大收肌腱转位重建内侧髌股韧带的应用解剖研究

发布时间：2017-12-28 17:39

本文关键词：大收肌腱转位重建内侧髌股韧带的应用解剖研究　出处：《安徽医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的通过对30侧尸体标本膝关节内侧区域进行解剖,观测膝关节内侧区域大收肌腱和内侧髌股韧带形态及其周围血管神经毗邻关系,评估大收肌腱转位重建内侧髌股韧带治疗髌骨脱位的术式可行性及可能的风险,并在尸体标本上采用两种方式(带线锚钉、丝线缝合)模拟手术探讨转位肌腱固定方法。临床上使用此种方法后,评价手术方法的实用性,进一步探讨该如何改善手术方法。方法解剖观察30侧尸体标本膝关节的大收肌腱及内侧髌股韧带形态及其周围血管神经等毗邻关系;测量大收肌腱长度(收肌结节至收肌裂孔距离)、大收肌腱宽度、大收肌腱厚度、内侧髌股韧带轴长长度、收肌结节至内侧髌股韧带股骨止点距离、收肌结节至大收肌腱移行部距离;拍摄解剖区域相关照片留取资料,并在尸体标本上模拟手术。临床上设计在关节镜辅助下使用大收肌腱转位重建内侧髌股韧带治疗髌骨脱位患者4例,采用双切口技术,术后石膏托固定并行股四头肌锻炼,通过门诊随访和电话随访收集术后恢复情况资料,评价手术方法的实用性。结果在对30侧尸体标本膝关节内侧区域解剖后,可见大收肌腱有两种形态:(1)腱膜型;(2)锥状。伴随大收肌腱的重要组织包括:穿过收肌裂孔的膝降动脉及其分支、隐神经;在尸体标本解剖中100%见内侧髌股韧带,内侧髌股韧带位于膝关节内侧软组织结构第二层,关节囊外的韧带结构,呈扇形,附着于股内侧斜肌深面,由股骨止点(股骨内侧髁与收肌结节间)向髌骨内侧走形,走形过程中越来越宽,形成两功能束:上斜束和下直束。使用游标卡尺(精确度为0.01mm)反复测量3次后取平均值得到数据如下:大收肌腱长度(收肌结节至收肌裂孔距离)为105±14mm(77-129mm),大收肌腱宽度为9±2mm(5-17mm),大收肌腱厚度为2±0.4mm(1-3mm),内侧髌股韧带轴长长度为46±6mm(33-57mm),收肌结节至内侧髌股韧带股骨止点距离为9±2mm(6-13mm),收肌结节至大收肌腱移行部距离为124±11mm(102-144mm)。模拟手术使用带线锚钉(强生公司提供)和丝线,重建内侧髌股韧带固定于髌骨内侧缘止点,手术效果满意,未见对膝关节内侧区域重要组织(膝降动脉及其分支、隐神经)有所损伤,拍取照片记录模拟手术操作过程并留取资料。4例患者术后切口愈合佳,未见切口有感染现象,术后均获得随访,时间为2-19个月。结果如下:术后复查拍摄膝关节髌骨轴位X片示髌骨在位,锚钉内固定在位见,所有患者出院后1个月膝关节基本上没有了疼痛感,在去除石膏托固定后,鼓励患者行股四头肌锻炼并下地行走,术后2-3个月随访膝关节功能基本恢复正常,术后均未再次出现髌骨脱位,Lysholm评分较术前明显改善。结论对内侧髌股韧带的修复或者重建成为治疗髌骨脱位的重要方法,最大限度恢复其解剖结构是手术成功的关键,通过对膝关节内侧区域进行解剖并在尸体标本上行模拟手术,我们认为一个长约55mm的大收肌腱移植物通过转位固定于髌骨内侧缘重建内侧髌股韧带可行,术中成功的避免了分离切取大收肌腱时对其周围毗邻组织(膝降动脉及其分支、隐神经)的损伤,在考虑和避免解剖风险的基础上,大收肌腱作为重建内侧髌股韧带的移植物是一个良好的选择。在临床实践中使用大收肌腱转位重建内侧髌股韧带治疗髌骨脱位后,术后膝关节功能恢复好,未见明显并发症发生,此种手术方法在临床值得推广。
[Abstract]:The anatomy of the 30 specimens of knee joint medial area, observation of medial knee region of great adductor muscle tendon and the medial patellofemoral ligament morphology and surrounding blood vessels and nerves adjacent relationship evaluation operation feasibility of great adductor muscle tendon transposition for reconstruction of medial patellofemoral ligament for the treatment of patellar dislocation and risk, and the two ways in cadavers on (with anchor and suture fixation method) tendon transposition surgery simulation study. After the clinical use of this method, the practicability of the surgical method is evaluated and how to improve the operation method is further discussed. Methods anatomic observation of 30 cadaver specimens of knee joint of the adductor magnus tendon and medial patellofemoral ligament morphology and peripheral vascular nerve adjacent relationship; measurement of great adductor muscle tendon length (adductor tubercle to the adductor hiatus distance), great adductor magnus muscle tendon width, thickness, axial length, the length of the medial patellofemoral ligament to the adductor tubercle the medial patellofemoral ligament femoral insertion distance and the adductor tubercle to the adductor magnus tendon migration distance; shooting photos taken from the anatomical region, and simulation operation in the specimens. The clinical design of great adductor muscle tendon transposition for reconstruction of medial patellofemoral ligament for the treatment of patients with patellar dislocation in 4 cases under arthroscopy, using double incision technique, postoperative plaster fixation in femoral head four parallel muscle exercise, data recovery were collected through outpatient follow-up and telephone follow-up, practical evaluation of surgical methods. Results after the anatomy of the medial knee joint of 30 sides of the cadaver specimens, there were two forms of the large adductor tendon: (1) aponeurosis type; (2) conical. With an organization of great adductor muscle tendon includes: through the adductor hiatus of descending genicular artery and its branches, saphenous nerve; in cadaver dissection in 100% medial patellofemoral ligament, the medial patellofemoral ligament in the knee joint medial soft tissue structure of second layers, ligament structure, joint capsule and fan-shaped, attached to the vastus medialis oblique deep from the surface, the femur (medial femoral condyle and the adductor tubercle to the medial patella between shape, shape) plays a more and more wide, the formation of two functions: oblique beam and straight beam. Use vernier caliper (accuracy 0.01mm) after repeated measurements of 3 average data is as follows: the great adductor muscle tendon length (adductor tubercle to the adductor hiatus distance) was 105 + 14mm (77-129mm), great adductor muscle tendon width was 9 + 2mm (5-17mm), great adductor muscle tendon thickness was 2 + 0.4mm (1-3mm), medial patellofemoral ligament axis length was 46 + 6mm (33-57mm), the adductor tubercle to the medial patellofemoral ligament femoral insertion distance was 9 + 2mm (6-13mm), the adductor tubercle to the adductor magnus tendon migration distance was 124 + 11mm (102-144mm). Simulated surgery using suture anchors (Johnson company) and silk, reconstruction of the medial patellofemoral ligament fixed on the patella medial border check point, the surgical results were satisfactory, no important knee medial area (descending genicular artery and its branches, saphenous nerve injury), take photographs to simulate the operation process and take the data. The incision healed well in 4 cases and no infection was found in the incision. All patients were followed up after 2-19 months. The results are as follows: after review of shooting patellar axial X film showed patella in anchor screw fixation in, all patients were discharged after 1 months of knee basically no pain after removal of plaster fixation, the patients were encouraged to unit four biceps exercise and ambulation, 2-3 months follow up the knee joint function returned to normal after surgery, postoperative had no relapse of patellar dislocation, Lysholm scores were improved significantly. The conclusion of the medial patellofemoral ligament repair or reconstruction has become an important method for the treatment of patellar dislocation, maximize the restoration of the anatomic structure is the key to successful operation, through the anatomy of the medial knee region and surgical simulation in cadaver specimens upward, we believe that a length of about 55mm by transposition of great adductor muscle tendon graft fixed in medial patella margin of medial patellofemoral ligament reconstruction surgery is feasible and successful in avoiding separation cut to the surrounding tissue adjacent to the adductor magnus tendon (when descending genicular artery and its branches, saphenous nerve injury) in considering and avoid the risk on the basis of anatomy, great adductor muscle tendon as reconstruction of medial patellofemoral ligament graft is a good the choice of. In the clinical practice, the use of adductor muscle tendon transposition and reconstruction of medial patellofemoral ligament for patellar dislocation, postoperative knee function recovery is good, no obvious complications occur. This surgical method is worth promoting in clinical practice.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687;R322

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