膝关节股骨内侧髁自发性骨坏死的阶梯治疗策略

背景：目前临床上对于膝关节自发性骨坏死已经有多种保守治疗和手术的方案，并取得了优良的效果，但在手术指征和具体手术方案选择方面尚未形成广泛的共识，临床中仍存在一发现膝关节自发性骨坏死就行单髁置换或全膝关节置换的误区，亟需普及阶梯治疗的理念。目的：从文献和临床病例中总结发现导致膝关节股骨内侧髁自发性骨坏死保守治疗效果欠佳的因素，同时与Koshino分期结合，提出膝关节股骨内侧髁自发性骨坏死阶梯治疗的策略。方法：系统检索文献数据库，总结发现导致膝关节股骨内侧髁自发性骨坏死保守治疗效果欠佳的因素。同时检索住院电子病例系统回顾性分析2017年1月至2023年1月在广东省中医院骨科因膝关节股骨内侧髁自发性骨坏死行保守和手术治疗的病例，对典型病例治疗成功和失败的原因进行总结分析。结果与结论：(1)膝关节自发性骨坏死的早诊断和早治疗，对预后有着非常重要的意义。临床上对突发的膝关节疼痛，X射线片检查未见明显异常时，如症状持续不能缓解大于1周，建议行MRI检查，可以发现早期的膝关节自发性骨坏死。(2)膝关节股骨内侧髁自发性骨坏死的Koshino1期和2期的影像在X射线片下较难区分，需借助MR进行区分，Ko...     

基于MRI的成人正常膝关节软骨形态学测量

目的：了解正常膝关节软骨分布及股骨髁承重区的软骨厚度特点,为膝关节病变早期诊断和动态观察提供依据。方法：选取100名成人志愿者,男、女各50名,年龄20—30岁,平均25．3岁,膝关节均行MRI扫描。应用MIMICS软件对图像进行处理,在矢状位窗面上测量膝关节各部位软骨最大厚度。选择膝关节正常运动时的承重区,测量承重区域软骨的最大厚度并与其他区域进行比较。基于MRI图像行膝关节软骨三维重建,观察膝关节软骨的三维形态特征。结果：膝关节各部位的最大软骨厚度如下。胫骨外侧平台3．19mm,胫骨内侧平台3．07mm,股骨外侧髁2．93mm,股骨内侧髁3．19mm,股骨滑车软骨3．57mm,髌软骨3．75mm。不同性别与左右侧之间的软骨厚度差异无统计学意义（P〉0．05）。胫股关节承重区软骨厚度大于其他区域,有统计学差异（P〈0．05）。结论：成人正常膝关节各区域软骨厚度不同,胫股关节承重区软骨厚度大于非承重区域。基于MRI可以准确地测量膝关节各部软骨的厚度及重建膝关节软骨的三维形态。     

可吸收钉与股骨内髁解剖钢板修复内侧髁Hoffa骨折:钢板贴附较好固定牢靠

背景:股骨内侧髁Hoffa骨折常伴有关节面粉碎,如治疗不当可出现骨折不愈合、膝关节功能障碍等并发症。单独使用螺钉固定很难实现粉碎骨折块整体化,固定强度欠佳;另外普通钢板用于内侧髁Hoffa骨折时往往需要术中进行不断塑形,且对螺钉固定方向有一定限制,影响复位后骨折块的稳定性。目的:探讨股骨内侧髁Hoffa骨折损伤特点并分析应用可吸收钉结合股骨內髁解剖钢板修复此类骨折的效果。方法:回顾性分析2010年5月至2013年6月天津医院创伤骨科采用可吸收钉结合股骨远端内侧解剖钢板修复股骨内侧髁Hoffa骨折12例患者的病例资料,男8例,女4例;年龄21-67岁,平均42岁。治疗前均行膝关节正、侧位X射线片及CT、MRI检查。12例患者均行切开复位内固定治疗,术中采用可吸收钉结合解剖钢板内固定骨折,治疗后随访观察患者骨折愈合及膝关节功能恢复情况。结果与结论:所有患者均获得随访,随访时间16-48个月。骨折均愈合,无内固定松动及骨折再移位等并发症发生,患者膝关节屈曲范围为110°-135°,按膝关节Letenneur评分标准评定疗效,优9例,良2例,可1例,优良率为92%。可见可吸收钉固定可实现关节面粉碎骨块的整体化,再结合股骨內髁解剖钢板治疗内侧髁Hoffa骨折,可进一步坚强固定骨折,操作方便,钢板贴附较好,具有固定牢靠、并发症少、可早期进行功能锻炼、修复效果好等优点,可为临床修复此类骨折提供参考。     

多发性骨软骨瘤病的临床特点及影像诊断

目的分析总结多发性骨软骨瘤的病因、临床特点及影像学表现。方法 2010年3月至2014年12月我院收治21例多发性骨软骨瘤患者,所有患者均行X射线DR检查,15例行CT扫描,4例行MRI检查。回顾性分析其临床及影像资料,结合文献进行影像学征象分析。结果 21例患者均有多发性骨软骨瘤病家族遗传史,好发于四肢长骨干骺端,特征表现为长骨的骨骺端带蒂或无蒂的有软骨帽覆盖的骨性肿块,常为双侧但并非均为对称性,下肢发病多于上肢,下肢以膝关节周围骨骼最多见,多背离关节方向生长。结论多发性骨软骨瘤病以软骨内化骨形成缺陷、骨性赘生物形成为其特点,多合并骨骼弯曲与短缩畸形及邻近关节活动障碍,根据典型临床特点及X射线、CT、MRI等影像学检查可明确诊断。     

膝关节自发性骨坏死MR诊断及鉴别诊断研究

目的：探讨膝关节自发性骨坏死(SONK)的影像学表现。方法在临床和影像学资料,对20例确诊患者膝关节自发性骨坏死。均行膝关节MRI检查,行CT检查4例,行平片检查4例。结果MRI显示软骨病变,位于股骨髁负重的地方14例。这表明2例软骨下骨折裂隙综合征；显示软骨状长T1短T2信号,2例骨髓水肿在信号；显示软骨下焦稍长T1长T2信号10例。CT检查45例,清晰显示病变2例；X线平片检查4例,仅1例病变。结论MRI能显示膝关节自发性骨坏死病变比CT,X射线敏感。结合临床表现和MRI诊断可以。     

成人大骨节病膝关节生物力学及形态学数字X线摄影评价

目的 探讨成人大骨节病(KBD)与原发性骨关节炎(OA)患者膝关节生物力学及X线形态学指标的差异,为成人KBD患者膝外科矫形提供参考。方法 回顾性分析2012年3月—2014年9月,甘肃省疾病控制中心地方病科确诊的326例成人KBD患者的膝关节数字X线摄影(DR)正位片资料,并作为KBD组。按随机数字表法抽取甘肃省中医院影像中心和武威市中医院放射科2012年10月—2014年10月接诊的271例原发性OA患者膝关节正位DR片(OA组),测量比较两组患者膝关节正位DR片中软骨下骨硬化厚度、游离体数、骨赘数,以及股骨角、胫骨角、股骨胫骨角、关节间隙角、股骨内外侧髁高度/宽度参数。结果 KBD组326例患者中182例(55.82%)软骨下骨硬化厚度为2.1～4.9 mm,171例(52.45%)关节腔游离体数为1～2个,173例(53.07%)骨赘数≥4个。OA组271例中107例(39.48%)软骨下骨硬化厚度为2.1～4.9 mm,123例(45.38%)关节腔游离体数为1～2个,145例(53.50%)骨赘数≥4个。两组患者DR片上软骨下骨硬化厚度、游离体数、骨赘数比较,差异均有统计学意义(Z=2.187、3.503、4.029,P值均＜0.05)。KBD组关节间隙角、股骨内侧髁高度/宽度比值均大于OA组,股骨胫骨角小于OA组,差异均有统计学意义(t=10.464、24.174、30.539,P值均＜0.01);而两组股骨角、胫骨角、股骨外侧髁高度/宽度比值,差异均无统计学意义(t=0.943、1.763、0.551,P值均＞0.05)。结论 成人KBD患者膝关节软骨下骨硬化程度、游离体数、骨赘数均高于OA患者。成人KBD患者和OA患者下肢力线均向内侧髁倾斜,但前者倾斜程度比后者严重。     

股骨内侧髁软骨不同缺损面积影响周围软骨应力的三维有限元分析

文题释义： Von Mises应力：是一种等效应力,用应力等值线来表示模型内部的应力分布情况,可以清晰描述出一种结果在整个模型中的变化,来确定模型中的最危险区域。在一定的变形条件下,当材料的单位体积形状改变的弹性位能(又称弹性形变能)达到某一常数时,材料就屈服。 箱式图：是指—种描述数据分布的统计图,是表述最小值、第一四分位数、中位数、第三四分位数与最大值的一种图形方法,可以粗略地看出数据是否具有对称性,分布的分散程度等信息。 背景：研究发现三维有限元分析可用于膝关节生物学研究,但关于股骨内侧髁不同缺损后周围软骨应力变化的研究不多。 目的：探讨膝关节股骨内侧髁软骨发生不同缺损前后周围关节软骨应力的变化趋势,为膝关节股骨内侧髁软骨缺损患者提供生物力学数据。 方法：选取正常成人1例建立三维数字有限元模型,在Abaques软件中将己划分好网格的模型录入材料力学特性,约束边界条件及在模型上加载载荷,进行有限元结构非线性计算,首先观察正常膝关节软骨半月板在载荷条件下的应力空间分布,然后观察股骨内侧髁软骨发生不同缺损(0,6,8,10,12,14,16,18,20 mm)后周边软骨在载荷条件下的应力空间分布,分析股骨内侧髁软骨缺损时发生在软骨上的应力改变情况。研究方案获得昆明医科大学第一附属医院伦理委员会批准,试验志愿者对试验过程完全知情同意。 结果与结论：①成功定义了模型的材料属性、边界条件及载荷的引入,并得出了膝关节内侧髁软骨发生不同直径缺损时关节软骨的应力云图及其应力数据,经统计分析得到,当股骨内侧髁软骨出现10 mm(面积0.78 cm²)和12 mm(面积1.13 cm²)缺损分别为股骨髁和胫骨平台软骨上的应力较无缺损时有显著性变化;②应用三维有限元法计算得出了在膝关节内侧髁的软骨发生不同直径缺损的情况下膝关节软骨的应力变化趋势;③结果表明股骨内髁直径10 mm(面积0.78 cm²)缺损可能是进行软骨修复手术干预的最小直径。 ORCID: 0000-0003-4694-9716(张叶明) 中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

继发性股骨髁骨梗死行单髁置换1例报道并文献复习

<正>1资料及方法骨梗死是一种较少见的骨科疾病,其发病机制尚不清楚,根据病因分为原发性和继发性。继发性骨梗死多见于皮质类固醇治疗、肾脏和全身系统性疾病等,而应用皮质类固醇是最常见的诱因,长时间饮酒、吸烟等是可能的高危因素[1]。继发性骨梗死在膝关节周围的发病率仅次于髋关节,髋关节骨梗死患者中约有10%的会累及膝关节[2]。股骨内髁骨梗死常累及软骨下骨,伴有软骨的剥脱,严重影响膝关节功能及患者的生活质量。目前针对股骨内髁骨梗死     

MRI对股骨远端负重区骨挫伤合并关节软骨损伤的诊断价值

背景：核磁共振检查弥补了X射线平片及CT在软骨成像方面的不足,能对骨挫伤和关节软骨损伤做出早期诊断。 目的：探讨MRI对股骨远端负重区骨挫伤合并关节软骨损伤的诊断价值。 方法：股骨远端骨挫伤35例,观察关节镜下关节软骨损伤情况,比较与MRI所见骨挫伤之间的相关性。 结果与结论：关节镜下所见关节软骨损伤与MRI所示股骨远端负重区骨挫伤部位基本吻合,后者信号改变的范围与软骨损伤面积成正比。提示,MRI对骨挫伤合并的关节软骨损伤有良好的诊断价值,尤其Ⅰ度软骨损伤,骨挫伤是重要的间接征象。但在某些情况下MRI尚不能真实反映出关节软骨损伤的严重程度。     

腓骨近端骨折对伸直状态下膝关节应力影响的有限元分析

背景：传统观点认为绝大多数的腓骨近端骨折是不需要固定的，他人和此次研究提示，近端腓骨结构对于膝关节后外侧结构的稳定性具有重要影响，其作用机制值得研究。目的：探讨腓骨近端骨折对于伸直状态膝关节各结构生物力学的影响。方法：运用有限元方法进行仿真生物力学试验。选用1名健康青年男性志愿者膝关节MRI和CT影像数据资料建立伸直状态下的膝关节有限元模型，并模拟4种近端腓骨形态：模型A为完整模型，模型B为腓骨头下以远1 cm骨折模型，模型C为腓骨近端最顶端向远端1 cm的尖端缺损骨折模型，模型D为腓骨近端最顶端向远端2 cm的骨缺损模型。在股骨干上施加纵向集中载荷1 500 N，对比分析膝关节伸直状态下，4种工况下膝关节各个结构最大等效应力、最大第一主应力的分布以及改变趋势。结果与结论：(1)模型A胫骨软骨、半月板外侧室最大等效应力大于内侧；胫骨平台、半月板内侧室最大第一主应力大于外侧；股骨软骨内侧髁最大等效应力大于外侧髁，股骨软骨内侧髁最大第一主应力大于内侧髁；(2)相较于模型A，模型C的软骨、半月板的最大等效应力和最大第一主应力大小以及分布情况无明显差异；(3)相较于模型A，模型B的最大等效应力...     

Drilling from the intercondylar area for treatment of osteochondritis dissecans of the knee joint

We demonstrate a new method in which a drilling is made from the intercondylar space, and its efficacy in treating osteochondritis dissecans (OCD) of the knee in skeletally immature patients with relatively stable lesions with an intact articular surface, in cases where there was failure of initial non-operative management. The lesions of 16 knees of 12 patients with OCD of the femoral condyles failed to heal by conservative treatment for more than 3 months (average 5-6 months) and thereafter were arthroscopically treated with drilling from not the transarticular but the intercondylar bare area without damaging the articular surface. Eight lesions involved the medial femoral condyle, and eight involved the lateral femoral condyle. The average follow-up was 16 months. All lesions healed after drilling, and the average time of healing was 4 months by X-ray and 7 months by MRI. The average Lysholm score improved from an average of 70.4 points at preoperation to an average of 97.8 points after operation. The results of the Hughston Rating Scale were similar: 10 of the 12 patients showed excellent results and the remaining two patients good results. We advocate our new and less invasive procedure of drilling from the bare area of the intercondylar space for OCD in the knee joint of skeletally immature patients who have had failure of initial non-operative management.     

基于定量动态负荷下膝关节骨性关节炎软骨MRIT2时间表现研究

目的通过比较膝关节骨性关节炎（OA）病人定量动态负荷前后膝关节软骨T2时间变化情况,分析MRIT2mapping序列反映软骨基质生物力学变化的灵敏度．并验证高磁场条件下人体关节负荷装置的有效性。方法10例膝关节OA病人,其中男性3例．女性7例：年龄4l～66岁．平均年龄57-3岁。依托人体下肢关节力学负荷装置,对其施加膝关节动态负荷。负荷前后行膝关节MRIT2maDping成像,将膝关节轴向负荷区软骨分为4个部位：胫骨平台内、外侧软骨区及股骨内、外侧髁软骨区．分别测量各部位软骨负荷前后的T,时间。对负荷前膝关节内、外侧软骨分级评估进行卡方检验,对同一软骨区动态负荷前后的T2时间进行配对t检验。结果负荷前膝关节内外侧软骨分级差异无统计学意义（P〉0．05）。OA病人负荷前后T2值,胫骨平台内侧软骨区分别为（39．59±4．17）ms、（40．14±4．49）ms（f=0．426,P=0．680）;胫骨平台外侧软骨区（38．85±6．72）ms、（41．25±6．54）ms（t=1．704,P=0．123）：股骨内侧髁软骨区（36．44±5．72）ms、（40．63±4．90）ms（t=1．783,P=0．108）;股骨外侧髁软骨区（39．30±5．78）ms、（46．14±5．03）ms（t=2．826,P=0．020）。结论OA病人负荷后膝关节局部区域软骨区T2时间延长．自行设计的动态加压装置适合在高磁场条件下完成加压及MRI检查,有一定推广意义。     

Osteochondritis dissecans of the weight-bearing surface of the medial femoral condyle in adults

Osteochondritis dissecans (OD) is a syndrome that can be characterized as a non-infectious disturbance of enchondral ossification or as a post-traumatic event. OD occurs in the joint cartilage and physis of long bones, as well as in the talus. The medial femoral condyle is the most commonly affected site. OD of the weight-bearing, inferocentral portion of medial femoral condyle is an uncommon, but still challenging issue in knee surgery. This study reports one surgeon's experience in the treatment of OD of the weight-bearing surface of the medial femoral condyle in adult patients. A total of 29 knees in 28 patients with OD were reviewed as the basis of this study. Four patients were women and 24 were men. The average age was 29.5 years. Patients were observed for an average of 2 years after surgery. Medial joint line tenderness, anterior knee pain, stiffness and locking were the major complaints in 60% of cases. Arthroscopic excision of loose bodies with or without drilling of the crater and fixation of the lesions with 2 K-wires, with or without bone grafting, was undertaken for the patients. In our study, the clinical outcome was excellent in 11 patients, good in 13, fair in four and poor in one. On subjective questioning, all patients reported marked improvement and satisfaction with the surgery.     

膝关节髌内侧滑膜皱襞综合症MRI诊断及临床治疗的相关性研究

目的 探讨膝关节髌内侧滑膜皱襞增生,引起的髌股关节撞击MRI影像特点,为临床提供更多的诊断依据,更好的为患者提供诊疗评估。方法 选取2016年9月~2016年12月膝关节磁共振髌内侧皱襞增生患者49例,按照Sakakibara法分型研究分析。结果 49例患者中,其中3例患者行双膝关节MRI平扫,且双膝关节髌内侧滑膜皱襞均增生,总共52例滑膜皱襞综合症。其中A、B型为19例,C、D型为33例。其中12例C、D型患者均有前膝疼痛症状,部分可见髌股关节面骨质水肿,内侧滑膜皱襞游离缘毛糙,考虑病理性滑膜皱襞综合症占比36.36%。结论 除去膝关节疼痛的常见因素,A、B型滑膜皱襞综合症患者无明显临床症状,C、D型滑膜皱襞综合症患者有临床意义。MRI检查能够明确诊断滑膜皱襞综合症,有助于指导临床诊治以及多次无创随访。     

股骨内髁参数对单髁置换中截骨及假体设计的参考意义

BACKGROUND: Knee-parameter measurements play an important role in the designing of the knee prosthesis. Currently, we have more and more research of the total knee replacement, while uni-condylar knee replacement study is few.  OBJECTIVE: To obtain the parameters of the normal femoral condyles and explore its correlation with osteotomy and prosthesis design of the knee joint during uni-condylar knee replacement. METHODS: Normal knee joints of 60 cases (60 knees) were selected. We measured the parameters by using thin-section CT scan and post-processing techniques, including arc diameter of the lowest point of the femoral condyle on the coronal plane, arc diameter of the distal point of the posterior condyle of the femur on the transverse plane, arc diameter of the distal point of the posterior condyle of the femur on the sagittal plane, and arc diameter of the lowest point of the femoral condyle on the sagittal plane, and analyzed the correlation with sex and height.  RESULTS AND CONCLUSION: The diameter of the arc that passes through the lowest point of femoral medial condyle in the coronal plane was (42.685±1.389) mm. The diameter of the arc that passes through the farthest point of posterior of femoral medial condyle in the cross-section was (42.732±1.440) mm. The diameter of the arc that passes through the lowest point of femoral medial condyle on the sagittal plane was (45.473±1.332) mm. The diameter of the arc that passes through the farthest point of posterior of femoral medial condyle on the sagittal plane was (42.587±1.446) mm. The results illustrate that knee condyle related parameters were positively correlated with height. Parameters in males were significantly greater than in females. The diameter of the arc that passes through the lowest point of femoral medial condyle on the sagittal plane was significantly larger than that of the farthest point of femoral posterior medial condyle on the sagittal plane (P < 0.001). There was no significant difference among the diameter of the arc that passes through the lowest point of femoral medial condyle on the coronal plane, the diameter of the arc that passes through the farthest point of posterior of femoral medial condyle on the cross-section and that of the farthest point of femoral posterior medial condyle on the sagittal plane.       

Matrix-assisted autologous chondrocyte implantation into a 14 cm2 cartilage defect,caused by steroid-induced osteonecrosis

Modern chemotherapy protocols have improved the prognosis for acute lymphoblastic leukaemia (ALL), one of the most common paediatric malignancies, but their high-dose corticosteroids lead to osteonecrosis in up to 9% of ALL patients. A 13.5-year-old female patient developed massive osteonecrosis of the right knee after successful ALL treatment. She presented at the age of 17.5 years as a candidate for knee arthroplasty after conservative treatment had failed. Magnetic Resonance Imaging (MRI) revealed severe osteonecrosis, with the cartilage layer of the medial femoral condyle completely detached from the bone. We preferred to attempt a two-step biological reconstruction in this young patient, with arthroscopy of the right knee joint and removal of the dissected cartilage layer of the medial condyle. Matrix-assisted autologous chondrocyte implantation (MACI) was performed with harvested chondrocytes after imaging had indicated vital bone remodelling. Rehabilitation was according to MACI guidelines and after 5.5 years, the patient shows continuous clinical improvement and is satisfied with the result. The Lysholm score improved from 45 to 99 and Tegner's activity score from 1 to 4. MRI follow-up showed a solid cartilage layer covering the medial condyle as a result of bone and chondral regeneration. Even if this approach had failed, bone remodelling would have still provided better conditions for knee arthroplasty.     

电针治疗膝骨性关节炎患者上下楼梯的三维有限元分析

针对电针治疗膝骨性关节炎患者上下楼梯运动生物力学特性改变进行有限元仿真研究,对比分析膝关节生物力学行为改变与电针治疗疗效的相关性.基于CT和MRI图像数据,结合Mimics和Geomagic医学图像处理软件,建立人体膝关节下楼梯屈曲15°和上楼梯屈曲50°时的三维有限元模型,模型包括股骨、胫骨、腓骨、内外侧半月板、股骨...     

An optimized medial parapatellar approach to the goat medial femoral condyle

Goats or sheep are the preferred animal model for the preclinical evaluation of cartilage repair techniques due to the similarity of the goat stifle joint to the human knee. The medial femoral condyle of the stifle joint is the preferred site for the assessment of articular cartilage repair, as this is the primary location for this type of lesion in the human knee. Proper surgical exposure of the medial femoral condyle is paramount to obtain reproducible results without surgical error. When applying the standard human medial arthrotomy technique on the goat stifle joint, there are some key aspects to consider in order to prevent destabilization of the extensor apparatus and subsequent postoperative patellar dislocations with associated animal discomfort. This paper describes a modified surgical technique to approach the medial femoral condyle of the caprine stifle joint. The modified technique led to satisfactory exposure without postoperative incidence of patellar luxations and no long‐term adverse effects on the joint.     

A case of compression fracture of medial tibial plateau and medial femoral condyle combined with posterior cruciate ligament and posterolateral corner injury

We report a case of compression fracture of anterior margin of medial tibial plateau and medial femoral condyle combined with the posterior cruciate ligament and posterolateral corner disruption. A thirty-seven-year old male had undergone the left knee injury 6 months before. The physical examination revealed positive posterior drawer test and tibial dial test, which evidenced the posterior cruciate ligament and posterolateral corner insufficiency. The plain lateral knee radiographs showed a marginal fracture of the anteromedial tibial plateau and a dimpling on the adjacent part of the medial femoral condyle. On arthroscopy, there were no gross tear of the cruciates, but the posterolateral capsule disclosed stigmata of stretching injury with multiple petechiae and scarring. The compression fracture on the anteromedial side and the stretching injury on the posterolateral side altogether support the mechanism of hyperextension pivoting on the anteromedial side of the knee joint. A small bony lesion around the knee joint should be inspected rigorously with an assumed mechanism of injury for it may herald major ligamentous injury.