髌骨脱位成形术dislocation of the patella课件.ppt

临 床 病 例 1 dislocation of the patella.,,患者 孙某，女, 23岁,10年前摔伤致左髌骨脱位，自行复位，未给予特殊治疗，近日感左膝关节无力，轻度屈膝关节即出现髌骨脱位查体：Q角（ quadriceps-angle ）26°（正常:女性 15+5°）变大， 恐惧试验，髌骨活动度，J征（J-sign-slight）阳性，髌骨研磨试验左膝关节查体,体格检查视频 1,,,,Q角,,,LT/LP大于1.2,Q角大于20°,测量髌骨关节匹配度,,,,TT-TG,CT测量胫骨结节外移程度 大于1.5厘米行结节内移,,CT,MRI,诊断？ 分型？ 治疗方案？ 固定方式？,初步诊断—— ？,左髌骨脱位,急性、复发性和固定性,保守和手术,单一固定和联合固定,手术治疗,外侧支持带松解近端内侧重排（支持带紧缩、MPFL重建等 ）远端重排（胫骨结节内移截骨等）髌骨切除（挽救性手术）,内侧髌股韧带重建（ MPFL）联合胫骨结节移位和关节镜下髌骨外侧支持带松解术,治疗方案—— 联合方案重建,手术方法,关节镜检查，取出游离体正常髌股关节在屈膝45度时髌骨归位，位于滑车中心髌骨轨迹不良时外移,内侧髌股韧带（MPFL）重建术,1.半腱肌切取和处理； 2.建立髌骨和股骨隧道； 3.肌腱植入固定。

MPFL重建,外侧支持带松解术,关节镜下前内侧入路，松解范围：距髌骨外侧缘1cm，自髌骨尖水平髌腱外侧缘至髌骨外上极的外侧2cm、近侧2cmFulkerson-osteotomy,方法： 沿着胫骨结节外侧做纵形切口，显露胫骨结节及胫骨嵴胫骨近端外侧面及内侧缘钻孔，成勺形形态，骨刀分离，保留胫骨远侧与胫骨主体的连接 内侧截骨线与冠状面成交45度截入，在松质骨区域做一个较为平整的骨面 将胫骨结节的近端向内侧推移1.5mm, 一般用2枚3.5mm螺钉完成固定Fulkerson- osteotomy,,Postoperative X-ray,Postoperative functional,,Operative vs conservative?,Conservative Nonsurgical management is generally recommended for first time dislocation,with immobilization in extension for 3–6 weeks with placement of a brace. Surgical A. Recurrent instability following initial conservative management occurs in 15–50 %. B. Chronic instability and recurrent dislocations may cause cartilage damage and eventual arthritic changes.,1.Christina Earhart. Transient lateral patellar dislocation: review of imaging findings, patellofemoral anatomy, and treatment options. Emerg Radiol .(2013) 20:11–23,2.M. Petri, E. Liodakis, M. Hofmeister, Operative vs conservative treatment of traumatic patellar dislocation: results of a prospective randomized controlled clinical trial . Archives of Orthopaedic and Trauma Surgery 2013, (133)2, pp 209-213,Osteochondral fragments骨软骨碎片/loose bodies（游离体） Persistent patellar subluxation（持续性髌骨半脱位） Femoral avulsion of medial stabilizers in the acute setting急性内侧髌股韧带股骨止点撕脱 Chronic patellar instability 慢性髌骨脱位 Ligamentous or meniscal injury韧带/半月板损伤,Indications for surgery,Bollier M, Fulkerson JP (2011) The role of trochlear dysplasia in patellofemoral instability. J Am Acad Orthop Surg 19(1):8–16,Tibial tuberosity transfer to a more medial position (TT–TG distance >20 mm) reduces Q-angle and decreases lateral stress on the patella.,Osseous realignment procedures（骨性重建）,Bollier M, Fulkerson JP (2011) The role of trochlear dysplasia in patellofemoral instability. J Am Acad Orthop Surg 19(1):8–16,Patients with normal TT–TG distance（ 胫骨结节股骨滑车沟距离正常的患者,Medial patellofemoral ligament reconstruction using semimembranosus allograft (or gracilis tendon autograft)半腱肌/股薄肌重建内侧髌股韧带Medial capsular plication 内侧关节囊 折叠术Trochlear reconstruction 滑车重建,1.Christina Earhart. Transient lateral patellar dislocation: review of imaging findings, patellofemoral anatomy, and treatment options. Emerg Radiol .(2013) 20:11–23,Patients with trochlear dysplasia滑车发育不良的患者,trochlear osteotomy截骨 or trochleoplasty 成形 Osteotomy: a bone graft is used to increase the height of the lateral wall and elevating the lateral trochlear facet.通过植骨增加滑车外侧壁的高度，改善滑车的横截面Trochleoplasty: subchondral bone is removed and the overlying cartilage is compressed into the defect.（去除软骨下骨，将软骨铺垫于缺损处,Yuki Kitta;Yasuo Niki. Severe valgus deformity of the knee with permanent patellar dislocation associated with melorheostosis: A case report and review of the literature . The Knee . 2014 ,(21) 2 ：589-593,Trochleoplasty—Open surgery,Panagiotis G. Ntagiopoulos• David Dejour . Current concepts on trochleoplasty procedures for the surgical treatment of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc. 11 April 2014,The Lyon’s sulcus-deepening trochleoplasty; subchondral bone is removed to deepen the groove, and the trochlea is osteotomized and repositioned according to the preoperative TT-TG value in a more lateral position,The rationale of the ‘recession-wedge’ trochleoplasty,Trochleoplasty—Open surgery,Panagiotis G. Ntagiopoulos• David Dejour . Current concepts on trochleoplasty procedures for the surgical treatment of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc. 11 April 2014,,arthroscopic trochleoplasty关节镜下滑车成形术,Panagiotis G. Ntagiopoulos• David Dejour . Current concepts on trochleoplasty procedures for the surgical treatment of trochlear dysplasia. Knee Surg Sports Traumatol Arthrosc. 11 April 2014,Summary,自体半腱肌腱移植重建MPFLMPFL为内侧静力稳定结构，承担53%的内侧应力，髌骨复发脱位时MPFL与VMO均丧失正常功能，此时重建MPFL已成为大多数医生的选择年幼或轻度不稳患者可采用内侧支持带紧缩术,Fulkerson截骨术,内移+前移，减轻髌股间压力，更适合软骨退变的患者调整截骨角度可改变内移或前移程度报道长期优良率86%Insall指数大于1.2时，应再向远端移位运动员慎用,,Thank you for your attention,。