内侧髌股韧带重建联合外侧支持带松解治疗复发性髌骨脱位

目的 回顾性分析自体半腱肌腱游离移植重建内侧髌股韧带联合外侧支持带松解治疗复发性髌骨脱位的临床结果.方法 复发性髌骨脱位31例行内侧髌股韧带重建联合外侧支持带松解,并对患者进行影像检查及膝关节功能评分.结果 术后随访24～56个月,31例均无再次脱位;功能评分术前与术后比较差异有统计学意义(P＜0.05).结论 自体半腱肌腱移植重建内侧髌股韧带联合外侧支持带松解治疗创伤性复发性髌骨脱位效果可靠.     

自体半腱肌腱游离移植重建内侧髌股韧带治疗儿童复发性髌骨脱位

[目的]探讨自体半腱肌腱游离移植重建内侧髌股韧带治疗儿童复发性髌骨脱位的疗效和安全性.[方法]2008年2月～ 2010年2月治疗复发性髌骨脱位患儿7例.术中关节镜探查髌骨轨迹,处理合并损伤.行外侧支持带松解,自体半腱肌腱游离移植重建内侧髌股韧带.股骨侧避开骺软骨放置3.5 mm锚钉,髌骨内缘钻2个4.5 mm骨道,髌骨复位后将肌腱穿入骨道打结固定.[结果]随访12 ～24个月(平均17个月),手术效果满意,无复发脱位,无骨骺早闭,术后X线片示髌股关节解剖关系恢复正常.[结论]关节镜探查结合外侧支持带松解和自体半腱肌腱游离移植重建内侧髌股韧带治疗儿童复发性髌骨脱位,方法简单安全,疗效可靠.     

内侧支持带紧缩术与内侧髌股韧带重建术治疗RDP的临床观察

目的 探讨复发性髌骨脱位(RDP)的治疗方法.方法 收治RDP 36例,随机分成两组,Ⅰ组18例,采用关节镜下髌外侧支持带松解内侧支持带紧缩术;Ⅱ组18例,采用关节镜下髌外侧支持带松解半腱肌腱移植重建内侧髌股韧带术.结果 36例获3～15个月随访,无一例复发,倾斜试验及恐惧试验阴性.膝部弥漫性疼痛均消失,上下楼梯时前...     

复发性髌骨脱位手术治疗进展

复发性髌骨脱位多见于一种或多种潜在解剖结构异常、易使髌骨脱位或半脱位的膝关节。保守治疗包括休息、肌肉训练、支具和胶带的应用等。复发性髌骨脱位多需要手术治疗,以纠正髌骨对线异常,但目前尚缺统一认识。传统的手术方法包括外侧支持带松解、内侧支持带紧缩、胫骨结节截骨及股骨滑车成形术等,疗效各异。近年来内侧髌股韧带在防止髌骨脱位中的作用越来越受到重视,通过内侧髌股韧带修补或重建来重获髌骨稳定性日益得到应用。无论选择何种手术疗法,详细了解髌股关节的解剖和生物力学并纠正髌骨对线异常,是最主要的目的。     

髌骨外侧支持带松解结合内侧皱缩术治疗髌股关节外侧挤压综合征

目的介绍关节镜下髌骨外侧支持带松解结合内侧皱缩术治疗髌股关节外侧挤压综合征的疗效。方法自2017-2018年共收治髌股关节外侧挤压综合征26例,男11例,女15例;年龄37~54岁,平均(40.0±1.3)岁。技术要点为关节镜下髌股外侧支持带囊外松解,内侧支持带皱缩术。患者病程10~28个月,平均(16.0±1.5)个月,手术前后根据Lysholm评分进行评价。结果术后26例获得6~12个月随访,平均随访时间(9.0±1.5)个月。Lysholm评分术前(64.53±3.25)分,末次随访评分为(90.75±4.11)分,手术前后比较差异有统计学意义(P<0.05)。结论关节镜下髌骨外侧支持带囊外松解结合内侧皱缩术治疗髌股关节外侧挤压综合征与传统术式相比显示了微创的优势,能获得满意的治疗效果。     

膝关节镜下外侧支持带松解及内侧支持带紧缩治疗急性髌骨脱位

目的探讨膝关节镜下外侧支持带松解及内侧支持带紧缩治疗急性髌骨脱位。方法1999年7月～2003年7月共对11例急性髌骨脱位患者施行膝关节镜手术,松解外侧支持带及外侧髌—股韧带,同时紧缩缝合内侧支持带及内侧髌—股韧带。结果平均随访21.2个月,所有病人均未发生再脱位,亦无残留髌骨不稳。膝关节活动度(ROM)正常。结论本术式疗效确切,具有创伤小、并发症少、功能恢复快等优点。     

关节镜监视下髌骨双隧道内侧髌股韧带重建外侧支持带松解治疗复发性髌骨脱位

[目的]探讨关节镜临视下髌骨双隧道内侧髌股韧带重建及外侧支持带松解治疗复发性髌骨脱位的疗效.[方法]对12例复发性髌骨脱位患者采用髌骨双隧道法重建内侧髌股韧带,同时常规行外侧支持带松解.[结果]患者术后均获随访,平均31个月(14～52个月),未见髌骨脱位复发.髌骨轴位X线片显示所有病例外侧髌股角均有所改善.手术前后IKDC膝关节功能主观评分分别为(38.3±5.1)分和(91.1±5.9)分.Lysholm膝关节功能综合评分分别为(72.3±4.6)分和(90.6±4.7)分.[结论]关节镜监视下髌骨双隧道内侧髌股韧带重建及外侧支持带松解是治疗复发性髌骨脱位的有效方法.     

关节镜下髌外侧支持带松解及内侧支持带紧缩治疗髌骨软化症

目的探讨膝关节镜下外侧支持带松解及内侧支持带紧缩治疗髌骨软化症的疗效。方法对31例(36膝)髌骨软化症患者在关节镜下用等离子刀松解外侧支持带及外侧髌—股韧带,同时紧缩缝合内侧支持带及内侧髌—股韧带。结果随访10～48个月,患者症状和体征均得到明显改善。与术前相比,Lysholm评分由70.2分提高至平均92.1分,差异有显著性(P<0.01)。结论该术式治疗髌骨软化症不仅能松解外侧支持带,同时还可有效地紧缩内侧支持带,疗效确切,具有创伤小、并发症少、功能恢复快等优点。     

综合手术方案治疗复发性髌骨脱位的疗效观察

目的评价采用关节镜下外侧松解、内侧支持带紧缩缝合、半髌腱移位术的综合手术方案治疗复发性髌骨脱位的临床疗效。方法以1998～2004年收治的38例患者为研究对象,男17例,女21例。29例有明确外伤史,不包括髌骨完全性脱位且关节活动时髌骨始终不与股骨髁间构成关节面关系的病例。通过了解病史、体查以及CT或MRI资料分析确定髌骨脱位病因。关节镜下外侧支持带松解与内侧支持带紧缩缝合、髌腱外1／2连同外侧胫骨结节止点向内侧交叉移位。术后不制动,髌骨行保护性的康复疗程。术后3个月以及每年随访,检查髌骨轨迹、关节活动度以及行髌骨切线位片或CT检查。结果29例患者获3～60个月(平均40．2个月)随访,均无脱位复发,恐惧感消失,物理及影像学检查表明髌骨稳定。按Lysholm评分评价膝关节功能,29患者术后平均评分为(91．3±3．8)分,较术前的(58．1±5．4)分明显提高,差异有统计学意义(P<0．01)。结论关节镜下外侧松解、内侧支持带紧缩缝合、半髌腱移位术的综合手术方案治疗复发性髌骨脱位疗效确切。操作简便,易于掌握。     

关节镜下内侧髌股韧带重建与内侧支持带紧缩治疗青少年复发性髌骨脱位疗效研究

目的 比较采用关节镜下内侧支持带紧缩联合外侧支持带松解(lateral retinacular release, LRR)与自体腓骨长肌肌腱重建内侧髌股韧带(medial patellofemoral ligament, MPFL)联合LRR治疗青少年复发性髌骨脱位的疗效分析。方法 本研究选取2017年6月至2020年6月新疆医科大学第四附属医院采用两种方式治疗的60例髌骨脱位患者，根据治疗方式不同，分为MPFL重建组(A组)30例和内侧支持带紧缩组(B组)30例。采用疼痛视觉模拟评分(visual analogue scale, VAS)在术后3个月、末次随访时评估患肢疼痛分级，采用Kujala评分及Lysholm评分评估患者术后3个月及末次随访膝关节功能，并通过屈膝30°CT平扫及MRI平扫测量髌骨倾斜角(patellar tilt angle, PTA)及髌骨适合角(patellar congruence angle, PCA)评估髌股关系，记录并比较两组术后再脱位等并发症情况。结果 两组患者均获随访，随访时间12～27个月，平均(19.18±3.67)个月。两组患者术后Kuja...     

关节镜下外侧支持带松解治疗髌骨外侧高压综合征

目的探讨关节镜下外侧支持带松解治疗髌骨外侧高压综合征的效果和临床意义.方法采用关节镜下外侧支持带松解术治疗39例(51膝)髌骨外侧高压综合征.男1例(1膝),女38例(50膝);单膝27例,双膝12例;平均年龄49.6岁(28～71岁).临床症状以髌股关节钝痛为特点,疼痛位置不易确定,髌股关节负荷过度的活动会使疼痛加重.物理检查见Q角增大(＞20°)45膝,髌软骨外侧小面抠触痛50膝,外侧支持带压痛39膝,被动髌骨倾斜试验阳性51膝,内外侧滑动试验阳性49膝,压髌试验阳性51膝.X线检查轴位片见髌股对合角异常32膝.术中在关节镜监视下,用射频汽化钩刀松解外侧支持带,必要时可向近端扩大松解范围,切断部分股外侧肌,达到完全松解.结果术后所有病例均得到随访,平均随访14.5个月(3～26个月).疗效评定参照改良Lysholm评分标准,优37膝,良12膝,可2膝.Lysholm评分从术前平均(62.04±5.98)分(49～75分)提高到术后平均(93.71±3.55)分(86～100分),有显著性差异(t=6.63,P＜0.001).髌股对合角异常的32膝中术后有30膝髌股对合角恢复正常(94%).术后5膝有血肿形成(10%).结论关节镜下外侧支持带松解是一种微创的软组织平衡手术,能够有效地缓解髌骨外侧高压综合征引起的髌股关节疼痛,且并发症较少.     

Sonography on injury of the medial patellofemoral ligament after acute traumatic lateral patellar dislocation: Injury patterns and correlation analysis with injury of articular cartilage of the inferomedial patella

Objective

The purpose of this study was to investigate the accuracy of high-frequency ultrasonography in the diagnosis of injuries of medial patellofemoral ligaments (MPFLs), analyse the characteristics of MPFL injury and correlations between injury of the MPFL and articular cartilage of the inferomedial patella in patients with acute traumatic lateral patellar dislocation.

Methods

High-frequency sonographic images of 49 patients with acute traumatic lateral patellar dislocations treated surgically were reviewed. The χ² tests were performed for statistical analysis.

Results

Twenty-eight cases of complete MPFL tear and 21 cases of partial MPFL tear were identified in operation, with 27 cases of MPFL tear located at their femoral attachment, 21 cases of tear at the patellar attachment and one case of midsubstance tear. The diagnostic accuracy of sonography regarding partial MPFL tear and complete MPFL tear was 89.8% and 89.8%. Among the patients with MPFL tear at the patellar attachment, eight and six cases were concomitant with chondral and osteochondral lesions in the inferomedial patella, respectively, in contrast to nine and six cases in patients with MPFL tear at the femoral attachment, respectively. There was no significant difference between the two locations described above regarding the prevalence rates of chondral or osteochondral lesions of the inferomedial patella (P = 0.732, P = 0.614). Among the patients with complete MPFL tear, 12 and 10 cases were concomitant with chondral and osteochondral lesions in the inferomedial patella, respectively, while six and two cases were concomitant with partial MPFL tear. There was no significant difference between the two types of injuries discussed above on the prevalence rates of chondral lesions of the inferomedial patella (P = 0.305), but the prevalence rate of osteochondral lesions between the two types of injuries discussed above was statistically different (P = 0.035).

Conclusions

The MPFL is most easily injured at the femoral attachment, secondly at the patellar attachment. High-frequency ultrasonography is an accurate method in the diagnosis of an MPFL tear. There are neither significant differences on the prevalence rates of chondral or osteochondral lesions of the inferomedial patella between locations of MPFL injuries, nor significant difference on the prevalence rates of chondral lesions between MPFL injury types; but the complete MPFL tear is more often concomitant with inferomedial patellar osteochondral lesions than the partial MPFL tear.     

Biomechanical Study of Patellar Component Fixation with Varying Degrees of Bone Loss

BackgroundThe decision as to whether or not to resurface the patella in revision total knee arthroplasty (TKA) is affected by the amount of patellar bone stock remaining; however, the impact of the cancellous bone status on patellar component fixation has not been studied. Therefore, we conducted a biomechanical study of patellar component fixation with varying degrees of cancellous bone loss.MethodsSixty pairs of cadaveric patellae were randomly assigned between 3 groups and prepared in similar manner to a TKA with the standard 3-hole configuration. A control patella and an experimental patella were designated in each pair. To simulate bone loss in the experimental patellae, 1, 2, and 3 of the standard drill holes were uniformly enlarged to 12 mm in group 1, group 2, and group 3, respectively. Afterward, an all-polyethylene patellar component was cemented to each patella, as done intraoperatively. Patellar components were then sheared off using a materials testing system. The resulting mean offset yield force was analyzed within each group using paired t-tests.ResultsThe mean offset yield force for the control patellae was greater than the experimental patellae in group 1. In groups 2 and 3, the experimental patellae produced a greater mean offset yield force than the control patellae. Comparison within each group did not demonstrate a statistically significant difference.ConclusionBone loss with enlargement of the patellar fixation holes, as is frequently seen in revision TKA, with holes up to 12 mm, does not significantly decrease patellar component fixation shear strength in this biomechanical cadaveric study.     

Computational approach to correcting joint instability in patients with recurrent patellar dislocation

Patellar dislocation is a debilitating injury common in active adolescents and young adults. Conservative treatment after initial dislocation is often recommended, but almost half of these patients continue to suffer from recurrent dislocation. The objective of this study was to compare preoperative patellofemoral joint stability with stability after a series of simulated procedures, including restorative surgery to correct to pre-injury state, generic tibial tubercle osteotomy, patient-specific reconstructive surgery to correct anatomic abnormality, less invasive patient-specific surgery, and equivalent healthy controls. Three-dimensional, subject-specific finite element models of the patellofemoral joint were developed for 28 patients with recurrent patellar dislocation. A 50 N lateral load was applied to the patella to assess the lateral stability of the patellofemoral joint at 10° intervals from 0° to 40° flexion. Medial patellofemoral ligament reconstruction, along with reconstructive procedures to correct anatomic abnormality were simulated. Of all the simulations performed, the healthy equivalent control models showed the least patellar internal–external rotation, medial–lateral translation, and medial patellofemoral ligament restraining load during lateral loading tests. Isolated restorative medial patellofemoral ligament reconstruction was the surgery that resulted in the most patellar internal–external rotation, medial–lateral translation, and medial patellofemoral ligament reaction force across all flexion angles. Patient-specific reconstruction to correct anatomic abnormality was the only surgical group to have non-significantly different results compared with the healthy equivalent control group across all joint stability metrics evaluated. Statement of clinical significance: This study suggests patient-specific reconstructive surgery that corrects underlying anatomic abnormalities best reproduces the joint stability of an equivalent healthy control when compared with the pre-injury state, generic tibial tubercle osteotomy, and less invasive patient-specific surgery. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:768-776, 2020     

改良髌骨双骨道法自体股薄肌腱重建髌骨内侧支持带治疗复发性髌骨脱位

目的探讨改良髌骨双骨道法自体股薄肌腱重建髌骨内侧支持带（medial patellofemoral ligament,MPFL）治疗复发性髌骨脱位的临床效果,同时探讨解剖高危因素对术后效果的影响。方法2007年1月-2010年2月,对36例髌骨复发性脱位（单侧31例,双侧5例）采用改良髌骨双骨道法自体股薄肌腱重建MPFL,在髌骨内上缘由后内向前外向髌骨内1／2表面平行钻2个3．5mm骨道,将股薄肌腱引过骨道,将股薄肌腱的两游离端拉入股骨内侧骨道,屈膝30。位可吸收螺钉固定。对所有患者的Beighton评分,Q角,Insall指数,滑车发育不良分级,胫骨结节一滑车沟距离（TT—TG）等进行测量。临床评分采用Kujala,Lysholm和Tegner评分,同时调查患者的满意度。结果32例对手术的效果非常满意,3例满意,1例不满意。Kujala、Lysholm、Tegner评分分别由术前（64．34-15．0）、（65．1±18．6）、（3．2±1．1）分显著提高到术后（92．4±9．2）分（t=4．657,P=0．002）,（92．0±10．1）分（t=3．936,P=0．006）和（5．2±1．0）分（t=6．633,P=0．001）。80．6％（29／36）的患者在术后6—8个月恢复到受伤前的运动水平。1例术后1年再次髌骨脱位。97．6％（40／41）的膝关节存在股骨滑车发育不良,Beighton评分（5．2±2．5）分,Insall指数为1．22±0．14,Q角（13．6±3．9）°,TT-TG值（13．7±4．4）mm,与功能评分无相关性（P〉0．05）。结论自体股薄肌腱改良髌骨双骨道法重建MPFL是一种可靠安全经济的手术方法。高危解剖因素如高位髌骨、滑车发育不良、关节松弛等情况广泛存在于髌骨复发性脱位的患者中,虽未发现其严重程度会直接影响手术效果,但当复合因素存在时,仅重建MPFL的软组织手术可能不足以完全防止髌骨脱位复发。     

Electromyographic investigation of unstable patella before and after its realignment operation

Background:

Patellar dislocations are either due to superolateral contracture of the soft tissue or imbalance of the power between the vastus medialis (VM) and the vastus lateralis (VL). The imbalance of muscle power as an etiology of patellar dislocation has not been studied. Hence, we studied the recurrent, habitual and permanent dislocations of the patella with an electromyogram (EMG) of the vastus medialis, vastus lateralis, and pes anserinus, before and after realignment operations, to document the muscle imbalance and effectiveness of the realignment operation.

Materials and Methods:

An electromyographic investigation was carried out on the vastus medialis and vastus lateralis in nine recurrent, 20 habitual, and 13 permanent dislocations of the patella, before and after their realignment operations. Pes anserinus transposition, which acted as a medial stabilizer of the patella, was also investigated with an EMG study, to understand its role on patellar stability at 0°, 30°, 60°, 90°, 120°, 150°, and full flexion of the knee. The age of the patients varied from nine to 30 (mean 15) years. There were 24 males and 18 females. Twenty-six patellar dislocations were on the right and 16 were on the left side.

Results:

Electromyographic pictures reveal subnormal activity of the vastus medialis in all types of dislocations and similar activities of the vastus lateralis in permanent and habitual dislocations recorded pre operatively, which recovered to almost normal values postoperatively, at the mean one-year follow-up. Pes anserinus, which was used for medial stabilization of the patella after its realignment, maintained normal EMG activity before and after the operation.

Conclusion:

This study is significant for understanding the imbalance of muscle activities in patients with an unstable patella, which can be rectified without recurrence after pes anserinus transposition.     

The Outcome of Total Knee Arthroplasty With and Without Patellar Resurfacing up to 17 Years: A Report From the Australian Orthopaedic Association National Joint Replacement Registry

BackgroundPatellar resurfacing in total knee arthroplasty (TKA) remains a controversial issue after more than 4 decades of TKA. Despite a growing body of evidence from registry data, resurfacing is still based largely on a surgeon’s preference and training. The purpose of this study is to provide long-term outcomes for patellar resurfaced compared to when the patella is not resurfaced.MethodsData from the Australian Orthopaedic Association National Joint Replacement Registry (1999-2017) were used for this study. The analysis included 570,735 primary TKAs undertaken for osteoarthritis. Hazard ratios (HRs) and 17-year cumulative percent revision rates were used to compare revision rates between 4 subgroups: minimally stabilized (MS) patellar resurfacing, posterior stabilized (PS) patellar resurfacing, MS unresurfaced, and PS unresurfaced patella. Additional analyses of the patellar implant type and a comparison of inlay and onlay patellar resurfacing were also performed.ResultsFor all primary TKA, procedures where the patella was not resurfaced have a higher rate of revision compared to procedures where the patella was resurfaced (HR, 1.31; confidence interval, 1.28-1.35; P < .001). Unresurfaced PS knees have the highest cumulative percent revision at 17 years (11.1%), followed by MS unresurfaced (8.8%), PS resurfaced (7.9%), and MS resurfaced (7.1%). Inlay patellar resurfacing has a higher rate of revision compared to onlay patellar resurfacing (HR, 1.27; confidence interval, 1.17-1.37; P < .001).ConclusionResurfacing the patella reduces the rate of revision for both MS and PS knees. MS knees with patellar resurfacing have the lowest rate of revision. Onlay patella designs are associated with a lower revision rate compared to inlay patella designs.     

Do surgical patellar interventions restore patellar kinematics in fixed-bearing,cruciate-retaining total knee arthroplasty? : An in vitro study

Despite different surgical patellar interventions, the decision how to treat the patella during TKA remains controversial. The purpose of this study was to quantify the effect of different reconstructive patellar interventions on patellar kinematics during TKA using optical computer navigation. We implanted ten navigated TKAs in full body specimens. During passive motion, the effect of different surgical patellar interventions on patellar kinematics was analysed. A contrarily tilt behaviour was observed in the TKA group without patellar intervention compared to the natural knee. Lateral release led to similar tilt values (P < 0.05). All surgical interventions led to a 3 to 5 mm medial shift of the patella (P < 0.05). None of the analysed surgical patellar interventions could restore natural patellar kinematics after TKA.     

Vascular supply at risk during lateral release of the patella during total knee arthroplasty: A cadaveric study

IntroductionLateral release to improve patellar tracking is commonly performed during total knee arthroplasty. Blood is supplied to the lateral patella by two main arteries: the superior and inferior lateral genicular arteries. The transverse infrapatellar artery also branches off the lateral inferior genicular artery to supply the inferior half of the patella. Severance of any of these arteries during lateral release can lead to avascular necrosis of the patella. This cadaveric study investigates the lateral vasculature to the patella and whether it can be visualized and preserved during lateral release of the patella.Materials and methodsThis study involved ten cadavers, each of which underwent lateral release of the patella. One senior joint surgeon performed and supervised the incisions and attempted to locate and preserve these vessels. We then quantified the number of cadavers with visualized blood vessels and analysed their location and course to determine whether they could be preserved during lateral release of the patella.ResultsIn our study, three of the ten cadavers had an artery that was visible within the incisional plane and preserved. Two were the inferior lateral genicular artery, and one was the superior lateral genicular artery. In the other seven cadavers, no vessels were visualized during the lateral dissection.ConclusionsThese results demonstrate that it is difficult to visualize blood supply to the patella during lateral release. Every attempt should be made to preserve these blood vessels to avoid devascularization to patella in the setting of an already severed medial vascularity due to standard approach to knee replacement.     

Sectioning the medial patellofemoral ligament alters patellofemoral joint kinematics and contact mechanics

Medial patellofemoral ligament (MPFL) disruption may alter patellofemoral joint (PFJ) kinematics and contact mechanics, potentially causing pain and joint degeneration. In this controlled laboratory study, we investigated the hypothesis that MPFL transection would change patellar tracking and PFJ contact pressures and increase the distance between the attachment points of the MPFL. Eight fresh frozen dissected cadaveric knees were mounted in a rig with the quadriceps and ITB loaded to 205 N. An optical tracking system measured joint kinematics, and pressure sensitive film between the patella and trochlea measured PFJ contact pressures. Length patterns of the distance between the femoral and patellar attachments of the MPFL were measured using a suture led to a linear displacement transducer. Measurements were repeated with the MPFL intact and following MPFL transection. A significant increase in the distance between the patellar and femoral MPFL attachment points was noted following transection (p < 0.05). MPFL transection resulted in significantly increased lateral translation and lateral tilt of the patella in early flexion (p < 0.05). Peak and mean medial PFJ contact pressures were significantly reduced and peak lateral contact pressures significantly elevated in early knee flexion following MPFL transection (p < 0.05). MPFL transection resulted in significant alterations to PFJ tracking and contact pressures, which may affect articular cartilage health. © 2013 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 31:1423–1429, 2013