改良股四头肌成形术治疗膝关节僵直

作者采用自行设计的改良股四头肌成形术治疗１３例膝关节伸直位僵直病人,取得了满意的疗效。本手术特点：（１）舍弃切口髌前段;（２）切断纤维化的股中间肌与股直肌之间的粘连及连接,但不切除股中间肌;（３）向远端松解推移髌上滑膜囊;（４）通过髌旁皮下隧道在滑膜外沿髌骨和髌韧带纵行切开膝内外侧髌支持带;（５）通过髌上囊内侧３ｃｍ切口在不完全开放膝关节的情况下松解髌股关节粘连。术前平均伸屈膝关节０°４９°,术后平均随访１６个月,平均伸屈膝关节可达０°１１０°,未见继发血肿感染。髌前皮肤坏死及伸膝无力等并发症     

髌骨交锁一例报告

患者女，28岁。因右膝顶伤后剧痛，膝关节不能屈曲就诊。查体：膝关节前内侧轻度肿胀，压痛（++）。行被动屈伸膝关节运动，剧痛难忍，患者拒绝活动。拟诊为“韧带扭伤”，嘱休息。24h后，膝关节仍处于伸直位，不能屈曲。摄X线片显示右髌骨纵轴线与股骨干纵轴线成45°角，髌骨下极与股骨髁间重叠（图１）。诊断为右髌骨交锁。强行屈膝数次失败后，左手将髌骨上极向股骨后方按压，使髌骨纵轴线与股骨纵轴线平行，右手屈曲膝关节，即听到弹响，髌骨复位，膝关节恢复正常屈伸功能，股四头肌及髌韧带均无损伤，股四头肌肌力5级（图2）。讨论髌…     

两侧髌韧带完全断裂一例报告

患者男,32岁,因跌伤致两侧膝关节肿痛活动受限2月入院。查体:两侧膝关节呈45°屈曲位,主动伸膝功能丧失,两侧髌骨下方均扪及一横形凹陷,膝关节侧方应力试验及抽屉试验均阴性。X线侧位片均见髌骨上移。诊断两侧髌韧带断裂。治疗:术中见两侧髌韧带完全横断于髌骨下缘2cm处,取φ3mm克氏针在髌骨中部及胫骨结节后方分别横行钻孔,用双股28号钢丝穿入环绕,膝关节伸直位拧紧,髌韧带断端都能紧密相靠,并间断缝合。术后膝关节伸直位长腿石膏固定。6周后取出钢丝并去石膏锻炼。术后1年6个月随访,两膝关节屈伸功能正常。     

腘绳肌髌韧带转移代股四头肌术（附80例报告）

近一年来，笔者采用腘绳肌髌韧带转移代股四头肌术８０例，效果满意，优良率为９３．７５％。该术式增加了替代肌之力臂，通过髌韧带直接作用于胫骨结节，有力地起到伸小腿作用。对３．５级肌力的　绳肌替代股四头肌术后，出能达到较好的效果。该术式扩大了手术适应证及手术范围，较　绳肌髌骨转移操作简便，省时省力，为代股４头肌术增加了一种新的术式     

髌韧带止点撕脱伤一例

患儿 ,男 ,13岁。准备跳栏杆时 ,突觉右膝下滑 ,有掉下去的感觉 ,伴剧烈疼痛 ,无力入院。查体 :右膝关节明显肿胀 ,髌骨下缘触之空虚 ,右髌骨较左髌骨上移 ,伸膝无力 ,但股四头肌收缩上提时髌骨上移度加大 ,浮髌试验(+)。Ｘ线片示 :右髌骨较左髌骨上移 2ｃｍ ,髌骨远端向前翘起 ,髌股关节间隙增宽 ,无髌骨骨折。初步诊断为 :右髌韧带断裂。遂立即在腰麻下手术 ,术中见髌韧带在髌骨止点处完全撕脱 ,并于髌骨外下缘有 2ｍｍ～ 15ｍｍ大小的髌骨软骨。将撕脱的髌韧带及髌骨外下缘软骨块复位 ,髌骨钻孔 ,钢丝固定髌骨及髌韧带。术后右下肢长腿石…     

髌韧带断裂的诊治进展

<正>膝关节伸肌装置由股四头肌腱、髌骨和髌韧带组成，膝关节伸肌装置断裂是一种罕见损伤。髌韧带断裂多发生于年龄<40岁男性^[1],通常由于膝关节处于屈曲位置时股四头肌突然收缩引起伸肌装置张力过载导致。患有基础疾病如甲状腺功能亢进、尿毒症、系统性红斑狼疮等，以及服用皮质醇类和喹诺酮类药物者更易出现髌韧带断裂^[2]。对于髌韧带断裂的治疗方法尚无统一标准，多凭医生的经验治疗，治疗效果参差不齐。本文对髌韧带断裂的诊断及治疗方法的研究进展进行综述，     

髌韧带减张与髌骨下极切除治疗髌骨下极粉碎性骨折疗效比较

目的 比较采用髌韧带减张与髌骨下极切除治疗髌骨下极粉碎性骨折的临床疗效.方法 33例(A组)髌骨下极粉碎性骨折采用髌骨下极切除重建伸膝装置治疗,27例(B组)采用髌韧带减张恢复髌骨正常解剖治疗.两组均采用膝前纵切口显露髌骨,A组去除髌骨下极碎骨块,修复伸膝装置;B组先在髌骨近断段端骨块和胫骨结节上用φ 1.5mm克氏针横向平行钻一骨隧道,然后屈膝45°用φ 1.25 mm钢丝行"8"字减张固定,伸直位复位髌骨骨折,修补髌前腱膜和股四头肌扩张部来固定髌骨骨折.两组术后均用石膏托固定3～6周.结果 A组33例中29例获得随访,时间12～21个月,骨折全部愈合;B组27例中24例获得随访,时间12～24个月,骨折全部愈合.两组间愈合率和愈合时间差异无统计学意义(P＞0.05).HSS膝关节评分两组差异有统计学意义(P＜0.05).两组最大膝关节屈曲度差异有统计学意义(P＜0.05),最大膝关节过伸度差异无统计学意义(P＞0.05).结论 采用髌骨下极切除治疗髌骨下极粉碎性骨折常导致髌骨整体下移而出现"错格现象",且合并髌股关节压力增加而导致膝关节疼痛,易过早发生髌股关节创伤性关节炎;部分患者在屈膝活动中出现髌骨倾斜,在伸膝时出现力量减弱.采用髌韧带减张重建髌骨正常解剖治疗髌骨下极粉碎性骨折则克服了上述不足,膝关节功能恢复明显优于前者.     

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。     

成年人髌股关节痛的X线改变

目的观察成年人髌股关节痛的Ｘ线改变。方法收集临床诊断为髌骨软骨软化或髌股关节骨性关节病的成年患者６５例,共计７２侧膝关节。摄屈膝３０侧位片和髌骨轴位片,进行Ｉｎｓａｌｌ－Ｓａｌｖａｔｉ和Ｍｅｒｃｈａｔ测量,并与对照组进行比较。结果两组髌骨高度的平均值比较,差异有显著性意义（ｔ检验,ｔ＝２．１５６,Ｐ＜０．０５）;两组髌骨指数平均值比较,差异有非常显著性意义（ｔ检验,ｔ＝０．６６８,Ｐ＜０．０１）;两组髌骨厚度平均值比较,差异有非常显著性意义（ｔ检验,ｔ＝４．８４２,Ｐ＜０．０１）;两组髌股协调角平均值比较,差异有非常显著性意义（ｔ检验,ｔ＝３．２５１,Ｐ＜０．０１）;两组髌股指数平均值比较,差异有非常显著性意义（ｔ检验,ｔ＝３．８０５,Ｐ＜０．０１）。５１侧髌骨Ｗｉｂｅｒｇ分型为稳定性较差的Ⅲ型。有４２侧膝关节有１～５种髌骨不稳定的Ｘ线其它旁证。结论成年髌股关节痛患者的髌股对线、对位、髌骨稳定性、髌骨运动轨迹均有异常。因此,对髌股关节痛患者要查明原因,针对病因进行治疗。Ｍｅｒｏｈａｔ位Ｘ线图像对髌股关节疾病的诊断、手术病例和手术方式的选择,以及对手术成败原因的评价具有重要意义。     

自体骨—髌韧带—骨移植重建前交叉韧带

前交叉韧带重建术后最常见的轻微并发症,包括前膝痛、髌股关节摩擦音、髌腱炎、膝关节僵硬、完全伸直受限和股四头肌无力等。严重的并发症有感染、髌韧带挛缩/髌骨下移、髌骨骨折、髌韧带断裂、非再损伤性移植失败、反射性交感神经性萎缩、神经或血管损伤、筋膜间室综合征和深静脉栓塞等,但十分罕见。 轻度的真性关节纤维性粘连或关节僵硬是前交叉韧带重建术最常见的并发症。真性关节纤维性粘连是关节周围和关节内纤维组织形成的过程,是对损伤的一种反应。前交叉韧带手术后轻度的关节纤维性粘连可见不同程度的膝     

Extensor mechanism reconstruction: a novel technique for bone patella allograft post partial patellectomy failure

Extensor mechanism disruption, whether due to patella fracture or tendon rupture, generally occurs after low-energy trauma and frequently involves an indirect mechanism. When the fracture is comminuted and reconstruction is impossible, a partial or total patellectomy may be indicated. Although some authors advocate total patellectomy, partial patellectomy remains the standard treatment, especially for young and active patients. In the rare instance of a failed tendon repair after partial or total patellectomy, inadequate tissue is usually available for adequate restoration of the extensor mechanism. Extensor mechanism allograft, using the tibial tuberosity, patellar tendon, patella, and quadriceps tendon in continuity or the Achilles' tendon with calcaneal bone-block in continuity has been reported for extensor mechanism repair after total knee arthroplasty in patients who did not undergo patellectomy. We present a novel technique, using the bone patellar tendon bone allograft to reconstruct a posttraumatic defect of the extensor mechanism in a 28-year-old, active patient with a failed partial patellectomy following fracture of his patella. Union of the allograft was seen on x-ray after 4 months. After 6 months, the patient reached full range of motion and returned to his previous sporting activities.     

Biomechanical experiment and clinical report of modified patellectomy for polar fracture of the patella

Ｐ　ＯｒｔｈｏｐａｅｄｉｃＤｅｐａｒｔｍｅｎｔ，ＲｅｓｅａｒｃｈＩｎｓｔｉｔｕｔｅｏｆＳｕｒｇｅｒｙ，ＤａｐｉｎｇＨｏｓｐｉｔａｌ，ＴｈｉｒｄＭｉｌｉｔａｒｙＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ，Ｃｈｏｎｇｑｉｎｇ４０００４２，Ｃｈｉｎａ（ＺｈａｏＪＨ，ＷｕＸＤａｎｄＰｅｎｇＸＬ）ａｔｅｌｌａｉｓａｎｉｍｐｏｒｔａｎｔｂｏｎｅｉｎｅｘｔｅｎｓｉｏｎｍｅｃｈａｎｉｓｍｏｆｔｈｅｋｎｅｅｊｏｉｎｔ．Ｔｈｅｐｒｉｎｃｉｐｌｅｏｆｐａｔｅｌｌａｒｆｒａｃｔｕｒｅｔｒｅａｔｍｅｎｔｉｓｔｒｙｔｏｒｅｐａｉｒ…     

Quadriceps and patellar tendon ruptures

Ruptures of the quadriceps as well as the patellar tendon occur in low frequency, but cause major functional deficits of the leg. These injuries usually require operative treatment. Acute quadriceps tendon ruptures are treated by suture repair, using heavy sutures guided through bone tunnels in the patella. Chronic defects and neglected cases require a local tendon transfer, either by a quadriceps tendon turn-down or by a V-Y-plasty of the quadriceps tendon. Ruptures of the patellar tendon are treated by suture of the tendon stumps plus an reinforcement procedure protecting the tendon and avoiding secondary patella alta. Patello-tibial fixation may be achieved by a cerclage technique using wire or an autologous tendon strip, alternatively a patello-tibial external fixator can be applied. In chronic and neglected cases, patellar tendon reconstruction is performed with autologous tendon grafts or with soft tissue allografts. The graft must be protected by a patello-tibial fixation for the first weeks.     

Chronic rupture of a patellar tendon: A technique for reconstruction with achilles allograft

Chronic ruptures of the patellar tendon fortunately are an uncommon event. These ruptures are often difficult to repair because they are generally accompanied by quadriceps muscle contracture and a great deal of scar tissue formation. We report the case of a repair of a chronic patellar tendon rupture. The patient's right patellar tendon was reconstructed approximately 10 months after the injury using quadricepsplasty and an Achilles tendon allograft with a suprapatellar wire for tension release. Four weeks postoperatively, he had attained 60° of flexion and full active extension. At 8 weeks, the suprapatellar wire was removed allowing the distribution of stresses on the reconstructed patellar tendon. At 6 months, the patient had 130° of flexion and full extension, but showed a persistent 40% deficit in right quad strength. The technique accomplished the preoperative goals of restoring quadriceps function, restoring the anatomic position of the patella, and allowing early mobilization after surgery. Although the use of a suprapatellar wire to reduce tension on the reconstructed tendon required a second operation for removal, it allowed early mobilization and better healing of the repair.     

Patellar tendon bone grafting for patellectomized patients having total knee arthroplasty

A technique for restoring the moment arm to improve quadriceps leverage after patellectomy has been developed and used in patients treated with total knee arthroplasty. Essentials of the technique involve use of a 2.5-cm diameter by 1-cm thick bone graft sewn into the previous anatomical position of the patella, using a subsynovial pouch for stabilization. Clinically, seven knees in six patients were treated with patellar tendon bone grafting during total knee arthroplasty. The final outcome of these patients was evaluated from 24 to 125 months (mean, 75.4 months). Good to excellent results were demonstrated in six of seven knees (85.7%) with sufficient extension power for normal gait in most cases. Failure to achieve painless, active extension was seen in one patient following revision knee arthroplasty complicated by chronic reflex sympathetic dystrophy of the knee. Patellar tendon bone grafting improves quadriceps leverage in previously patellectomized knees and is useful in restoring extensor function in such patients having primary or revision knee arthroplasty.     

钢丝环形加“8”字内固定治疗髌骨骨折

为对髌骨骨折钢丝环形加“８”字内固定进行生物力学评价，本实验采用截肢获得的６个髌骨标本进行研究。保留股四头肌腱和髌韧带。于髌骨纵向中点横形锯开，造成横形骨折。髌骨骨折四种内固定方法即：钢丝环形加“８”字、钢丝“８”字、钢丝环形和克氏针加钢丝“８”字内固定。使固定的髌骨韧带标本屈曲９０°，应用电测法对固定性能进行测试。载荷—应变评价结果表明，钢丝环形加“８”字固定效果最好。因此，从１９８８年３月～１９９１年７月应用此法治疗１２７例髌骨骨折，获得随访９６例，优、良结果占９５．８％。     

Rupture of the quadriceps tendon: an association with a patellar spur

We reviewed the records of 107 consecutive patients who had undergone surgery for disruption of the knee extensor mechanism to test whether an association existed between rupture of the quadriceps tendon and the presence of a patellar spur. The available standard pre-operative lateral radiographs were examined to see if a patellar spur was an indicator for rupture of the quadriceps tendon in this group of patients. Of the 107 patients, 12 underwent repair of a ruptured patellar tendon, 59 had an open reduction and internal fixation of a patellar fracture and 36 repair of a ruptured quadriceps tendon. In the 88 available lateral radiographs, patellar spurs were present significantly more commonly (p < 0.0005) in patients operated on for rupture of the quadriceps tendon (79%) than in patients with rupture of the patellar tendon (27%) or fracture of the patella (15%). In patients presenting with failure of the extensor mechanism of the knee in the presence of a patellar spur, rupture of the quadriceps tendon should be considered as a possible diagnosis.     

Transossäre Naht der Patellarsehnenruptur

OBJECTIVE: Restoration of active knee extension. Restoration of active knee stabilization. Avoiding secondary patella alta. INDICATIONS: Acute rupture of the patellar tendon within 3-5 days. Chronic rupture of the patellar tendon. CONTRAINDICATIONS: Compromised general health status or associated injuries. Compromised local soft-tissue situation. SURGICAL TECHNIQUE: Exposure of the ruptured tendon. Coronal drill hole through the distal third of the patella and coronal drill hole through the tibial tuberosity. After anatomic positioning of the patella (adjusting correct height), patellotibial fixation with monofil or woven (Labitzke) cerclage wire or PDS cord. Suture repair of the patellar tendon and repair of the ruptured medial and lateral retinaculum. Drain insertion. Wound closure in layers. POSTOPERATIVE MANAGEMENT: Full load bearing in cylinder cast. Week 0-2: flexion restricted to 30 degrees , quadriceps muscle isometry. Week 2-4: flexion restricted to 60 degrees , strengthening of hip abductors and extensors. Week 4-6: flexion restricted to 90 degrees . After week 6: removal of cylinder cast. After week 12: return to sporting activities, removal of the cerclage wire. RESULTS: Good results after surgical therapy. Low rate of secondary rupture. Low rate of muscle weakness.     

The effect of an augmentation patella prosthesis versus patelloplasty on revision patellar kinematics and quadriceps tendon force: an ex vivo study

The purpose of this study was to assess the effect of 2 revision reconstructive interventions on patellofemoral joint mechanics in comparison to control. We flexed 8 cadaver knee specimens from 0 degrees to 60 degrees of flexion in a test rig designed to simulate weight-bearing flexion and extension (Oxford rig). Quadriceps tendon extensor force and patellar kinematics were recorded for control total knee arthroplasty (TKA) (normal primary TKA with patella resurfaced) and then for each of the 2 revision patellar interventions (after patelloplasty of typical revision knee patellar bone defect to leave a simple bony shell, and after TKA with augmentation patella resurfacing). Our results demonstrate that patellar kinematics and quadriceps extensor force are optimized when the patella is reconstructed to normal anteroposterior thickness.     

Ruptures of the extensor mechanism of the knee joint. Clinical results and patellofemoral articulation

The functional results of 28 cases of rupture of the quadriceps and patellar tendons are reported. Excellent or good results were noted in 15 of 18 quadriceps and 7 of 10 patellar tendons. Radiographic comparison with the opposite knee disclosed incongruences between the patella and the femoral groove in the tangential view and/or cranial-caudal position of the patella in the lateral view in 13 of the quadriceps tendon ruptures and seven of the patellar tendon ruptures. Patients with residual pain had patellofemoral incongruity but since two-thirds of the patients with incongruity were asymptomatic, incongruity alone may not be the cause of the symptoms. There was no positive correlation to muscular strength or range of movement. Nevertheless, exact adaptation of the patellar tendon and periarticular tissue seems necessary to obtain correct patello-femoral articulation. Reinforcement of the tendon with a wire cerclage is recommended to decrease the tension on the suture line and the consequent risk of a secondary rupture. In acute ruptures of the quadriceps tendon end-to-end sutures are sufficient.