Arthroscopic repair of the medial retinaculum after first time dislocation of the patella

Between March 1994 and December 1997, an arthroscopic repair of the medial retinaculum after first time dislocation of the patella was performed 38 times in 34 patients. The operative technique is being described as well as the results after an average follow-up of 25 months in 31 cases. In the group with radiologically determined predisposing factors (n = 20) as many osteochondral flakes were found as in the group without these factors, but there were significantly less chondral lesions on the lateral femoral condyle and the medial patellar facet. There were no complications during hospitalization, although in 3 (10 %) cases a redislocation occurred during follow-up. According to the subjective Turba Score, 84 % of the patients showed a good or very good, and 16 % a fair result, including cases with redislocation. The arthroscopic repair of the medial retinaculum after first time patellar dislocation is a minimal invasive method with very low peri- and postoperative morbidity. The redislocation rate can be reduced to at least 50 % compared to the published data on conservative treatment.     

髌股关节发育不良对髌骨脱位磁共振成像表现的影响

背景：当存在髌股关节发育不良时,髌骨脱位的损伤程度较轻,因此更加依赖影像学诊断。 目的：比较髌股关节发育不良患者和髌股关节发育正常患者髌骨脱位时磁共振成像（MRI）表现的异同。 方法：回顾性分析54例经临床证实的髌骨脱位患者的MRI影像学资料。髌股关节发育不良患者32例,髌股关节发育正常患者22例。记录患者MRI中髌骨内侧骨挫伤或撕脱骨折、髌骨关节面骨软骨骨折、股骨外侧髁外侧部骨挫伤、髌股内侧支持带撕裂等情况。 结果：髌股关节发育不良组的32例患者中,髌骨内缘骨折12例,内侧支持带损伤10例,髌骨软骨损伤7例,股骨外髁骨挫伤18例;髌股关节发育正常组的22例患者中,髌骨内缘骨折8例,内侧支持带损伤14例,髌骨软骨损伤14例,股骨外髁骨挫伤14例。两组在内侧支持带损伤和髌骨内缘骨折上有显著统计学差异（P＜0.05）。 结论：MRI可以较好地诊断髌骨脱位。当髌股关节发育不良时,内侧支持带损伤和髌骨内缘骨折的发生率降低。     

关节镜辅助下小切口重建内侧髌股韧带治疗创伤性复发性髌骨脱位

目的探讨关节镜辅助下小切口同种异体肌腱重建内侧髌股韧带(MPFL)治疗创伤性复发性髌骨脱位的临床效果。方法回顾性分析自2006年1月～2010年4月共收治28例创伤性复发性髌骨脱位,所有患者在第一次脱位均为膝关节外伤所致,伤后患膝明显肿胀及髌骨脱位-复位感,此后出现髌骨脱位3次以上者。手术方法:先行关节镜检查,髌骨外侧支持带紧张者行松解术,关节镜监视下调整MFPL的张力并于其解剖止点以同种异体肌腱重建MFPL,术后接受正规功能康复锻炼。结果术后平均随访26个月(12～36个月)。重建术后无髌骨再次脱位发生,髌股关节稳定。术前、术后均采用Lysholm和Kujala膝关节评分标准,手术前后评分差异有统计学意义(P<0.05)。结论选择适当的病例,重建内侧髌股韧带是治疗创伤性复发性髌骨脱位的有效方法。     

A new minimally invasive surgical technique for medial retinaculum repair following traumatic patellar dislocation

A new surgical method is introduced offering a less invasive approach to reattach the medial retinaculum following acute patellar dislocation. This retrospective analysis comprised 12 cases of medial retinacular repair in 10 patients. The surgical technique achieved reinforced reattachment of the torn region of the medial retinaculum for improved patellar support and stabilization. During follow-up, no recurrent patellar dislocations occurred, except where one patient reported a subjective feeling of patellar dislocation. The average Kujala score for our sample group after 2 years was 89.2. A plethora of methods are described in the literature to repair a tear to the medial patellofemoral ligament, which attaches at the superomedial patella. However, it is our contention that traumatic patellar dislocation invariably results in osteochondral avulsion at the inferomedial patella, refuting medial patellofemoral ligament involvement, and, rather, implicating the inferior aspect of the deep layer of medial retinaculum. Our surgical technique enables stable fixation of the region, decreasing the rate of recurrent dislocations. No grafts are used, permitting tendinous and ligamentous anatomy to remain intact. We further postulate that performing a CT examination preoperatively may reduce time between diagnosis and surgery, in addition to locating fracture sites more precisely.     

Arthroscopic repair of the medial retinaculum and capsule in acute patellar dislocations

Treatment for acute dislocations of the patella is highly controversial among many knee surgeons. This study proposes an arthroscopic technique for the surgical repair of the retinacular-capsular defects caused from acute patellar dislocation. The clinical material used involved 30 cases with no previous history of patellar instability and with history of documented lateral dislocation accompanied by an acute hemarthrosis. All individuals in this study were treated with arthroscopic medial capsular-retinacular repair and lateral retinacular release. The follow-up on these patients, ranging from 1 to 7 years postoperatively, revealed that the results of treatment were gratifying in all instances with the exception of one traumatic redislocation. It appears that the arthroscopic procedure used in this study was successful in stabilization of the acute dislocation of the patella, and that it is a beneficial addition to present surgical treatment for the acute dislocation of the patella. This technique provides early accurate diagnosis and, thus, early accurate restoration of normal anatomy. This technique is by no means the only way, but it is one way to obtain satisfactory results in the treatment of this most difficult problem.     

急性滑脱性髌股关节撞击综合征的关节镜下治疗

 目的 探讨急性滑脱性髌股关节撞击综合征的损伤机制、MRI诊断特征以及关节镜下诊治方法。方法 2005年9月至2012年10月应用改良髌内侧支持带紧缩缝合治疗急性滑脱性髌股关节撞击综合征46例,男9例,女37例;年龄15~31岁,平均21.6岁。术前常规行膝关节X线及MR检查,测量Q角、外侧髌股角及髌骨外移度。MRI髌内侧支持带损伤按照Schweitzer分级标准：Ⅰ度15例、Ⅱ度18例、Ⅲ度8例、Ⅳ度5例。手术于关节镜监视下施行,清除关节内积血,关节内探查,取出游离软骨和骨软骨碎片,软骨成形,修整损伤软骨面。对髌内侧支持带Ⅰ度损伤者行关节镜下清理及髌内侧支持带固缩。对髌内侧支持带Ⅱ~Ⅲ度损伤伴明显髌骨移位者采用改良髌内侧支持带紧缩缝合术,对受伤时间超过2周的9例同时行髌外侧支持带松解。对髌内侧支持带Ⅳ度损伤者行切开加固缝合。结果 急性滑脱性髌股关节撞击综合征的关节镜下表现包括关节内血肿46例、股骨外髁和髌骨内侧骨软骨损伤37例、游离体形成28例及髌内侧支持带撕裂46例。所有病例均获得随访,随访时间12~36个月,平均18.2个月,无感染、神经血管损伤和再脱位等并发症发生。手术前后Lysholm膝关节评分、Tegner膝关节运动水平评分、AAOS膝关节评分、外侧髌股角及髌骨外移度的差异有统计学意义,患者运动功能均较术前有所改善。结论 关节镜下改良髌内侧支持带紧缩缝合辅助髌外侧支持带松解术,是治疗急性滑脱性髌股关节撞击综合征髌内侧支持带Ⅱ~Ⅲ度损伤的有效方法,有利于恢复膝关节功能,近期疗效好。     

Significance of lateral release in the therapy of patellar chondromalacia

A retrospective study was performed in 26 patients who underwent an operation for femoro-patellar pain due to a patellar chondromalacia with or without minor patellar dislocation/lateral pressure syndrome. The average age of the patients was 28.5 (15-39) years. 22 of the 26 patients revealed minor chondral damages of the stages 1 and 2 according to Outerbridge. In 12 patients ("lavage" group), an arthroscopic joint debridement only was carried out, while an additional open, lateral retinaculum release was made in 14 patients ("lateral release" group). The patella's distance of dislocation according to Hepp was reduced on an average of 3.0 (0-7) mm (p = 0.0019). The results of Bentley's score obtained during the follow-up interval on an average of 30.1 (9 to 60) months were almost identical for both groups. "Good" and "very good" results were achieved in the "lavage" group (83.3 %) and "lateral release" group (78.6 % of the patients). Lateral release should be used in cases of patellar decentration between 5 and 10 mm and adequate pain symptoms. The post-operative distance of dislocation should be less than 5 mm. Under such conditions and with minor chondral damage, a combined approach by using an arthroscopic joint debridement and open lateral release is promising to treat a patellar dislocation/lateral pressure syndrome.     

急性髌内侧支持带损伤关节镜下修复术的疗效

目的:采用高频超声对急性髌内侧支持带损伤进行准确定位,利用定位点行髌内侧支持带修补术探讨其疗效。方法:回顾性分析2009年6月至2014年3月收治的急性髌骨脱位患者17例,男6例,女11例;年龄11~40岁,平均(16.2±6.2)岁;病史2周以内。术前均行髌内侧支持带的高频超声检查,并对韧带纤维不连续的点位做皮肤标示。5例髌内侧支持带自体部损伤者行关节镜下过线缝补;12例支持带自髌骨边缘止点撕脱者将锚钉固定在骨内,用锚钉自带线缝补。术前及随访18个月时,进行Kujala评分和CT测量髌骨倾斜角,查最大主动、被动屈膝度及髌骨恐惧症。结果:随访18个月后Kujala评分92.2±11.1,髌骨倾斜角(11.5±4.2)°,与受伤前差异无统计学意义。最大主动屈膝(133.5±4.2)°,与正常值无差异。最大被动屈膝(153.5±4.6)°,超声显示髌内侧支持带纤维连续。髌骨恐惧症1例,无髌骨不稳复发。结论:髌内侧支持带损伤在超声定位下完成了准确的定位和关节镜下的修补,术后制动时间短。随访18个月,膝关节功能满意,无髌骨不稳复发。     

急性滑脱性髌股关节撞击综合征的关节镜诊断与治疗

目的探讨急性滑脱性髌股关节撞击综合征的发生机制、病理改变及其关节镜下诊断和治疗方法。方法2000年1月至2003年5月,在关节镜下诊断和治疗急性滑脱性髌股关节撞击综合征25例,均为膝关节急性屈曲外翻扭伤。根据撞击后肌肉松弛状态下髌股关节的稳定性将其分为3型:无脱位型9例,半脱位型11例,脱位型5例。关节镜检查25例均存在软骨损伤、髌骨内侧支持带损伤及关节囊积血,18例有关节内游离体。根据分型及关节镜下检查结果采用不同的手术方式:无脱位型患者行关节清理术;半脱位型患者中髌骨内侧支持带Ⅰ度损伤者,行关节清理术 外侧支持带松解术;半脱位及脱位型患者中,轻者行关节清理术 髌骨内侧支持带缝合术 外侧支持带松解术,严重者或存在滑车发育异常者同时行胫骨结节移位术。结果所有患者均获随访,时间6～46个月,平均17个月。优18例,良4例,可2例,差1例,优良率88%。1例术后1年发生再脱位,2例有关节僵直。结论关节镜检查对急性滑脱性髌股关节撞击综合征的诊断具有极高的价值,可以明确诊断,并对损伤情况作出全面评估及制定合理的治疗方案,修复须紧急处理的结构。对于急性滑脱性髌股关节撞击征早期诊断、早期合理治疗,均可获得良好的效果。     

关节镜下内侧髌股支持带缝合与石膏固定治疗急性髌骨脱位的病例对照研究

目的:比较关节镜下髌内侧支持带紧缩术和石膏固定法治疗急性髌骨脱位的疗效.方法:回顾性分析2006年2月至2012年10月收治的急性髌骨脱位患者29例,病史2周以内,年龄9～31岁,分为手术组和非手术组.手术组17例,男7例,女10例,平均年龄(16.2±6.2)岁,采用关节镜下髌内侧支持带紧缩术治疗;非手术组12例,男5例,女7例,平均年龄(16.3±5.0)岁,行石膏外固定治疗.治疗前及随访1年时,进行Kujala评分,行CT检查测量髌骨倾斜角,观察髌骨恐惧症发生情况.结果:手术组治疗前后髌骨倾斜角差异无统计学意义,治疗后Kujala评分低于治疗前;非手术组治疗后髌骨倾斜角大于治疗前,Kujala评分低于治疗前.随访1年,手术组Kujala评分84.1±5.6,高于非手术组73.3±10.5;髌骨倾斜角(13.5±3.5)°,小于非手术组(21.2±5.3)°.结论:关节镜下采用髌内侧支持带紧缩术治疗急性髌骨脱位相比石膏外固定治疗,在术后1年之内具有更好的效果.     

关节镜下髌骨内侧支持带紧缩术治疗青少年复发性髌骨脱位

目的探讨关节镜下髌骨内侧支持带紧缩术(medial retinaculum plication,MRP)治疗青少年复发性髌骨脱位的临床疗效。方法对2000年3月-2007年10月收治的30例符合选择标准的青少年复发性髌骨患者进行前瞻性研究,其中28例获完整随访者纳入研究。男5例,女23例;年龄12～19岁,平均14.7岁。左膝12例,右膝16例。髌骨首次脱位至入院时间4～39个月,平均18.8个月。患者既往髌骨2～4次脱位。患者髌骨外推恐惧试验均为阳性,髌骨外移度为(2.9±0.7)°,髌骨外推无硬性终止点。国际膝关节文献委员会(IKDC)、Lysholm、Kujala以及Tegner评分分别为(47.7±3.7)、(52.6±4.9)、(66.7±5.9)和(3.1±1.3)分。患者均于关节镜下行MRP治疗。结果患者术后切口均Ⅰ期愈合,无感染或神经、血管损伤等早期并发症发生。患者均获随访,随访时间2～7年,平均4.8年。术后随时间延长,髌骨外推恐惧试验阳性患者数逐渐增加,24个月时为12例;髌骨外推有硬性终止点患者逐渐减少,24个月时为3例;髌骨外移度逐渐增加,24个月为(2.3±1.1)°;以上3项指标除髌骨外移度外,与术前比较差异均有统计学意义(P<0.05)。术后6例发生再脱位,23例出现单纯髌骨不稳。术后24个月IKDC、Lysholm、Kujala以及Tegner评分分别为(62.5±6.2)、(70.7±5.1)、(76.6±4.8)和(3.9±0.7)分,均较术前显著提高(P>0.05)。CT检查示,术后即刻患者髌股关节适配角、髌骨外侧角以及髌骨倾斜角均恢复至正常水平,但术后24个月与术前比较差异均无统计学意义(P>0.05);术后24个月髌骨外移距离与术前比较,差异有统计学意义(P<0.05)。结论关节镜下MRP治疗青少年复发性髌骨脱位虽在改善膝关节功能方面有一定疗效,但不能较好维持髌骨矫正后的位置。     

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。     

关节镜下支持带松解术治疗髌股关节紊乱的评价

为了评价关节镜下外侧支持带松解术治疗髌股关节紊乱的临床价值，我们复习了４０例外侧松解术的资料并进行１－５年的随访。回顾性研究表明，该术式的优良率在髌股关节疼痛伴外侧支持带紧张者中为８７％，在髌股关节骨关节不髌骨不稳者中为５０％，而在髌骨脱位或半脱位组仅为４０％。     

关节镜辅助下三联手术治疗复发性髌骨脱位

目的探讨关节镜辅助下三联手术治疗复发性髌骨脱位的近期疗效。方法对23例复发性髌骨脱位患者在关节镜辅助下行外侧支持带松解、内侧髌股韧带重建及改良Fulkerson截骨术。术后随访,评估影像学检查结果、Tegner下肢运动能力主观评分、Lysholm膝关节功能综合评分和Kujala髌股关节评分。结果 23例均获随访,时间12~36(24.3±7.82)个月。患者无髌骨再脱位或半脱位,Q角在正常范围。患膝CT显示,髌骨/股骨滑车适配角从术前13.30°±5.15°改善至末次随访时5.72°±3.32°(P0.01),髌股关节外侧张开角从术前0.70°±2.85°改善至末次随访时8.13°±2.75°(P0.01)。Lysholm评分从术前47.92分±16.23分提高至末次随访时93.27分±7.91分(P0.01);Tegner评分从术前5.32分±1.10分提高至末次随访时6.37分±0.83分(P0.01);Kujala髌股关节评分从术前55.3分±11.23分提高至末次随访时83.2分±13.91分(P0.01)。结论关节镜辅助下三联手术治疗复发性髌骨脱位能有效防止复发和恢复髌股关节功能,疗效满意。     

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。     

Irreducible dislocation of the knee joint

Posterolateral knee dislocations are very rare and generally irreducible by closed reduction. It is due to interposition of various portions of medial capsule-ligamentous structure in the knee joint space. In such cases, open reduction is recommended. Only a few cases have been reported in the literature. This article presents an unusual case of irreducible knee dislocation, in which the medial femoral condyle buttonholed through the medial retinaculum and capsular structure. Closed reduction attempt was unsuccessful. Open joint reduction was performed. Direct repair of the medial collateral ligament and retinaculum, and arthroscopic assisted posterior cruciate ligament reconstruction were also performed. Arthroscopic-assisted anterior cruciate ligament reconstruction was carried out in staged operation.     

关节镜下改进紧缩髌骨内侧支持带治疗复发性髌骨脱位

目的 探讨关节镜下改进紧缩髌骨内侧支持带治疗复发性髌骨脱位的疗效.方法 我科于2013年7月至2015年7月收治复发性髌骨脱位病人23例,男4例,女19例,年龄为10~25岁,平均为15.8岁.手术在关节镜下操作,用等离子刀常规进行松解髌骨外侧支持带,用ACCU PASS自动连续传递缝合钩将PDS缝线四等分整体跨越髌骨内侧支持带,采用对称集中打结法拉紧缝线,实现对髌骨内侧支持带的有效紧缩.术后鼓励病人在膝关节支具保护下早期进行功能锻炼.比较手术前后Lysholm膝关节评分、Tegner膝关节运动水平评分和髌骨外移度.结果 单膝的关节镜下操作时间为40~55 min,平均为46.4 min.术中实现髌股关节面复位,屈膝关节活动(0°~90°)时髌骨活动轨迹满意,病人没有发生再脱位.随访时间为18~36个月,平均为24.6个月.末次随访时病人髌骨位置满意,膝关节静息位或屈伸活动时未发生髌骨再脱位.术后18个月Lysholm膝关节评分为(79.6±5.4)分、Tegner膝关节运动水平评分为(5.4±0.9)分、髌骨外移度为(3.8±1.1)mm与术前的(51.9±7.9)分、(2.8±1.2)分、(11.8±2.1)mm比较,差异均有统计学意义(均P<0.05).结论 关节镜下采用ACCU PASS自动连续传递缝合钩可以方便对髌骨内侧支持带紧缩的操作,PDS缝线行对称集中式打结能获得坚强的固定紧缩效果,本方法具有操作便捷、固定强度好、膝关节功能恢复快、近期疗效好的特点.     

Shoulder dislocation and -subluxation

The diagnosis and treatment of shoulder instability require basic differentiation between unidirectional, multidirectional, and voluntary dislocation. Within unidirectional instability primary dislocation, recurrent dislocation, and recurrent subluxation need to be considered separately.--Primary dislocation: In 160 patients with primary dislocation a follow-up was done by questionnaire. In the case of atraumatic primary dislocation the redislocation rate was 100%. Predisposing factors inherent in the bony, cartilaginous, and capsular components of the joint favoured the tendency of primary dislocation. In the case of traumatic primary dislocation the redislocation rate was lower after immobilisation of the joint than without when it had not been immobilised.--Recurrent subluxation: In 52 patients with a clinical diagnosis of recurrent subluxation a tear of the glenoid labrum was found by arthroscopy. In 21 cases the detached labrum was refixed arthroscopically and in 18 cases the repair was done by an open Bankart procedure. Seventy-two percent of the patients who underwent arthroscopic repair showed good to excellent results. In all cases but one in which the Bankart procedure was applied the results were excellent.--Recurrent dislocation: Since 1984 a total of 183 patients were operated on for recurrent shoulder dislocation. All these patients were examined preoperatively by CT scan. The CT findings were used in selection of the appropriate procedure. In 114 patients the Bankart procedure was applied and in 39 cases, a bone-block method. The remaining patients were subjected to various other procedures. Not one of the patients showed postoperative redislocation. (ABSTRACT TRUNCATED AT 250 WORDS)     

Medial patella retinaculum plasty for treatment of habitual patellar dislocation in adolescents

Purpose

The surgical technique, medial patellar retinaculum plasty, can almost restore both static and dynamic stability and verge on anatomical repair for the treatment of habitual patellar dislocation in adolescents.

Methods

In accordance with the injury patterns of the medial patellar retinaculum through knee MRI, we repaired different injury sites with this surgical procedure. We reviewed this technique in 16 patients with an average age of 15 years. Retrospective review of charts and radiographs immediately after the surgery up to the latest follow-up (range 12–36 months) was undertaken.

Results

All patients were evaluated clinically and radiologically over an average of 20.7 months. The recovery of knee mobility results were good. No recurrence of patellar instability has been found.

Conclusion

We think this could be a valid technique to treat habitual patellar dislocation in adolescents.     

Operative versus non-operative management of primary patellar dislocation: A systematic review and network meta-analysis

BackgroundAcute patellar dislocation is a common knee injury in adolescents and adults that is associated with a high incidence of medial patellofemoral ligament (MPFL) injuries. The aim of this network meta‐analysis was to compare the different operative and non-operative protocols for the management of primary patellar dislocation (PPD).MethodsWe searched Medline, Embase, and CENTRAL databases. We included randomized controlled trials (RCTs) that compared operative and non-operative protocols for adolescent or adult patients with acute traumatic PPD. We sought to evaluate the clinical and functional outcomes of each management protocol by considering the results of Kujala score, Tegner activity score, redislocation rate, and subluxation rate. The effectiveness of the different management protocols was measured through frequentist network meta-analysis, using the Netmeta statistical package in R software. All treatment protocols were ranked using the netrank function, yielding P scores.ResultsA total of 10 RCTs were deemed eligible. As per P-scores, open MPFL repair yielded the highest effectiveness with respect to Kujala score (P=0.81) and lowest odds for redislocation (P=0.14) whereas arthroscopic MPFL repair yielded the highest effectiveness with respect to Tegner activity score (P=0.85) and lowest odds for subluxation (P=0.21). Arthroscopic MPFL repair showed a significant reduction in redislocation and subluxation rate.ConclusionThis network meta-analysis demonstrated arthroscopic MPFL repair is the most effective treatment protocol for the management of acute primary patellar dislocation.