髌骨脱位成形术.ppt

临 床 病 例 1 dislocation of the patella.,患者 孙某，女, 23岁,10年前摔伤致左髌骨脱位，自行复位，未给予特殊治疗，近日感左膝关节无力，轻度屈膝关节即出现髌骨脱位。,查体：Q角（ quadriceps-angle ）26（正常:女性 15+5）变大， 恐惧试验，髌骨活动度，J征（J-sign-slight）阳性，髌骨研磨试验。,左膝关节查体,体格检查视频 1,Q角,LT/LP大于1.2,Q角大于20,测量髌骨关节匹配度,TT-TG,CT测量胫骨结节外移程度 大于1.5厘米行结节内移,CT,MRI,诊断？ 分型？ 治疗方案？ 固定方式？,初步诊断 ？,左髌骨脱位,急性、复发性和固定性,保守和手术,单一固定和联合固定,手术治疗,外侧支持带松解 近端内侧重排（支持带紧缩、MPFL重建等 ） 远端重排（胫骨结节内移截骨等） 髌骨切除（挽救性手术）,内侧髌股韧带重建（ MPFL）联合胫骨结节移位和关节镜下髌骨外侧支持带松解术,治疗方案 联合方案重建,手术方法,关节镜检查，取出游离体 正常髌股关节在屈膝45度时髌骨归位，位于滑车中心 髌骨轨迹不良时外移,内侧髌股韧带（MPFL）重建术,1.半腱肌切取和处理； 2.建立髌骨和股骨隧道； 3.肌腱植入固定。,MPFL重建,外侧支持带松解术,关节镜下前内侧入路，松解范围：距髌骨外侧缘1cm，自髌骨尖水平髌腱外侧缘至髌骨外上极的外侧2cm、近侧2cm。,Fulkerson-osteotomy,方法： 沿着胫骨结节外侧做纵形切口，显露胫骨结节及胫骨嵴。胫骨近端外侧面及内侧缘钻孔，成勺形形态，骨刀分离，保留胫骨远侧与胫骨主体的连接。 内侧截骨线与冠状面成交45度截入，在松质骨区域做一个较为平整的骨面。 将胫骨结节的近端向内侧推移1.5mm, 一般用2枚3.5mm螺钉完成固定。,Fulkerson- osteotomy,Postoperative X-ray,Postoperative functional,Operative vs conservative?,Conservative Nonsurgical management is generally recommended for first time dislocation,with immobilization in extension for 36 weeks with placement of a brace. Surgical A. Recurrent instability following initial conservative management occurs in 1550 %. B. Chronic instability and recurrent dislocations may cause cartilage damage and eventual arthritic changes.,1.Christina Earhart. Transient lateral patellar dislocation: review of imaging findings, patellofemoral anatomy, and treatment options. Emerg Radiol .(2019) 20:1123,2.M. Petri, E. Liodakis, M. Hofmeister, Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial . Archives of Orthopaedic and Trauma Surgery 2019, (133)2, pp 209-213,Osteochondral fragments骨软骨碎片/loose bodies（游离体） Persistent patellar subluxation（持续性髌骨半脱位） Femoral avulsion of medial stabilizers in the acute setting急性内侧髌股韧带股骨止点撕脱 Chronic patellar instability 慢性髌骨脱位 Ligamentous or meniscal injury韧带/半月板损伤,Indications for surgery,Bollier M, Fulkerson JP (2019) The role of trochlear dysplasia in patellofemoral instability. J Am Acad Orthop Surg 19(1):816,Tibial tuberosity transfer to a more medial position (TTTG distance 20 mm) reduces Q-angle and decreases lateral stress on the patella.,Osseous realignment procedures（骨性重建）,Bollier M, Fulkerson JP (2019) The role of trochlear dysplasia in patellofemoral instability. J Am Acad Orthop Surg 19(1):816,Patients with normal TTTG distance（ 胫骨结节股骨滑车沟距离正常的患者,Medial patellofemoral ligament reconstruction using semimembranosus allograft (or gracilis tendon autograft)半腱肌/股薄肌重建内侧髌股韧带 Medial capsular plication 内侧关节囊 折叠术 Trochlear reconstruction 滑车重建,1.Christina Earhart. Transient lateral patellar dislocation: review of imaging findings, patellofemoral anatomy, and treatment options. Emerg Radiol .(2019) 20:1123,Patients with trochlear dysplasia滑车发育不良的患者,trochlear osteotomy截骨 or trochleoplasty 成形 Osteotomy: a bone graft is used to increase the height of the lateral wall and elevating the lateral trochlear facet.通过植骨增加滑车外侧壁的高度，改善滑车的横截面 Trochleoplasty: subchondral bone is removed and the overlying cartilage is compressed into the defect.（去除软骨下骨，将软骨铺垫于缺损处,Yuki Kitta;Yasuo Niki. Severe valgus deformity of the knee with permanent patellar dislocation associated with melorheostosis: A case report and review of the literature . The Knee . 2019 ,(21) 2 ：589-593,TrochleoplastyOpen surgery,Panagiotis G. Ntagiopoulos David Dejour . Current concepts on trochleoplasty procedures for the surgical treatment of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc. 11 April 2019,The Lyons sulcus-deepening trochleoplasty; subchondral bone is removed to deepen the groove, and the trochlea is osteotomized and repositioned according to the preoperative TT-TG value in a more lateral position,The rationale of the recession-wedge trochleoplasty,TrochleoplastyOpen surgery,Panagiotis G. Ntagiopoulos David Dejour . Current concepts on trochleoplasty procedures for the surgical treatment of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc. 11 April 2019,arthroscopic trochleoplasty关节镜下滑车成形术,Panagiotis G. Ntagiopoulos David Dejour . Current concepts on trochleoplasty procedures for the surgical treatment of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc. 11 April 2019,Summary,自体半腱肌腱移