关节镜辅助内侧髌股韧带探查修补治疗初次髌骨脱位或半脱位

[目的]探讨关节镜辅助下内侧髌股韧带(medial patellofemoral ligament,MPFL)探查修补治疗初次髌骨脱位或半脱位的手术方法及临床效果.[方法]先行关节镜检查,仔细观察髌股关节对合情况,伴发伤给予镜下相应处理.髌骨内侧纵形或斜形切口,切开后仔细查找MPFL,对于MPFL探查明显破裂者,给予修补缝合;探查不明显者,可取一1.2 cm左右宽度的条状内侧支持带,远髌骨端游离,通过关节镜监视,在适当的张力下,将游离端缝合在内侧副韧带股骨止点处.股内侧肌和远端切口缝合,将重建韧带包埋.[结果]术后随访时间为12～56个月,平均23个月,关节功能良好,髌骨稳定性好,髌股关节对合良好,与健侧对比无明显差异.术后Lysholm评分:优25膝,良4膝,可1膝,优良率为96.67%.[结论]关节镜辅助下内侧髌股韧带探查修补治疗初次髌骨脱位或半脱位,直观,准确,能够有效防止其复发脱位,对于维持髌骨的稳定性有重要作用.     

关节镜辅助下手术治疗成人习惯性髌骨脱位

目的评价关节镜辅助下治疗成人（骨骺发育成熟患者）髌骨习惯性脱位的临床疗效。方法在关节镜辅助下,应用改良Maquet术及内侧髌股韧带解剖重建术治疗成年人习惯性髌骨脱位8例,年龄16～32岁,平均为21.5岁;术后通过平均20.6个月（15～28个月）的随访,了解膝关节脱位复发、Q角改变情况,并采用Lysholm评分评估患肢整体功能康复情况。结果所有病例均未发生再脱位,且疼痛均明显减轻。手术前后Q角分别为（20.6±3.5）°和（12±1.2）°（P〈0.01）,伸膝力线均有所改善。术前和术后Lysholm膝关节功能评分为（52.00±11.25）分和（86.06±9.62）分（P〈0.05）,所有患者的运动能力均较术前有一定改善。结论在关节镜辅助下手术治疗成人习惯性髌骨脱位,术后膝关节功能恢复,主客观疗效均较满意。     

早期内侧髌股韧带重建治疗急性创伤性髌骨脱位疗效分析

目的评估早期内侧髌股韧带(medial patellofemoral ligament,MPFL)重建治疗急性创伤性髌骨脱位的临床疗效。方法急性髌骨创伤性脱位病人15例,伤后早期行MPFL重建手术治疗。术后定期随访,评估髌骨稳定性,并比较病人伤前及术后末次随访的膝关节Lysholm评分、Kujala评分和Tegner评分。结果所有病人术后随访平均18.6个月。末次随访时,均未出现髌骨再次脱位,体检髌骨外推试验及恐惧试验均为阴性。伤前膝关节Lysholm评分、Kujala评分和Tegner评分分别为(90.6±13.1)分、(92.3±12.4)分和(5.9±1.3)分;术后末次随访评分分别为(91.2±12.5)分、(95.1±13.2)分和(6.2±1.6)分,与伤前比较差异无统计学意义(P0.05)。结论急性创伤性髌骨脱位早期行MPFL重建手术,能够良好恢复髌骨稳定性和膝关节功能。     

复发性髌骨脱位治疗的现状及进展

复发性髌骨脱位是以膝关节周围持续弥漫性钝痛、膝关节不稳、肿胀以及髌骨反复向外侧脱位为主要表现。其致病因素主要包括:1膝关节外侧支持带挛缩;2膝关节内侧支持带松弛;3股骨外髁和/或髁间凹发育不良;4膝外翻畸形;5髌腱止点偏外;6股骨内(外)旋;7高位髌骨。目前治疗方法很多,主要包括4大类:1髌骨近端力线调整:膝关节外侧支持带松解术、内侧支持带或关节囊紧缩术、内侧髌股韧带重建术和股内侧肌止点移位术;2髌骨远端调整:包括肌腱转位术、髌腱手术、胫骨结节移位术和股骨滑车成形术;3髌骨切除股四头肌成形术;4关节镜辅助技术。但目前尚无一种统一有效的术式能够治愈复发性髌骨脱位。     

急性髌骨脱位的关节镜治疗

目的探讨关节镜辅助治疗急性髌骨脱位的疗效。方法对15例急性髌骨脱位患者结合临床表现、骨骺闭合、TT-TG值等情况,采用关节镜辅助下清理术、外侧支持带松解、内侧关节囊重叠缝合、内侧髌股韧带重建及胫骨结节内移术等不同术式联合治疗。手术前后采用Lysholm评价表进行评分。结果患者均获得随访,时间4～20(15±2.3)个月。Lysholm评分术前(65.00±11.35)分,术后改善至(91.27±4.17)分,差异有统计学意义(P<0.05)。术后无髌骨再脱位发生,髌骨倾斜和恐惧试验均阴性。结论对急性髌骨脱位患者,结合具体病情,采用关节镜辅助下不同手术联合方案,可收到良好疗效。     

复发性髌骨脱位的临床治疗分析

目的 通过关节镜下行膝关节外侧支持带松解、内侧髌股韧带重建联合胫骨结节内移治疗复发性髌骨脱位,观察其临床效果。方法 分析中国人民解放军联勤保障部队第九四〇医院2019年4月至2020年4月治疗的20例复发性髌骨脱位患者,其中男5例,女15例;年龄13～34岁,平均25岁。股骨滑车发育不良分型,A型3例,B型5例,C型8例,D型4例。先行膝关节腔内探查术,探查完毕后行关节镜下髌股外侧支持带松解术,取同侧半腱肌肌腱移植髌股内侧韧带重建术,术前测量胫骨结节-股骨滑车间距(tibial tuberosity-trochlear groove distance, TT-TG)>20 mm者同时行胫骨结节内移截骨术,对于合并股骨或髌骨关节面骨折和软骨损伤患者,尽最大可能复位骨折,修复关节软骨。结果 术后随访6～12个月,均未出现再次脱位,患侧膝关节恐惧试验阴性,无膝关节打软。末次随访平均髌股关节功能评分(60.8±7.2)分,与术前比较差异有统计学意义(P<0.05)。结论 关节镜下髌外侧支持带松解、取同侧半腱肌肌腱移植重建髌股内侧韧带重建术,联合胫骨结节内移术治疗复发性髌骨脱位,临床...     

髌骨双骨道双束重建与单束等张重建内侧髌股韧带治疗复发性髌骨脱位的疗效对比

[目的]对比观察髌骨双骨道双束重建和单束等张重建内侧髌股韧带治疗复发性髌骨脱位的临床效果。[方法]回顾性研究2010年1月~2013年10月在本院治疗的复发性髌骨脱位患者共78例(78膝),男28例(28膝),女50例(50膝),年龄16~26岁。单束重建组40例(40膝),双束重建组38例(38膝)。术后随访记录髌骨再脱位的病例数。复查术后屈膝20°CT测量髌骨外移率、髌股适合角、髌骨倾斜角,进行膝关节Kujala功能评分。应用SPSS 19.0统计学软件包分析随访数据。[结果]所有患者随访10~14个月,平均12个月,均未出现切口不愈合、深静脉血栓、髌骨再次脱位、髌骨骨折情况,分别对比单束重建组和双束重建组手术前后指标,术后髌骨外移率、髌股适合角、髌骨倾斜角、膝关节Kujala功能评分均较术前改善(P0.05),对比单束重建组和双束重建组两组术后髌骨外移率、髌股适合角、髌骨倾斜角、膝关节Kujala功能评分,差异均无统计学意义(P0.05)。[结论]髌骨双骨道双束重建和单束等张重建内侧髌股韧带均可以有效恢复髌骨稳定性,改善膝关节功能,短期临床疗效对比两种重建方法无显著差别。     

改良的髌骨单隧道重建内侧髌股韧带手术治疗复发性外侧髌骨脱位

目的 观察改良的髌骨单隧道重建内侧髌股韧带手术治疗复发性外侧髌骨脱位的手术疗效。方法 回顾性分析自2015-03—2021-03采用改良的髌骨单隧道重建内侧髌股韧带手术治疗的40例（40膝）复发性外侧髌骨脱位,观察术后髌骨滑车对合关系及韧带在股骨内侧和髌骨内缘的位置,手术疗效采用IKDC膝关节评分、膝关节Lysholm评分和Tegner评分进行评估,同时测评髌骨外推试验、髌骨恐惧试验是否阳性,测量髌骨倾斜角并记录髌骨脱位有无复发和症状缓解情况。结果 40例均获得随访,随访时间13～72个月,平均36个月。随访期间均无髌骨再次脱位,髌骨恐惧试验和髌骨外推试验均为阴性,无疼痛等不适情况。术后第12、24个月IKDC膝关节评分、膝关节Lysholm评分和Tegner评分都明显高于术前,差异有统计学意义（P<0.05）;但是术后第12个月与第24个月IKDC膝关节评分、膝关节Lysholm评分和Tegner评分差异无统计学意义（P>0.05）。术后第12、24个月髌骨倾斜角都明显小于术前,差异有统计学意义（P<0.05）;但是术后第12个月与第24个月髌骨倾斜角差异无统计学意...     

内侧髌股韧带重建治疗髌骨脱位患者的康复护理

目的探讨内侧髌股韧带重建治疗髌骨脱位手术后的康复护理方法。方法对99例髌骨脱位患者行内侧髌股韧带重建治疗,术前行心理护理和功能锻炼,术后采取持续的、渐进式的功能康复锻炼,包括膝关节活动度和股四头肌肌力锻炼。结果 99例患者手术顺利,术前、术后坚持康复锻炼,无并发症发生,平均住院5.0 d出院;术后随访3~26个月,未发生屈、伸膝受限及再脱位。结论围手术期针对性的护理和康复指导可以有效地提高患者的主观能动性,积极进行功能锻炼,达到满意疗效。     

内侧髌股韧带重建治疗髌骨脱位患者的康复护理

目的探讨内侧髌股韧带重建治疗髌骨脱位手术后的康复护理方法。方法对99例髌骨脱位患者行内侧髌股韧带重建治疗,术前行心理护理和功能锻炼,术后采取持续的、渐进式的功能康复锻炼,包括膝关节活动度和股四头肌肌力锻炼。结果 99例患者手术顺利,术前、术后坚持康复锻炼,无并发症发生,平均住院5.0 d出院;术后随访3~26个月,未发生屈、伸膝受限及再脱位。结论围手术期针对性的护理和康复指导可以有效地提高患者的主观能动性,积极进行功能锻炼,达到满意疗效。     

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。     

The mechanism of primary patellar dislocation

Background and purpose Several mechanisms are responsible for patellar dislocation. We investigated how the primary pathomechanism relates to patient characteristics and the outcome.

Methods 126 patients (81 females) with primary patellar dislocation reported the knee position before the episode, the movement during it, and whether the patella was locked in dislocation. The median age was 20 (9–47) years. The subjective outcome and Kujala, Hughston VAS, and Tegner scores were evaluated after an average of 7 years.

Results 102 patients moved to flexion during the dislocation, 98 from a straight start and 4 from a well-bent start. 10 extended the knee from a well-bent start; they were older (mean 25 vs. 19 years) and more often had low trauma energy (5/10 vs. 15/102) and a locked dislocation (10/10 vs. 50/102). 4 had a direct hit to the knee and 1 only rotated it while stretching. 24 of 60 patients with open growth line of the tibial tubercle and 43 of 66 with closed tubercle had locked primary dislocation (p = 0.005). 33% of girls, 52% of boys, 57% of women, and 71% of men had locked primary dislocation. There was no correlation between trauma mechanism and outcome.

Interpretation Movement to flexion occurred in 84% of primary patellar dislocations and movement to extension in 8%. Spontaneous patellar relocation is common in skeletally immature girls and locked dislocation is common in skeletally mature men.     

Operative treatment of primary patellar dislocation does not improve medium-term outcome

Background?The best treatment for primary patellar dislocation has been the subject of debate. Surgery has been recommended for all patients or for special subgroups to improve outcome. We have previously reported similar 2-year results after closed or open treatment. This report concerns 127 patients who were re-evaluated by questionnaire at least 5 years after the primary onset.

Patients and methods?At baseline, the patients were randomized regarding closed treatment (57) or individually adjusted proximal realignment operation (70). All patients were re-evaluated after a mean follow-up of 7 (6-9) years.

Results?The outcomes were similar: the patient's own overall opinion was excellent or good after closed treatment in 81% of cases and after operative treatment in 67%. Mean Kujala and Hughston VAS knee scores were 90 and 94, respectively, after closed treatment and 88 and 89 after operative treatment. The proportions of stable patellae were 30% and 36% for closed treatment and operative treatment, respectively. In a multivariate risk analysis, there was a correlation between a Kujala score of less than 90 and female sex (OR: 3.5; 95% CI: 1.4-9.0), loose bodies on radiographs (4.1; 1.2-15), and also an initial history of contralateral patellar instability (3.6; 0.9-15). There were 2 risk factors for recurrent instability: initial contralateral instability (4.9; 0.9-28) and young age (0.9; 0.8-1.0/year). Girls with open tibial apophysis had the worst prognosis for instability (88%; 95% CI: 77-98).

Interpretation?We do not recommend proximal realignment surgery for treatment of primary dislocation of the patella.     

关节镜手术治疗急性髌骨脱位的临床疗效分析

目的：探讨关节镜在急性髌骨脱位中的应用,评价关节镜下治疗方法的临床疗效。方法：2002年5月至2009年3月,共收治急性髌骨脱位36例,男6例,女30例;年龄12～30岁,平均20.5岁;左侧15例,右侧21例,均为单侧受累。术前对所有患者行放射学检查观察股骨髁发育、下肢对线状况,测量Q角、股骨滑车角。全部病例在关节镜下手术,取出游离骨软骨碎片,松解外侧支持带以及皮下紧缩缝合内侧支持带。结果：随访13～60个月,平均42个月,均未发生感染等并发症,全部病例膝关节活动恢复正常,无疼痛、绞锁等症状。Lysholm评分由术前平均（28.9±2.5）分增加到术后平均（95.1±8.4）分,未发生再脱位。结论：急性髌骨脱位是一个潜在的破坏性损伤,关节镜手术治疗在急性髌骨脱位中实用,创伤小,恢复快,有效且可靠。     

复发性髌骨脱位的治疗现状

复发性髌骨脱位的主要表现是膝关节周围广泛的疼痛、肿胀和反复的髌骨向外侧脱位。其发病的主因是患者存在膝关节解剖结构异常,如Q角增加、髌骨高位、股骨外髁发育不良、髌骨形态异常、股直肌内侧头萎缩或股直肌外侧头肥大等。本文综述45篇文献,总结了其手术治疗方法。目前复发性髌骨脱位的治疗方法有很多种,大致包括五类:外侧松解、伸膝装置近端重排、伸膝装置远端重排、伸膝装置远、近端联合手术及髌骨切除和股四头肌成形修补术。其中远端重排手术效果最佳,目前尚无一种方法能成功地用于矫正复发性髌骨脱位。     

关节镜辅助治疗创伤性髌骨脱位

[目的]探讨关节镜辅助治疗创伤性髌骨脱位方法和疗效.[方法]2001年1月～2008年7月收治创伤性髌骨脱位25例,男18例,女7例.左膝9例,右膝16例,平均年龄(20.7±4.6)岁.病人人选条件:所有病人均有明确膝关节暴力外伤史,排除关节松弛和髌股关节发育异常.初次急性脱佗13例,以前有脱位史近期再脱位者12例.先行关节镜检查并清理关节腔内积血和处理关节丽受伤后,拇指推髌骨外缘向内,若髌骨复位无明显障碍,只做髌内侧支持带修复术;若外侧支持带紧张影响复位,则先行髌骨外侧支持带松解后再修复内侧支持带.[结果]25例病人获得随访,术后随访9～96个月,平均26.7个月.全部病例未再次发生脱位,恐惧试验全部阴性.关节活动度均在正常范围,4例关节过屈时有轻度紧张感,随访病人均恢复创伤前的生活状态.以Lysholm临床评分系统对膝关节功能进行评估,由术前平均46.5分改善为术后平均评分93.5分(80～100分)(P<0.01).摄X线片及MRI复查,髌股关节关系正常,原关节面损伤区无扩大或进一步退变.[结论]初次创伤性髌骨脱位,若无发育异常,并不一定需要行外侧支持带松解,仪修复内侧支持带结构就可恢复髌骨的位置,对初次脱位和多次脱位病例采取不同的内侧支持带结构修复方法,可以进一步减小创伤又不影响疗效.     

Surgical versus conservative treatment of primary patellar dislocation. A systematic review and meta-analysis

Purpose

The purpose of this study was to determine the efficacy of surgical and conservative treatment in the prevention of recurrence after primary patellar dislocation.

Methods

Studies were searched on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINHAL from their inception to April 2015. All randomized controlled clinical trials comparing surgical versus conservative treatment after first patellar dislocation were included. Primary outcomes were: recurrent dislocation, subluxation, overall instability and subsequent surgery. Secondary outcomes included imaging, and subjective and objective clinical assessment tools. Methodological quality of the studies was assessed using Cochrane Collaboration’s “Risk of Bias” tool. Pooled analyses were reported as risk ratio (RR) using a random effects model. Continuous data were reported as standardized mean difference (SMD) and 95 % confidence intervals (CIs). Heterogeneity was assessed using I².

Results

Nine studies were included in the meta-analyses. Methodological quality of the studies was moderate to low. Meta-analyses showed that surgical treatment significantly reduces the redislocation rate (RR?=?0.62; 95% CI?=?0.39, 0.98, p?=?0.04) and provides better results on Hughston VAS score (SMD?=??0.32; 95% CI?=??0.61, ?0.03; p?=?0.03) and running (OR?=??0.52; 95% CI?=?0.31, 0.88; p?=?0.01). Conservative treatment showed less occurrence of minor complications (OR?=?3.46; 95% CI?=?2.08, 5.77; p?=?0.01) and better results in the figure-of-8 run test (SMD?=?0.42; 95% CI?=?0.06, 0.77; p?=?0.02) and in the squat down test (SMD?=??0.45; 95% CI?=??0.81, ?0.10; p?<?0.00001). No other significant differences could be found.

Conclusions

Based on the available data, surgical treatment of primary patella dislocation significantly reduces the risk of patella redislocation.

     

经骨缝合手术治疗急性髌骨脱位合并髌骨软骨Peeloff损伤早期疗效观察

目的评价经骨缝合手术治疗急性髌骨脱位合并髌骨软骨骨折(Peeloff损伤)的早期临床疗效。方法回顾性分析自2019-05—2020-03诊治的15例急性髌骨脱位合并髌骨软骨Peeloff损伤,膝关节镜检查并确诊髌骨软骨缺损,关节腔内找到与缺损区域吻合的游离软骨片,关节镜下或内侧小切口取出游离软骨片;再作髌内侧切口,将游离软骨片复位并在其边缘选取4个合适进针点,用带孔克氏针在髌骨主体上从内向外垂直钻孔,每两孔之间导入可吸收缝线,经孔道将克氏针抽出时带出缝线并打结。结果 15例均获得随访,随访时间平均8(3~13)个月。术后3个月MRI显示所有患者髌骨关节面软骨骨折均愈合。2例出现早期髌股关节疼痛(1例VAS评分为4分,1例VAS评分为5分),经康复治疗后好转,其余13例疼痛VAS评分平均1.8(1~3)分。末次随访时Tegner运动评级:3级5例,4级9例,5级1例。末次随访时膝关节功能Lysholm评分80~96(88.9±4.7)分,其中优6例,良7例。结论关节镜下探查可确诊急性髌骨脱位合并的髌骨软骨Peeloff损伤,采用可吸收缝线经骨缝合固定髌骨关节面软骨片无需特殊内固定器械及二次手术取出,既能实现软骨稳定固定、正常愈合,又能保证膝关节功能良好恢复。     

综合术式治疗髌骨习惯性脱位

目的 探讨治疗习惯性髌骨脱位的手术方法。方法 利用外侧松解、内侧紧缩、股内侧肌止点下移、外侧1／2半髌韧带止点或胫骨结节内移及内侧筋膜瓣牵拉治疗10例（12膝）习惯性髌骨脱位患者。结果 随访3个月－2年,患者关节功能良好,髌骨脱位无复发,优良率75％。结论 该方法简单易行,效果肯定。