关节镜下内外侧支持带松解治疗髌股关节软骨软化症

目的 探讨髌股关节软骨软化症更为有效的手术治疗方法.方法 采用髌骨内外侧支持带同时松解术式治疗56个关节.结果 56个关节随访8个月～4年2个月,平均2年9个月.所有关节的髌前疼痛缓解或消失.结论 与外侧支持带松解术式相比,本术式更能纠正髌股关节的病理运动轨迹,使髌股关节内外侧间隙平衡更为容易,对髌前疼痛的缓解更有效,术后无关节内血肿、髌骨坏死和髌骨脱位等并发症发生.     

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。     

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。     

髌股关节不稳定症的影像学诊断与治疗

髌股关节是伸膝装置中的重要组成部分，髌骨在股骨滑车凹中正常运动轨迹依赖于髌骨与股骨髁间凹的骨性关节和关节囊、支持带提供的静态稳定作用，以及股四头肌的动态稳定作用。如果髌股关节不稳定，就会发生髌股关节运动轨迹的改变、髌骨向外侧倾斜和／或半脱位，使外侧髌股关节面产生过高压力，软骨被磨损，最终导致软骨软化和骨关节炎。     

髌外侧软组织松解术联合改良Elmslie-Trillat术治疗复发性髌骨脱位

复发性髌骨脱位是一种多发生于年轻人的疾病,由于髌骨反复在股骨髁间凹中沿异常轨迹滑动,造成髌股关节软骨的磨损,进而产生一系列临床症状,甚至出现早期髌股关节退变的严重后果.自2002年9月至2005年12月我科采用髌外侧软组织松解术联合改良Elmslie-Trillat术治疗复发性髌骨脱位,疗效满意.     

髌内外侧稳定结构与髌股关节稳定性实验研究

目的 :了解髌内外侧稳定结构对髌骨的稳定作用,探讨临床中松解髌外侧支持带的治疗作用及效果,为临床治疗髌骨不稳提供生物力学依据。方法:6例新鲜膝关节标本,对股四头肌进行加载(模拟肌力正常的情况),在不同屈曲度,对髌骨施加外侧方移位载荷,使髌骨外侧半脱位,读取记录载荷大小。干预1:松解髌内侧支持带(模拟病理状态),重复上述操作,读取记录载荷大小;干预2:在干预1的基础上进一步松解外侧支持带(模拟手术治疗),重复上述操作,读取记录载荷大小。结果:松解髌内侧支持带后,使髌骨半脱位的载荷比支持带完整时减小,差异有统计学意义(P0.05)。进一步松解外侧支持带,半脱位载荷进一步减小,但与干预1差异无统计学意义(P0.05)。结论:髌内侧支持带在维持髌骨稳定及髌股关节正常运动轨迹中有重要作用,在临床治疗复发性髌骨脱位或半脱位时,应该重视髌内侧支持带的修复重建,单纯松解外侧支持带的方法并非最佳选择。     

自体半腱肌腱游离移植重建内侧支持带治疗复发性髌骨脱位

目的探讨关节镜下外侧髌股支持带松解和自体肌腱游离移植重建内侧髌股支持带治疗复发性髌骨脱位的疗效。方法复发性髌骨脱位18例,男6例,女12例。年龄17～24岁,平均20岁。关节镜下软骨Ⅳ度损伤者7例采用刨削打磨后微骨折术,软骨损伤Ⅱ度6例和Ⅲ度5例采用射频气化清理。外侧髌股支持带充分松解后,采用自体半腱肌腱游离移植重建内侧髌股支持带,关节镜下动态调整移植肌腱在不同角度下屈伸活动时的张力和髌骨运动轨迹,观察股骨滑车与髌骨的对应关系。采用可吸收界面螺钉将肌腱端固定于股骨内收肌结节的骨道内。结果所有患者术后均获随访,平均13个月(9～19个月)。术后膝关节稳定性增加,无髌骨再脱位发生。恐惧试验阴性,髌骨倾斜试验对称,髌股关节研磨试验阴性16例,阳性2例。1例术后髌骨下极骨折,经手术后功能恢复正常。髌骨轴位X线片和MRI显示髌股关节解剖关系恢复正常15例,髌骨轻度半脱位3例。Lysholm评分术前平均(78.0±4.5)分,术后(94.0±3.5)分。结论关节镜下外侧髌股支持带松解与自体肌腱游离移植重建内侧髌股支持带治疗复发性髌骨脱位,方法简便,对于维持髌骨的运动轨迹具有重要作用。     

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。     

关节镜下髌外侧支持带松解治疗髌骨外侧压迫综合征

[目的]探讨关节镜下髌外侧支持带松解术对髌骨外侧压迫综合征的治疗效果。[方法]本组共24例30膝；年龄21～64岁，平均48岁，采用镜下清理、髌外侧支持带松解术治疗，术后结合康复训练。[结果]本组全部病例获随访6个月～18个月（平均10个月），临床评价优良率90％。[结论]关节镜下能直观、动态地观察髌股关节对合中，手术松解彻底，创伤小，并发症少，明显缓解或消除膝前痛症状，效果满意。     

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。     

Role of arthroscopic lateral release in the treatment of patellofemoral disorders.

The results of 50 arthroscopic lateral releases are reported. The average follow-up period was 36 months with a range of 18-52 months. Satisfactory results were achieved in 71% of 21 patients with patellar pain alone and in 76% of those (Betz RR, Lonergan R, Patterson R. The percutaneous lateral retinacular release Orthopaedics 1982;5:57-62) with instability. Patients with patellofemoral osteoarthritis or patellar dislocation were excluded from the series. Postoperative hemarthrosis occurred in 10%. Unsatisfactory results could be related to incomplete release, severe chondromalacia, or insufficient rehabilitation. Lateral release is capable of producing high rates of success with a low incidence of complication when used to treat patellar pain with tight retinaculum, patellar instability, and subluxation.     

Arthroscopic lateral release for patellar pain or instability

Forty-five arthroscopic lateral releases were reviewed with a follow-up from 2 to 6 years (average 4 years). Satisfactory results were obtained in 60% of the patellar pain group (20 knees) and 68.5% of the instability group (19 knees). The results in osteoarthrosis (6 knees) were unsatisfactory. Postoperative hemarthrosis was infrequent (2.2%). Unfavorable prognostic factors are an incomplete release with an insufficient postoperative passive patellar tilt in the pain group and more than five preoperative dislocations in the instability group. After failure of conservative treatment, a lateral release can be reasonably used in pain syndromes with a tight lateral retinaculum and lateral patellar tracking and in milder cases of instability.     

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。     

髌骨半脱位70例治疗分析

目的探讨髌骨半脱位的治疗方法及其预后。方法回顾性分析70例（130膝）髌骨半脱位患者的临床资料,其中男30例,女40例;年龄10～48岁,平均23岁。患者髌骨的形态均为WibergⅡ、Ⅲ型,其中伴有外侧髌股关节骨关节炎者58例108膝,高位髌骨23例46膝,外伤后股四头肌内侧头肌张力不良10例10膝。Q角20°～40°。全部行手术治疗,手术方式包括：髌外侧支持带充分松解（130膝）;髌内侧支持带紧缩、股内侧肌移位至髌骨前内侧（12膝）;髌骨外侧部分切除（17膝）;胫骨结节前、内侧移位（46膝）,平均内移1．0cm、前移1．2cm;缝匠肌前移（11膝）,半腱肌前移（13膝）;关节镜下髌外侧支持带松解,髌内侧支持带紧缩（31膝）。术中见全部病例髌外侧支持带均明显增厚。结果随访3～180个月,根据Insall等评分系统评估分析疗效,术后疗效优78膝,良33膝,可12膝,差7膝。患者术后疼痛、关节活动功能均得到明显改善,尤其是解除膝前痛效果显著。结论根据病因及病理改变选择恰当的手术方式治疗髌骨半脱位均可取得满意的效果,特别是关节镜手术具有创伤小、恢复快的特点,值得进一步推广应用。     

Long-term functional outcome after lateral patellar retinacular release in adolescents: an observational cohort study with minimum 5-year follow-up

BACKGROUND: Lateral patellar retinacular release has been recommended for patients with patellar tilt, tight lateral retinaculum, patellar subluxation, patellar dislocation, and patellofemoral pain. Studies of long-term outcomes after lateral release are limited, especially for differing indications. HYPOTHESIS: Adolescents do well after lateral retinacular release in the 5- to 22-year time frame. METHODS: Patients having undergone lateral retinacular release between the years of 1981 and 1999 were contacted. Evaluation was by the Cincinnati and Lysholm scales and by level of satisfaction and need for reoperation. RESULTS: One hundred forty knees were studied. Mean age at operation was 15.4 years (SD, 2.7 years). Average follow-up was 8.5 (SD, 4.1 years; range, 5.2-22.5 years). Twenty-five patients had needed reoperation, indicating failure of the index operation. Kaplan-Meier survivorship was 78% at 15 years. Cincinnati and Lysholm scores indicated well-functioning knees in those not requiring reoperation. Overall satisfaction improved as time from operation increased.Comparisons were made between the group requiring reoperation and those who did not. Focus was placed on knees with patellar maltracking or tilt versus patellar instability and between males and females. No differences were found among groups for reoperation rate, level of satisfaction, average Lysholm score, or average Cincinnati score. There were no differences in demographics or outcome measures between patients with patellar instability and those with tilt. Instability patients trended toward higher reoperation rates than did tilt patients, but the difference was not significant. There were no differences between males and females. CONCLUSION: The majority of patients are satisfied with their knee 5 to 22 years after lateral patellar retinacular release and scored well on questions rating knee health and function.     

Lateral patellar retinaculum tension in patellar instability

The patellar retinaculum is important in patellar tracking. However, little attention has been paid to the biomechanics of the retinaculum. This study assessed the change in tension of the lateral patellofemoral ligament before and after anteromedial tibial tubercle transfer for patellar instability. Twenty-seven knees in 21 patients were studied and the mean age of the patients at surgery was 19 years. A buckle transducer was clamped on the lateral patellofemoral ligament and the transducer was calibrated to zero with the knee at full extension. The knee then was flexed 30 degrees, 60 degrees, 90 degrees, and 120 degrees, and the transducer recorded changes in tension within the lateral patellofemoral ligament. After anteromedial tibial tubercle transfer, lateral patellofemoral ligament tension was measured in the same manner. Although average lateral patellofemoral ligament tension increased with knee flexion with the maximum at 120 degrees flexion, these changes showed four different patterns measuring variability of patellar instability. An increase of lateral patellofemoral ligament tension after anteromedial tibial tubercle transfer meant that lateral retinacular release should be done concurrently to balance patellar tracking. This information may be useful in deciding the appropriate surgical procedure for each patient.     

Mesh expansion release of the lateral patellar retinaculum during total knee arthroplasty

BACKGROUND: Release of the lateral patellar retinaculum can be used to treat patellofemoral instability and to balance the extensor mechanism during knee replacement operations. However, conventional lateral release disrupts the integrity of the lateral knee capsule, may damage the blood supply to the patella, and is associated with several other potential complications. Mesh expansion release of the lateral patellar retinaculum was developed to achieve the goal of lateral release and to reduce the potential for postoperative morbidity. METHODS: Thirteen consecutive knees in eleven patients were treated with mesh expansion lateral release during a total knee arthroplasty and were evaluated after a minimum duration of follow-up of two years. The mesh release technique consisted of multiple, longitudinal, parallel 5 to 10-mm stab incisions to mesh and expand the lateral patellar retinaculum and thereby medialize the patella in the trochlear groove of the femoral implant. RESULTS: Mesh expansion lateral release balanced the extensor mechanism in each knee, maintained the mechanical integrity of the lateral capsule, and avoided disruption of the lateral genicular blood supply to the patella. After a minimum duration of follow-up of two years, no complications had been noted in association with mesh expansion lateral release. CONCLUSION: Mesh expansion release of the lateral patellar retinaculum effectively balanced the patellofemoral joint during total knee arthroplasty, maintained the integrity of the lateral capsule, and preserved the lateral genicular blood supply.     

关节镜下髌骨外侧支持带松解术治疗髌骨倾斜挤压综合征

目的探讨关节镜下髌骨外侧支持带松解术治疗髌骨倾斜挤压综合征的效果。方法对14例髌骨倾斜挤压综合征患者15个膝关节行关节镜下髌骨外侧支持带松解术。手术前后按Lysholm膝关节功能评分进行评估。屈膝20°位CT片测量手术前后髌骨倾斜角（PTA）、外侧髌股角（LPFA）。结果14例均获6-18个月随访,Lysholm评分术前为54.53分±5.54分,术后6个月为88.73分±7.0分（P〈0.01）;PTA术前为2.78°±0.40°,术后为18.53°±0.83°（P〈0.01）;LPFA术前为0.97°±0.47°,术后为8.32°±0.63°（P〈0.01）。结论关节镜下髌骨外侧支持带松解术能有效纠正髌骨倾斜,缓解疼痛,恢复膝关节运动功能,且创伤小,并发症少。     

关节镜下内侧髌股韧带紧缩并外侧髌韧带松解治疗髌股关节疼痛综合征临床对照试验

目的：探讨关节镜下内侧髌股韧带紧缩并外侧髌韧带松解治疗髌股关节疼痛综合征的手术疗效。方法：将100例髌股关节疼痛综合征患者随机分为治疗组和对照组各50例，男35例，女65例；年龄50-70岁，平均63岁。手术均在关节镜下进行，治疗组采用内侧髌股韧带紧缩、外侧髌韧带松解术式；对照组采用临床广泛使用单一外侧髌韧带松解手术。结果：随访平均13个月，采用HSS（hospitalforspecialsurgery）慢性疾病及关节炎评估系统评价疗效，治疗组平均积分（73．52±11．17）分；对照组平均积分（65．50±13．70）分（P〈O．05）。结论：内侧髌股韧带紧缩并外侧髌韧带松解治疗髌股关节疼痛综合征临床疗效满意。与外侧髌韧带松解术式相比，更能纠正髌股关节的病理运动轨迹，使髌股关节内外侧间隙平衡更为容易，对髌前疼痛的缓解更有效，术后无关节内血肿、髌骨坏死和髌骨脱位等并发症发生。     

The outside-in subcutaneous arthroscopically assisted lateral retinacular release: a new technique

Arthroscopic lateral retinacular release in the knee has been used extensively for the treatment of patellar pain and instability. The release can be performed using a number of techniques, but achieving access to the retinaculum can often be difficult, particularly in obese patients. We describe a simple modification of an arthroscopically assisted method, which utilises electrosurgery through a subcutanous channel to perform an outside-in release.