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.     

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。     

Removal of the lateral or medial third of patellar tendon alters the patellofemoral contact pressure and area: an in vitro experimental study in dogs

OBJECTIVES: To compare patellofemoral contact pressure and areas after immediate removal of the lateral, central, or medial third of patellar tendon. DESIGN: In vitro experiment in 12 dogs. BACKGROUND: Alteration of the vector sum of the quadriceps muscle contraction after removal of partial patellar tendon might result in changes of patellar tracking in the trochlea. METHODS: Patellofemoral contact pressure and areas were recorded using Fuji pressure-sensitive film at 45 degrees, 60 degrees, and 90 degrees of knee flexion under an isometric quadriceps force of 100% body weight. The patellofemoral contact imprint from the intact knees were obtained as control, and the lateral (n=4), central (n=4), and medial (n=4) third of the patellar tendon were subsequently removed and the patellofemoral contact imprint was recorded. RESULTS: The patellofemoral contact area was found to increase with increasing knee flexion angles. No change in patellofemoral contact pressure and areas was found after removal of the central third patellar tendon. However, after removal of either lateral or medial third of patellar tendon, the patellofemoral contact was rotated with increasing knee flexion angles. This was due to the altered vector sum of the quadriceps force, resulting in significantly decreased patellofemoral contact areas and simultaneously a significantly increased contact pressure, characterized with concentration of patellofemoral contact pressure on both lateral and medial facets of the patellofemoral joint. CONCLUSIONS: The results suggest that removal of the central third of patellar tendon may not alter the patellofemoral contact pressure and areas as compared with removal of either lateral or medial third of patellar tendon that may result in an altered postoperative tracking mechanism of the patellofemoral joint immediately after operation. RELEVANCE: Findings of this in vitro animal study supports the use of central third of patellar tendon as autograft for anterior cruciate ligament reconstruction. However, further experimental studies are needed to investigate how the postoperative healing of the host patellar tendon will influence the findings obtained from this in vitro study.     

Tibial tuberosity anteriomedialization vs. medial patellofemoral ligament reconstruction for treatment of patellar instability related to malalignment: Computational simulation

BackgroundMedial patellofemoral ligament reconstruction and tibial tuberosity anteromedialization are common treatment options for recurrent lateral patellar instability, although ligament reconstruction is not commonly applied to knees with lateral malalignment.MethodsMultibody dynamic simulation was used to assess knee function following tibial tuberosity anteromedialization and medial patellofemoral ligament reconstruction for knees with lateral malalignment. Dual limb squatting was simulated with six models representing knees being treated for patellar instability with an elevated tibial tuberosity to trochlear groove distance. The patellar tendon attachment on the tibia was shifted medially (10 mm) and anteriorly (5 mm) to represent tibial tuberosity anteromedialization. A hamstrings tendon graft was represented for medial patellofemoral ligament reconstruction. Patellar tracking was quantified based on bisect offset index. The patellofemoral contact pressure distribution was quantified using discrete element analysis. Data were analyzed with repeated measures comparisons with post-hoc tests.FindingsBoth procedures significantly reduced bisect offset index, primarily at low flexion angles. The decrease was larger for tibial tuberosity anteromedialization, peaking at 0.18. Tibial tuberosity anteromedialization shifted contact pressures medially, significantly increasing the maximum medial contact pressure at multiple flexion angles, with the maximum pressure increasing up to 1 MPa.InterpretationThe results indicate tibial tuberosity anteromedialization decreases lateral patellar maltracking more effectively than medial patellofemoral ligament reconstruction, but shifts contact pressure medially. Tibial tuberosity anteromedialization is likely to reduce the risk of post-operative instability compared to medial patellofemoral ligament reconstruction. The medial shift in the pressure distribution should be considered for knees with medial cartilage lesions, however.     

Sekundäre mediale Patellainstabilität

Secondary medial patellar instability represents a severe complication following lateral retinacular release. Patients experience a new and different patellofemoral pain after surgery combined with medial patellar subluxation and subsequent weakness of the extensor mechanism. Incorrect indications and/or techniques with overrelease are the main reasons for these complaints. Medial patellar instability is documented using stress CT scans. Open revision with secondary reconstruction of the lateral structures using local tissue or, if insufficient, a tendon graft is necessary to eliminate medial patellar subluxation.     

Relationship between knee range of motion and Kellgren-Lawrence radiographic scores in knee osteoarthritis

OBJECTIVE: To investigate the relationships between the joint range of motion and Kellgren-Lawrence radiographic scores of knee joint compartments in patients with knee osteoarthritis. DESIGN: Forty knees of 20 consecutive bilateral, primary knee osteoarthritis patients were examined in the study. Maximal flexion, extension, and internal and external rotation were assessed using a goniometer. Kellgren-Lawrence radiographic scores were determined for medial tibiofemoral, lateral tibiofemoral, and patellofemoral compartments of the knee joint on lateral, tangential, and standing anteroposterior radiographs. RESULTS: Statistically significant negative correlations were found between the range of motion and radiographic scores. Specifically, internal rotation was correlated with lateral compartment scores (r = -0.439, P < 0.01), and external rotation and flexion were correlated with medial compartment scores (r = -0.361, P < 0.05; r = -0.338, P < 0.05; respectively) [corrected]. Extension values were correlated with patellofemoral ( = -0.533, < 0.01), medial (r = -0.456, P < 0.01), and lateral (r = -0.327, P < 0.05) compartment scores. CONCLUSIONS: A clear relationship is present between joint range of motion and Kellgren-Lawrence radiographic scores in knee osteoarthritis patients. Examination of the joint range of motion can give information about the compartmental distribution of the disease and help the physician focus on the compartment or compartments involved when performing diagnostic and therapeutic procedures. Evaluation of the compartments of the knee joint in radiographs can be informative about the joint range of motion in knee osteoarthritis.     

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.     

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。      

Is latero-medial patellar mobility related to the range of motion of the knee joint after total knee arthroplasty?

Diminished range of motion (ROM) of the knee joint after total knee arthroplasty (TKA) is thought to be related to reduced patellar mobility. This has not been confirmed clinically due to a lack of quantitative methods adequate for measuring patellar mobility. We investigated the relationship between patellar mobility by a reported quantitative method and knee joint ROM after TKA. Forty-nine patients [osteoarthritis – OA: 29 knees; rheumatoid arthritis – RA: 20 knees] were examined after TKA. Respective medial and lateral patellar mobility was measured 1 and 6 months postoperatively using a patellofemoral arthrometer (PFA). Knee joint ROM was also measured in each of those 2 sessions. Although the flexion and extension of the knee joints improved significantly from 1 to 6 months after TKA, the medial and lateral patellar displacements (LPDs) failed to improve during that same period. Moreover, only the changes in knee flexion and medial patellar displacement (MPD) between the two sessions were positively correlated (r = 0.31, p < 0.05). However, our findings demonstrated that medial and lateral patellar mobility had no sufficient longitudinal relationship with knee ROM after TKA.     

The quantitative influence of current treatment options on patellofemoral stability in patients with trochlear dysplasia and symptomatic patellofemoral instability - a finite element simulation

BackgroundTrochlear dysplasia is highly associated with patellofemoral instability. The goal of conservative and surgical treatment is to stabilize the patella while minimizing adverse effects. However, there is no literature investigating the quantitative influence of different treatment options on patellofemoral stability in knees with trochlear dysplasia. We created and exploited a range of finite element models to address this gap in knowledge.MethodsMRI data of 5 knees with trochlear dysplasia and symptomatic patellofemoral instability were adapted into this previously established model. Vastus medialis obliquus strengthening as well as double-bundle medial patellofemoral ligament reconstruction and the combination of medial patellofemoral ligament reconstruction and trochleoplasty were simulated. The force necessary to dislocate the patella by 10 mm and fully dislocate the patella was calculated in different flexion angles.FindingsOur model predicts a significant increase of patellofemoral stability at the investigated flexion angles (0°-45°) for a dislocation of 10 mm and a full dislocation after medial patellofemoral ligament reconstruction and the combination of medial patellofemoral ligament reconstruction and trochleoplasty compared to trochleodysplastic (P = 0.01) and healthy knees (P = 0.01–0.02). Vastus medialis obliquus strengthening has a negligible effect on patellofemoral stability.InterpretationsThis is the first objective quantitative biomechanical evidence supporting the place of medial patellofemoral ligament reconstruction and medial patellofemoral ligament reconstruction combined with trochleoplasty in patients with symptomatic patellofemoral instability and trochlear dysplasia type B. Vastus medialis obliquus strengthening has a negligible effect on patellar stability at a low total quadriceps load of 175 N.     

Revisionseingriffe zur Patellastabilisierung nach erfolgloser Operation am Streckapparat

More than 150 different techniques have been described for the treatment of patellofemoral instability. However, to restore patellofemoral instability correctly, it is essential to understand the static, passive and active stabilizers properly. As a consequence of various widely used techniques, such as medial reefing, lateral release and medialization of the tuberosity, not only persisting instability but also patellofemoral pain could occur. Revisions determine a restricted indication which includes a detailed clinical and radiological examination putting the main focus on the location of the pain, scars, apprehension test and any valgus and/or rotational leg deformity in addition to an exact case history. Depending on the previous operations and the results of the examination, the revision has to address not only the former operation but particularly all additional pathologies. The reconstruction of the medial patellofemoral ligament as well as trochleaplasty and/or osteotomy contribute to restoration of patellofemoral stability and pain relief.     

Dynamic measurement of patellofemoral contact pressure following reconstruction of the medial patellofemoral ligament: an in vitro study

BACKGROUND: Surgical reconstruction of the medial patellofemoral ligament used to stabilize the patella against lateral dislocation may concomitantly produce alteration of the patellofemoral contact pressure distribution. Two different tendon transfer techniques of reconstructing the medial patellofemoral ligament, one dynamic and one static, as well as a proximal soft tissue realignment of the patella were investigated. METHODS: Eight human knee specimens were mounted in a kinematic knee simulator and isokinetic extension motion was simulated. Patellofemoral pressure was measured using a pressure sensitive film while a 100 N laterally directed dislocation load was applied to the patella. The specimens were evaluated in a physiologic state, as well as after dynamic reconstruction of the medial patellofemoral ligament using a distal transfer of the semitendinosus tendon, following static reconstruction using a semitendinosus autograft, and following proximal soft tissue realignment of the patella. FINDINGS: Following both reconstruction techniques of the medial patellofemoral ligament patellofemoral contact pressure was not significantly (P=0.49) altered. In contrast, after proximal realignment a trend (P=0.07) towards higher contact pressure near knee extension was observed. In the absence of a lateral dislocation load dynamic and static reconstruction resulted in a medialization (P=0.04) of the center of pressure, whereas under the application of a 100 N dislocation load the center of pressure showed no significant alteration. Following proximal realignment the center of pressure was significantly medialized without (P<0.01) and with a dislocation load (P=0.01) throughout the entire range of knee motion. INTERPRETATION: Static and dynamic ligament reconstruction of the medial patellofemoral ligament did not alter patellofemoral pressure. Proximal realignment, on the other hand, resulted in a constant medialization of the patellofemoral pressure. The data suggest that the reconstruction techniques would be associated with a low risk of causing premature cartilage degeneration due to excessive patellofemoral contact pressure, whereas proximal realignment could cause medial overload of the patellofemoral joint.     

关节镜指导下锚钉固定自体游离股薄肌腱加强内侧髌股韧带治疗髌骨不稳定

目的:探讨关节镜指导下锚钉固定自体游离股薄肌腱加强内侧髌股韧带治疗髌骨不稳定的手术方法和临床疗效。方法:1997年5月~2010年10月经临床和关节镜诊断的髌骨不稳定患者46例(49膝),A组在行膝关节支持带外侧松解、内侧紧缩的基础上,配合胫骨结节内移的综合术式治疗;B组在行膝关节支持带外侧松解基础上,配合锚钉固定自体游离股薄肌腱加强内侧髌股韧带的综合术式治疗。结果:随访15~87个月(平均39个月),A组优良率93.3%;B组优良率92.3%。按照Lysholm法评估膝关节功能,两组术后平均得分与术前比较均有显著性差异(P<0.001)。结论:关节镜指导下锚钉固定自体游离股薄肌腱加强内侧髌股韧带治疗髌骨不稳定可恢复髌股关节稳定性,手术方式简单、创伤小、效果好,是治疗髌骨不稳定的理想方法。     

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.     

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.     

Laterale Retinakulumverlängerung bei arthroskopischen Eingriffen

Increased pain in the lateral patellofemoral joint during loaded flexion may be caused by shortened and too tight lateral structures (e.g. retinacula, capsule, iliotibial tract, lateral vastus muscle) due to intraarticular pathologies, such as plicae, cartilage damage and osteoarthritis. The mobility of the patella is decreased and accentuated on the lateral side with a negative patella tilt, therefore creating lateral hypercompression and pain in the patellofemoral joint. In combination with the arthroscopic treatment for the intraarticular pathology, mini-open lengthening of the lateral retinaculum decreases the compression forces and normalizes the patellofemoral gliding mechanism. This procedure has the same therapeutic benefits as lateral retinacular release but the secondary medial patellar instability, as frequently seen after lateral retinacular release, can be avoided and individual soft tissue balancing is possible.     

关节镜下外侧支持带松解后的髌骨轨迹分析（英文）

背景：外侧支持带松解是治疗髌股关节紊乱症首选的治疗方法,然而有些文献报道部分病例的长期随访结果并不满意。目的：分析关节镜下外侧支持带松解后的髌骨轨迹,以探讨外侧支持带松解后部分病例随访优良率下降的原因。方法：临床采集符合纳入标准的57膝（34例）样本,松解前后分别行10°,20°,30°,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。结果与结论：通过测量髌股适合角,髌骨外移角发现髌骨轨迹17膝松解后无改善,40膝明显改善。40膝的股骨远端内侧扭转角均大于9°,17膝的股骨远端内侧扭转角均小于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。     

Physical therapist examination, evaluation, and intervention following the surgical reconstruction of a grade III acromioclavicular joint separation

BACKGROUND AND PURPOSE: This case report describes the examination, intervention, and outcome of a patient following the surgical reconstruction of a grade III acromioclavicular (AC) joint separation. Detailed postoperative interventions have not previously been described in the literature. CASE DESCRIPTION: The patient was a 34-year-old male college professor with a left grade III AC joint separation and no prior restrictions of upper-extremity function. After 12 weeks of presurgical treatment, the patient's complaints included crepitus and the inability to push open heavy doors. INTERVENTION: Surgical reconstruction of the AC joint and a 4-month graded exercise program were used. OUTCOME: The patient returned to preinjury levels of function 5 months after surgery with scores of 3.33/100 and 0/100 on the Disabilities of the Arm, Shoulder and Hand questionnaire and optional Sport/Music or Work Module, respectively. DISCUSSION: An intervention focusing on restoring shoulder strength, range of motion, flexibility, and neuromuscular control of the shoulder following a surgical reconstruction of the AC joint can lead to a successful functional outcome.     

Study of patellar kinematics after reconstruction of the medial patellofemoral ligament

Background

Medial patellofemoral ligament reconstruction is currently the technique of choice for the treatment of patellar instability. But what should be the most appropriate graft tension for optimal restoration of patellofemoral kinematics?

Methods

Six freshly frozen cadaveric knees were studied, the three bone segments were respectively equipped with opto-reflective markers. The acquisitions were made using the Motion Analysis System®. Six successive acquisitions were performed for each knee under different levels of graft tension.

Findings

With an intact medial patellofemoral ligament, the medial patellar tilt increased up to a mean value of 2.02° (SD 3.1), the medial patellar translation gradually increased up to a mean value of 3.3 mm (SD 2.25) with a slight lateral rotation over the first 30° of knee flexion with a maximum mean value of 1.22° (SD 0.8) at 20° of knee flexion.Reconstruction of the medial patellofemoral ligament was performed using different levels of tension applied to the graft. Only 10 N of graft tension could restore normal patellar tilt, lateral shift and rotation, with results approximating those measured on healthy knee.

Interpretation

This study confirms the role of the medial patellofemoral ligament in providing adequate patellar stability during the first 30° of knee flexion. According to our findings, a 10 N tension applied to the graft appears sufficient to ensure proper control of patellar tracking whereas 20, 30 and 40 N of tension are excessive tension values inducing a major overcorrection in all studied parameters.