髕骨減容術(shù)的臨床應(yīng)用

髕骨減容術(shù)的臨床應(yīng)用第1頁(yè)，共28頁(yè)，2023年，2月20日，星期三

髕骨減容術(shù)（髕骨修整術(shù)）：常用于治療髕骨關(guān)節(jié)骨關(guān)節(jié)炎患者，通過(guò)對(duì)髕骨骨性組織、髕骨周圍軟組織（如外側(cè)支持韌帶、內(nèi)側(cè)支持韌帶）等處進(jìn)行修整，達(dá)到減輕髕股關(guān)節(jié)面壓力、恢復(fù)髕骨正常運(yùn)動(dòng)軌跡的目的，從而緩解膝關(guān)節(jié)前方疼痛癥狀，延緩髕股關(guān)節(jié)骨關(guān)節(jié)炎進(jìn)展。髕骨減容術(shù)概念第2頁(yè)，共28頁(yè)，2023年，2月20日，星期三發(fā)病率Davies

CORR

2002:

–

在206

例膝關(guān)節(jié)X線檢查中9.6%>

40歲13.6%

女性

>

60歲15.4

%男性>

60歲McAlindon

Ann

Rheum

Dis:

–

24

%

的女性，11%

的男性有骨性關(guān)節(jié)炎的癥狀

>

55

歲有單純性髕股關(guān)節(jié)炎Curl

Arthroscopy

1997

–

31,516

例關(guān)節(jié)鏡中:

4%

關(guān)節(jié)面4度損傷.

–

其中21%有髕骨損傷，15%有滑車損傷第3頁(yè)，共28頁(yè)，2023年，2月20日，星期三髕股關(guān)節(jié)炎分級(jí)1.根據(jù)髕骨軸位片分級(jí)：

Ⅰ級(jí)：關(guān)節(jié)間隙變窄，接近3mm；Ⅱ級(jí)：關(guān)節(jié)間隙變窄，<3mm，沒(méi)有骨性接觸；Ⅲ級(jí)：關(guān)節(jié)骨性部分接觸；Ⅳ級(jí)：整個(gè)關(guān)節(jié)骨性接觸第4頁(yè)，共28頁(yè)，2023年，2月20日，星期三髕股關(guān)節(jié)炎分級(jí)2.根據(jù)關(guān)節(jié)鏡下軟骨損傷分級(jí)（Outerbridge分級(jí)）：

O級(jí)：正常關(guān)節(jié)軟骨；Ⅰ級(jí)：軟骨變軟或局部腫脹Ⅱ級(jí)：軟骨表面纖維化輕，軟骨缺損厚度小于50%；Ⅲ級(jí)：軟骨表面纖維化重，軟骨缺損厚度大于50%，但尚未暴露軟骨下骨；Ⅳ級(jí)：軟骨完全缺損，軟骨下骨外露。第5頁(yè)，共28頁(yè)，2023年，2月20日，星期三髕股關(guān)節(jié)炎臨床表現(xiàn)1.膝關(guān)節(jié)前方疼痛；2.上下樓梯、爬山、從坐姿站立、跪或蹲可加重；3.有時(shí)可因髕骨、滑車之間骨性摩擦出現(xiàn)絞鎖癥狀；體查：1.膝關(guān)節(jié)屈伸活動(dòng)受限；2.可觸及摩擦音；3.髕周壓痛（+）；4.髕骨活動(dòng)度差；5.髕骨研磨試驗(yàn)（+）；第6頁(yè)，共28頁(yè)，2023年，2月20日，星期三髕股關(guān)節(jié)炎影像學(xué)及關(guān)節(jié)鏡下表現(xiàn)第7頁(yè)，共28頁(yè)，2023年，2月20日，星期三保守治療康復(fù)治療

非甾體抗炎藥

關(guān)節(jié)內(nèi)注射

–

可的松

–

透明質(zhì)酸支具

氨基葡萄糖?

富含血小板血漿?第8頁(yè)，共28頁(yè)，2023年，2月20日，星期三髕骨成形術(shù)

髕股關(guān)節(jié)炎常用手術(shù)治療方法，通過(guò)切除髕骨周圍增生骨贅，恢復(fù)光滑髕骨關(guān)節(jié)面，減少髕骨和滑車之間骨性摩擦，達(dá)到減容目的。優(yōu)點(diǎn)：最大程度地保留髕骨骨量以及強(qiáng)度，術(shù)后療效可靠，并發(fā)癥發(fā)生率低。第9頁(yè)，共28頁(yè)，2023年，2月20日，星期三髕骨鉆孔術(shù)（微骨折技術(shù)/骨髓刺激技術(shù)/microfracture技術(shù)/nanofracture技術(shù)）適用于：局部軟骨退變及局部創(chuàng)傷性病變。小面積缺損（0.5-2cm2）或大面積損傷但功能要求低，損傷區(qū)邊緣軟骨質(zhì)量要好。第10頁(yè)，共28頁(yè)，2023年，2月20日，星期三嚴(yán)格選擇Microfracture技術(shù)修復(fù)的手術(shù)適應(yīng)癥，平均70%-95%的患者能提高膝關(guān)節(jié)功能，尤其以股骨髁軟骨損傷患者術(shù)后效果最好。Steadman等在對(duì)233例患者采用Microfracture技術(shù)治療，3年隨訪結(jié)果顯示75%患者疼痛改善。但是術(shù)后18-24個(gè)月臨床結(jié)果開(kāi)始向壞的方向發(fā)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．骨髓刺激技術(shù)---microfracture技術(shù)第11頁(yè)，共28頁(yè)，2023年，2月20日，星期三髕骨部分切除術(shù)并外側(cè)支持帶松解術(shù)長(zhǎng)期髕骨不穩(wěn)定，髕骨運(yùn)動(dòng)軌跡異常，反復(fù)慢性髕骨外側(cè)半脫位或脫位，導(dǎo)致髕骨軟骨面壓力不平衡，外側(cè)面負(fù)荷增加，造成關(guān)節(jié)面軟骨的破壞；髕骨外移可導(dǎo)致外側(cè)支持帶攣縮，內(nèi)外側(cè)力量失衡；可形成髕骨外側(cè)牽拉型骨贅。第12頁(yè)，共28頁(yè)，2023年，2月20日，星期三髕骨部分切除術(shù)并外側(cè)支持帶松解術(shù)適應(yīng)癥：1.嚴(yán)重髕股關(guān)節(jié)面病變，特別是外側(cè)髕股關(guān)節(jié)退變；2.存在髕骨外側(cè)半脫位或脫位；3.合并髕骨外側(cè)軟組織攣縮。第13頁(yè)，共28頁(yè)，2023年，2月20日，星期三關(guān)節(jié)面切除術(shù)

:結(jié)果Poulos:Arthroscopy2008

–88%滿意或者非常滿意@5yearsMcCarrol:1983CORR:

–75%滿意@4yearsMartens:1990ActaOrthopBelg

–65%良好,25%中等,10%差Yercan:CORR2005:

–疼痛減輕@8years第14頁(yè)，共28頁(yè)，2023年，2月20日，星期三第15頁(yè)，共28頁(yè)，2023年，2月20日，星期三第16頁(yè)，共28頁(yè)，2023年，2月20日，星期三第17頁(yè)，共28頁(yè)，2023年，2月20日，星期三關(guān)節(jié)面切除術(shù):

長(zhǎng)期隨訪Knee.

2012

Aug;19(4):411-5.

Epub

2011

May

18.Patellofemoral

osteoarthritis

treated

by

partial

lateral

facetectomy:

results

at

long-termfollow

up.WetzelsT,

BellemansJ.SourceDepartment

of

Orthopaedic

Surgery,

University

Hospital

Pellenberg,

Katholieke

UniversiteitLeuven,

Weligerveld

1,

3012

Pellenberg,

Belgium.

tjmwetzels@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

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).

Average

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

eithergood

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.第18頁(yè)，共28頁(yè)，2023年，2月20日，星期三外側(cè)支持帶松解的生物力學(xué)效果:KneeSurgSportsTraumatolArthrosc.

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.OstermeierS,

HolstM,

HurschlerC,

WindhagenH,

Stukenborg-ColsmanC.SourceOrthopaedics

Department,

Hannover

Medical

School,

Anna-von-Borries-Str.

1-7,

30625,

Hannover,

Germany.sven.ostermeier@annastift.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.

Human

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

moment

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

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)

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

significant

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

patellar

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.第19頁(yè)，共28頁(yè)，2023年，2月20日，星期三

外側(cè)支持帶松解術(shù):

適應(yīng)癥外側(cè)髕股關(guān)節(jié)退化性病變

Arthroscopy.

2002

Apr;18(4):399-403.

Lateral

release

for

patellofemoral

arthritis.

AderintoJ,

CobbAG.

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

analoguescale

(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

of

patellofemoral

arthritis

appeared

to

predominate.

RESULTS:The

average

patient

age

was

53

years

(range,

27

to

79

years).

There

were

14

men

(28%)

and

36

women

(72%).

Follow-up

was

a

mean

of

31

months

(range,

12

to

65

months).

Four

patients

underwent

total

knee

replacement

at

7,

14,

16,

and

18

months

after

lateral

release

for

recurrence

of

symptoms.

In

the

remaining

49

knees,

mean

pain

VAS

was

3.8

+/-

2.8.

In

39knees(80%),patients

judged

that

they

had

experienced

a

reduction

in

paincomparedwiththeirpreoperativestate

(2

were

pain

free),

8

(16%)

were

unchanged,

and

2

(4%)

were

worse.

The

average

Oxford

knee

score

was

27

(range,

12-48).

At

follow-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:

Arthroscopiclateralreleaseiseffectiveinreducingthepainofsymptomaticpatellofemoralosteoarthritisandgivesreasonableratesofpatientsatisfaction

irrespectiveofthepresenceoftibiofemoralarthritis第20頁(yè)，共28頁(yè)，2023年，2月20日，星期三外側(cè)支持帶松解+關(guān)節(jié)面切除術(shù)ActaOrthopBelg.

1990;56(3-4):563-7.Facetectomy

of

the

patella

in

patellofemoral

osteoarthritis.MartensM,

DeRyckeJ.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-femoralosteoarthritis

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

presented.Agood-to-moderateresultwasobtainedin90%.

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

handthis

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

Maquet

reconstructive

procedures,

or

a

patellofemoralprosthesis.第21頁(yè)，共28頁(yè)，2023年，2月20日，星期三髕骨周圍去神經(jīng)化術(shù)髕骨周圍的神經(jīng)主要有：1.皮神經(jīng)；2.隱神經(jīng)上支；3.伸膝肢關(guān)節(jié)支；原理：通過(guò)射頻燒灼髕骨周圍神經(jīng)，起到“去神經(jīng)化”目的，可以減少疼痛的傳導(dǎo)，緩解膝關(guān)節(jié)前方疼痛。髕骨周圍神經(jīng)彼此分布交叉重疊，即使切斷，也不能完全阻斷髕叢神經(jīng)支配，不會(huì)影響髕骨周圍皮膚感覺(jué)，具有快捷、方便、準(zhǔn)確以及安全等優(yōu)點(diǎn)第22頁(yè)，共28頁(yè)，2023年，2月20日，星期三脛骨結(jié)節(jié)截骨術(shù):方法前側(cè):

–

運(yùn)用移植:

Maquet技術(shù)

–

不運(yùn)用移植:

Cole技術(shù)前內(nèi)側(cè)

–

Fulkerson技術(shù)第23頁(yè)，共28