关节炎早期髌骨软化症ppt课件.ppt

髌骨软化症 Doctorwang 髌骨软化症是髌软骨面及与其相对的股骨髌面的关节软骨由于损伤而引起的退行性变 病因病机 本病多发生于运动员 常由慢性或急性损伤引起 如膝的长期猛烈屈伸活动 使髌股之间发生长期猛烈的摩擦 Definition Chondromalaciapatella Softeninganddegenerativechangesintheposteriorsurfaceofthepatella Pathology FirstusedbyAlemanin1917 chondromalaciapatellawasthenamegiventoadegenerationofthepatellararticularcartilage KipnisandScuderi 1995 Truechondromalaciapatellainvolvesthedegenerationofthearticularfacetsofthepatella withresultingraggedfrondededges WelshandHutton 1990 andisaverycommoninjuryamongstbothmenandwomenofoursportingpopulation Williams 1990 Alongwithosteoarthritis chondromalaciapatellaisatypeofcartilagedamageresultinginanteriorkneepain Itisalsonamedasacauseofthesymptomsofpatellofemoralpainsyndrome Reid 1992 Whencomparedtothenumberofpatientswhoareseenwithpatellofemoralpain andthosewithactualchangestothearticularcartilageofthepatella chondromalaciapatellaisarareconditionthough Nofthall 1990 Cartilagechangesoccurduetoexcesscompressionwhichdisruptstheintermediateanddeeplayersofcartilageofthepatella sarticularsurface Reid 1992 Kulund 1988 alsodescribeschangeswhichoccurtothesubchondralbone microfracturesandsclerosis bothofwhichmakethebonelessresilientandleadtogreatershocktothecartilage Mostchondromalacicchangesareseenalongthemedianridgeofthepatella andherecartilageisthickest Kulund 1988 PatellatraumaAfractureinvolvingthefullthicknessofthepatellainachildisextremelyrare Howeverfracturesofthepatellararticularfacetsarelessuncommon PATELLA Medialcontactoffemurinextremeflexion rose FacetformedialfemoralcondyleFacetforlateralfemoralcondyleAttachmentofpatellarligament Lateralrelease 4x sbodyweightwithkneeflexed70 80degreesofflexion PatellaPathologies PatellofemoralStressSyndromeMechanismS SHistoryInspectionPalpationAROMPROMRROMSpecialTests Anatomy PatellarRetinaculumLongitudinaltendinousfibersPatellofemoralligamentsBloodSupplyPrimarilyderivedfromgeniculatearteries Biomechanics Thepatellaundergoesapproximately7cmoftranslationfromfullflexiontoextensionOnly13 38 ofthepatellarsurfaceisincontactwiththefemurthroughoutitsrangeofmotion Biomechanics ThepatellaincreasesthemomentarmaboutthekneeContributesupto30 increaseinforcewithextensionPatellawithstandscompressiveforcesgreaterthan7Xbodyweightwithsquatting Biomechanics Twiceasmuchtorqueisneededtoextendthekneethefinal15degreesthantoextendfromafullyflexedpositionto15degreesofflexion ModifiedTensionBandWiring Transverse noncomminutedfracturesAfterreduction fractureisfixedwithtwoparallel 1 6mmKirschnerwiresplacedperpendiculartothefracture18gaugewirepassedbehindproximallyanddistally ModifiedTensionBandWiring WireconvertsanteriordistractiveforcestocompressiveforcesatthearticularsurfaceTwotwistsareplacedonoppositesidesofthewireTightensimultaneouslytoachievesymmetrictensionRepairanyretinaculartears 分级 OuterbridgeChondralDefectClassification OuterbridgeChondralDefectClassification Grade0 normalcartilageGradeI cartilagewithsofteningandswelling OuterbridgeChondralDefectClassification GradeII apartial thicknessdefectwithfissuresonthesurfacethatdonotreachsubchondralboneorexceed1 5cmindiameter OuterbridgeChondralDefectClassification GradeIII fissuringtothelevelofsubchondralboneinanareawithadiametermorethan1 5cm OuterbridgeChondralDefectClassification GradeIV exposedsubchondralbone 诊断 一 临床表现患者初为膝部不适 继而有髌骨后方疼痛 膝内侧隐痛 活动时或活动后疼痛加重 上 下楼梯尤为明显 自觉髌股之间有摩擦感 压迫髌骨有疼痛 尤以膝外侧压痛明显 膝关节活动度正常 但有细小摩擦音 二 检查 1 髌骨压磨试验2 单腿下蹲试验患肢单腿站立 三 X线检查 RadiographicAppearance Plainradiographyofthekneeisoflimiteduse onaskylineaxialprojectionthesmallfissuresmaybevisibleandinthefinalgrade4stagesosteoarthritic scleroticchangestakeplaceandosteophytesarevisibleMRisabletoprovi