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1、髌骨减容术的临床应用 广东省中医院二沙骨科 许树柴 陈伯健 刘洪亮 黄 泽鑫 髌骨减容术 髌骨修整术 常用于治疗髌骨关节骨关节炎患者 通 过对髌骨骨性组织 髌骨周围软组织 如外侧支持韧带 内侧支持韧带 等处进行修整 达到减轻髌股关节面压力 恢复髌骨正常运动轨迹的目的 从而缓解膝关节前方疼痛症状 延缓髌股关节骨关节炎进展 髌骨减容术概念 发病率 Davies CORR 2002 在206 例膝关节X线检查中9 6 40岁 13 6 女性 60岁 15 4 男性 60岁 McAlindon Ann Rheum Dis 24 的女性 11 的男性有骨性关节炎的症状 55 岁有单纯性髌股关节炎 Cur
2、l Arthroscopy 1997 31 516 例关节镜中 4 关节面4度损伤 其中21 有髌骨损伤 15 有滑车损伤 髌股关节炎分级 1 根据髌骨轴位片分级 级 关节间隙变窄 接近3mm 级 关节间隙变窄 3mm 没有骨性 接触 级 关节骨性部分接触 级 整个关节骨性接触 髌股关节炎分级 2 根据关节镜下软骨损伤分级 Outerbridge分级 O级 正常关节软骨 级 软骨变软或局部肿胀 级 软骨表面纤维化轻 软骨缺损厚 度小于50 级 软骨表面纤维化重 软骨缺损厚 度大于50 但尚未暴露软骨下骨 级 软骨完全缺损 软骨下骨外露 髌股关节炎临床表现 1 膝关节前方疼痛 2 上下楼梯 爬山
3、 从坐姿站立 跪或蹲可加重 3 有时可因髌骨 滑车之间骨性摩擦出现绞锁症状 体查 1 膝关节屈伸活动受限 2 可触及摩擦音 3 髌周压痛 4 髌骨活动度差 5 髌骨研磨试验 髌股关节炎影像学及关节镜下表现 保守治疗 康复治疗 非甾体抗炎药 关节内注射 可的松 透明质酸 支具 氨基葡萄糖 富含血小板血浆 髌骨成形术 髌股关节炎常用手术治疗方法 通过切除髌骨周围增生骨 赘 恢复光滑髌骨关节面 减少髌骨和滑车之间骨性摩擦 达 到减容目的 优点 最大程度地保 留髌骨骨量以及强度 术后疗效可靠 并 发症发生率低 髌骨钻孔术 微骨折技术 骨髓刺激技术 microfracture技术 nanofractur
4、e技术 适用于 局部软骨退变及局部创伤性病变 小面积缺损 0 5 2cm2 或大面积损伤但功能要求低 损伤区边缘软骨 质量要好 严格选择Microfracture技术修复的手术适应症 平均70 95 的患者能提高膝关节功能 尤其以股骨髁软骨损伤患 者术后效果最好 Steadman等在对233例患者采用Microfracture技术治疗 3年随访结果显示75 患者疼痛改善 但是术后18 24个月临床结果开始向坏的方向发展 Curl WW Krome J Gordon ES et a1 Cartilage injuries areview of 31516 knee arthroscopies A
5、rthroscopy 1997 13 4 456 460 Steadman JR Briggs KK Rodrigo JJ et al Outcomesof microfracture for traumaticchondral defects of theknee average11 year followup J Arthroscopy 2003 19 477 484 Knutsen G Engebretsen L Ludvigsen TC et al Autologous chondrocyte implantation compared with microfracture in th
6、e knee Arandomizedtrial J J Bone Joint Surg Am 2004 86 455 464 骨髓刺激技术 microfracture技 术 髌骨部分切除术并外侧支持带松解术 长期髌骨不稳定 髌骨运动轨迹异常 反复慢性髌骨外侧半脱 位或脱位 导致髌骨软骨面压力不平衡 外侧面负荷增加 造 成关节面软骨的破坏 髌骨外移可导致外侧支持带挛缩 内外侧力量失衡 可形成髌骨外侧牵拉型骨赘 髌骨部分切除术并外侧支持带松解术 适应症 1 严重髌股关节面病变 特别是外侧髌股关节退 变 2 存在髌骨外侧半脱位或脱位 3 合并髌骨外侧软组织挛缩 关节面切除术 结果 Poulos Ar
7、throscopy 2008 88 满意或者非常满意 5 years McCarrol 1983 CORR 75 满意 4 years Martens 1990 Acta Orthop Belg 65 良好 25 中等 10 差 Yercan CORR 2005 疼痛减轻 8 years 关节面切除术 长期随访 Knee 2012 Aug 19 4 411 5 Epub 2011 May 18 Patellofemoral osteoarthritis treated by partial lateral facetectomy results at long term follow up W
8、etzels T Bellemans J Source Department of Orthopaedic Surgery University Hospital Pellenberg Katholieke Universiteit Leuven Weligerveld 1 3012 Pellenberg Belgium tjmwetzels Abstract Excision of the eroded lateral patellar facet has been suggested as an acceptable treatment for short term pain reduct
9、ion in patients with isolated patellofemoral osteoarthritis The outcome of this procedure at long term is however not known We therefore reviewed the results of 155 consecutive patients 168 knees treated at our institution with lateral facetectomy at an average follow up of 10 9 years 6 9 years SD D
10、uring follow up 62 knees 36 9 had failed and were revised to either TKA 60 knees patellofemoral arthroplasty one case or total patellectomy one case Average time to reoperation in the failure group was 8 0 years 6 2 years SD Kaplan Meier survival rates with reoperation as endpoint were 85 at 5 years
11、 67 2 at 10 years and 46 7 at 20 years respectively At final follow up 79 74 5 of the knees that had not been re operated were rated as either good or fair which corresponds to 47 of the original group Our study therefore demonstrates that asatisfactory outcome after lateral patellar facetectomy for
12、 isolated patellofemoral osteoarthritis can be expected in approximately half of the cases at 10 year follow up 外侧支持带松解的生物力学效果 Knee Surg Sports Traumatol Arthrosc 2007 May 15 5 547 54 Epub 2007 Jan 16 Dynamic measurement of patellofemoral kinematics and contact pressure after lateral retinacular rel
13、ease an in vitro study Ostermeier S Holst M Hurschler C Windhagen H Stukenborg Colsman C Source Orthopaedics Department Hannover Medical School Anna von Borries Str 1 7 30625 Hannover Germany sven ostermeier annastift de Abstract The purpose of this study was to investigate the influence of lateral
14、retinacular release and medial and lateral retinacular deficiency on patellofemoral position and retropatellar contact pressure Human knee specimens n 8 mean age 65 SD 7 years all male were tested in a kinematic knee simulating machine During simulation of an isokinetic knee extension cycle from 120
15、 degrees to full extension a hydraulic cylinder applied sufficient force to the quadriceps tendon to produce an extension moment of 31 Nm The position of the patella was measured using an ultrasound based motion analysis system CMS 100 Zebris The amount of patellofemoral contact pressure and its pre
16、ssure distribution was measured using a pressure sensitive film Tekscan Boston Patellar position and contact pressure were first investigated in intact knee conditions after a lateral retinacular release and a release of the medial and lateral retinaculum After lateral retinacular release the patella continuously moved from a significant medialised position at flexion P 0 01 to a lateralised position P 0 02 at full knee extension compared to intact conditions the centre of patellofemoral contact
