髌骨减容术的临床应用.pptx

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 DaviesCORR2002 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 McAlindonAnnRheumDis 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CurlArthroscopy1997 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 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 nanofracture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 CurlWW KromeJ GordonES eta1 Cartilageinjuries areviewof31516kneearthroscopies Arthroscopy 1997 13 4 456 460SteadmanJR BriggsKK RodrigoJJ etal Outcomesofmicrofracturefortraumaticchondraldefectsoftheknee average11 yearfollowup J Arthroscopy 2003 19 477 484 KnutsenG EngebretsenL LudvigsenTC etal Autologouschondrocyteimplantationcomparedwithmicrofractureintheknee Arandomizedtrial J JBoneJointSurgAm 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 Arthroscopy2008 88 满意或者非常满意 5yearsMcCarrol 1983CORR 75 满意 4yearsMartens 1990ActaOrthopBelg 65 良好 25 中等 10 差Yercan CORR2005 疼痛减轻 8years 关节面切除术 长期随访 Knee 2012Aug 19 4 411 5 Epub2011May18 Patellofemoralosteoarthritistreatedbypartiallateralfacetectomy resultsatlong termfollowup WetzelsT BellemansJ SourceDepartmentofOrthopaedicSurgery UniversityHospitalPellenberg KatholiekeUniversiteitLeuven Weligerveld1 3012Pellenberg Belgium tjmwetzels AbstractExcisionoftheerodedlateralpatellarfacethasbeensuggestedasanacceptabletreatmentforshort termpainreductioninpatientswithisolatedpatellofemoralosteoarthritis Theoutcomeofthisprocedureatlong termishowevernotknown Wethereforereviewedtheresultsof155consecutivepatients 168knees treatedatourinstitutionwithlateralfacetectomyatanaveragefollowupof10 9years 6 9yearsSD Duringfollowup62knees 36 9 hadfailedandwererevisedtoeitherTKA 60knees patellofemoralarthroplasty onecase ortotalpatellectomy onecase Averagetimetoreoperationinthefailuregroupwas8 0years 6 2yearsSD Kaplan Meiersurvivalrateswithreoperationasendpointwere85 at5years 67 2 at10years and46 7 at20yearsrespectively Atfinalfollowup79 74 5 ofthekneesthathadnotbeenre operatedwereratedaseithergoodorfair whichcorrespondsto47 oftheoriginalgroup Ourstudythereforedemonstratesthatasatisfactoryoutcomeafterlateralpatellarfacetectomyforisolatedpatellofemoralosteoarthritiscanbeexpectedinapproximatelyhalfofthecasesat10yearfollowup 外侧支持带松解的生物力学效果 KneeSurgSportsTraumatolArthrosc 2007May 15 5 547 54 Epub2007Jan16 Dynamicmeasurementofpatellofemoralkinematicsandcontactpressureafterlateralretinacularrelease aninvitrostudy OstermeierS HolstM HurschlerC WindhagenH Stukenborg ColsmanC SourceOrthopaedicsDepartment HannoverMedicalSchool Anna von Borries Str 1 7 30625 Hannover Germany sven ostermeier annastift deAbstractThepurposeofthisstudywastoinvestigatetheinfluenceoflateralretinacularreleaseandmedialandlateralretinaculardeficiencyonpatellofemoralpositionandretropatellarcontactpressure Humankneespecimens n 8 meanage 65SD7years allmale weretestedinakinematicknee simulatingmachine Duringsimulationofanisokinetickneeextensioncyclefrom120degreestofullextension ahydrauliccylinderappliedsufficientforcetothequadricepstendontoproduceanextensionmomentof31Nm Thepositionofthepatellawasmeasuredusinganultrasoundbasedmotionanalysissystem CMS100 Zebris Theamountofpatellofemoralcontactpressureanditspressuredistributionwasmeasuredusingapressuresensitivefilm Tekscan Boston Patellarpositionandcontactpressurewerefirstinvestigatedinintactkneeconditions afteralateralretinacularreleaseandareleaseofthemedialandlateralretinaculum Afterlateralretinacularreleasethepatellacontinuouslymovedfromasignificantmedialisedpositionatflexion P 0 01 toalateralisedposition P 0 02 atfullkneeextensioncomparedtointactconditions thecentreofpatellofemoralcontactpressurewassignificantlymedialised 0 04 between120degreesand60degreeskneeflexion Patellofemoralcontactpressuredidnotchangesignificantly Inthedeficientkneeconditionsthepatellamovedonasignificantlateralisedtrack P 0 04 throughtheentireextensioncyclewithalateralisedcentreofpatellofemoralpressure P 0 04 withatrend P 0 08 towardsincreasedpatellofemoralpressure Theresultssuggestthatlateralretinacularreleasedidnotinevitablystabiliseormedialisepatellartrackingthroughtheentirekneeextensioncycle butcoulddecreasepressureonthelateralpatellarfacetinkneeflexion Thereforelateralretinacularreleaseshouldbeconsideredcarefullyincasesofpatellarinstability 外侧支持带松解术 适应症外侧髌股关节退化性病变 Arthroscopy 2002Apr 18 4 399 403 Lateralreleaseforpatellofemoralarthritis AderintoJ CobbAG METHODS Fiftypatientswhounderwent53lateralretinacularreleaseproceduresbetween1995and1999forthetreatmentofsymptomaticpatellofemoralarthritiswereassessedbyquestionnairecomprisingtheOxfordkneescore avisualanalogue scale VAS 0 10 forpain andquestionsrelatingtolevelofpatientsatisfaction Patientswereincludedinthisstudywhether ornottibiofemoralarthritiswaspresent butlateralreleasewasperformedonlyinthoseforwhomtheanteriorkneepainofpatellofemoralarthritisappearedtopredominate RESULTS Theaveragepatientagewas53years range 27to79years Therewere14men 28 and36women 72 Follow upwasameanof31months range 12to65months Fourpatientsunderwenttotalkneereplacementat7 14 16 and18monthsafterlateralreleaseforrecurrenceofsymptoms Intheremaining49knees meanpainVASwas3 8 2 8 In39 knees 80 patientsjudgedthattheyhadexperiencedareductioninpain comparedwiththeirpreoperativestate 2werepainfree 8 16 wereunchanged and2 4 wereworse TheaverageOxfordkneescorewas27 range 12 48 Atfollow up 33 ofpatientswereverysatisfied 26 satisfied and41 dissatisfiedwiththeirknee Thepresenceoftibiofemoraldiseasedidnotaffectanyoftheoutcome measures Twopatientsdevelopedsuperficialinfectionsofthearthroscopicportsites Therewerenocasesofhemarthrosis CONCLUSIONS Arthroscopiclateralreleaseiseffectiveinreducingthepainofsymptomaticpatellofemoralosteoarthritisandgivesreasonableratesofpatientsatisfactionirrespectiveofthepresenceoftibiofemoralarthritis 外侧支持带松解 关节面切除术 ActaOrthopBelg 1990 56 3 4 563 7 Facetectomyofthepatellainpatellofemoralosteoarthritis MartensM DeRyckeJ DepartmentofOrthopaedicSurgery UniversityHospital Pellenberg Belgium AbstractPatellofemoralosteoarthritisisacommondiseasewhichmayoccuraloneorinassociationwithtibiofemoralgonarthrosis Incasesofisolatedsymptomaticpatello femoralosteoarthritiswithtypicallateralmalalignmentandformationofosteophytesatthelateralborderofthepatello femoraljointweperformalateralfacetectomyofthepatellaandassociatedlateralretinaculumrelease Theresultsofaprospectivestudyof20caseswithameanfollow upof2yearsarepresented Agood to moderateresultwasobtainedin90 Theaverageagewas60years Wehad2failureswithasubjectiveratingofpoor Theprincipalreasonwastibiofemoralgonarthrosistoofaradvancedatthetimeoftheoperation whichthenprogressedinthepostoperativecourse Ontheotherhandthistechniqueresultsinmarkedimprovementformanycasesandcarriesonlyasmallrisk Furtherreconstructivesurgeryofthekneeisnotexcluded Becauseoftheminorsurgeryandquickrecovery thisoperationpresentsavalidalternativetomoreinvolvedoperationssuchaspatellectomy BandiorMaquetreconstructiveprocedures orapatellofemoralprosthesis 髌骨周围去神经化术 髌骨周围的神经主要有 1 皮神经 2 隐神经上支 3 伸膝肢关节支 原理 通过射频烧灼髌骨周围神经 起到 去神经化 目的 可以减少疼痛的传导 缓解膝关节前方疼痛 髌骨周围神经彼此分布交叉重叠 即使切断 也不能完全阻断髌丛神经支配 不会影响髌骨周围皮肤感觉 具有快捷 方便 准确以及安全等优点 胫骨结节截骨术 方法 前侧 运用移植 Maquet技术 不运用移植 Cole技术前内侧 Fulkerson技术 胫骨结节截骨 适应症 力线不正和不负重的髌骨和股骨滑车软骨缺损提高合并软骨面重建的疗效 文献回顾 胫骨结节截骨术治疗髌股关节骨关节炎 Maquet术 62 96 Schmid LongTermResultsMaquetCORR1993 80 良好 非