髌骨减容术的临床应用

1、髌骨减容术的临床应用髌骨减容术的临床应用广东省中医院二沙骨科广东省中医院二沙骨科许树柴许树柴 陈伯健陈伯健 刘洪亮刘洪亮 黄泽鑫黄泽鑫 髌骨减容术（髌骨修整术）：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。髌骨减容术概念髌骨减容术概念发病率发病率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 An

2、n 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Curl 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

3、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

4、少髌骨和滑车之间骨性摩擦，达到减容目的。优点：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（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

5、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 a1Cartilage injuries：areview of 31516 knee arthroscopiesArthroscopy，1997，13(4)456-460Steadman JR，Briggs KK，Rodrigo JJ，et al Outcomesof microfracture for traumaticchondral defects of theknee:average11-year followupJArthroscopy，2003，19:477484Knutsen

6、G，Engebretsen L，Ludvigsen TC，et alAutologous chondrocyte implantation compared with microfracture in the kneeArandomizedtrialJJ Bone Joint Surg Am，2004，86:455464骨髓刺激技术骨髓刺激技术-microfracture技术技术髌骨部分切除术并外侧支持带松解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

7、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: Arthroscopy 2008 88% 满意或者非常满意 5 yearsMcCarrol: 1983 CORR: 75% 满意 4 yearsMartens: 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Kn

8、ee. 2012 Aug;19(4):411-5. Epub 2011 May 18.Patellofemoral osteoarthritis treated by partial lateral facetectomy: results at long-termfollow up.Wetzels T, Bellemans J.SourceDepartment of Orthopaedic Surgery, University Hospital Pellenberg, Katholieke UniversiteitLeuven, Weligerveld 1, 3012 Pellenberg

9、, Belgium. AbstractExcision of the eroded lateral patellar facet has been suggested as an acceptable treatmentfor short-term pain reduction in patients with isolated patellofemoral osteoarthritis. Theoutcome of this procedure at long-term is however not known. We therefore reviewed theresults of 155

10、 consecutive patients (168 knees) treated at our institution with lateralfacetectomy at an average follow up of 10.9 years ( 6.9 years SD). During follow up 62knees (36.9%) had failed and were revised to either TKA (60 knees), patellofemoralarthroplasty (one case) or total patellectomy (one case). A

11、verage time to reoperation in thefailure group was 8.0 years ( 6.2 years SD). Kaplan-Meier survival rates with reoperation asendpoint were 85% at 5 years, 67.2% at 10 years, and 46.7% at 20 years respectively. Atfinal follow up 79 (74.5%) of the knees that had not been re-operated were rated as eith

12、ergood or fair, which corresponds to 47% of the original group. Our study thereforedemonstrates that asatisfactory outcome after lateral patellarfacetectomy for isolated patellofemoral osteoarthritis can beexpected 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 Spo

13、rts Traumatol Arthrosc. 2007 May;15(5):547-54. Epub 2007 Jan 16.Dynamic measurement of patellofemoral kinematics and contact pressure after lateral retinacularrelease: an in vitro study.Ostermeier S, Holst M, Hurschler C, Windhagen H, Stukenborg-Colsman C.SourceOrthopaedics Department, Hannover Medi

14、cal School, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany.sven.ostermeierannastift.deAbstractThe purpose of this study was to investigate the influence of lateral retinacular release and medial and lateralretinacular deficiency on patellofemoral position and retropatellar contact pressure. Hum

15、an knee specimens (n= 8, mean age = 65 SD 7 years, all male) were tested in a kinematic knee-simulating machine. Duringsimulation of an isokinetic knee extension cycle from 120 degrees to full extension, a hydraulic cylinder appliedsufficient force to the quadriceps tendon to produce an extension mo

16、ment of 31 Nm. The position of the patellawas measured using an ultrasound based motion analysis system (CMS 100, Zebris). The amount ofpatellofemoral contact pressure and its pressure distribution was measured using a pressure sensitive film(Tekscan, Boston). Patellar position and contact pressure

17、were first investigated in intact knee conditions, aftera lateral retinacular release and a release of the medial and lateral retinaculum. After lateral retinacular releasethe patella continuously moved from a significant medialised position at flexion (P = 0.01) to a lateralisedposition (P = 0.02)

18、at full knee extension compared to intact conditions,the centre ofpatellofemoral contact pressure was significantly medialised (0.04)between 120 degrees and 60 degrees knee flexion. Patellofemoral contact pressuredid not change significantly. In the deficient knee conditions the patella moved on a s

19、ignificant lateralised track(P = 0.04) through the entire extension cycle with a lateralised centre of patellofemoral pressure (P = 0.04) witha trend (P = 0.08) towards increased patellofemoral pressure. The results suggest that lateral retinacularrelease did not inevitably stabilise or medialise pa

20、tellar tracking through the entire knee extension cycle, butcould decrease pressure on the lateral patellar facet in knee flexion. Therefore lateral retinacular releaseshould be considered carefully in cases of patellar instability.外侧支持带松解术: 适应症外侧髌股关节退化性病变Arthroscopy. 2002 Apr;18(4):399-403.Lateral

21、release for patellofemoral arthritis.Aderinto J, Cobb AG.METHODS:Fifty patients who underwent 53 lateral retinacular release procedures between 1995 and 1999 for the treatment ofsymptomatic patellofemoral arthritis were assessed by questionnaire comprising the Oxford knee score, a visual analoguesca

22、le (VAS, 0-10) for pain, and questions relating to level of patient satisfaction. Patients were included in this study whetheror not tibiofemoral arthritis was present, but lateral release was performed only in those for whom the anterior knee pain ofpatellofemoral arthritis appeared to predominate.

23、RESULTS:The average patient age was 53 years (range, 27 to 79 years). There were 14 men (28%) and 36 women (72%). Follow-upwas a mean of 31 months (range, 12 to 65 months). Four patients underwent total knee replacement at 7, 14, 16, and 18months after lateral release for recurrence of symptoms. In

24、the remaining 49 knees, mean pain VAS was 3.8 +/- 2.8. In 39knees(80%),patients judged that they had experienced a reduction in paincompared with their preoperative state (2 were pain free), 8 (16%) were unchanged, and 2 (4%) wereworse. The average Oxford knee score was 27 (range, 12-48). At follow-

25、up, 33% of patients were very satisfied, 26%satisfied, and 41% dissatisfied with their knee. The presence of tibiofemoral disease did not affect any of the outcomemeasures. Two patients developed superficial infections of the arthroscopic port sites. There were no cases of hemarthrosis.CONCLUSIONS:A

26、rthroscopic lateral release is effective in reducing the pain of symptomaticpatellofemoral osteoarthritis and gives reasonable rates of patient satisfactionirrespective of the presence of tibiofemoral arthritis外侧支持带松解+关节面切除术Acta Orthop Belg. 1990;56(3-4):563-7.Facetectomy of the patella in patellofe

27、moral osteoarthritis.Martens M, De Rycke J.Department of Orthopaedic Surgery, University Hospital, Pellenberg, Belgium.AbstractPatellofemoral osteoarthritis is a common disease which may occur alone or in associationwith tibiofemoral gonarthrosis. In cases of isolated symptomatic patello-femoraloste

28、oarthritis with typical lateral malalignment and formation of osteophytes at the lateralborder of the patello-femoral joint we perform a lateral facetectomy of the patella andassociated lateral retinaculum release. The results of a prospective study of 20 cases with amean follow-up of 2 years are pr

29、esented.A good-to-moderate result wasobtained in 90%. The average age was 60 years. We had 2 failures with a subjectiverating of poor. The principal reason was tibiofemoral gonarthrosis too far advanced at thetime of the operation, which then progressed in the postoperative course. On the other hand

30、this technique results in marked improvement for many cases and carries only a small risk.Further reconstructive surgery of the knee is not excluded. Because of the minor surgeryand quick recovery, this operation presents a valid alternative to more involved operationssuch as patellectomy, Bandi or

31、Maquet reconstructive procedures, or a patellofemoralprosthesis.髌骨周围去神经化术髌骨周围去神经化术髌骨周围的神经主要有：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：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: