止血带对全膝关节置换术中股骨远端旋转定位时髌骨轨迹的影响

目的 探讨止血带对全膝关节置换术中以外科髁上轴线为股骨远端旋转定位线的髌骨轨迹的影响.方法 2002年12月至2008年8月,首选以外科髁上轴线为股骨远端旋转定位标志的初次全膝关节置换349例(526膝),男124例(155膝),女225例(371膝);年龄33～84岁,平均68岁.膝内翻387膝,膝外翻94膝.均使用同一种保留后十字韧带的活动平台假体,由同一位手术医生操作.采用前内侧髌旁入路,以外科髁上轴线为股骨远端旋转定位线,以no thumb test检测髌骨轨迹.对髌骨轨迹不良者,缝合髌骨内上缘支持带并松开止血带.对再次检查髌骨轨迹不良者行外侧支持带松解术.术后3个月患者能够极度屈曲膝关节时摄X线片检查髌骨轨迹.结果 术中no thumb test阳性138膝,其中半脱位12膝(膝外翻),髌骨倾斜126膝(膝外翻74膝).缝合髌骨内上缘支持带并松开止血带后,no thumb test阳性40膝,其中半脱位8膝(膝外翻),髌骨倾斜32膝(膝外翻29膝).髌骨外侧支持带松解率7.6%(40/526),膝外翻松解率39.4%(37/94).结论 在全膝关节置换术中,高压止血带对髌骨轨迹有干扰作用.术中缝合髌骨内上缘支持带并松开止血带,可降低外侧支持带松解率.     

改良髌旁外侧入路用于外翻膝人工全膝关节置换术

目的探索外翻膝人工全膝关节置换入路与软组织平衡的新技术。方法设计并应用于临床兼有松解髌外侧支持带功能的改良髌旁外侧入路,通过平行分离髌骨外侧支持带深浅两层,并向外翻转脂肪垫暴露膝关节,术中松解髌骨外侧支持带、髂胫束或膝关节后外侧关节囊、膝外侧副韧带等紧张结构,假体安装后错位缝合外侧支持带深层与浅层,既维持了松解的外侧支持带的适当张力和髌股关节正常活动轨迹,又确保了术后深筋膜的闭合。术后2周内行CPM锻炼,2周后扶拐行走。结果11例患者下肢力线从术前平均外翻10.2°矫正至平均内翻1.5°,膝关节冠状面畸形矫正率达85.3%。术后伤口愈合良好,术后2个月伸屈活动度平均达105°,11例患者均可自如地平地行走,其中9例可上下楼梯。膝关节稳定性好。结论改良髌旁外侧入路能较方便地显露膝关节外侧稳定结构,有利于对外侧挛缩结构的精确松解,并保持良好的髌股关节活动轨迹,是严重外翻膝行全膝关节置换的良好入路。     

膝关节镜下外侧支持带松解及内侧支持带紧缩治疗急性髌骨脱位

目的探讨膝关节镜下外侧支持带松解及内侧支持带紧缩治疗急性髌骨脱位。方法1999年7月～2003年7月共对11例急性髌骨脱位患者施行膝关节镜手术,松解外侧支持带及外侧髌—股韧带,同时紧缩缝合内侧支持带及内侧髌—股韧带。结果平均随访21.2个月,所有病人均未发生再脱位,亦无残留髌骨不稳。膝关节活动度(ROM)正常。结论本术式疗效确切,具有创伤小、并发症少、功能恢复快等优点。     

内侧髌股韧带重建联合外侧支持带松解治疗复发性髌骨脱位

目的 回顾性分析自体半腱肌腱游离移植重建内侧髌股韧带联合外侧支持带松解治疗复发性髌骨脱位的临床结果.方法 复发性髌骨脱位31例行内侧髌股韧带重建联合外侧支持带松解,并对患者进行影像检查及膝关节功能评分.结果 术后随访24～56个月,31例均无再次脱位;功能评分术前与术后比较差异有统计学意义(P＜0.05).结论 自体半腱肌腱移植重建内侧髌股韧带联合外侧支持带松解治疗创伤性复发性髌骨脱位效果可靠.     

关节镜监视下髌骨双隧道内侧髌股韧带重建外侧支持带松解治疗复发性髌骨脱位

[目的]探讨关节镜临视下髌骨双隧道内侧髌股韧带重建及外侧支持带松解治疗复发性髌骨脱位的疗效.[方法]对12例复发性髌骨脱位患者采用髌骨双隧道法重建内侧髌股韧带,同时常规行外侧支持带松解.[结果]患者术后均获随访,平均31个月(14～52个月),未见髌骨脱位复发.髌骨轴位X线片显示所有病例外侧髌股角均有所改善.手术前后IKDC膝关节功能主观评分分别为(38.3±5.1)分和(91.1±5.9)分.Lysholm膝关节功能综合评分分别为(72.3±4.6)分和(90.6±4.7)分.[结论]关节镜监视下髌骨双隧道内侧髌股韧带重建及外侧支持带松解是治疗复发性髌骨脱位的有效方法.     

关节镜下髌外侧支持带松解及内侧支持带紧缩治疗髌骨软化症

目的探讨膝关节镜下外侧支持带松解及内侧支持带紧缩治疗髌骨软化症的疗效。方法对31例(36膝)髌骨软化症患者在关节镜下用等离子刀松解外侧支持带及外侧髌—股韧带,同时紧缩缝合内侧支持带及内侧髌—股韧带。结果随访10～48个月,患者症状和体征均得到明显改善。与术前相比,Lysholm评分由70.2分提高至平均92.1分,差异有显著性(P<0.01)。结论该术式治疗髌骨软化症不仅能松解外侧支持带,同时还可有效地紧缩内侧支持带,疗效确切,具有创伤小、并发症少、功能恢复快等优点。     

外侧支持带松解术后髌骨轨迹的分析

[目的]探讨膝关节外侧支持带松解前后髌骨轨迹的变化,寻找外侧支持带松解术后部分病例效果不佳的原因。[方法]临床采集符合纳入标准的92例(138膝)样本,松解前后分别行10°、20°、30°和40°屈膝位髌股关节CT扫描,测量髌股适合角,髌骨外移角和股骨远端内侧扭转角,比较松解前后髌骨轨迹的变化。[结果]通过测量髌股适合角,髌骨外移角发现髌骨轨迹29膝松解后无改善,109膝明显改善。109膝的股骨远端内侧扭转角均9°,29膝的股骨远端内侧扭转角均9°。说明股骨远端内侧扭转角可能是影响外侧支持带松解后髌骨轨迹的一个重要因素。[结论]外侧支持带松解术是治疗髌股关节紊乱症非常有效的手术,但是术后部分病例效果并不理想,尤其是长期随访效果,其中原因并不明了,通过实验发现术后髌骨轨迹未发生改变可能是主要的原因,而股骨远端扭转可能是影响髌骨轨迹恢复的重要因素。     

综合手术方案治疗复发性髌骨脱位的疗效观察

目的评价采用关节镜下外侧松解、内侧支持带紧缩缝合、半髌腱移位术的综合手术方案治疗复发性髌骨脱位的临床疗效。方法以1998～2004年收治的38例患者为研究对象,男17例,女21例。29例有明确外伤史,不包括髌骨完全性脱位且关节活动时髌骨始终不与股骨髁间构成关节面关系的病例。通过了解病史、体查以及CT或MRI资料分析确定髌骨脱位病因。关节镜下外侧支持带松解与内侧支持带紧缩缝合、髌腱外1／2连同外侧胫骨结节止点向内侧交叉移位。术后不制动,髌骨行保护性的康复疗程。术后3个月以及每年随访,检查髌骨轨迹、关节活动度以及行髌骨切线位片或CT检查。结果29例患者获3～60个月(平均40．2个月)随访,均无脱位复发,恐惧感消失,物理及影像学检查表明髌骨稳定。按Lysholm评分评价膝关节功能,29患者术后平均评分为(91．3±3．8)分,较术前的(58．1±5．4)分明显提高,差异有统计学意义(P<0．01)。结论关节镜下外侧松解、内侧支持带紧缩缝合、半髌腱移位术的综合手术方案治疗复发性髌骨脱位疗效确切。操作简便,易于掌握。     

关节镜微创治疗复发性髌骨脱位

[目的]探讨膝关节镜下外侧支持带松解,内侧髌股韧带重建术在治疗复发性髌骨脱位中的临床疗效.[方法]自2006年1月～ 2011年6月收治复发性髌骨脱位18例进行了分析.[结果]术后无髌骨脱位复发.[结论]膝关节镜下外侧支持带松解,结合内侧髌股韧带重建术疗效满意.     

急性滑脱性髌股关节撞击综合征的关节镜下治疗

 目的 探讨急性滑脱性髌股关节撞击综合征的损伤机制、MRI诊断特征以及关节镜下诊治方法。方法 2005年9月至2012年10月应用改良髌内侧支持带紧缩缝合治疗急性滑脱性髌股关节撞击综合征46例,男9例,女37例;年龄15~31岁,平均21.6岁。术前常规行膝关节X线及MR检查,测量Q角、外侧髌股角及髌骨外移度。MRI髌内侧支持带损伤按照Schweitzer分级标准：Ⅰ度15例、Ⅱ度18例、Ⅲ度8例、Ⅳ度5例。手术于关节镜监视下施行,清除关节内积血,关节内探查,取出游离软骨和骨软骨碎片,软骨成形,修整损伤软骨面。对髌内侧支持带Ⅰ度损伤者行关节镜下清理及髌内侧支持带固缩。对髌内侧支持带Ⅱ~Ⅲ度损伤伴明显髌骨移位者采用改良髌内侧支持带紧缩缝合术,对受伤时间超过2周的9例同时行髌外侧支持带松解。对髌内侧支持带Ⅳ度损伤者行切开加固缝合。结果 急性滑脱性髌股关节撞击综合征的关节镜下表现包括关节内血肿46例、股骨外髁和髌骨内侧骨软骨损伤37例、游离体形成28例及髌内侧支持带撕裂46例。所有病例均获得随访,随访时间12~36个月,平均18.2个月,无感染、神经血管损伤和再脱位等并发症发生。手术前后Lysholm膝关节评分、Tegner膝关节运动水平评分、AAOS膝关节评分、外侧髌股角及髌骨外移度的差异有统计学意义,患者运动功能均较术前有所改善。结论 关节镜下改良髌内侧支持带紧缩缝合辅助髌外侧支持带松解术,是治疗急性滑脱性髌股关节撞击综合征髌内侧支持带Ⅱ~Ⅲ度损伤的有效方法,有利于恢复膝关节功能,近期疗效好。     

Preoperative Radiological Parameters Predicting the Need for Lateral Retinacular Release in Total Knee Arthroplasty

BackgroundProper patellar tracking is essential for well-functioning total knee arthroplasty (TKA). Besides implanting components in the correct position and rotation, balancing parapatellar soft tissues is also important in aiding normal patellar tracking. Patellar maltracking during TKA can be improved by lateral retinacular release (LRR).MethodsWe studied the incidence of LRR in consecutive primary TKA with nonresurfaced patella and posterior-stabilized implant design. We analyzed data from 250 consecutive primary TKAs (212 patients) from January 2016 to May 2016. We evaluated the preoperative radiological parameters like patellar tilt, patellar shift, patellar morphology, Insall-Salvati ratio, femoro-tibial angle, distal femoral valgus angle, and proximal tibia varus angle which predict the need for LRR during TKA. We used multivariate regression analysis to find the association of individual radiological parameters and the LRR.ResultsThe need for LRR is significantly associated with preoperative radiological parameters like patellar shift and patellar tilt (P < .001). Compared to the nonreleased group, the adjusted odds of LRR were greater for morphological parameters like Wiberg type 3 patella (odds ratio [OR] 17.45, 95% confidence interval [CI] 7.21-42.20), lateral facet thinning (OR 4.38, 95% CI 2.37-8.07), lateral patellofemoral arthritis (OR 14.36, 95% CI 6.82-30.23), and coronal valgus deformity (OR 4.95, 95% CI 1.60-10.68).ConclusionPreoperative assessment of these radiological parameters in the axial view implies a high chance of tight lateral retinacular structures. This helps in identifying patients who have a higher likelihood for patellar maltracking during TKA. Appropriate LRR helps to provide better patellar tracking post TKA.     

Patellar retinacular peel: an alternative to lateral retinacular release in total knee arthroplasty

The need to perform a lateral retinacular release (LRR) during total knee arthroplasty (TKA) may be lessened or eliminated by performing a patellar retinacular peel (PRP). PRP involves peeling the extensor retinaculum off the dorsolateral border of the patella to the extent necessary to facilitate patellar eversion. Generally, a portion of the lateral patellar facet is removed to allow conformity with a round patellar prosthesis. The combination of retinacular peel and partial facetectomy decreases lateral retinacular tension, which reduces the tendency toward lateral subluxation. In the study reported here, a series of 50 TKAs that included a PRP in all cases was compared with an earlier series of 50 TKAs that included LRR for control of patellar tracking, as needed. The incidence of anterior knee pain was lower in the PRP group than in the LRR group, though this difference was not significant from a statistical perspective. The 2 groups were virtually identical on other comparison criteria. PRP seems to be a viable alternative to LRR.     

髌骨缩小联合外侧支持带松解对膝关节置换术的疗效影响

目的探讨髌骨缩小联合外侧支持带松解对人工全膝关节置换术后膝前痛发生及膝关节功能疗效的影响。 方法筛选2016年1月至2017年6月广东省第二中医院骨科136例退行性膝骨关节炎拟行初次单侧全膝关节置换术的患者136例(136膝)，剔除同侧髋病及严重内外翻畸形膝，术前按随机分配法分为观察组(术中行髌骨缩小联合外侧支持带松解，68例)和对照组(术中常规去除髌骨边缘硬化骨但不松解外侧支持带，68例)，余手术操作均一致。记录两组患者术前术后膝前痛及并发症发生情况、手术时间、美国特种外科医院(HSS)膝关节评分、髌骨Feller评分、膝前痛评分，并进行术前术后和两组间的比较。拍摄术后膝关节正侧位和Merchant位X(屈膝30°髌骨轴位片)线片，观察髌骨轨迹情况。对计数资料和正态分布的计量资料采用卡方检验或t检验。 结果观察组3例患者失访，2例外伤致胫腓骨骨折；对照组7例患者术中行"无拇指"试验发现需松解外侧支持带，排除研究；两组最终纳入63例和61例。所有患者均获得相同的随访时间。观察组术后膝前疼痛率为4.8%(3/63)，对照组为16.4%(10/61)，观察组优于对照组，差异有统计学意义(t＝6.325，P<0.05)；两组患者手术时间比较差异均无统计学意义(P>0.05)；术后18个月时两组患者HSS评分、Feller评分、膝前痛评分、膝关节活动度均较术前显著改善(P<0.05)；但观察组在HSS评分、髌骨Feller评分、膝前痛评分方面明显优于对照组(t＝3.125，P<0.05)；两组均未发生髌骨坏死、髌骨骨折、髌骨高压等并发症，比较差异无统计学意义(P>0.05)。观察组和对照组分别有2例和11例发生髌骨轨迹不良，比较差异有统计学意义(t＝11.218，P<0.05)。 结论膝关节置换术中进行髌骨缩小联合外侧支持带松解能明显减少膝前痛及并发症发生，有效改善膝关节功能并较好维持术后髌骨的轨迹，提高TKA手术的整体疗效。     

内侧髌股韧带重建术中应用止血带对髌骨轨迹的影响

背景：内侧髌股韧带（MPFL）是限制髌骨向外侧脱位的主要静力稳定结构,MPFL重建术成为治疗髌骨不稳的主要选择。术中止血带的应用对减少出血量,改善手术视野提供了重要保障,同时也不可避免改变了股四头肌的张力,然而对于髌骨轨迹是否产生明显影响一直未有明确定论。目的：比较MPFL重建术中应用止血带对髌骨轨迹的影响。方法：2008年3月至2011年2月行双束解剖重建MPFL的髌骨复发性脱位患者53例（66膝）,男23例（28膝）,女30例（38膝）;年龄18-34岁,平均26岁。发病至手术时间1个月-13年,其中44例有明显外伤致髌骨脱位史。术中观察止血带充气前、后对髌骨轨迹的影响,以及是否需行外侧支持带松解。结果：53例（66膝）中,止血带未充气时,判断需行外侧支持带松解者5膝（5/66）;止血带充气后,判断需行外侧支持带松解者6膝（6/66）,两者比较无统计学差异（P〉0.05）。重建MPFL后再次应用止血带观察,当止血带充气时,66膝髌骨轨迹良好;当止血带放松后,2膝出现髌骨内移（2/66）,两者比较无统计学差异（P〉0.05）。结论：使用止血带前、后对髌骨轨迹无明显影响,术中观察髌骨轨迹良好则无需行外侧支持带松解。     

The lateral approach to the valgus knee. Surgical technique and analysis of 53 cases with over two-year follow-up evaluation

Valgus deformity correction poses a major challenge in total knee arthroplasty (TKA). The standard medial approach has many technical limitations and disadvantages that include patellofemoral maltracking and subsequent patellar problems. The lateral approach has been developed and utilized successfully in 79 cases (53 with over two-year follow-up evaluation) since 1980. The biomedical rationale of the approach is sound, and addresses the pathologic anatomy of fixed valgus deformity. Surgical technique is direct, anatomical, more physiologic, and maintains soft-tissue integrity. The "lateral release" is performed as part of the approach. Patellofemoral tracking and alignment stability are optimized and medial blood supply preserved. Clinical experience has shown the approach to be more aesthetic and results objectively superior. Scores have been good/excellent in 94.3% of cases. Knee stability is enhanced with the use of nonconstrained prostheses in this difficult group of patients. The lateral approach is recommended as the "approach of choice" for fixed valgus deformity in TKA.     

Prospective comparative study of intraoperative “Towel clip test” and “Vertical patella test” assessing lateral retinaculum tightness in patients undergoing TKA

BackgroundProper patellar tracking is one of the most important aspect of TKA to ensure good functional outcome. A patellar tracking problem noted intraoperatively serves as a warning sign and should prompt the surgeon to reassess position of each component. Various tests are there to assess lateral retinaculum tightness viz. "No thumb test", "Towel clip test". A new test "Vertical patella test" is described to assess lateral retinaculum tightness. A study was conducted to assess the effectiveness, correlation and validity of two techniques.Materials & MethodsPatients >50 years of age and with diagnosis of Osteoarthritis knee having less than 30 varus and flexion deformity going in for primary TKA were selected with a sample size of 100 knees in a tertiary care centre. Revision cases or patients with flexion contracture more than 30, complex knee surgery; with pre existing patellar tilt were excluded from study.ResultsResults of both tests were found to correlate in 75% of case with sensitivity of 96.65% and specificity of 75.00%. Kappa came out to be 0.634 which shows good agreement of vertical patella test and towel clip test. Result was computed using excel and SPSS and was found to be significant with p value< 0.05. Lateral retinaculum release was done in 8 knees.ConclusionsVertical patella test correlates with towel clip test, is easy to perform and saves time. The limitation of our study was small sample size.     

The effect of a tourniquet on intraoperative patellofemoral tracking during total knee arthroplasty

A prospective investigation was performed on the effect of the tourniquet on intraoperative patellofemoral tracking during primary total knee arthroplasty (TKA). A total of 75 TKAs in 67 patients were performed by 1 surgeon in a consecutive series using the same technique. Using strict criteria, patellar tracking was assessed both before and after tourniquet release. Patients were placed into 1 of 3 groups: Group I were knees that tracked properly both before and after tourniquet release. Group II were knees that maltracked with the tourniquet inflated and subsequently corrected with the tourniquet released. Group III were knees that maltracked both before and after tourniquet release, therefore requiring a lateral release. Knees were categorized as group I, 34 of 75 (45.3%); group II, 36 of 75 (48.0%); and group III, 5 of 75 (6.7%). Using this criterion, lateral release was avoided in all group II knees. Tourniquet application alters intraoperative patellofemoral tracking during TKA. When contemplating lateral release, tourniquet deflation and reevaluation of patellofemoral tracking should be considered.     

Patellar tilt and subluxation following subvastus and parapatellar approach in total knee arthroplasty: Implication for surgical technique

Eighty-nine posterior-stabilized total knee arthroplasties (TKAs) were studied using a Merchant view to assess patellar tilt or subluxation. Forty TKAs were performed via the subvastus approach (SVA) and 49 via the standard parapatellar approach (PPA). Intraoperative tracking was assessed using a “no thumbs” test, and a lateral release was performed if necessary. Following the SVA, 40.0% of patellas tracked centrally compared to 44.9% for the PPA. With the SVA, a lateral release was necessary in 27.5% of procedures compared to 51.0% for the PPA. The data suggest that the no thumbs test may overestimate the need for lateral release following the PPA. Since there are fewer lateral releases following the SVA, reapproximation of the medial retinaculum to assess intraoperative tracking may result in fewer lateral releases being performed without adversely affecting patellar position. Medial tilting of the patella is also found to be common; 29.7% of the patellas tilted this way, including 40.0% of knees operated via the SVA. Why this occurs is unclear, but the incidence of medial tilting increased after posterior-stabilized TKA.     

Combining different rotational alignment axes with navigation may reduce the need for lateral retinacular release in total knee arthroplasty

Purpose

The aim of the study was to compare femoropatellar alignment and the incidence of lateral retinacular release (LRR) in total knee arthroplasty (TKA) in which the rotational alignment of the femoral component was determined using a combination of different rotational alignment axes and navigation or a single reference axis in the standard procedure.

Methods

We assessed 66 patients undergoing TKA in whom the rotation of the femoral component was determined on the posterior condylar axis in standard procedures (group A) and 65 patients in whom it was determined by combining the posterior condylar axis, anteroposterior axis and epicondylar axis in navigated procedures (group B). The mean age was 68 and 69 years in groups A and B, respectively. Patellar tracking was assessed after deflation of the tourniquet and LRR performed in the presence of maltracking. Visual analogue scale (VAS), Knee Society Score (KSS), Lonner patellar score and patellar tilt were recorded.

Results

LRR was carried out in 18 cases (27 %) in group A and in four (6 %) in group B (p = 0.003). The KSS and VAS were improved significantly compared to the preoperative status, but with no significant differences between the two groups. The patellar score showed a greater improvement in the navigated compared to the standard group at the four week follow-up. Patella tilt improved significantly in both groups. The complication rate was similar in the two groups.

Conclusions

Combining different rotational alignment axes with navigation significantly reduces patellar maltracking and the need for LRR compared to the standard procedure in which the posterior condylar axis is used as single anatomical reference.