,术后患者膝关节功能改善明显,手术操作简便,易于掌握.