關(guān)節(jié)鏡輔助內(nèi)側(cè)髕股韌帶雙束聯(lián)合股內(nèi)側(cè)肌斜束解剖重建治療髕骨脫位的臨床研究
發(fā)布時間：2018-08-05 15:41
【摘要】：目的:由于髕骨的運動軌跡復(fù)雜性,周圍軟組織的調(diào)控多樣性,髕骨脫位已成為骨科常見疾病,其治療也成為骨科醫(yī)生極大的挑戰(zhàn)。隨著近年對生物力學(xué)的研究發(fā)現(xiàn),在限制髕骨外傾以及控制髕骨軌跡的內(nèi)側(cè)軟組織中,內(nèi)側(cè)髕股韌帶(MPFL)約占50%-60%的作用,因此重建MPFL也成為治療髕骨脫位的主要手術(shù)選擇。目前重建MPFL手術(shù)方法種類較多,而最近研究的雙束解剖重建手術(shù),近年來被越來越多學(xué)者所接受。MPFL雙功能束概念,分為下直束及上斜束,而上斜束在髕骨止點附近與股內(nèi)側(cè)肌斜束(VMO)網(wǎng)狀交叉聯(lián)合,在屈膝的早期,VMO使在限制髕骨外移中的作用遠遠超過靜態(tài)的50%,所以重建MPFL時應(yīng)注意VMO的重建。本文研究介紹,通過對MPFL雙束解剖重建及VMO的聯(lián)合重建,恢復(fù)髕骨內(nèi)側(cè)軟組織的穩(wěn)定性,同時輔以關(guān)節(jié)鏡下探查關(guān)節(jié)內(nèi)情況、髕骨位置、髕骨與股骨之間的對合關(guān)系等治療髕骨脫位,同時通過術(shù)后隨訪觀察其手術(shù)效果,進一步為臨床應(yīng)用提供較好的方法。方法:回顧性研究分析自2013年6月至2014年12月河北醫(yī)科大學(xué)第三臨床醫(yī)學(xué)院關(guān)節(jié)外科經(jīng)體檢及影像學(xué)檢查,確診為髕骨脫位并行雙束聯(lián)合股內(nèi)側(cè)肌斜束解剖重建內(nèi)側(cè)髕股韌帶治療的34例(34膝)的患者的數(shù)據(jù),男12例,女22例,年齡范圍16-40歲,平均年齡24歲,術(shù)中均采用自體半腱肌-股薄肌腱移植物,分別解剖重建內(nèi)側(cè)髕股韌帶的雙功能束,股骨側(cè)止點選定為內(nèi)收肌結(jié)節(jié)和股骨內(nèi)側(cè)髁的最高點之中點,髕骨側(cè)兩止點選定為髕骨的內(nèi)側(cè)緣中點及髕骨近上極處。股骨側(cè)端的固定方式為:用直徑為7mm的鉆頭,鉆取大約3cm的骨性隧道,用直徑為7x23mm可吸收的擠壓螺釘固定。而髕骨端的固定方式采用:半隧道的骨橋固定或錨釘縫合的固定,再找到VMO在髕骨的內(nèi)側(cè)緣的附著點,將其縫合于重建的MPFL的上斜束。最后行手法檢查及關(guān)節(jié)鏡下監(jiān)測,保證患者尤其在屈膝活動的早期,髕骨能順利的進入股骨滑車溝內(nèi),同時鏡下觀察膝關(guān)節(jié)在0-120°屈伸活動中髕股關(guān)節(jié)的動態(tài)對應(yīng)關(guān)系。術(shù)后支具保護,指導(dǎo)康復(fù)功能鍛煉。隨訪患者有無術(shù)后并發(fā)癥的發(fā)生,再次髕骨脫位的例數(shù),體格查體主要為髕骨的穩(wěn)定性及髕骨恐懼試驗。術(shù)后CT檢查為膝關(guān)節(jié)屈曲20°時測量髕骨外移率(PSLR)及髕骨傾斜角(PTA)等指標,觀察髕骨的位置。用Kujala和Lysholm評分系統(tǒng)共同對膝關(guān)節(jié)進行功能評估。將數(shù)據(jù)用SPSS13.0(SPSS13.0 Chicago,III)統(tǒng)計軟件處理,組間均數(shù)差異的比較配對t檢驗。P0.05為差異存在統(tǒng)計學(xué)的意義。結(jié)果:術(shù)后患者切口均愈合良好,無感染,無下肢動靜脈血栓形成等并發(fā)癥。隨訪期間所有患者的髕骨傾斜試驗、髕骨恐懼試驗(-),無半脫位、再次脫位或骨折的發(fā)生,術(shù)后CT測量,關(guān)節(jié)適合角(congruance angle,CA)由20.20±3.38減小到10.17±2.33;髕骨傾斜角(patella tilting angle,PTA)由18.94±2.24減小到10.93±1.51;髕骨外移率(patellar lateral shift rate,PLSR)由19.42±1.28減小到9.82±1.64;膝關(guān)節(jié)功能評分:Kujala評分由59.74±3.68提高為91.19±3.11;Lysholm評分由59.73±4.79提高為92.60±1.94,均具有統(tǒng)計學(xué)意義(P0.05)。結(jié)論:內(nèi)側(cè)髕股韌帶雙束聯(lián)合股內(nèi)側(cè)肌斜束聯(lián)合重建治療髕骨脫位,更能明顯的改善髕骨的滑動軌跡,并在關(guān)節(jié)鏡下輔助下動態(tài)觀察關(guān)節(jié)內(nèi)的情況及髕股關(guān)節(jié)的匹配情況,更好的提高膝關(guān)節(jié)的功能。但由于髕骨脫位的力學(xué)機制非常之復(fù)雜,涉及的因素很多,仍需要大樣本長期的臨床隨訪來觀察臨床療效。
[Abstract]:Objective: because of the complexity of the patellar movement and the diversity of the control of the surrounding soft tissue, patellar dislocation has become a common disease in the Department of orthopedics, and its treatment has become a great challenge for doctors in the Department of orthopedics. With the recent research on biomechanics, the medial patellar tendon (MPFL) in the medial patellar tendon, which limits the patellar extroversion and the locus of the patellar bone, has been found. About the role of 50%-60%, so the reconstruction of MPFL is also the main choice for the treatment of patellar dislocation. Currently, there are many kinds of methods to reconstruct the MPFL operation. In recent years, more and more scholars have accepted the concept of.MPFL double function bundle, which are divided into the lower straight and the upper oblique, and the upper oblique tract is near the patellar stop. In the early stage of knee flexion, the role of VMO in the reticular interlocking of the medial femoral muscle (VMO) is far more than that of the static 50%, so the reconstruction of VMO should be paid attention to in the reconstruction of MPFL. This paper introduces the stability of the medial soft tissue of the patella by the double beam reconstruction of MPFL and the joint reconstruction of VMO, with the arthroscope supplemented by arthroscopy. Under the joint condition, the position of patella, the relationship between the patellar and the femur in the treatment of patellar dislocation, and the postoperative follow-up observation of the effect of the operation, and further provide a better method for clinical application. Methods: retrospective study and analysis from June 2013 to December 2014, the third clinical medicine Hospital of Hebei Medical University. The data of 34 patients (34 knees) treated with patellar dislocation and double bundle combined with medial patellar tendon repair were confirmed by physical examination and imaging examination, 12 men, 22 women, 16-40 years of age and 24 years of age. Autologous semitendinosus tendon graft was used during the operation, and the medial patellar tendon was rebuilt respectively. The lateral stop point of the femur is selected as the midpoint of the adductor tubercle and the highest point of the medial condyle of the femur. The two stop of the patellar side is selected as the medial point of the patellar medial margin and the proximal patellar pole. The fixation method of the femur side is that the bone tunnel of about 3cm is drilled with the diameter of 7mm, and the extruded screw with the diameter of 7x23mm absorbable Fixation. The patellar end is fixed by the bone bridge of the half tunnel or the anchorage fixation, and then the attachment point of the medial edge of the patella is found, and the VMO is sutured to the reconstructed MPFL's upper oblique bundle. Finally, the manual examination and arthroscopy are used to ensure that the patella can enter the trochlear smoothly, especially at the early stage of the knee flexion. The dynamic corresponding relationship between the knee joint and the patellar joint during the 0-120 degree flexion and extension was observed under the microscope. The postoperative support was protected to guide the rehabilitation function exercise. The follow-up patients had no postoperative complications, the number of cases of patellar dislocation again, the physical examination mainly for the patellar stability and patellar fear test. The postoperative CT examination was the knee joint flexion. The patellar displacement (PSLR) and patellar tilting angle (PTA) were measured at 20 degrees. The position of the patellar bone was observed. The function of the knee joint was evaluated with the Kujala and Lysholm scoring system. The data were treated with SPSS13.0 (SPSS13.0 Chicago, III) statistical software, and the comparison of the difference of mean number difference between groups was statistically significant. Results: the incision healed well, no infection, no lower limb arteriovenous thrombosis and other complications. All patients were followed up with patellar tilt test, patellar fear test (-), no subluxation, re dislocation or fracture, CT measurement, and joint angle (congruance angle, CA) from 20.20 + 3.38 to 10.17 + 2.33; patellar patellar The bone tilt angle (patella tilting angle, PTA) decreased from 18.94 + 2.24 to 10.93 + 1.51; the external displacement of the patella (patellar lateral shift rate, PLSR) decreased from 19.42 + 1.28 to 9.82 + 1.64. The score of knee joint function: Kujala score increased from 59.74 + 3.68 to 91.19 + 3.11, Lysholm score was increased from 59.73 to 4.79. P0.05) conclusion: the double bundle of medial patellar ligament combined with the medial femoral medial muscle oblique bundle combined with the reconstruction of patellar dislocation can improve the patellar trajectory more obviously. Under the arthroscope, the dynamic observation of the intraarticular and patellar joint is better to improve the function of the knee joint, but the mechanical mechanism of patellar dislocation is not good. Often complex, involving many factors, still need large sample long-term clinical follow-up to observe the clinical efficacy.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.3
[Abstract]:Objective: because of the complexity of the patellar movement and the diversity of the control of the surrounding soft tissue, patellar dislocation has become a common disease in the Department of orthopedics, and its treatment has become a great challenge for doctors in the Department of orthopedics. With the recent research on biomechanics, the medial patellar tendon (MPFL) in the medial patellar tendon, which limits the patellar extroversion and the locus of the patellar bone, has been found. About the role of 50%-60%, so the reconstruction of MPFL is also the main choice for the treatment of patellar dislocation. Currently, there are many kinds of methods to reconstruct the MPFL operation. In recent years, more and more scholars have accepted the concept of.MPFL double function bundle, which are divided into the lower straight and the upper oblique, and the upper oblique tract is near the patellar stop. In the early stage of knee flexion, the role of VMO in the reticular interlocking of the medial femoral muscle (VMO) is far more than that of the static 50%, so the reconstruction of VMO should be paid attention to in the reconstruction of MPFL. This paper introduces the stability of the medial soft tissue of the patella by the double beam reconstruction of MPFL and the joint reconstruction of VMO, with the arthroscope supplemented by arthroscopy. Under the joint condition, the position of patella, the relationship between the patellar and the femur in the treatment of patellar dislocation, and the postoperative follow-up observation of the effect of the operation, and further provide a better method for clinical application. Methods: retrospective study and analysis from June 2013 to December 2014, the third clinical medicine Hospital of Hebei Medical University. The data of 34 patients (34 knees) treated with patellar dislocation and double bundle combined with medial patellar tendon repair were confirmed by physical examination and imaging examination, 12 men, 22 women, 16-40 years of age and 24 years of age. Autologous semitendinosus tendon graft was used during the operation, and the medial patellar tendon was rebuilt respectively. The lateral stop point of the femur is selected as the midpoint of the adductor tubercle and the highest point of the medial condyle of the femur. The two stop of the patellar side is selected as the medial point of the patellar medial margin and the proximal patellar pole. The fixation method of the femur side is that the bone tunnel of about 3cm is drilled with the diameter of 7mm, and the extruded screw with the diameter of 7x23mm absorbable Fixation. The patellar end is fixed by the bone bridge of the half tunnel or the anchorage fixation, and then the attachment point of the medial edge of the patella is found, and the VMO is sutured to the reconstructed MPFL's upper oblique bundle. Finally, the manual examination and arthroscopy are used to ensure that the patella can enter the trochlear smoothly, especially at the early stage of the knee flexion. The dynamic corresponding relationship between the knee joint and the patellar joint during the 0-120 degree flexion and extension was observed under the microscope. The postoperative support was protected to guide the rehabilitation function exercise. The follow-up patients had no postoperative complications, the number of cases of patellar dislocation again, the physical examination mainly for the patellar stability and patellar fear test. The postoperative CT examination was the knee joint flexion. The patellar displacement (PSLR) and patellar tilting angle (PTA) were measured at 20 degrees. The position of the patellar bone was observed. The function of the knee joint was evaluated with the Kujala and Lysholm scoring system. The data were treated with SPSS13.0 (SPSS13.0 Chicago, III) statistical software, and the comparison of the difference of mean number difference between groups was statistically significant. Results: the incision healed well, no infection, no lower limb arteriovenous thrombosis and other complications. All patients were followed up with patellar tilt test, patellar fear test (-), no subluxation, re dislocation or fracture, CT measurement, and joint angle (congruance angle, CA) from 20.20 + 3.38 to 10.17 + 2.33; patellar patellar The bone tilt angle (patella tilting angle, PTA) decreased from 18.94 + 2.24 to 10.93 + 1.51; the external displacement of the patella (patellar lateral shift rate, PLSR) decreased from 19.42 + 1.28 to 9.82 + 1.64. The score of knee joint function: Kujala score increased from 59.74 + 3.68 to 91.19 + 3.11, Lysholm score was increased from 59.73 to 4.79. P0.05) conclusion: the double bundle of medial patellar ligament combined with the medial femoral medial muscle oblique bundle combined with the reconstruction of patellar dislocation can improve the patellar trajectory more obviously. Under the arthroscope, the dynamic observation of the intraarticular and patellar joint is better to improve the function of the knee joint, but the mechanical mechanism of patellar dislocation is not good. Often complex, involving many factors, still need large sample long-term clinical follow-up to observe the clinical efficacy.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R687.3
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