关节镜下外侧支持带松解、内侧紧缩与髌股韧带重建治疗复发性髌骨脱位

目的探讨关节镜下外侧支持带松解、内侧紧缩与髌股韧带重建在治疗复发性髌骨脱位中的临床疗效。方法笔者自2011-05—2014-05诊治32例复发性髌骨脱位。术前均未行手术治疗,常规测量Q角和CT片中TT-TG值。比较手术前后Lysholm和IKDC评分。结果所有患者获得平均18(13~30)个月随访,无一例出现髌骨脱位复发,术后切口均一期愈合。术后Lysholm膝关节功能综合评分为(94.23±8.38)分,术前为(48.25±6.92)分,手术前后Lysholm评分比较差异有统计学意义(t=36.80,P0.001);术后IKDC膝关节主观功能评分为(93.20±5.33)分,与术前(35.57±5.10)分比较差异有统计学意义(t=47.23,P0.001)。结论关节镜下外侧支持带松解、内侧紧缩与髌股韧带重建治疗复发性髌骨脱位疗效确切,操作简便,可早期进行功能锻炼,有利于膝关节功能的恢复,值得临床推广。     

关节镜下髌骨支持带外侧松解内侧紧缩术治疗髌骨半脱位

目的探讨关节镜下行髌骨支持带外侧松解内侧紧缩术治疗髌骨半脱位的临床疗效。方法手术治疗44例髌骨半脱位患者,在关节镜下采用低温等离子电刀松解髌骨外侧支持带,同时采用PDS线沿髌骨内侧缘上极、中点、下极缝合加强内侧支持带,使术中膝关节屈曲过程中髌骨处于正常轨道。根据Lysholm膝关节功能评分及IKDC 2000主观评分进行术前、术后膝关节功能评估。结果 44例均获得随访,时间3~30个月。术后X线片显示髌骨位置良好。末次随访患肢膝关节活动度恢复良好,无关节僵硬、功能障碍等表现,未见复发半脱位。Lysholm评分由术前44~71(52.2±6.3)分提高到术后80~94(88.1±3.9)分(P0.001),IKDC 2000主观评分由术前42~69(52.7±6.1)分提高到术后82~97(89.7±3.1)分(P0.001)。结论关节镜下髌骨支持带外侧松解内侧紧缩术治疗髌骨半脱位,可维持髌骨活动稳定,效果良好。     

关节镜下内侧髌股韧带重建和外侧支持带松解治疗复发性髌骨脱位

目的:评价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的临床效果.方法:2011年3月至2013年6月在关节镜下进行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15例,男5例,女10例;年龄14～32岁,平均19.4岁;髌骨脱位2次及以上.术前常规行X线、CT、MR检查了解髌股关节及内侧髌股韧带情况,关节功能Lysholm评分69.85±11.52,术中镜下查看髌股对合关系及髌骨运动轨迹.术中使用自体腘绳肌腱重建内侧髌股韧带同时关节镜下外侧支持带松解.结果:所有患者获随访,时间12～36个月,平均27.6个月,患者无再发髌骨脱位及半脱位,伸直位及屈曲30°位恐惧试验和髌骨外移试验均为阴性,术后12个月患者完全恢复正常活动,膝关节无主观不适,术后Lysholm评分92.60±5.75,较术前提高.结论:关节镜下内侧髌股韧带重建联合外侧支持带松解手术能有效治疗复发性髌骨脱位,缓解症状,重建髌骨稳定性.     

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.     

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.     

Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction

The tensile strength of the medial patellofemoral ligament (MPFL), and of surgical procedures which reconstitute it, are unknown. Ten fresh cadaver knees were prepared by isolating the patella, leaving only the MPFL as its attachment to the medial femoral condyle. The MPFL was either repaired by using a Kessler suture or reconstructed using either bone anchors or one of two tendon grafting techniques. The tensile strength and the displacement to peak force of the MPFL were then measured using an Instron materials-testing machine. The MPFL was found to have a mean tensile strength of 208 N (SD 90) at 26 mm (SD 7) of displacement. The strengths of the other techniques were: sutures alone, 37 N (SD 27); bone anchors plus sutures, 142 N (SD 39); blind-tunnel tendon graft, 126 N (SD 21); and through-tunnel tendon graft, 195 N (SD 66). The last was not significantly weaker than the MPFL itself.     

儿童内踝骨与皮肤缺损重建的中远期随访

目的探讨腓骨头复合组织瓣重建儿童内踝骨与皮肤缺损的中远期临床效果。方法对采用腓骨头复合组织瓣重建儿童内踝骨与皮肤缺损9例进行随访,随访时间3.5~8年,并对踝关节功能进行评价,对出现并发症的患者进行有效地治疗。结果所有患者均在校学习,能参加各项活动,双足发育未见明显差异;移植的腓骨头与内踝重建结合部均骨性愈合,随访期间未发生二次骨折;所有移植的腓骨头未出现骨骺闭合现象,移植腓骨头均出现同步生长现象。3例胫骨下端内侧骨骺出现不同程度的骨骺早闭,出现轻度的足内翻,对于较为严重的2例,1例行外侧骨骺阻滞术(9岁),1例行内侧植骨矫形术(14岁)。根据AOFAS中足评分标准对患足功能进行评定:优3例,良4例,可2例。结论腓骨头复合组织瓣是重建儿童内踝骨与皮肤缺损的一种较好方法,在发育过程中出现的并发症要及时治疗,可以达到良好的治疗效果。     

Triple-flap medial canthal reconstruction

A patient with a medial facial defect, following oncological resection involving the medial canthus, nose, upper and lower eyelids, and the cheek, is presented. The defect was reconstructed using a combination of local flaps to provide tissue similar to native tissue, addressing both functional and aesthetic aspects.     

Peroneal tendon subluxation in athletes: fibular groove deepening and retinacular reconstruction

BACKGROUND: The purpose of this study was to evaluate the results of operative treatment of recurrent peroneal tendon dislocations followed by accelerated rehabilitation incorporating early range of motion and intermittent immobilization. METHODS: Four female and nine male athletes with an average age of 24 years had objective clinical evidence of peroneal tendon dislocation (14 ankles). Operative treatment involved removing a bone flap from the distal posterior fibula, deepening the posterior fibular groove, and reattaching the bone flap within the deepened groove. The superior peroneal retinaculum also was reconstructed. Postoperatively, a removable boot was worn for approximately 4 weeks, when it was replaced with a stirrup brace. RESULTS: At an average followup of 35 months, no recurrent subluxation or dislocation of the peroneal tendons had occurred. All patients were able to return to sports by 3 months after surgery. Nine of the 14 ankles regained normal range of motion, and the remaining five were within 5 degrees of the opposite side. Four patients were completely pain free, and nine patients had mild occasional pain that did not limit their activities. Eight patients returned to preinjury sports participation, and five patients elected to participate in sports at a level lower than they had before surgery for reasons not related to their ankle injury. CONCLUSIONS: This procedure was reliable for preventing recurrent peroneal tendon instability. Range of motion was nearly normal, immobilization time was minimal, and all patients returned to daily activities and sports within 3 months of surgery.     

内侧髌骨股骨韧带的概念及临床意义

内侧髌骨股骨韧带(medial patellofemoral ligament,MPFL)是膝关节内侧稳定髌骨的主要静力结构,往往在髌骨脱位时受到损伤,导致髌骨不稳甚至反复脱位。在认识到MPFL的存在并研究其精确解剖结构及生物力学功能之后,重建MPFL成为了治疗髌骨不稳或脱位的主流方法,而且重建技术层出不穷。本文系统阐述MPFL的解剖学、生物力学、手术指征和重建技术,推崇以锚钉固定、双束解剖重建MPFL的方法。     

A new technique for the repair and reconstruction of frontoethmoidal encephalomeningoceles by medial orbital composite-unit translocation.

A frontoethmoidal encephalomeningocele is a herniation of brain and meninges through a congenital bone defect in the skull at the junction of the frontal and ethmoidal bones. Between 1992 and 1999, we treated 145 cases of frontoethmoidal encephalomeningocele. Before 1993, the operation was performed in two stages. An intracranial repair by neurosurgeons preceded the external extirpation of the mass. In 70 cases that were operated on after 1993, a one-stage closure of the skull defect with a medial orbital composite-unit translocation technique was used. The medial orbital rim on each side, with intact periosteum, medial canthal ligament and lacrimal apparatus, was translocated as a unit to the midline. The advantages of this technique are that it allows convenient access to resect the herniation mass and close the defect, it restores normal interorbital and intercanthal distances and it eliminates the need for a transnasal medial canthopexy. Augmentation rhinoplasty can be avoided in most cases by tilting the composite unit with its preserved blood supply.     

Arthroscopic medial retinacular imbrication for the treatment of recurrent patellar instability: a simple and all-inside technique

Proximal soft tissue realignment is the main surgical intervention for recurrent patellar instability. In recent years, all-inside arthroscopic procedures or mini-open surgeries have replaced traditional surgeries, which have more associated morbidity and poor cosmetic results. This article describes a simple and all-inside arthroscopic technique for the operative treatment of recurrent patellar instability. Using 2 epidural needles in several steps and no accessory portals required, the medial patellar retinaculum is imbricated to the desired tension. The combination of lateral release and medial retinacular placation obviously improves the patellar tracking compared with preoperatively.     

膝前、后交叉韧带与内侧副韧带损伤的一期修复重建

目的探讨膝关节镜下重建前、后交叉韧带联合有限切开修复内侧副韧带恢复膝关节稳定和功能的疗效。方法 2003年4月-2010年10月,收治14例(14膝)前、后交叉韧带伴内侧副韧带损伤患者。男10例,女4例;年龄21～71岁,平均41岁。致伤原因:交通事故伤11例,高处坠落伤3例。患者受伤至入院时间为1～4 d,平均2 d。Lysholm评分为(17.00±8.29)分,国际膝关节文献委员会(IKDC)评分为(20.93±8.28)分。伴膝关节脱位9例,半月板损伤5例。关节镜下采用同种异体肌腱(2例)或自体腘绳肌腱(12例)重建前、后交叉韧带,有限切开修复内侧副韧带。结果术后切口均Ⅰ期愈合;3例出现下肢麻木,自行缓解。患者均获随访,随访时间为12～18个月,平均14个月。患者膝关节均于3个月内达屈曲120°,伸直0°。术后1年膝关节IKDC评分为(89.93±6.26)分,Lysholm评分为(88.93±4.82)分,与术前比较差异有统计学意义(P<0.01)。结论对于膝关节韧带多发伤,关节镜配合有限切开修复重建韧带,避免了开放关节腔,同时由于创伤小,术后关节粘连轻,关节功能恢复快。     

Postoperative change in medial meniscal length in concurrent all-inside meniscus repair with anterior cruciate ligament reconstruction

Purpose

Meniscus repair can restore meniscal function that transfers the axial compressive force to circumferential tensile strain. However, few reports have investigated the relationship between concurrent meniscus repair with acute anterior cruciate ligament (ACL) reconstruction and postoperative meniscal position. This study aimed to evaluate medial meniscal size and clinical results in patients who underwent ACL reconstruction and concomitant all-inside medial meniscus repair.

Methods

Twenty patients underwent ACL reconstruction and concurrent medial meniscus repair of a peripheral longitudinal tear using the FasT-Fix meniscal repair device. Medial tibial plateau length (MTPL) and width (MTPW) were determined by radiographic images. We evaluated the Lysholm score, anteroposterior instability, meniscal healing and magnetic resonance imaging (MRI)-based medial meniscal length (MML) and width (MMW). Correlations between MRI-based meniscal size, radiographic measurement and height were investigated.

Results

All patients showed complete healing of the repaired meniscus in arthroscopic evaluation. However, one patient needed a subsequent meniscus repair during the follow-up period. Lysholm score and anteroposterior instability improved significantly. A better correlation was observed between MMW and MTPW than between MML and MTPL. Concurrent all-inside medial meniscus repair with ACL reconstruction significantly increased MML percentage (%MML) (100 MML/MTPL) but did not affect MMW percentage (%MMW) (100 MMW/MTPW).

Conclusions

Concurrent all-inside medial meniscus repair with ACL reconstruction had satisfactory clinical results. %MML was increased by concurrent medial meniscus repair without affecting %MMW. Our results suggest that medial meniscus repair associated with ACL reconstruction may restore meniscal function by adjusting the anteroposterior length of the torn medial meniscus.     

Navigation-aided reconstruction of medial orbital wall and floor contour in cranio-maxillofacial reconstruction

The reconstruction of the anterio-posterior inclination of the medial aspect of the orbital floor, despite a wide 360 degrees exposure, including coronal and conjunctival incisions, is a challenging task in severe injuries of the orbit with massive comminution and complete displacement of the medial orbital wall and orbital floor. Out of a total of 20 patients with orbital fractures, five underwent a surgical intervention of repositioning the medial aspect of the orbital floor and especially the transition area between the orbital floor and medial orbital wall, using navigation-aided procedures. Using the mirroring tool of the Stryker-Leibinger STN-system, post-operative CTs indicated an average difference of the globe position of -4.9% between the operated side and the unaffected side, depending on the position of the medial aspect of the orbital floor. Navigation-aided procedures proved to be an essential precondition for achieving precise and predictable results in orbital reconstruction. In such cases, unlike those with an intact medial orbital wall remnant as a surgical target, bone grafts for reconstruction of the orbital floor cannot be implanted as onlay grafts.     

Techniques of acetabular reconstruction

Acetabular reconstruction and revision can be a complex and demanding procedure. This article reviews the essential components of preoperative planning and surgical technique. In addition, there are several unsolved issues that will be addressed along the author's current prejudice on these issues.