内侧髌股韧带重建治疗髌骨脱位患者的围手术期护理

目的探讨内侧髌股韧带重建治疗髌骨脱位患者的术中及术后护理。方法对76例髌骨脱位患者,手术前后采用Kujala及Lysholm膝关节功能综合评分,比较髌股关节不稳症状恢复情况,并行髌骨轴位片检查进行术前术后对比。结果Kujala术前评分（41．0±8．4）分,与术后评分（87．0±4．2）分比较,差异有统计学意义（p〈0．01）;Lysholm术前评分（42．8±7．1）分与术后评分（87．2±3．63）分比较,差异有统计学意义（P〈0．01）,髌股关节功能有明显改善。结论采用内侧膑股韧带重建可以纠正髌股关节不稳定,能改善髌股关节功能。     

髌股关节排列紊乱的CT检查

目的　评价髌股关节排列紊乱的CT检查价值。方法　膝关节疼痛患者2 1例(2 6膝) ,对膝关节屈曲0°、15°、30°髌股关节进行CT检查,对髌骨的位置作出定性评价。结果　在伸展状态下至屈膝30°股肌收缩导致髌骨出现移位和倾斜。最常见的异常是髌骨移外侧位伴倾斜。在屈膝30°股肌收缩时,在患膝组中10个未发现髌股关节异常排列的膝中,有3例出现外移和/或倾斜。余下7个未发现髌股关节异常排列的膝中,在屈膝15°股肌收缩时,发现有3个为潜在性髌骨位置异常。结论　屈膝0°～30°在股肌收缩状态下,髌股关节CT扫描是检出髌股关节排列紊乱的有效手段。     

髌股关节疼痛及其临床治疗的研究

概述过去十年作者在实验室进行有关髌股关节及髌股关节疼痛综合征(PFPS)的研究,研究了正常人髌股关节的几个指标及PFPS患者的康复成效。研究结果反映股内侧肌(VMO)对于控制髌股关节的压力分布所发挥的力学作用、下肢方位对促进VMO募集的影响,以及髌骨叩压、股四头肌的疲劳恢复与生物反馈辅助对PFPS康复治疗的作用。     

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。     

内侧髌股韧带解剖和重建与髌股关节不稳

髌股关节不稳是指髌骨在伸屈活动中向外过度移位.在屈膝30°时,外推髌骨超过1 cm,或轴位片上两侧髌股间隙相差2 mm,即可诊断髌股关节不稳.     

股四头肌肌力与髌股关节稳定性关系的研究

目的:了解组成股四头肌的4块肌在维持髌骨稳定性中的作用,为临床治疗髌股关节不稳提供理论依据。方法:对6例新鲜膝关节标本,在不同屈曲度下,分4种工况进行加载分别模拟组成股四头肌的4块肌在生理及不同病理状态下的肌力。对髌骨施加外侧方移位载荷,记录使髌骨向外移位1cm的载荷。结果:生理状态下,在膝关节屈曲过程中,20°时使髌骨向外侧半脱位的载荷最小(61±13N),约为屈曲90°时的1/3;在松解股内侧肌后,屈膝10°—30°半脱位载荷明显减小(P<0.05),进一步松解股外侧肌导致整个屈膝过程中半脱位载荷均明显减小(P<0.05)。结论:整个股四头肌在髌骨外侧半脱位的预防、治疗及康复过程中具有重要作用,手术治疗不宜破坏股外侧肌,康复尤其应重视股内侧肌肌力的恢复。     

中医康复护理在髌三联术治疗髌股关节不稳患者中的应用

目的 探讨髌三联术治疗髌股关节不稳患者的中医康复护理方法.方法 选取2014年9月至2015年12月我院骨科收治的骸股关节不稳患者30例为研究对象,应用中医综合康复护理方法.手术前后采用国际通用的髌骨稳定性相关功能评价表(Kujala)对患者的膝关节日常活动进行综合评分,比较手术前后的膝关节功能恢复情况、髌股关节对合情况.结果 本组30例患者术后随访未见复发,Q角、膝关节功能及髌股关节对合等参考指标改善均优于术前,差异均有统计学意义(均P<0.05).结论 髌三联术治疗术后采用规范、有针对性的中医康复护理方法可以纠正髌股关节不稳,改善髌股关节功能,值得推广.     

皱襞综合征——一种被遗忘的以膝前疼痛为特征的病变

皱襞是位于膝关节髌骨滑膜和胫股关节之间的褶状滑膜襞。正常膝关节可有髌上襞、内侧襞、下侧襞三个皱襞 ,通常无症状。有症状的皱襞可引起前膝痛、弹响、关节不稳、关节交锁 ,与髌股关节活动轨迹异常、髌股关节不稳的症状相似。皱襞的检查应当成为膝关节检查的一部分。病理皱襞用理疗难以治愈 ,通常采用关节镜切除。     

全膝关节置换：股内侧肌下与内侧髌旁入路的比较☆

背景：目前国内全膝关节置换以内侧髌旁入路为主,创伤大、恢复慢,而经股内侧肌下入路更符合正常解剖,能完整保留伸膝装置,临床对于二者的相关比较研究极少。
　　目的：对比经股内侧肌下入路与内侧髌旁入路行全膝关节置换的早期疗效。
　　方法：2009年1月至2010年1月,55例(70膝)膝关节病变患者被随机分为股内侧肌下入路组26例(35膝)和内侧髌旁入路组29例(35膝),分别采用经股内侧肌下入路与内侧髌旁入路行全膝关节置换。比较2组患者切口长度、手术时间、置换后引流量、依托考昔片追加量、疼痛度、直腿抬高时间、起始下地时间、住院时间、膝关节活动度、膝关节功能评分、假体力线对位以及并发症情况。所有假体均选用 Johnson&Johnson公司旋转平台的Sigma型假体。
　　结果与结论：55例患者获得12-24个月随访,均未出现感染、下肢深静脉血栓、血管神经损伤、关节不稳、假体松动或移位等并发症。所有假体均获得正确的力线对位。股内侧肌下入路组患者置换手术时间大于内侧髌旁入路组(P=0.00),而切口长度、置换后引流量、依托考昔片追加量、目测类比疼痛评分、直腿抬高时间、起始下地时间、住院时间、置换后3 d 膝关节活动度及美国特种外科医院评分均优于内侧髌旁入路组(P <0.05)。置换后3个月膝关节活动度、膝关节功能评分2组差异无显著性意义。提示经股内侧肌下入路全膝关节置换早期疗效显著优于经内侧髌旁入路,而2种入路在假体力线对位方面无差异。     

髌股关节骨关节病的关节镜治疗

目的:以同一髌股关节骨关节病关节镜下出现不同病理改变的成因及治疗进行初步探讨。方法：总结髌股关节骨关节病关节镜治疗23例，通过髌骨轴位相从髌骨不稳、髌股关节排列异常分析同一髌股关节出现不同病理改变的成因，并用关键镜检加以证实从而决定手术方案。结果：关节镜下检视髌股关节骨关节病可获得比临床及X线更早期、全面的诊断，并可从同一关节软骨的不同退变程度推断髌股关节骨关节病的成因，从而采取不同的关节镜下治疗方法，取得了满意的临床效果。结论：髌骨不稳、髌股关节排列不吻合是造成同一髌股关节软骨出现不同病理改变的主要原因。关节镜下检视髌股关节，有利于早期、全面诊断并为治疗提供依据；镜下清理术具有有限式微创之特点，疗效好、恢复快、可重复、并发症少， 是治疗髌股关节骨关节病的理想方法。     

Activation of the quadriceps muscle during semisquatting with different hip and knee positions in patients with anterior knee pain.

OBJECTIVE: We measured the surface electromyographic activities of vastus medialis obliquus and vastus lateralis in 16 subjects with patellofemoral joint pain syndrome. DESIGN: Each subject performed bilateral static knee extension exercises at 60% of his or her maximal voluntary effort under different combinations of hip rotation (30 degrees of medial rotation, neutral, 45 degrees of lateral rotation) and knee flexion (20 and 40 degrees) in a standing position. The ratio of surface-integrated electromyographic signals of vastus medialis obliquus over vastus lateralis was calculated for each of the six conditions. Because of significant interaction of hip rotation and knee flexion in the two-way analysis of variance, data were analyzed separately with paired t tests for the effect of knee positions and one-way repeated measures analysis of variance for hip positions. RESULTS: At 20 degrees of knee flexion, there was no significant difference among the three hip positions, whereas at 40 degrees of knee flexion, medial rotation of the hip resulted in significantly higher vastus medialis obliquus over vastus lateralis activity ratio than lateral rotation (P < 0.05). CONCLUSIONS: There was relatively more activation of vastus medialis obliquus than vastus lateralis at 40 degrees of semisquat with the hip medially rotated by 30 degrees. This finding has clinical implications for training the vastus medialis obliquus in patients with patellofemoral joint pain syndrome.     

Temporal activity of vastus medialis obliquus and vastus lateralis in symptomatic knee osteoarthritis

OBJECTIVE: Knee osteoarthritis has a major impact on quadriceps function, yet its effect on the specific temporal recruitment of vastus medialis obliquus and vastus lateralis is unknown. The aim of this study was to determine the electromyographic onset of vastus medialis obliquus activity relative to that of vastus lateralis in individuals with symptomatic knee osteoarthritis and in an asymptomatic control group during the functional task of stair climbing. DESIGN: Cross-sectional, comprising 41 participants with symptomatic knee osteoarthritis and 33 controls matched for age, sex, and body mass. RESULTS: No significant differences were detected in the timing of onset of vastus medialis obliquus relative to that of vastus lateralis between the osteoarthritis and control groups. Radiographic osteoarthritis severity, presence of patellofemoral joint disease, and pain intensity did not seem to influence the temporal relationship of the vastii in the osteoarthritis group. CONCLUSION: The presence of symptomatic, radiographic knee osteoarthritis is not associated with deficits in the temporal recruitment of vastus medialis obliquus and vastus lateralis during stair climbing. This implies that selective retraining of the individual components of the quadriceps is not indicated in rehabilitation programs for patients with this disease.     

Changes in patellofemoral joint contact pressures caused by vastus medialis muscle weakness

Background

Patellofemoral joint pain is a common knee disorder, but its underlying causes remain unknown. One proposed mechanism is an imbalance in force in the knee extensor muscles. Specifically, the vastus medialis and vastus lateralis are thought to play a crucial role in proper patellar tracking, and weakness in vastus medialis is thought to lead to a lateral shift in the patella causing increased contact pressures and pain. The purpose of this study was to create an animal model of vastus medialis weakness and to test the effect of this weakness on patellofemoral contact pressures.

Methods

Experiments were performed using New Zealand white rabbits (mass 4.9–7.7 kg, n = 12). Loading of the patellofemoral joint was produced by femoral nerve stimulation of the knee extensor muscles. Knee extensor imbalance was produced by vastus medialis ablation. Fuji pressure sensitive film was used to record contact area, shape and pressures for maximal and sub-maximal, matched-force contractions at knee angles of 30°, 60°, and 90°.

Findings

Patellofemoral peak pressures, average pressures, contact areas and contact shapes were the same across all loading conditions for matched-force contractions before and after elimination of vastus medialis.

Interpretation

We conclude that vastus medialis weakness does not cause changes in patellofemoral contact pressures. Since the muscular and knee joint geometry in rabbits and humans is similar, we question the idea of vastus medialis weakness as a cause of patellar mal-tracking and patellofemoral joint pain.     

Vastus lateralis and vastus medialis obliquus muscle activity during the application of inhibition and facilitation taping techniques

OBJECTIVE: To evaluate the effect of inhibition and facilitation taping techniques on the activity of vastus lateralis and vastus medialis obliquus. DESIGN: Repeated-measures design. SETTING: Laboratory in an educational institution. SUBJECTS: Thirty healthy females aged between 18 and 23 years. INTERVENTION: Subjects were tested during the application of inhibition tape, facilitation tape and no tape to vastus lateralis in random order. MAIN OUTCOME MEASURES: Electromyographic activity of vastus lateralis and vastus medialis obliquus during stair descent was recorded using bipolar surface electrodes. RESULTS: Electromyographic activity of vastus lateralis and vastus medialis obliquus during the application of inhibition tape or facilitation tape did not alter significantly compared with no tape condition. CONCLUSIONS: Taping designed to inhibit or facilitate muscle activity via sensory stimulation does not affect vastus lateralis or vastus medialis obliquus activity in healthy subjects. Further investigation is required to find a means of muscle taping that could be recommended as an intervention for patients with patellofemoral pain syndrome.     

Patellofemoral Pain Syndrome: A Critical Analysis of Current Concepts

Abstract

Patellofemoral pain syndrome (PFPS) is one of the most common diagnoses treated by physical therapists in the orthopedic setting. The etiological mechanism of PFPS is poorly understood, however it is purported that biomechanical dysfunction of the patellofemoral joint leads to anterior knee pain and decreased function. Current rehabilitation of PFPS focuses on restoring normal patellofemoral mechanics by resolving patellofemoral malalignment, promoting tissue extensibility, promoting optimal timing and strength of the vastus medialis obliquus muscle, and normalizing mechanics of the subtalar joint. However, most of the aforementioned management strategies have not been subjected to scientific scrutiny and therefore lack an evidence-base. The expansive range of therapies currently being utilized is an indication that there is little consensus on the most efficient and effective management strategies for PFPS. The purpose of this paper is to discuss the normal anatomy and biomechanics of the patellofemoral joint in detail and provide a critical analysis of the current literature as it relates to conservative management of PFPS.     

Alterations in in vivo knee joint kinematics following a femoral nerve branch block of the vastus medialis: Implications for patellofemoral pain syndrome

Background

A potential source of patellofemoral pain, one of the most common problems of the knee, is believed to be altered patellofemoral kinematics due to a force imbalance around the knee. Although no definitive etiology for this imbalance has been found, a weak vastus medialis is considered a primary factor. Therefore, this study's purpose was to determine how the loss of vastus medialis obliquus force alters three-dimensional in vivo knee joint kinematics during a volitional extension task.

Methods

Eighteen asymptomatic female subjects with no history of knee pain or pathology participated in this IRB approved study. Patellofemoral and tibiofemoral kinematics were derived from velocity data acquired using dynamic cine-phase contrast MRI. The same kinematics were then acquired immediately after administering a motor branch block to the vastus medialis obliquus using 3–5 ml of 1% lidocaine. A repeated measures analysis of variance was used to test the null hypothesis that the post- and pre-injection kinematics were no different.

Findings

The null hypothesis was rejected for patellofemoral lateral shift (P = 0.003, max change = 1.8 mm, standard deviation = 1.7 mm), tibiofemoral lateral shift (P < 0.001, max change = 2.1 mm, standard deviation = 2.9 mm), and tibiofemoral external rotation (P < 0.001, max change = 3.7°, standard deviation = 4.4°).

Interpretation

The loss of vastus medialis obliquus function produced kinematic changes that mirrored the axial plane kinematics seen in individuals with patellofemoral pain, but could not account for the full extent of these changes. Thus, vastus medialis weakness is likely a major factor in, but not the sole source of, altered patellofemoral kinematics in such individuals.     

Effects of squats accompanied by hip joint adduction on the selective activity of the vastus medialis oblique

[Purpose] This study evaluated the effective selective activation method of the vastus medialis oblique for knee joint stabilization in patients with patellofemoral pain syndrome. [Subjects and Methods] Fifteen healthy college students (9 males, 6 females); mean age, height, and weight: 22.2 years, 167.8 cm, and 61.4 kg, respectively) participated. The knee angle was held at 60°. Muscle activities were measured once each during an ordinary squat and a squat accompanied by hip joint adduction. The muscle activities of the vastus medialis oblique and vastus lateralis were measured by electromyography for five seconds while maintaining 60° knee flexion. Electromyography signals were obtained at a sampling rate of 1,000 Hz and band pass filtering at 20–50 Hz. The obtained raw root mean square was divided by the maximal voluntary isometric contraction and expressed as a percentage. The selective activity of the vastus medialis oblique was assessed according to the muscle activity ratio of the vastus medialis oblique to the vastus lateralis. [Results] The activity ratio of the vastus medialis oblique was higher during a squat with hip joint adduction than without. [Conclusion] A squat accompanied by hip joint adduction is effective for the selective activation of the vastus medialis oblique.Key words: Patellofemoral pain syndrome, Vastus medialis oblique, Squat     

The influence of orthotic devices and vastus medialis strength and timing on patellofemoral loads during running

OBJECTIVE: To use a musculoskeletal model and simulation of running to examine: (1) the influence of two commonly prescribed treatments for patellofemoral pain (vastus medialis oblique strengthening and orthoses) and (2) the functional significance of timing differences between vastus medialis oblique and vastus lateralis on lateral patellofemoral joint loads. DESIGN: A three-dimensional musculoskeletal model of the lower extremity was used to simulate running at 4 m/s. BACKGROUND: Repetitive and excessive joint loading is often associated with overuse injuries that require clinical treatments to reduce pain and restore function. Affecting one in four runners, patellofemoral pain is one of the most common injuries in running. Although conservative treatments have been reported to successfully treat patellofemoral pain, the effectiveness is often based on subjective or empirical data, which have generated disagreement on the most effective treatment. METHODS: Nine subject specific running simulations were generated and experiments were performed by applying the treatments and timing differences to the nominal simulations. RESULTS: Both treatments significantly reduced the average patellofemoral joint load and the vastus medialis strengthening also significantly reduced the peak patellofemoral joint load. In addition, when the vastus medialis oblique timing was delayed and advanced relative to the vastus lateralis timing, a significant increase and decrease in the joint load was observed, respectively, during the loading response.Conclusions. Increasing vastus medialis oblique strength yielded more consistent results across subjects than the orthosis in reducing patellofemoral joint loads during running. The effect of orthoses was highly variable and sensitive to the individual subject's running mechanics. Vastus medialis oblique activation timing is an important determinant of lateral patellofemoral joint loading during the impact phase. RELEVANCE: These findings indicate that a reduction in patellofemoral pain may be achieved through techniques that selectively increase the vastus medialis oblique strength. Therefore, future studies should be directed towards identifying such techniques. Additionally, the functional significance of timing differences between the vastus medialis oblique and vastus lateralis is an important consideration in patellofemoral pain treatment and orthoses may be beneficial for some patients depending on their running mechanics.     

Alterations in patellofemoral kinematics following vastus medialis transection in the anterior cruciate ligament deficient rabbit knee

Background

Anterior cruciate ligament deficiency and quadriceps muscle weakness are considered to be important risk factors for aberrant patellar tracking and subsequent patellofemoral osteoarthritis. However, data from in vivo experiments looking at dynamic patellar joint kinematics and muscle force are scarce. Therefore, the purpose of this study was to evaluate the effects of anterior cruciate ligament transection and loss of vastus medialis force on patellar tracking in the rabbit knee in vivo.

Methods

Eight skeletally mature New Zealand White Rabbits, weighing 6.0 kg (0.6 kg standard deviation) were used. The experimental trials consisted of active, concentric and eccentric movements of the knee joint. Measurements were performed with the intact, the anterior cruciate ligament deficient, and the vastus medialis transected knee. Patellofemoral kinematics (shift, rotation) were quantified from high speed video.

Findings

Following anterior cruciate ligament transection, patellar tracking occurred more laterally, and caused a significant lateral rotation of the patella. The addition of vastus medialis transection did not alter patellar tracking or rotation significantly for any of the force-matched experimental conditions.

Interpretation

The loss of the anterior cruciate ligament results in lateral patellar shift and rotation while the loss of vastus medialis muscle force does not affect patellar tracking or rotation in the anterior cruciate ligament deficient knee. We suggest that the current results should be considered carefully in future interpretations of knee extensor imbalance. More research is needed to describe the contribution of vastus medialis muscle strength to medial patellofemoral stability and confirm these results in the human knee.     

Comparison of muscle activation levels and knee valgus between individuals with medial patellofemoral ligament reconstruction and healthy individuals during fatiguing step down task

BackgroundMedial patellofemoral ligament reconstruction becomes first-choice surgical procedure for patients with a history of lateral patellar dislocations but there is limited knowledge about neuromuscular activation patterns of individuals with a history of patellar dislocation who underwent medial patellofemoral ligament reconstruction.ObjectiveThe aim of this study was to compare muscle activation levels and knee valgus during step down performance test between individuals with a history of medial patellofemoral ligament reconstruction and healthy individuals.MethodsFifteen individuals with medial patellofemoral ligament reconstruction and 15 healthy individuals were included. Vastus medialis obliquus, vastus lateralis and gluteus medius muscle activation levels and knee valgus were measured during 60-s- step down performance test. Two-way repeated-measures of analysis of covariance was used for statistical analysis.FindingsCompared to the healthy individuals, individuals with medial patellofemoral ligament reconstruction showed lower vastus medialis obliquus (p = .04) and gluteus medius (p = .005) activation levels, and higher knee valgus (p = .002) in last period of the step down performance test.InterpretationSince the significant results were only observed in the fatiguing section of the test, endurance tests may provide more information about neuromuscular control of the individuals with history of medial patellofemoral ligament reconstruction. Future studies should investigate whether endurance exercises that target to improve vastus medialis obliquus and gluteus medius activity result in better clinical outcomes than conventional programs for individuals with medial patellofemoral ligament reconstruction.