Classification of patellofemoral disorders

Patellofemoral disorders represent a large portion of the average orthopedist's practice. Despite the improvements in patellofemoral radiographs and arthroscopic diagnostic techniques, these disorders are too frequently misunderstood and frustrating to treat. This report proposes a clinical classification for patellofemoral disorders that, it is hoped, will aid our understanding and improve our results of treatment. A major feature of this classification is the recognition that a developmental and familial abnormality, patellofemoral dysplasia, is the etiology for most patellofemoral disorders. Equally important is the assignment of chondromalacia patellae to a secondary position for the most part. Other causes of anterior knee pain and disability are included to complete the classification.     

髌股关节置换术治疗单纯髌股关节骨关节炎

 目的 探讨髌股关节置换术治疗单纯髌股关节骨关节炎的疗效和影响因素。方法 回顾性分析2006年3月至2014年12月,采用髌股关节置换术治疗并获得随访的18例单纯髌股关节骨关节炎患者资料,男3例,女15例;年龄46~74岁,平均54岁;术前美国特种外科医院膝关节评分（hospital for special surgery knee score,HSS）为44~63分,平均（53.28±5.71）分;疼痛视觉模拟评分（visual analogue scale, VAS）为4~7分,平均（5.33±0.99）分。术前根据临床症状、体征和影像学资料严格把握手术指征,其中11例采用AVON髌股关节假体（Stryker公司）,7例采用Gender Solutions髌股关节假体（Zimmer公司）。术后第1天患膝即开始行主动和被动功能康复锻炼。结果 18例患者术后均获得随访,随访时间6~104个月,平均63.98个月。VAS,术后1个月（1.17±0.79）分（范围,0~3 分）,术后3个月（0.72±0.67）分（范围,0~2 分）,术后9个月疼痛基本消失;HSS,术后1个月（70.06±6.33）分（范围,61~80分）,术后3个月（86.06±5.12）分（范围,77~95分）,术后9个月（91.39±4.83）分（范围,82~97分）,末次随访（92.06±4.05）分（范围,84~97分）,其中优15例、良3例,优良率100%,较术前有明显改善。患者主观满意率94.4%（17/18）。1例患者术后2年再次出现上下楼梯时膝前疼痛,给予非甾体类抗炎药和适当减少活动后症状缓解。随访期间无一例患者出现切口感染、髌骨脱位、假体松动等并发症。结论 髌股关节置术后疗效与手术适应证、假体设计、手术技巧等因素密切相关,在选用合适的髌股关节假体、严格把握手术适应证、掌握好手术技巧及积极术后康复功能锻炼等基础上,采用髌股关节置换术治疗单纯髌股关节骨关节炎可以获得良好的疗效。     

髌股关节炎的治疗进展

髌股关节炎是最常见的膝关节疾病之一,目前髌股关节炎的诊治尚无明确的临床共识,保守治疗仅对于早期、单一的疾病阶段有一定的价值,随着对发病机制认识的不断进步和手术技术的改进,微创和关节置换技术得到了飞速的发展,可选择的治疗方案越来越多,早期曾采用的胫骨结节截骨、髌骨切除等技术目前已少见临床应用。根据疾病的发展阶段,并结合患者的年龄、经济能力、术后膝关节功能要求等因素综合考虑,关节镜下的软组织平衡和去神经化对于软骨损伤Ⅰ-Ⅲ级的老年患者是较为合适的术式,而软骨损伤Ⅳ级的老年患者,关节置换的效果更理想,早期争论在于全膝关节置换术是否存在过度医疗,随着假体设计的改进,髌股关节置换术满足了单一髌股关节退变的置换需求。由于软骨移植技术的手术难度大,加之髌股关节的解剖特性,目前髌股关节炎的软骨移植应用报道较少,但随着技术的不断改进,软骨移植技术将会是改善临床症状、降低医疗费用、推迟关节置换时间的一种很好的选择方案。     

安装大腿近侧气囊止血带对髌股关节运动的影响

目的探讨膝关节屈曲和伸直状态下安装大腿近侧气囊止血带对髌股关节运动的影响。方法收集住院的非髌股关节疾病患者,选择膝关节20侧,在腰麻或连续硬膜外状态下屈膝30°时测量膝关节髌骨高度和股骨滑车角,然后分伸膝位安装止血带和屈膝位安装止血带两组自身先后对比,测量膝关节不同屈曲角度下Laurin髌股关节外侧角和Merchant吻合角。比较气囊止血带在膝关节不同屈伸状态下对髌股关节运动学的影响。结果在膝关节屈曲30°时,髌骨高度的Caton指数为(1.02±0.19),股骨滑车角(138.9±7.4)°。在膝关节屈曲过程中,髌股关节呈现Merchant吻合角增大的趋势,尤其在膝关节屈曲30~45°的时候变化明显,当屈曲角度继续增大时吻合角基本稳定;Lauren髌股关节外侧角保持相对稳定。伸直位和屈曲位安装止血带引起髌股关节Merchant吻合角和Lauren髌股关节外侧角间的差异没有统计学意义。结论在正常膝关节,大腿近侧气囊止血带对髌股轨迹的影响主要表现为最初屈曲的45°内Merchant髌股吻合角的的增大,而Laurin髌股关节外侧较保持相对稳定。伸直位和屈曲位安装大腿近侧气囊止血带对正常膝关节髌股关节运动的改变没有统计学意义。     

The Lubinus patellofemoral arthroplasty: a series of 17 cases

Introduction The Lubinus patellofemoral arthroplasty was introduced in our institution in 1994. The first 17 patients were followed-up in order to identify the short-term outcome for this prosthesis.Materials and methods The average age at surgery was 66 years (range 37–82 years). The mean follow-up was 19 months. The indications for surgery were strictly limited to radiographically proven primary osteoarthritis affecting only the patellofemoral joint (13) and secondary arthritis due to maltracking, subluxation (3) or trauma to the patella (1). At review, the range of movement and Lysholm and Tegner scores were recorded and radiographs obtained. Patients were also asked if their outcome was satisfactory or unsatisfactory.Results At review, only 9 (53%) knees were classified as satisfactory by the patients. Further surgery had been carried out in 6 cases (35%) including revision to total knee arthroplasty in 4 (24%). Other complications included clicking and subluxation in 3 cases (18%), extension block in 3 (18%) and infection in 1 (6%). Progression of osteoarthritis to involve other compartments occurred in 2 cases (12%).Conclusions Many of these early problems are related to the unforgiving nature of the prosthesis on insertion. These poor early results have led us to stop using the prosthesis.     

手法治疗髌股关节紊乱

髌股关节紊乱（髌骨倾斜、髌骨半脱位）是髌骨不稳定的常见原因，而髌骨排列和运动轨迹异常及由此形成的应力分布异常所造成的关节软骨损伤，是髌股关节疼痛的主要原因，是髌股关节常见病。表现为膝前疼痛、髌骨轨迹异常和髌股关节软骨损伤。随着人们对以软骨退变为主要特征的膝关节骨关节病研究的不断深入，发现髌股关节紊乱在膝关节骨关节病中占有很高比例，其治疗的成功与否直接关系着膝关节骨关节病的疗效：2005年12月至2007年4月完成病例治疗观察，报告如下。     

YouTube provides insufficient information on patellofemoral instability

Objective:Videos uploaded to YouTube do not go through a review process, and therefore, videos related to patellofemoral instability may have little educational value. The purpose of this study was to assess the educational quality of YouTube videos regarding patellofemoral instability.Methods:A standard search was performed on the YouTube database using the following terms: “unstable kneecap,” “patellar instability,” “patellofemoral instability,” “kneecap dislocation,” and “patellar dislocation,” and the top 50 videos based on the “relevance” assignment of the YouTube algorithm were included for analysis. The properties, content, and source of each video were recorded. The educational quality of videos was analyzed according to scores obtained using DISCERN, the criteria of Journal of the American Medical Association, Global Quality Score, and Patellofemoral Instability Specific Score, and the quality of the videos was evaluated according to the groupings of these scoring systems.Results:A total of 250 videos were identified, of which 89 were included in the study for analysis. The mean video duration was 11.72 ± 22.03 minutes. The median number of views was 4516.5 (range, 3-6 044 971). The content of the videos was disease-specific in 60%, 20% were related to surgical technique or approach, and 14.1% were exercise videos. Most of the videos were uploaded by physicians (33.7%). The Global Quality Score and DISCERN scores were significantly correlated with video duration. The Patellofemoral Instability Specific Score was significantly correlated with video duration, number of views, view rate, likes, and Video Power Index. According to the DISCERN classification, 69.9% of the videos were very insufficient or insufficient. According to the Patellofemoral Instability Specific Score, 65.2% of videos were evaluated as very low or low. According to the Global Quality Score, 60.7% of videos were rated as poor quality.Conclusion:The quality of YouTube videos about Patellofemoral instability is insufficient. It was found that viewers tend to watch short and low-quality videos.     

Osteotomy of the patella in the patellofemoral pain syndrome

Summary In 40 patients with patellofemoral pain, intra-osseous pressure measurements were recorded under anaesthesia with the knee first in extension and then in flexion prior to performing a longitudinal osteotomy of the patella. There was a statistically significant increase of pressure in painful knees compared with normal knees (29 mm Hg. vs 15 mm Hg.), and a marked increase when compared during sustained flexion (97 mm Hg. vs 60 mm Hg.). However wide variability of individual results made the diagnostic value of a single pressure measurement unreliable.A clinical test, based on reproduction of the characteristic pain by sustained knee flexion, proved to be reliable in predicting a good response to operation.The effect of the operation was encouraging, with significant relief of pain as measured by a visual analogue scale.

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Résumé Chez 40 malades présentant un syndrome douloureux rotulien, on a pratiqué sous anesthésie une mesure de la pression intra-osseuse sur le genou en extension, puis en flexion; ceci avant de réaliser une ostéotomie longitudinale de la rotule. On a trouvé une augmentation significative de la pression au niveau des genoux douloureux comparativement aux genoux normaux (29 mm Hg contre 15 mm Hg) et une augmentation notable lorsqu'on la compare après une flexion prolongée (97 mm Hg contre 60 mm Hg). Cependant l'existence d'importantes variantions individuelles ne permet pas d'accorder une valeur diagnostique à une measure de pression isolée.A l'inverse, un test clinique, basé sur le déclenchement de la douleur caractéristique par la flexion prolongée du genou, permet de prédire avec certitude le bon résultat de l'opération.Ces résultats sont encourageants puisqu'ils comportent une importante amélioration des douleurs que l'on peut mesurer grâce à une abaque.

     

Bone scan in the patellofemoral pain syndrome

Summary Eighty patients who complained of retropatellar pain underwent evaluation by bone scintigraphy, intraosseous pressure determination, radiography, arthroscopy and physical diagnostic tests. The bone scans showed that 48% of the painful knees had an increased uptake compared with 9% for the normal joints. A highly significant correlation was evident between an increased uptake and established chondromalacia. For the diagnosis of a high pressure patella, radiography was only 7% sensitive (6/88), compared with 44% (39/88) for bone scintigraphy and 78% for the clinical sustained flexion test. The positive predictive value of a bone scan for detecting a high pressure patella was 0.72 (39/54). The best predictor was a positive sustained flexion test with a predictive value of 0.85 (69/81).

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Résumé Dix-huit malades se plaignant de douleurs rétro-patellaires ont été examinés par scintigraphie, mesure de la pression intra-osseuse, radiographie, arthroscopie et tests cliniques. La scintigraphie a montré que 48% des genoux douloureux présentaient une hyperfixation contre 9% des articulations normales. Il existait une corrélation évidente, hautement significative, entre l'hyperfixation et la chondropathie rotulienne. Pour le diagnostic d'hyperpression intrapatellaire, la radiographie n'était démonstrative que dans 7% des cas (6/88) alors que la scintigraphie l'était dans 44% (30/88) et le test clinique de «flexion prolongée» dans 78%. La valeur d'une scintigraphie positive en faveur du diagnostic d'hyperpression intra-patellaire est de 0.72 (39/54). L'élément le plus fiable est la positivité du test de flexion prolongée qui a une valeur prédictive de 0.85 (69/81).

     

半月板不同切除术对髌股关节影响的生物力学研究

目的探讨半月板不同部位,不同程度切除后对膝关节髌股关节的影响,为半月板不同切除术的比较提供生物力学依据。方法采用6具人膝关节新鲜标本,保留内、外侧副韧带、关节囊及膝关市伸膝装置,Staubli机器人模拟生理状态下膝关节站立至下蹲屈膝过程,采用超低压型压敏片测量完整膝关节和半月板不同部化及程度切除术后不同屈膝角度下髌股关节接触面积、接触压,并用SPSS 12．0进行双因素方差分析。结果1．无论何种状念的半月板切除,其髌股关节接触的总体趋势没有改变,即膝火节心曲0°～90°髌股关节的接触面积会逐渐增加;2．半月板部分切除与正常膝关节在髌股接触面积、髌股平均接触从压力间的差异无统计学意义;3．外侧半月板全切除与正常膝关节在髌股接触面积之间的差异有统计学意义,其骸股接触面积在各个屈曲角度均小于正常膝关节,其髌股接触平均压力存各个屈曲角度均大于正常膝关节的髌股接触平均压力;4．内侧十月板全切除与正常膝关节在髌股接触面积间的差异无统计学意义,内侧半月板全切其在膝关节屈曲0°～30°之间其髌股关节平均压力均大于正常膝关节髌股关节间平均压力;60°～90°之间与正常膝关节髌股关节间平均压力间的差异无统计学意义。结论外侧半月板全切除术后髌股关节高接触压力、内侧半月板全切除术后髌股关节低接触压力及半月板部分切除术后髌股关节压力分布小均是术后髌股关节炎发生不可忽视的原因。     

Adolescent patellofemoral pain: implicating the medial patellofemoral ligament as the main pain generator

Purpose  The purpose of this study is to define the clinical presentation of adolescent patellofemoral pain. Methods  A review was completed of all patients with patellofemoral pain at a children’s hospital sports clinic over a 3-year period. Results  One hundred and one patients (91 female) with 136 symptomatic knees were identified. Mean age was 14.4 years. Knee pain was localized to the anteromedial or anterior region of the knee in 96% of patients and was typically produced with running (94%), jumping (92%) and stair use (69%). On physical examination there was usually a non antalgic gait (99%), no patellofemoral crepitation (98%), normal lower extremity angular (84%) and rotational alignment (94%), with no foot malalignment (>97%). The medial patellofemoral ligament (MPFL) was the most palpably tender area of the knee in 98% of patients. During “lateral apprehension” testing, 89% had pain at the MPFL, but not true apprehension. A “J-sign” was present at terminal knee extension in 65%. Mean Q-angle was 18.7°. Means of all radiographic measures were within normal ranges. Conclusion  The prototypical patient had anterior/anteromedial knee pain of insidious onset during running and jumping. The most consistent physical findings were focal tenderness at the MPFL, positive terminal J-sign, and an elevated Q-angle. Most patients required only nonsurgical treatments, but 18% underwent surgical interventions for persistent pain.     

髌股疼痛综合征病因及治疗的新进展

髌股疼痛综合征是膝关节疼痛中最常见诊断之一，常见于青春期和成年期活动量较大患者。髌股疼痛是由各种解剖，生物力学，心理，社会和行为等多种因素综合作用产生，如髌骨位置异常、双下肢生物力学不良、髋关节运动学改变、股四头肌失衡、髌股内侧支持带损伤、髂胫束过紧等。目前以保守治疗为主，保守治疗方法包括运动疗法、髌骨扎贴、髌骨支具、足矫形垫等，保守治疗失败之后，可以考虑手术治疗。     

关节镜下髌骨去神经化处理联合微骨折术治疗髌股关节炎

目的 :探讨关节镜下髌骨去神经化联合微骨折术治疗髌股关节炎的临床疗效。方法 :自2015年5月至2018年5月治疗60例膝关节退行性髌股关节炎患者,男28例,女32例;年龄24～56(40.5±3.35)岁。其中30例行单纯关节镜检查清理术(对照组),30例行关节镜下清理、髌骨周围去神经化联合软骨锥髌股关节面微骨折处理(治疗组)。术后采用VAS、Lysholm、Kujala评分评价治疗效果。结果:所有患者术后未出现切口感染、血管神经损伤、下肢深静脉血栓等并发症。60例患者均获随访,时间7～36个月,平均12.5个月。两组患者术后4周VAS评分均改善,而且治疗组改善明显优于对照组,差异有统计学意义(P0.05)。两组患者术后末次随访时行Lysholm、Kujala评分比较,治疗组改善明显优于对照组。结论:髌骨去神经化处理联合微骨折术治疗髌股关节炎能更好地缓解疼痛,改善膝关节功能。     

膝关节X线对外侧髌股挤压综合征的评估

目的评估外侧髌股挤压综合征患者膝关节X线片,明确其诊断意义。方法对实验组和对照组摄膝关节X线片,观察膝关节骨质结构情况,测量滑车角、吻合角及髌股指数,两组间进行比较。结果实验组滑车角（132.44±10.21）°,吻合角（7.67±5.81）°,髌股指数（2.49±1.40）,对照组滑车角（136.8±4.87）°,吻合角（-2.2±-2.71）°,髌股指数（1.25±0.15）。两组间滑车角差异无统计学意义（t=0.887,P〉0.05）;两组间吻合角和髌股指数差异均有统计学意义（吻合角t=4.318,P〈0.05;髌股指数t=2.633,P〈0.05）。两组间髌股关节软骨下骨质硬化,实验组9膝,对照组2膝,差异有统计学意义（2=12.169,P〈0.01）;两组间髌股关节外侧边缘骨赘增生,实验组13膝,对照组3膝,差异有统计学意义（2=12.60,P〈0.01）。结论膝关节X线片是诊断外侧髌股挤压综合征最基本的手段,其中髌股指数应用方便。     

髌骨内推联合股四头肌锻炼可有效改善老年髌股关节炎的症状和功能

目的：观察髌骨内推和股四头肌功能锻炼对老年髌股关节炎患者症状和功能的影响。方法髌股关节炎患者在膝关节伸直状态下,对髌骨进行内推,髌骨活动后,进行股四头肌功能锻炼。对患者治疗前和后的IKDC评分、膝关节非负重状态下的屈曲度进行比较。所有的患者内推前和6个月后进行了膝关节的正侧位片检查。结果2010年10月至2011年12月,符合髌股关节炎诊断的患者168例共203个关节,患者都进行了髌骨内推和股四头肌功能锻炼。所有的患者都得到了最短6个月的随访,平均随访（10±2.5）个月。治疗前、后IKDC评分比较有显著性差异,治疗1月后IKDC评分高于6月后。膝关节非负重状态下屈曲度检查显示治疗前、后比较有显著性差异（ P＜0.05）。 X-ray膝关节侧位片显示Insall-Salvati指数治疗后没有显著改变（ P＞0.05）。结论髌骨内推和股四头肌功能锻炼能够显著改善髌股关节炎的症状和功能。     

Effects of retinacular release and tibial tubercle elevation in patellofemoral degenerative joint disease

Release of the patellar retinaculum and tibial tubercle elevation have both been advocated for the treatment of patellofemoral degeneration. Questions remain, however, regarding the magnitude and predictability of such effects in diseased joints. Using cadaver knee joints exhibiting a range of patellofemoral cartilage degeneration, we investigated the effects on joint contact pressures on release of the patellar retinaculum, followed by tibial tubercle elevations of 1.25 and 2.5 cm. Retinacular release failed to alter the joint-loading parameters significantly. Tibial tubercle elevation reduced the patello-femoral joint contact area and contact force, but failed to cause a consistent change in contact pressure. Tibial tubercle elevation also caused a migration of the joint contact area superolaterally on the retropatellar surface. This migration occurred in conjunction with ventral tilting of the inferior pole of the patella as the tubercle was elevated, suggesting that significant changes in joint kinematics may result from this procedure.     

Prognostic factors for isolated medial patellofemoral ligament reconstruction: A systematic review

BackgroundEvidence concerning the influence gender, age, and the time elapsed from the first dislocation to surgery in the outcomes of Medial Patella Femoral Ligament (MPFL) reconstruction are lacking. This systematic review was conducted to investigate whether patient characteristics have an influence in the clinical outcomes of MPFL reconstruction for patients with patellofemoral instability.Material and methodsThis study followed the PRISMA guidelines. The main databases were accessed in February 2021. All the studies reporting outcomes of primary MPFL reconstruction in patients with recurrent patellofemoral instability were considered for inclusion. A multivariate analysis diagnostic tool was used to analyse the association between age, gender and time from injury to surgery and the surgical outcomes at last follow-up.ResultsA total of 50 articles (2037 procedures) were included. The mean follow-up was 40.90 ± 24.8 months. The mean age was 23.6 ± 3.9 years. 64.3% (1309 of 2037 patients) were female. The mean time from injury to surgery was 64.5 ± 48.9 months. Women showed no statistically significant association with the Kujala score or complications. Older patients had a reduced risk to incur re-dislocations (P = 0.01) and revisions (P = 0.01). Longer time from injury to surgery was associated with greater risk to incur re-dislocations (P = 0.01), and with lower Kujala score (P < 0.0001). No other statistically significant association was evidenced.ConclusionThe time span from the first patellar dislocation to the surgical reconstruction was a negative prognostic factor, while sex had no influence on surgical outcomes. The role of patients age on surgical outcomes remains unclear.     

髌股关节置换术治疗单纯髌股关节炎的疗效研究

目的:探讨髌股关节置换术治疗单纯髌股关节炎的临床疗效。方法 :2013年7月至2017年6月行髌股关节置换术患者35例42膝,女34例,男1例;年龄45～70(55.0±8.2)岁;病程6～36(13.7±2.5)个月。术前及末次随访时对患者进行牛津膝关节评分,末次随访时对患者进行手术满意度评估,另摄膝关节正侧位X线片及髌骨轴位片,评估有无假体松动,记录患者术后出现的血肿、关节感染等并发症。结果:35例患者42膝随访时间18～65(35.0±7.2)个月,手术时间(56.2±8.7) min。牛津膝关节评分由术前(28.14±0.36)分提高至术后末次随访(37.19±0.47)分,差异有统计学意义(P<0.05),其中疼痛项目评分由术前(10.12±0.26)分提高至术后末次随访(15.83±0.30)分,功能项目评分由术前(18.02±0.13)分提高至术后末次随访(21.36±0.23)分,差异均有统计学意义(P<0.05)。有1例患者双膝术后早期出现伤口线结反应,经清创后好转;另1例术后5周出现伤口周围红肿,经抗生素治疗后好转;1例术后1个月出现股四头肌缝合处撕裂,...     

中药熏蒸在髌股外侧高压综合征患者中的疗效

目的 探讨中药熏蒸在髌股外侧高压综合征患者中的疗效.方法 以2016年8月至2019年8月于河北省沧州中西医结合医院骨科收治的120例患者髌股外侧高压综合征患者为研究对象,按随机数字表法分为对照组(60例,给予单纯关节镜下松解髌股外侧支持带治疗)和研究组(60例,在对照组治疗的基础上给予中药熏蒸治疗).观察记录治疗前、...