膝关节 Q 角变化规律的实验研究

本研究利用精密三维位移测读仪，研究分析了Ｑ角的变化趋势，以及对髌股关节运动的影响。研究结果表明，Ｑ角是一空间夹角，随屈膝角的增大而增大。力线在平面上的投影所呈的平面夹角Ｑｐ也就是通常所指的Ｑ角，在屈膝１５°左右达最大，而在９０°左右达最小。整个屈膝过程中，ＱＰ在５°－１５°之间变化，变化幅度达１０°左右。     

CT在评估髌股关节排列中的应用

目的介绍和分析利用ＣＴ评估髌股关节排列的方法和价值。方法在屈膝３０°时用ＣＴ检测３２例５０侧膝髌股关节疼痛者（轴位Ｘ线片上髌股排列基本正常）和１５例２０侧膝无症状者的髌股关节,测量其髁间沟角、和谐角及外侧髌股角,观察病变在ＣＴ上的表现,分析髌股关节疼痛患者的髌股排列状况。结果髌股关节疼痛患者较无症状者具有较明显的髌股排列紊乱,单纯髌骨外置者１１侧膝,单纯髌骨倾斜者８侧膝,髌骨外置合并髌骨倾斜者１０侧膝。结论利用ＣＴ评估髌股关节排列较普通Ｘ线片有显著的优越性,可指导治疗的术式选择     

成年人高位髌骨的X线改变及临床分析

目的观察成年人高位髌骨患者的X线改变,并根据X线改变进行临床分级,以估计预后和指导临床治疗.方法对临床诊断为高位髌骨的18例成年患者,共计34侧膝关节,进行屈膝30°侧位片和髌骨轴位片的拍摄,然后在X片上测定Blumensaat距离、髌骨高度、股骨滑车沟角、髌股协调角、外侧髌股角、髌股指数、髌骨外移度七项参数,并与对照组进行比较.选用Blumensaat距离,髌骨高度及髌股协调角作为临床分级的参数指标.结果病例组与对照组比较Blumensaat距离,髌骨高度的差异有非常显著性意义(P＜0.01);髌股协调角、外侧髌股角、髌股指数、髌骨外移度的差异有显著性意义(P＜0.05);股骨滑车沟角的差异无显著性意义(P＞0.05).临床分级10侧膝关节属轻度,表现为髌骨软骨软化症,药物疗效好;21侧属重度,表现为髌股关节骨关节炎,药物疗效差.结论成年人高位髌骨的X线改变以髌骨的异常高位为主,伴有一定程度的髌骨外移和向外侧倾斜,临床分级在定性诊断的基础上,融入了定量诊断,有进一步研究的必要性.     

髌腱腱病患者髌股关节排列的磁共振成像

目的:利用磁共振成像技术探讨髌腱腱病患者中髌股关节的排列状态。材料和方法:36名运动员60膝参加本研究,其中髌腱腱病组21例共30膝,正常对照组15例共30膝。受试者以双侧(无症状成人)或患侧(髌腱腱病患者)膝接受MRI检查,在屈膝0°位非负重及负重15%体重状态下分别进行扫描。选取髌骨中部切面图像,测量滑车沟角、髌股适合角髌骨倾斜角以及髌骨外侧偏移量。结果:两组均在负重后髌股适合角减小、髌骨倾斜角减小、髌骨外侧偏移量增大(P<0.05)。髌腱腱病组在非负重状态下各指标与正常对照组相似(P>0.05),负重后髌骨外侧偏移量较正常对照组小(P<0.05),髌骨外侧偏移量负重前后之差也较正常对照组小(P<0.05)。结论:髌腱腱病患者存在髌股排列异常,负重后髌骨外侧偏移量低于正常。     

排球运动员髌骨软骨软化症与Q角关系的研究 Ⅱ.不同Q角对髌股关节生物力学的影响

本文对28名男子排球运动员的股四头肌进行等速肌力测试以提供髌股关节生物力学计算数据。根据膝关节等速测试力学模型和髌股关节作用力(PFJRF)三维力学模型、分析不同Q角对髌股剪切力(Fs),正压力(Fc)和合力(R)的影响。发现Q角增大对Fs影响最大,并使R方向明显偏外。而伸膝肌力大小或测试速度则对R和Fc产生明显影响。当Q角达18°时,Fs最大达2.1BW,R最大达6.6BW。如此之大的Fs及方向偏外的R,将导致压力分布严重不均和髌骨不稳、或许还造成膝关节运动过程中髌骨在股骨髁间沟内的旋转。因此,从生物力学上也证实Q角较大对排球运动员的髌股关节是不利的。     

应用关节镜治疗创伤性髌骨半脱位的5年随访研究

目的：探讨采用关节镜治疗创伤性髌骨半脱位的长期治疗效果。方法对2005年1月～2009年1月收治的46例（56膝）关节镜治疗的创伤性髌骨半脱位患者进行5年随访,术后采用Kujala评分对髌股关节功能进行评定。此外,通过屈膝30°髌骨轴位X线片检查,对46例（56膝）患者手术前后反映髌股关节对合情况的相关指标进行测量并对比观察,包括外侧髌股角（ LPA）、适合角（ CA）、髌股指数（ PFI）、髌骨外移值（ LS）。结果5年随访结果提示：依据Kujala评分标准,髌股关节功能术后明显得到改善,影像学指标手术前后均有显著性差异（ P＜0.05）。结论关节镜治疗创伤性髌骨半脱位是一种非常有效的治疗方法。     

股骨髁髌股、胫股关节运动重叠接触区域测定

 目的描记膝关节运动过程中胫股、髌股关节在股骨髁关节面接触的重叠区域,明确其具体范围,为进一步研究膝关节髌骨、胫骨和股骨三者对应解剖关系以及生物力学特性,为优化股骨假体设计奠定基础.方法Instron 8501生物力学测试仪模拟生理状态下膝关节站立到下蹲屈膝过程,收集8具新鲜膝关节尸体标本,通过染色法分别描记髌股、胫股关节运动在股骨髁面的接触区域,标记其重叠范围.结果髌股、胫股关节在股骨髁关节面运动存在重叠接触区域,范围大致相当股骨髁面全髌股关节接触区域的开始于屈膝75°髌股接触区域的后部分.结论膝关节股骨假体的设计应该考虑股骨髁与髌股关节、胫股关节运动的重叠接触区域解剖特点.     

改良髌骨双骨道及界面螺钉固定技术解剖重建内侧髌股韧带治疗创伤性髌骨脱位

目的:探讨改良髌骨双骨道及界面螺钉固定游离半腱肌腱解剖重建内侧髌股韧带治疗创伤性髌骨脱位的疗效。方法:2010年1月至2012年10月对30例创伤性髌骨脱位患者关节镜辅助下行内侧髌股韧带(MPFL)双束解剖重建,移植半腱肌腱,髌骨固定方式采用改良双骨道及界面螺钉挤压固定。结果:所有患者随访时间6~18个月,平均12个月。30例手术后均无再脱位,髌骨运动轨迹正常,关节活动无受限,恐惧试验阴性,未发生髌骨骨折,髌骨外移率、髌股适合角及外侧髌股角较术前改善(P<0.05)。结论:采用改良髌骨双骨道及界面螺钉固定技术解剖重建内侧髌股韧带,手术方式简单、损伤小、腱骨结合处固定良好、髌骨稳定性好、并发症少。     

股骨髁髌股、胫股关节运动重叠接触区域及其生物力学测定

目的 :明确膝关节运动时胫骨、髌骨与股骨髁接触的重叠区域 ,测量并比较分析重叠区域内髌股、胫股关节各自接触压大小及分布特点 ,探讨髌股关节置换术中股骨滑车假体长度的设计。方法 :收集 8具新鲜膝关节尸体标本 ,在Instron 85 0 1生物力学测试仪上构建实验平台 ,模拟生理状态下膝关节站立到下蹲屈膝的过程 ,采用染色法描记重叠区域、压敏法测量髌股、胫股关节在该区域接触压。结果 :股骨髁关节面存在髌股、胫股关节运动重叠接触区域 ,范围大致相当股骨髁髌股关节接触区域内、始于屈膝 75°髌股接触部的后部分区域 ;重叠区域内髌股、胫股关节各自接触压测定显示 ,前者的接触压明显高于后者。结论 :股骨滑车假体的有效长度应涵盖髌股关节在股骨髁所有接触区域。     

髌骨倾斜导致髌股关节接触压力与面积改变

我们采用压敏片测量技术对髌骨倾斜状态下髌股关节的生物力学变化特点进行了研究。７例新鲜人尸体标本采用手术方法将髌外侧支持带紧缩造成髌骨外侧倾斜状态，超低压型压敏片置于髌股关节之间，等长加载２００Ｎ，分别在正常状态及髌骨倾斜状态下于屈膝３０°、６０°、９０°、１２０°时测量髌股关节接触压力与面积。结果表明：髌骨倾斜后使髌股关节原正常的“哑铃型”接触压迹转变为“彗星尾状”，外侧面孤立接触，内侧面接触区减少或失接触，接触压力改变表现为髌内侧软骨面接触压力减少或消失，外侧面接触压力集中且明显增高上述改变均以屈膝３０°时最明显。实验结果提示：各种纠正髌骨倾斜状态及治疗髌骨软骨软化症的手术方法，必须以恢复髌骨内外侧关节面压力平衡为标准，特别是屈膝３０°时病理力学的改善最为重要     

The effects of medialization and anteromedialization of the tibial tubercle on patellofemoral mechanics and kinematics

BACKGROUND: Medialization and anteromedialization of the tibial tubercle are used to correct patellar subluxation in adults. PURPOSE: To compare the effects of the 2 osteotomies on patellofemoral joint contact pressures and kinematics. STUDY DESIGN: Controlled laboratory study. METHODS: Tibial tubercle osteotomies were performed on 10 cadaveric human knees. The knees were tested between 0 degrees and 90 degrees of flexion while dynamic patellofemoral joint contact pressure and kinematic data were simultaneously obtained. Four conditions were tested: normal knee alignment, simulated increased Q angle, postmedialization of the tibial tubercle, and postanteromedialization of the tubercle. RESULTS: An increased Q angle laterally translated the patella, shifted force to the lateral facet, and increased patella contact pressures. Both medialization and anteromedialization partially corrected the abnormal contact pressures. Medialization partially corrected the shift of force to the lateral facet induced by an increased Q angle, whereas the anteromedialization could not. Both medialization and anteromedialization corrected the patella maltracking. CONCLUSION: Medialization and anteromedialization are equivalent in their ability to correct abnormal patellar mechanics and kinematics.     

Effect of bracing on patellar kinematics in patients with patellofemoral joint pain

PURPOSE: Bracing is commonly used to correct patellar malalignment syndromes. However, there are little objective data documenting the effect of such supports on patellofemoral joint relationships. The purpose of this study was to assess the effectiveness of an elastic patellofemoral sleeve brace in altering patellar tracking in subjects with patellofemoral pain. METHODS: Ten female subjects (12 patellofemoral joints) between the ages of 17 and 46 participated in this study. All subjects had a diagnosis of patellofemoral pain and demonstrated lateral patellar tracking based on magnetic resonance imaging (MRI) assessment. Each subject underwent kinematic MRI of the patellofemoral joint through a range of 45 to 0 degrees of knee flexion against a resistance of 15% body weight. Imaging was performed with and without a patellofemoral joint brace (Bauerfeind Genutrain P3 brace, Atlanta, GA). Measurement of medial/lateral patellar displacement, medial/lateral patellar tilt, and the depth of the trochlear groove (sulcus angle) were obtained with midpatellar image sections at 45, 36, 27, 18, 9 and 0 degrees of knee flexion. RESULTS: No statistically significant differences in medial/lateral patellar displacement or tilt were found between braced and unbraced trials across all knee flexion angles (P < 0.05). A small but statistically significant increase in sulcus angle was found across all knee flexion angles with the braced trials (P > 0.05). CONCLUSIONS: These results do not support the hypothesis that the brace used in this study corrects patellar tracking patterns in subjects with patellofemoral pain. However, the increased sulcus angle indicates a change in patella position within the trochlea. It is possible that the clinical improvements seen with bracing may be the result of subtle differences in joint mechanics and not gross changes in alignment.     

The influence of patellar bracing on patellar and knee load-distribution and kinematics: an experimental cadaver study

The aim of this study was to analyze the biomechanical consequences of patella bracing in order to evaluate possible mechanisms supporting its clinical application. The hypothesis is that the patellar bracing reduces patellofemoral pressure by influencing patellar and knee kinematics, and load distribution. Physiologic isokinetic knee extension motions were simulated on ten human knee cadaver specimens using a knee kinematic simulator. Joint kinematics were evaluated using an ultrasound-based motion analysis system and patellofemoral contact pressure was measured using a thin-film piezoresistive pressure measuring system. Infrapatellar tissue pressure was analyzed using a closed sensor-cell. Three different patella braces were fitted to the knee cadavers and their influence on the kinematic and kinetic biomechanical parameters were evaluated and compared to the physiologic situation. Patellar bracing resulted in a significant (p = 0.05) proximalization of the patella up to 3 mm. Depending on the type of brace used, a decrease in the infrapatellar fat pad pressure was found and the patellofemoral contact area was decreased significantly (p = 0.05) between 60° of knee flexion and full extension (maximum 22%). Patella bracing significantly (p = 0.05) reduced the patellofemoral contact pressure an average of 10%, as well as the peak contact pressure which occurred. Patellar bracing significantly influences patella biomechanics in a reduction of the patellofemoral contact area and contact pressure as well as a decrease in the infrapatellar tissue pressure. The application of infrapatellar straps is suggested for the treatment and prevention of anterior knee pain, especially in high level sports.     

In vivo sagittal plane kinematics of the FPV patellofemoral replacement

Purpose

Isolated symptomatic patellofemoral osteoarthritis has been reported in 2% of men and 8% of women older than the age of 55?years in the community. With the development of improved designs and surgical techniques, interest in the use of patellofemoral replacement has increased. The primary aim of the newer generation of patellofemoral replacement implant designs has been to more closely reproduce normal knee kinematics. This study compares the functional sagittal plane in vivo kinematics of a contemporary patellofemoral prosthesis, the FPV, with normal knee kinematics using the patella tendon angle and patella flexion angle relationships with the knee flexion angle.

Methods

The in vivo kinematics for a group of 8 patients (15 knees) with patellofemoral replacement and 22 normal subjects was measured for both a step-up and a lunge exercise using an established fluoroscopic method.

Results

The patella tendon angle characteristics of the implanted knees were similar to those of the normal knees for the step-up exercise with a significant difference only observed at 50° knee flexion angle. For the lunge exercise, the patella tendon angle for the implanted knee was consistently lower than that measured for the normal knee. Overall the subjects had excellent clinical scores post-patellofemoral replacement showing a significant improvement from their pre-operative scores.

Conclusion

The kinematics of the FPV implant was closer to normal than those of total knee implants; however, there were still differences from the normal knees.

Level of evidence

III.     

髌骨位姿异常对髌股关节接触影响的研究

目的 深入研究髌骨位姿异常对髌股关节的接触影响.方法 通过正常膝关节MRI图像数据建立了髌股关节的正常和异常接触模型,基于正交试验对不同水平的髌股关节异常接触模型进行了有限元仿真模拟.结果 1)在膝关节屈曲过程中,髌股关节接触特性(Von Mises应力、接触压力和接触面积)对髌骨的屈曲和旋转参数最为敏感;2)髌股异常...     

髌骨轴位X线检查辅助装置的设计与临床应用

目的:设计一套髌骨轴位X线检查辅助装置,以满足膝关节不同程度屈曲受限患者髌骨轴位X线摄影及其临床应用价值.方法:髌骨轴位辅助装置制作材料均使用不锈钢材质,由膝部定位组件和探测器支撑组件两部分组成.本研究纳入100例膝关节髌股关节炎患者,膝关节均有不同程度屈曲受限,使用辅助装置进行髌骨轴位摄影,由2名擅长骨关节影像诊断的高年资影像医师观察髌骨轴位图像,并对其主要解剖结构显示能力及图像质量进行评价.结果:使用髌骨轴位辅助装置首次摄影成功率为98％,优级片率为93％,图像质量符合诊断要求;能够在膝关节屈曲不同角度(15°～90°)下拍摄髌骨轴位,并清晰显示髌骨运行轨迹情况以及准确测量髌骨沟角、适合角等相关参数.结论:使用髌骨轴位X线检查辅助装置简单、易行、摄影成功率高,图像质量符合影像诊断学要求.对于髌股关节炎、髌骨习惯性脱位、髌骨骨折的诊断有一定的临床价值.     

Computed tomography of the normal patellofemoral joint

Radiographic assessment of the patellofemoral joint (PFJ) is problematic because conventional views are cumbersome, difficult to standardize, and not reliable for displaying this joint with flexion of the knee less than about 30 degrees. We used computed tomography (CT) to obtain conveniently a direct transaxial view of the PFJ in ten normal human volunteers at different 0 degree, 20 degrees, and 45 degrees of knee flexion and during both contraction and relaxation of the quadriceps muscle. From the CT images we measured femoral trochlear angle, patellar centralization, femoral trochlear depth, and patella tilt angle. In full extension, with the quadriceps muscle relaxed, 19 of 20 knees showed the patella well centered in the femoral trochlear groove. The tilt and centralization of the patella were largely unchanged at 20 and 45 degrees of knee flexion with quadriceps contraction. CT appears to be an optimal method of studying the PFJ. The normal relationships described in this report can be the basis for evaluating patients with known or suspicious history of recurrent subluxation or dislocation of the patella.     

屈膝过程中的胫股运动特性分析

本文采用三维位移测量方法，测试１０例离体人膝标本的胫股关节三维运动特性。发现屈膝过程中，胫股运动也具有典型的三维运动特点。其中在屈膝初期的３０°内，胫骨内旋最明显并伴有胫骨内翻现象，平均内旋８°，内翻６－７ｍｍ，膝关节完全伸直时胫股扣锁使膝关节稳定，屈曲时胫股“解锁”使膝关节松弛，具重要的临床意义，同时提示，在解释传统的胫股扣锁现象时不应遗漏伴随发生的胫骨内／外翻现象。     

髌股关节退行性病变的摄影方法学研究

目的 探讨髌股关节多角度侧位投照方法的临床价值.方法 收集50例膝关节疼痛的患者,分别采取180°、135°、90°膝关节屈伸角度侧位等多角度髌股关节X线摄影,比较髌股关节退行性病变的X线表现.结果 多角度髌股关节侧位投照显示,髌骨后缘关节面增生毛糙50例,股骨滑车面增生硬化及髌股关节间隙变窄43例,胫股关节间隙变窄23例,髌骨同定6例,而常规位置阳性显示率较低.2种投照摄影方法比较,股骨滑车、髌骨后缘、髌股关节间隙及髌骨活动范围等部位显示率差异有统计学意义(P＜0.05).多角度投照方法对观察股骨滑车面、髌骨关节面、髌骨移动范围、髌股和胫股关节间隙以及确定髌骨高位等退变特征有明显优势.结论 多角度髌股关节侧位投照是一种相对客观的显示髌骨位置及髌股关节间隙的X线摄影方法,可在临床检查中广泛使用.