关节镜辅助内侧髌股韧带双束联合股内侧肌斜束解剖重建治疗髌骨脱位的临床研究
发布时间：2018-08-05 15:41
【摘要】：目的:由于髌骨的运动轨迹复杂性,周围软组织的调控多样性,髌骨脱位已成为骨科常见疾病,其治疗也成为骨科医生极大的挑战。随着近年对生物力学的研究发现,在限制髌骨外倾以及控制髌骨轨迹的内侧软组织中,内侧髌股韧带(MPFL)约占50%-60%的作用,因此重建MPFL也成为治疗髌骨脱位的主要手术选择。目前重建MPFL手术方法种类较多,而最近研究的双束解剖重建手术,近年来被越来越多学者所接受。MPFL双功能束概念,分为下直束及上斜束,而上斜束在髌骨止点附近与股内侧肌斜束(VMO)网状交叉联合,在屈膝的早期,VMO使在限制髌骨外移中的作用远远超过静态的50%,所以重建MPFL时应注意VMO的重建。本文研究介绍,通过对MPFL双束解剖重建及VMO的联合重建,恢复髌骨内侧软组织的稳定性,同时辅以关节镜下探查关节内情况、髌骨位置、髌骨与股骨之间的对合关系等治疗髌骨脱位,同时通过术后随访观察其手术效果,进一步为临床应用提供较好的方法。方法:回顾性研究分析自2013年6月至2014年12月河北医科大学第三临床医学院关节外科经体检及影像学检查,确诊为髌骨脱位并行双束联合股内侧肌斜束解剖重建内侧髌股韧带治疗的34例(34膝)的患者的数据,男12例,女22例,年龄范围16-40岁,平均年龄24岁,术中均采用自体半腱肌-股薄肌腱移植物,分别解剖重建内侧髌股韧带的双功能束,股骨侧止点选定为内收肌结节和股骨内侧髁的最高点之中点,髌骨侧两止点选定为髌骨的内侧缘中点及髌骨近上极处。股骨侧端的固定方式为:用直径为7mm的钻头,钻取大约3cm的骨性隧道,用直径为7x23mm可吸收的挤压螺钉固定。而髌骨端的固定方式采用:半隧道的骨桥固定或锚钉缝合的固定,再找到VMO在髌骨的内侧缘的附着点,将其缝合于重建的MPFL的上斜束。最后行手法检查及关节镜下监测,保证患者尤其在屈膝活动的早期,髌骨能顺利的进入股骨滑车沟内,同时镜下观察膝关节在0-120°屈伸活动中髌股关节的动态对应关系。术后支具保护,指导康复功能锻炼。随访患者有无术后并发症的发生,再次髌骨脱位的例数,体格查体主要为髌骨的稳定性及髌骨恐惧试验。术后CT检查为膝关节屈曲20°时测量髌骨外移率(PSLR)及髌骨倾斜角(PTA)等指标,观察髌骨的位置。用Kujala和Lysholm评分系统共同对膝关节进行功能评估。将数据用SPSS13.0(SPSS13.0 Chicago,III)统计软件处理,组间均数差异的比较配对t检验。P0.05为差异存在统计学的意义。结果:术后患者切口均愈合良好,无感染,无下肢动静脉血栓形成等并发症。随访期间所有患者的髌骨倾斜试验、髌骨恐惧试验(-),无半脱位、再次脱位或骨折的发生,术后CT测量,关节适合角(congruance angle,CA)由20.20±3.38减小到10.17±2.33;髌骨倾斜角(patella tilting angle,PTA)由18.94±2.24减小到10.93±1.51;髌骨外移率(patellar lateral shift rate,PLSR)由19.42±1.28减小到9.82±1.64;膝关节功能评分:Kujala评分由59.74±3.68提高为91.19±3.11;Lysholm评分由59.73±4.79提高为92.60±1.94,均具有统计学意义(P0.05)。结论:内侧髌股韧带双束联合股内侧肌斜束联合重建治疗髌骨脱位,更能明显的改善髌骨的滑动轨迹,并在关节镜下辅助下动态观察关节内的情况及髌股关节的匹配情况,更好的提高膝关节的功能。但由于髌骨脱位的力学机制非常之复杂,涉及的因素很多,仍需要大样本长期的临床随访来观察临床疗效。
[Abstract]:Objective: because of the complexity of the patellar movement and the diversity of the control of the surrounding soft tissue, patellar dislocation has become a common disease in the Department of orthopedics, and its treatment has become a great challenge for doctors in the Department of orthopedics. With the recent research on biomechanics, the medial patellar tendon (MPFL) in the medial patellar tendon, which limits the patellar extroversion and the locus of the patellar bone, has been found. About the role of 50%-60%, so the reconstruction of MPFL is also the main choice for the treatment of patellar dislocation. Currently, there are many kinds of methods to reconstruct the MPFL operation. In recent years, more and more scholars have accepted the concept of.MPFL double function bundle, which are divided into the lower straight and the upper oblique, and the upper oblique tract is near the patellar stop. In the early stage of knee flexion, the role of VMO in the reticular interlocking of the medial femoral muscle (VMO) is far more than that of the static 50%, so the reconstruction of VMO should be paid attention to in the reconstruction of MPFL. This paper introduces the stability of the medial soft tissue of the patella by the double beam reconstruction of MPFL and the joint reconstruction of VMO, with the arthroscope supplemented by arthroscopy. Under the joint condition, the position of patella, the relationship between the patellar and the femur in the treatment of patellar dislocation, and the postoperative follow-up observation of the effect of the operation, and further provide a better method for clinical application. Methods: retrospective study and analysis from June 2013 to December 2014, the third clinical medicine Hospital of Hebei Medical University. The data of 34 patients (34 knees) treated with patellar dislocation and double bundle combined with medial patellar tendon repair were confirmed by physical examination and imaging examination, 12 men, 22 women, 16-40 years of age and 24 years of age. Autologous semitendinosus tendon graft was used during the operation, and the medial patellar tendon was rebuilt respectively. The lateral stop point of the femur is selected as the midpoint of the adductor tubercle and the highest point of the medial condyle of the femur. The two stop of the patellar side is selected as the medial point of the patellar medial margin and the proximal patellar pole. The fixation method of the femur side is that the bone tunnel of about 3cm is drilled with the diameter of 7mm, and the extruded screw with the diameter of 7x23mm absorbable Fixation. The patellar end is fixed by the bone bridge of the half tunnel or the anchorage fixation, and then the attachment point of the medial edge of the patella is found, and the VMO is sutured to the reconstructed MPFL's upper oblique bundle. Finally, the manual examination and arthroscopy are used to ensure that the patella can enter the trochlear smoothly, especially at the early stage of the knee flexion. The dynamic corresponding relationship between the knee joint and the patellar joint during the 0-120 degree flexion and extension was observed under the microscope. The postoperative support was protected to guide the rehabilitation function exercise. The follow-up patients had no postoperative complications, the number of cases of patellar dislocation again, the physical examination mainly for the patellar stability and patellar fear test. The postoperative CT examination was the knee joint flexion. The patellar displacement (PSLR) and patellar tilting angle (PTA) were measured at 20 degrees. The position of the patellar bone was observed. The function of the knee joint was evaluated with the Kujala and Lysholm scoring system. The data were treated with SPSS13.0 (SPSS13.0 Chicago, III) statistical software, and the comparison of the difference of mean number difference between groups was statistically significant. Results: the incision healed well, no infection, no lower limb arteriovenous thrombosis and other complications. All patients were followed up with patellar tilt test, patellar fear test (-), no subluxation, re dislocation or fracture, CT measurement, and joint angle (congruance angle, CA) from 20.20 + 3.38 to 10.17 + 2.33; patellar patellar The bone tilt angle (patella tilting angle, PTA) decreased from 18.94 + 2.24 to 10.93 + 1.51; the external displacement of the patella (patellar lateral shift rate, PLSR) decreased from 19.42 + 1.28 to 9.82 + 1.64. The score of knee joint function: Kujala score increased from 59.74 + 3.68 to 91.19 + 3.11, Lysholm score was increased from 59.73 to 4.79. P0.05) conclusion: the double bundle of medial patellar ligament combined with the medial femoral medial muscle oblique bundle combined with the reconstruction of patellar dislocation can improve the patellar trajectory more obviously. Under the arthroscope, the dynamic observation of the intraarticular and patellar joint is better to improve the function of the knee joint, but the mechanical mechanism of patellar dislocation is not good. Often complex, involving many factors, still need large sample long-term clinical follow-up to observe the clinical efficacy.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3
[Abstract]:Objective: because of the complexity of the patellar movement and the diversity of the control of the surrounding soft tissue, patellar dislocation has become a common disease in the Department of orthopedics, and its treatment has become a great challenge for doctors in the Department of orthopedics. With the recent research on biomechanics, the medial patellar tendon (MPFL) in the medial patellar tendon, which limits the patellar extroversion and the locus of the patellar bone, has been found. About the role of 50%-60%, so the reconstruction of MPFL is also the main choice for the treatment of patellar dislocation. Currently, there are many kinds of methods to reconstruct the MPFL operation. In recent years, more and more scholars have accepted the concept of.MPFL double function bundle, which are divided into the lower straight and the upper oblique, and the upper oblique tract is near the patellar stop. In the early stage of knee flexion, the role of VMO in the reticular interlocking of the medial femoral muscle (VMO) is far more than that of the static 50%, so the reconstruction of VMO should be paid attention to in the reconstruction of MPFL. This paper introduces the stability of the medial soft tissue of the patella by the double beam reconstruction of MPFL and the joint reconstruction of VMO, with the arthroscope supplemented by arthroscopy. Under the joint condition, the position of patella, the relationship between the patellar and the femur in the treatment of patellar dislocation, and the postoperative follow-up observation of the effect of the operation, and further provide a better method for clinical application. Methods: retrospective study and analysis from June 2013 to December 2014, the third clinical medicine Hospital of Hebei Medical University. The data of 34 patients (34 knees) treated with patellar dislocation and double bundle combined with medial patellar tendon repair were confirmed by physical examination and imaging examination, 12 men, 22 women, 16-40 years of age and 24 years of age. Autologous semitendinosus tendon graft was used during the operation, and the medial patellar tendon was rebuilt respectively. The lateral stop point of the femur is selected as the midpoint of the adductor tubercle and the highest point of the medial condyle of the femur. The two stop of the patellar side is selected as the medial point of the patellar medial margin and the proximal patellar pole. The fixation method of the femur side is that the bone tunnel of about 3cm is drilled with the diameter of 7mm, and the extruded screw with the diameter of 7x23mm absorbable Fixation. The patellar end is fixed by the bone bridge of the half tunnel or the anchorage fixation, and then the attachment point of the medial edge of the patella is found, and the VMO is sutured to the reconstructed MPFL's upper oblique bundle. Finally, the manual examination and arthroscopy are used to ensure that the patella can enter the trochlear smoothly, especially at the early stage of the knee flexion. The dynamic corresponding relationship between the knee joint and the patellar joint during the 0-120 degree flexion and extension was observed under the microscope. The postoperative support was protected to guide the rehabilitation function exercise. The follow-up patients had no postoperative complications, the number of cases of patellar dislocation again, the physical examination mainly for the patellar stability and patellar fear test. The postoperative CT examination was the knee joint flexion. The patellar displacement (PSLR) and patellar tilting angle (PTA) were measured at 20 degrees. The position of the patellar bone was observed. The function of the knee joint was evaluated with the Kujala and Lysholm scoring system. The data were treated with SPSS13.0 (SPSS13.0 Chicago, III) statistical software, and the comparison of the difference of mean number difference between groups was statistically significant. Results: the incision healed well, no infection, no lower limb arteriovenous thrombosis and other complications. All patients were followed up with patellar tilt test, patellar fear test (-), no subluxation, re dislocation or fracture, CT measurement, and joint angle (congruance angle, CA) from 20.20 + 3.38 to 10.17 + 2.33; patellar patellar The bone tilt angle (patella tilting angle, PTA) decreased from 18.94 + 2.24 to 10.93 + 1.51; the external displacement of the patella (patellar lateral shift rate, PLSR) decreased from 19.42 + 1.28 to 9.82 + 1.64. The score of knee joint function: Kujala score increased from 59.74 + 3.68 to 91.19 + 3.11, Lysholm score was increased from 59.73 to 4.79. P0.05) conclusion: the double bundle of medial patellar ligament combined with the medial femoral medial muscle oblique bundle combined with the reconstruction of patellar dislocation can improve the patellar trajectory more obviously. Under the arthroscope, the dynamic observation of the intraarticular and patellar joint is better to improve the function of the knee joint, but the mechanical mechanism of patellar dislocation is not good. Often complex, involving many factors, still need large sample long-term clinical follow-up to observe the clinical efficacy.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3
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