股骨滑车成形联合内侧髌股韧带双束解剖重建治疗髌骨脱位

目的探讨股骨滑车成形联合内侧髌股韧带双束解剖重建治疗髌骨脱位伴有严重股骨滑车发育不良的临床效果。方法回顾性研究自2006年3月至2008年12月在我院诊断为髌骨脱位伴有严重股骨滑车发育不良的患者5例(5膝),接受股骨滑车成形联合内侧髌股韧带双束解剖重建治疗。测量比较手术前后胫骨结节滑车沟间距(TT-TG值),髌股适合角(CA),髌骨倾斜角(PTA),髌骨外移率(PLSR),手术前后的Lysholm膝关节功能评分及Kujala髌股关节不稳症状评分评估手术效果。结果患者术后均获得随访,最短随访时间为3年。术后伤口均Ⅰ期愈合,未发生感染。无复发性髌骨脱位。Kujala髌股关节不稳症状评分从术前的54.20±8.04增加到术后的81.60±3.97,Lysholm膝关节功能评分从术前的54.60±5.22增加到82.60±2.70。术后患者的TT-TG值、CA、PTA、PLSR均恢复到正常范围,与术前相比差异具有统计学意义(P<0.05)。结论对于临床上髌骨脱位伴有严重滑车发育不良的患者采用股骨滑车成形联合内侧髌股韧带双束解剖重建治疗可以有效纠正髌股关节的运动轨迹,改善膝关节功能,临床效果较好。     

双束髌股韧带解剖重建治疗急性髌骨脱位21例

目的探讨双束髌股韧带重建治疗急性髌骨脱位的临床效果。方法回顾性分析21例急性髌骨脱位行双束髌股韧带重建术患者的临床资料。结果术后1、3、6、12、24个月各随访1次,无髌骨脱位及半脱位发生,术后1a患膝关节活动度恢复正常,0°及屈膝30。髌骨外推试验和外推恐惧试验均阴性,2例存在髌股关节摩擦感,1例股四头肌力量减退。末次随访时,本组患者Lysholm膝关节功能评分85～97分,Tegner运动水平主观评分5～7分,Kujala评分89～96分。结论双束髌股韧带解剖重建治疗急性髌骨脱位创伤小、对伸膝装置影响小,可有效恢复髌股关节功能及防止复发。     

内侧髌股韧带重建治疗创伤性髌骨脱位25例

【目的】探讨游离肌腱移植重建内侧髌股韧带（MPFL）手术方法及治疗髌骨脱位的疗效。【方法】2008年5月至2012年7月收治创伤性髌骨脱位患者25例共25膝,均采用游离自体半腱肌腱,通过髌骨双隧道移植重建MPFL,关节镜下动态调整移植肌腱的张力,确保髌股关系对合正常,应用挤压螺钉固定肌腱游离端于股骨止点。手术前后均行 Lysholm评分。【结果】25例患者均获得随访,随访时间8～48个月,平均26个月。全部病例复查时均未再发生脱位,恐惧试验阴性,经MRI证实髌股对合关系正常。术后Lysholm评分末次随访为（87．3±6．5）分,较术前（61．2±8．6）分差异有统计学意义（t＝-23．6,P＜0．05）。4例在术后6个月内感膝关节屈曲时髌内侧有紧张感,末次随访时均消失;3例患者末次随访时诉膝前在上下楼梯时有酸痛感,此3例患者均为手术时髌骨软骨面有损伤。【结论】采用以游离肌腱重建 MPFL手术治疗创伤性髌骨脱位,临床效果满意。     

关节镜下自体半腱肌腱重建内侧髌股韧带联合Fulkerson截骨治疗复发性髌骨脱位

目的探讨联合应用关节镜下自体半腱肌腱重建内侧髌股韧带术联合Fulkerson截骨治疗复发性髌骨脱位的效果。方法对18例复发性髌骨脱位的患者在关节镜下进行髌股外侧支持带松解术和自体半腱肌腱重建内侧髌股韧带,同时进行Fulkerson胫骨结节截骨内移抬高术。术后随访了解膝关节脱位复发、患膝主观症状以及患肢整体功能康复情况。结果所有患者术后均获得满意随访,随访时间6~24个月,平均随访时间12.7个月。髌骨脱位无复发。术后X线检查对比发现,髌骨-股骨滑车适配角从术前(25.8±6.9)°改善为(1.5±7.1)°(P0.01),髌骨外侧面张开角从术前的(-1.3±6.2)°改善为术后的(12.8±3.9)°(P0.01)。膝关节术后1年时的Lysholm评分为(94.7±3.1)分,明显高于术前的(65.6±4.6)分(P0.05);术后1年Kujala评分为(91.6±3.1)分,也明显高于术前的(60.3±3.3)分(P0.05)。术后1年根据Insall膝关节功能评分标准,其中优13膝,良4膝,可1膝,优良率达94.4%。结论关节镜下进行髌骨外侧支持带松解术和自体半腱肌腱重建内侧髌股韧带,结合Fulkerson胫骨结节截骨内移抬高术能够有效治疗复发性髌骨脱位,防止复发,并有利于缓解症状,恢复膝关节功能。     

自体半腱肌腱游离移植重建内侧髌股韧带治疗创伤性复发性髌骨脱物

回顾性分析2002-06/2005-12本科收治的创伤性复发性髌骨脱位11例,男5例,女6例,年龄15～26岁.X射线平片显示无股骨髁部发育异常.Lysholm评分移植前平均(75.5±4.7)分.分别采用自体半腱肌腱游离移植重建内侧髌股韧带.随访时间大于6个月.移植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.髌骨轴位X射线平片显示髌股关节解剖关系恢复正常10例,髌骨轻度半脱位1例.移植后Lysholm评分平均(94.8±2.6)分.自体肌腱游离移植重建髌股韧带是治疗复发性脱位的一种有效方法.     

自体半腱肌移植重建内侧髌股韧带治疗髌骨不稳定

目的探讨内侧髌股韧带重建术治疗复发性髌骨脱位及半脱位的手术方法及临床疗效。方法经临床关节镜检查诊断的髌骨脱位及半脱位患者8例(10膝),在行半腱肌重建内侧髌股韧带的基础上,配合胫骨结节内移及股薄肌前移等手术治疗。手术前后均对患者的膝关节功能进行Lysholm评分。结果8例患者随访2～14个月(平均8个月),术后膝关节稳定性增加,无髌骨再脱位发生,恐惧试验均为阴性。Lysholm评分术前平均(78.3&#177;3.8),术后平均(93.2&#177;3.3)。结论半腱肌重建内侧髌股韧带为主的综合术式治疗髌骨不稳定能有效防止其复发,对维持髌骨的稳定有重要作用。     

三联手术治疗复发性髌骨脱位后康复训练的效果

目的 探讨三联手术治疗复发性髌骨脱位的康复训练的效果.方法 对61例复发性髌骨脱位的病人进行手术治疗,术后根据病人不同的情况,制订了详细的康复计划,在理疗科的配合下术后第1天开始进行系统的功能锻炼至6个月左右.结果 61例髌骨脱位的病人均获得随访,术前Kujala评分（75.43±24.77）分、Lysholm评分（76.10±25.90）分,术后12个月,Kujala评分（94.93±9.03）分、Lysholm评分（95.18±10.82）分.手术前后Kujala评分和Lysholm评分比较差异有统计学意义,全部病人术后无并发症.结论 术后系统的康复计划是病人功能恢复良好的必要条件,仔细的讲解能够使病人积极地配合功能锻炼.     

半腱肌重建内侧髌股韧带治疗复发性髌骨脱位

目的探讨关节镜辅助下外侧髌骨支持带松解和半腱肌游离移植重建内侧髌股韧带治疗复发性髌骨脱位的疗效。方法本组21例病人（25个膝关节）,男4例,女17例,其中4例女性为双膝,所有病人均有外伤病史,髌骨反复脱位至少2次以上,5例病人合并有膝关节游离体。膝关节X线片及MR I示髌骨内侧关节面有相应的骨损伤,行外侧支持带松解后采用自体半腱肌重建内侧髌股韧带。结果所有病人术后均获得1.5~3.5年随访,平均2.1年,全部病例术后髌骨脱位未见复发,无脱位恐惧感。关节活动恢复正常。采用Lysholm临床评分系统对膝关节功能进行评估,术后平均评分91分。结论关节镜辅助下半腱肌重建内侧髌股韧带,是治疗髌骨复发性脱位的一种理想的手术方法。     

关节镜辅助下治疗髌骨不稳定的效果分析

目的对比分析改良Maquet三联手术与关节镜辅助下自体腘绳肌腱重建内侧髌股韧带治疗髌骨不稳定的临床疗效。方法选取2009年1月至2012年12月因髌骨不稳定住院治疗的患者90例,实验组采取关节镜辅助下自体腘绳肌腱重建内侧髌股韧带治疗,对照组采取改良Maquet三联手术治疗,对比分析两组患者手术前后外侧髌股角、髌骨适合角及髌骨外移程度,同时对于所有患者术后进行为期12个月的随访,对比两组患者的Lysholm评分(LKSS)和Kujala评分,并复查两组患者的膝关节正侧位及屈膝60°X线平片。结果两组患者术后的外侧髌骨角均显著大于术前,髌骨适合角及髌骨外移程度均显著小于术前(P0.01);且实验组的外侧髌骨角、髌骨适合角和髌骨外移程度改善优于对照组(P0.01)。术后12个月两组患者的Lysholm评分和Kujala评分均显著高于术前(P0.01),且实验组术后12个月的两组评分均显著高于对照组(P0.01)。结论关节镜辅助下自体腘绳肌腱重建内侧髌股韧带治疗髌骨不稳定相比于传统开放性手术,可取得较好的术后疗效,同时有效防止术后复发,值得临床进一步推广。     

自体肌腱移植双束解剖重建内侧髌股韧带治疗髌骨脱位

背景:对于髌骨不稳的治疗,临床上一般分为保守和手术治疗,其中手术治疗方法众多,每种方法各有侧重,对于使用何种方法治疗髌骨不稳,目前仍没有形成统一的共识.目的:探讨应用自体移植肌腱双束解剖重建内侧髌股韧带治疗髌骨脱位.方法:选择安徽医科大学第一附属医院骨科行膝关节镜辅助下内侧髌股韧带重建髌骨脱位患者46例,所有患者均采用自体移植肌腱双束解剖重建.结果与结论:重建后随访2~16个月,观察患者关节稳定性及灵活度.46例患者随访期间未见严重并发症,患膝轻度伸直受限1例,重建后均未见髌骨复发脱位.重建后随访Lysholm膝关节评分和Kujala评分均高于重建前(P < 0.01).结果证实,采用膝关节镜辅助下自体移植肌腱双束解剖重建内侧髌股韧带治疗髌骨脱位效果较好.     

Rekonstruktion des Lig. patellofemorale mediale bei patellofemoraler Instabilität

Although patellofemoral instability and malalignment are common orthopedic problems, the understanding of interacting factors influencing patellar kinematics and stability is still poor. Patellofemoral stability is provided by passive and active factors such as patellofemoral congruence and medial and lateral ligamentous restraints as passive stabilizers as well as muscle forces of the knee extensor apparatus as active stabilizers. The main stabilizing factor is the passive restraint of the medial patellofemoral ligament (MPFL). Rupture of the MPFL is the essential pathology of the patellofemoral joint responsible for patellofemoral instability and observed radiologically in 90% of all primary patellar dislocations. As it was proven in clinical and biomechanical studies, reconstruction of the MPFL not only provides higher patellofemoral stability compared to conventional surgical procedures involving the extensor apparatus, it also causes less postoperative anterior knee pain. Thus, MPFL reconstruction should be viewed as the primary choice to treat recurrent patellar dislocation.     

基于Kaplan-Meier的关节镜下髌骨脱位三联修复术远期效果评价

目的使用Kaplan-Meier分析法评价关节镜下复发性髌骨脱位三联修复术远期效果。 方法入选髌骨脱位患者69例髌骨脱位患者随机分为观察组（n=36）及对照组（n=33）,分别给予关节镜下三联修复及普通双束解剖重建内侧髌股韧带治疗髌骨脱位。对以上患者进行为期5年的长期随访,比较手术前后外侧髌股角、Lysholm评分及疗效维持情况。 结果治疗前两组外侧髌股角及Lysholm评分均无组间差异（P ＞0.05）;末次随访时,两组患者的外侧髌股角及Lysholm评分均显著大于/高于手术前,观察组上述两者显著大于/高于对照组（P＜0.05）。两组分别有3及4例患者删失,删失率无统计学差异（P ＞0.05）。两组最长疗效维持时间分别为75及68个月;观察组的疗效维持时间的算术均数及中位数分别为58及54个月,而对照组分别为48及42个月。Kaplan-Meier分析显示两组患者的累积疗效维持率差异具有统计学意义（χ2=3.481,P=0.032）。结论关节镜下复发性髌骨脱位三联修复术远期效果优于普通双束解剖重建内侧髌股韧带法。      

Lateral patellofemoral ligament reconstruction to restore functional capacity in patients previously undergoing lateral retinacular release

AIM: To study patient outcomes after surgical correction for iatrogenic patellar instability. METHODS: This retrospective study looked at 17 patients (19 knees) suffering from disabling medial patellar instability following lateral release surgery. All patients underwent lateral patellofemoral ligament (LPFL) reconstruction by a single surgeon. Assessments in all 19 cases included functional outcome scores, range of motion, and assessment for the presence of apprehension sign of the patella to determine if LPFL reconstruction surgery was successful at restoring patellofemoral stability. RESULTS: No patients reported any residual postoperative symptoms of patellar instability. Also no patients demonstrated medial patellar apprehension or examiner induced subluxation with the medial instability test described earlier following LPFL reconstruction. Furthermore, all patients recovered normal range of motion compared to the contralateral limb. For patients with pre and postoperative outcome scores, the mean overall knee injury and osteoarthritis outcome score increased significantly, from 34.39 preoperatively (range: 7.7-70.12) to 69.54 postoperatively (range: 26.82-91.46) at final follow-up (P < 0.0001). CONCLUSION: This novel technique for LPFL reconstruction is effective at restoring lateral restraint of the patellofemoral joint and improving joint functionality.     

Comparison of the Clinical Effects of Open and Closed Chain Exercises after Medial Patellofemoral Ligament Reconstruction

[Purpose] To compare the effects of open-chain exercise (OCE) and closed-chain exercise (CCE) for patients after medial patellofemoral ligament (MPFL) reconstruction. [Subjects and Methods] Forty patients after MPFL reconstruction were randomly divided into an OCE group and a CCE group. All the patients were evaluated at four different time points. [Results] The mean change of thigh circumference decrease in the CCE group was lower than that in the OCE group at both the 3rd and 6th month after surgery. The Lysholm score of the CCE group was higher than that of the OCE group at both the 3rd and 6th month. At the 3rd month after surgery, the visual analog scale score of the CCE group was lower than that of the OCE group. [Conclusion] CCE is better than OCE for both short and long term outcomes of patients after MPFL reconstruction.Key words: Medial patellofemoral ligament reconstruction, Open-chain exercise, Closed-chain exercise     

Patellafraktur nach MPFL-Plastik bei erhöhtem TTTG-Abstand

A 19-year-old patient suffered recurrent patellar dislocations and was treated by medial patellofemoral ligament (MPFL) reconstruction with a gracilis ligament autograft. Normal knee flexion while bowling led to a patella fracture 4 years after surgery. Further diagnostics showed a normal mechanical axis, no torsional deformity, no patellar or trochlear dysplasia and normal patella height. Source of the patellar instability was an increased tibial tuberosity-trochlea groove distance (19 mm). Surgical treatment was carried out with screw fixation of the patella fracture and tibial tuberosity transfer. The source of the patellar instability was not completely analyzed before surgery and ultimately led to a patellar fracture. A complete diagnostics of a patellar dislocation is always necessary before surgery.     

不同软组织移植治疗儿童复发性髌骨脱位的比较

背景：成人复发性髌骨脱位由于不必考虑损伤骨骺的问题，多数采用骨移植，但在儿童复发性髌骨脱位采用骨移植并不适宜，多数学者采用软组织移植治疗。目的：回顾性评估22例骨骺未闭儿童复发性髌骨脱位患者采用软组织移植治疗的临床效果。方法：回顾性分析2006年5月至2009年4月上海长征医院关节外科采用软组织移植治疗儿童复发性髌骨脱位患者22例共29膝，分别在移植后3周，6周，3个月，1年和此后每年对患者进行随访，评估髌骨稳定性、主观症状以及患膝康复情况。结果与结论：22例患者中1例复发，1例发生髌骨内侧脱位，其余患者均取得较好疗效。软组织移植前后膝关节功能主观评分分别为46．99±5．91与94．40±9．70（P〈0．01），Lysholm膝关节功能综合评分在移植前后分别为44．37±4．49与90．10±11．00（P〈0．01），移植后髌骨一滑车适配角由移植前（16．27±6．74）°改善为移植后（5．33±8．78）°（P〈0．01），髌股外侧角由移植前（-1．92±7．64）°改善为移植后（11．95±3．99）°（P〈0．01）。软组织移植治疗骨骺未闭儿童复发性髌骨脱位，简单易行、可操作性强、疗效确切，有利于缓解症状，改善膝关节功能。     

去神经化术在髌股关节炎膝前痛治疗中的应用

目的探究膝关节镜下清理术联合去神经化术对髌股关节炎膝前痛的疗效。方法选取2012年9月-2015年9月该院收治的60例髌股关节炎膝前痛患者为研究对象,采用随机数表法将患者分为观察组和对照组,各30例。给予对照组患者关节镜清理术治疗,给予观察组患者关节镜清理术联合髌骨周围去神经化术治疗。对比观察组和对照组患者术前和术后3个月的美国西部Ontario和McMaster大学骨关节炎指数(WOMAC)评分、Lysholm评分和Kujala评分。结果术前观察组和对照组患者各项评分差异均无统计学意义(P0.05)。观察组和对照组患者术后3个月的各项评分较术前均显著改善,且观察组患者的WOMAC评分、Lysholm评分和Kujala评分较对照组患者均较佳,差异有统计学意义(P0.05)。术后3个月观察组30例患者出现2例感染和1例血管神经损伤,对照组30例患者出现1例感染和1例关节活动受限,两组患者术后不良反应差异无统计学意义(P0.05)。结论给予髌股关节炎膝前痛患者关节镜清理术联合髌骨周围去神经化术治疗能够缓解疼痛,改善髌股关节功能和临床疗效,可以在临床上进一步推广和使用。     

Erweiterte Indikationen für die Rekonstruktion des medialen patellofemoralen Ligaments

The medial patellofemoral ligament (MPFL) is the main restraint of the patellofemoral joint against lateral patella dislocation in the extended knee. The indications to reconstruct the MPFL are subacute and/or chronic dislocations of the patella to regain stability and physiological joint kinematics, which is achieved by placing the graft anatomically and using a two-bundle technique. Due to the multifactorial genesis of patellofemoral instability, the exclusive reconstruction of the MPFL should only be done after exclusion of further pathomorphologies. Nevertheless, reconstruction of the MPFL in combined surgical interventions, such as trochleaplasty, derotation osteotomy and implantation of prostheses is an essential part of the successful operative treatment of patellofemoral instability.     

Die Patellaluxation im Kindes- und Jugendalter

Background

Lateral dislocation of the patella is a common injury in adolescents and young adults which is often associated with an imbalance of the active, passive and static stabilizers of the patellofemoral joint. Therefore, a detailed medical history and a thorough clinical and radiological examination are required to detect the relevant predisposing factors to lateral patellar instability. When indicated radiographic analysis of the lower leg geometry should be added to standard radiographs and magnetic resonance imaging (MRI) examination of the affected knee joint.

Methods

Recent randomized control trials of operatively treated primary lateral patellar dislocations failed to improve the redislocation rate or the subjective clinical outcome compared with conservative management. Thus, non-operative therapy has been recommended as the treatment of choice in primary dislocations. However, the indications for operative treatment after primary patellar dislocations include the presence of an osteochondral fragment, substantial disruption of the medial soft tissue stabilizers and a laterally subluxated patella with normal alignment of the contralateral knee. Although, there is no conclusive evidence that primary medial patellofemoral ligament (MPFL) repair in first time patellar dislocations reduces the incidence of recurrence, it seems reasonable to address MPFL injury at least in those cases where an osteochondral flake fracture requires an early operative procedure. Surgery may be required in patients where non-operative treatment has failed and instability episodes recur. In these patients preoperative planning requires a detailed analysis of the individual anatomy, including the identification and evaluation of predisposing factors that contribute to patellofemoral instability but has to respect the open growth plates in the young patient. Injury to the MPFL occurs in almost all patients after primary patellar dislocations even in adolescents and young adults. Therefore MPFL augmentation techniques without violating the distal medial femur epiphysis have gained in importance in recent years.

Conclusion

In view of the high rates of patellar redislocation particularly in young patients, patellofemoral instability necessitates a better understanding of the factors that lead to recurrent dislocations. Therefore, prospective-randomized controlled trials are required to establish evidence-based recommendations how to treat first time instability. In addition more comprehensive data is needed to differentiate between those patients who have a high likelihood of recurrent episodes of patellar instability and those for whom conservative treatment might be successful.