包含胫骨结节下移的联合手术治疗合并高位髌骨的复发性髌骨脱位
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摘要
目的探讨包含胫骨结节下移的联合手术治疗合并高位髌骨的复发性髌骨脱位的手术技术及临床疗效。方法 2010年4月—2016年5月,采用包含胫骨结节下移的联合手术治疗14例合并高位髌骨的复发性髌骨脱位患者。男5例,女9例;年龄13~26岁,平均18.5岁。左膝9例,右膝5例。髌骨脱位2~5次,平均3.3次;首次脱位至该次就诊时间为4~60个月,平均19.7个月。患者主要症状为膝关节疼痛、活动受限。术前膝关节X线片、CT、MRI检查示骺板均已闭合;3例存在髌骨内缘撕脱性骨折,2例关节腔内有游离体。比较手术前后胫骨结节-股骨滑车沟(tibial tuberosity-trochlear groove,TT-TG)间距、髌骨滑车沟间距、Caton-Deschamps指数以及膝关节活动度、Lysholm评分、国际膝关节文献委员会(IKDC)评分、Kujala评分、Tegner评分。结果术后切口均Ⅰ期愈合。所有患者均获随访,随访时间24~72个月,平均34.6个月。术后复查X线片及CT提示髌骨脱位均纠正;胫骨结节截骨移位处均愈合,愈合时间3~5个月,平均3.8个月。术后1 d及1年时TT-TG间距、髌骨滑车沟间距、Caton-Deschamps指数与术前比较,差异均有统计学意义(P<0.05);术后1 d及1年比较,差异无统计学意义(P>0.05)。术后1年及2年时膝关节活动度、Lysholm评分、IKDC评分、Kujala评分、Tegner评分均优于术前(P<0.05);术后1年及2年比较,差异无统计学意义(P>0.05)。结论采用包含胫骨结节下移的联合手术治疗合并高位髌骨的复发性髌骨脱位,安全可靠,近期疗效满意。
Objective To explore the clinical effects of combined operation involving tibial tubercle distalization for the recurrent patellar dislocation with patella alta. Methods Between April 2010 and May 2016, 14 cases of recurrent patellar dislocation with patella alta were treated with combined operation involving tibial tubercle distalization. There were 5 males and 9 females with an average age of 18.5 years(range, 13-26 years). The left knee was involved in 9 cases and the right knee in 5 cases. The patella had dislocated 3.3 times on average(range, 2-5 times). The interval between the first dislocation and admission was 19.7 months on average(range, 4-60 months), and the main symptoms were knee pain and limited knee movement. Preoperative X-ray films, CT, and MRI examinations of knee joint showed that the epiphyseal plate closed in all patients. Of all patients, 3 patients had avulsion fracture of the inner edge of patella, and 2 patients had free body in articular cavity. The tibial tuberosity-trochlear groove(TT-TG) distance, patellar-trochlear-groove distance,Caton-Deschamps index, knee range of motion(ROM), Lysholm score, International Knee Documentation Committee(IKDC) score, Kujala score, and Tegner score were compared pre-and post-operation. Results All patients had primary wound healing. All patients were followed up 24-72 months with an average of 34.6 months. X-ray film and CT examination showed that the patellar dislocation was corrected and the osteotomy of the tibial tubercle healed with an average healing time of 3.8 months(range, 3-5 month). At 1 day and 1 year after operation, the TT-TG distance,patellar-trochlear-groove distance, and Caton-Deschamps index showed significant differences when compared with preoperative values(P<0.05), but there was no significant difference between 1 day and 1 year after operation(P>0.05). At the 1 year and 2 years after operation, the knee ROM, Lysholm score, IKDC score, Kujala score, and Tegner score showed significant differences when compared with preoperative values(P<0.05), and there was no significant difference between the 1 year and 2 years after operation(P>0.05). Conclusion Combined operation involving tibial tubercle distalization is a safe and reliable method, which has satisfactory short-term effectiveness for the recurrent patellar dislocation with patella alta.
Objective To explore the clinical effects of combined operation involving tibial tubercle distalization for the recurrent patellar dislocation with patella alta. Methods Between April 2010 and May 2016, 14 cases of recurrent patellar dislocation with patella alta were treated with combined operation involving tibial tubercle distalization. There were 5 males and 9 females with an average age of 18.5 years(range, 13-26 years). The left knee was involved in 9 cases and the right knee in 5 cases. The patella had dislocated 3.3 times on average(range, 2-5 times). The interval between the first dislocation and admission was 19.7 months on average(range, 4-60 months), and the main symptoms were knee pain and limited knee movement. Preoperative X-ray films, CT, and MRI examinations of knee joint showed that the epiphyseal plate closed in all patients. Of all patients, 3 patients had avulsion fracture of the inner edge of patella, and 2 patients had free body in articular cavity. The tibial tuberosity-trochlear groove(TT-TG) distance, patellar-trochlear-groove distance,Caton-Deschamps index, knee range of motion(ROM), Lysholm score, International Knee Documentation Committee(IKDC) score, Kujala score, and Tegner score were compared pre-and post-operation. Results All patients had primary wound healing. All patients were followed up 24-72 months with an average of 34.6 months. X-ray film and CT examination showed that the patellar dislocation was corrected and the osteotomy of the tibial tubercle healed with an average healing time of 3.8 months(range, 3-5 month). At 1 day and 1 year after operation, the TT-TG distance,patellar-trochlear-groove distance, and Caton-Deschamps index showed significant differences when compared with preoperative values(P<0.05), but there was no significant difference between 1 day and 1 year after operation(P>0.05). At the 1 year and 2 years after operation, the knee ROM, Lysholm score, IKDC score, Kujala score, and Tegner score showed significant differences when compared with preoperative values(P<0.05), and there was no significant difference between the 1 year and 2 years after operation(P>0.05). Conclusion Combined operation involving tibial tubercle distalization is a safe and reliable method, which has satisfactory short-term effectiveness for the recurrent patellar dislocation with patella alta.
引文
1 Koh JL, Stewart C. Patellar instability. Clin Sports.Med, 2014,33(3):461-476.
2 Mayer C, Magnussen RA, Servien E, et al. Patellar tendon tenodesis in association with tibial tubercle distalization for the treatment of episodic patellar dislocation with patella alta. Am J Sports Med,2012,40(2):346-351.
3 Clark D, Metcalfe A, Wogan C, et al. Adolescent patellar instability:current concepts review. Bone Joint J, 2017, 99-B(2):159-170.
4 Bartsch A, Lubberts B, Mumme M, et al. Does patella alta lead to worse clinical outcome in patients who undergo isolated medial patellofemoral ligament reconstruction? A systematic review Arch Orthop Trauma Surg, 2018, 138(11):1563-1573.
5 Magnussen RA, De Simone V, Lustig S, et al. Treatment of patella alta in patients with episodic patellar dislocation:a systematic review. Knee Surg Sports Traumatol Arthrosc, 2014, 22(10):2545-2550.
6 Otsuki S, Nakajima M, Fujiwara K, et al. Influence of age on clinical outcomes of three-dimensional transfer of the tibial tuberosity for patellar instability with patella alta. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8):2392-2396.
7 Luyckx T, Didden K, Vandenneucker H, et al. Is there a biomechanical explanation for anterior knee pain in patients with patella alta?:influence of patellar height on patellofemoral contact force, contact area and contact pressure. J Bone Joint Surg(Br),2009,91(3):344-350.
8 Stefanik JJ, Zhu Y, Zumwalt AC, et al. Association between patellaalta and the prevalence and worsening of structural features of patellofemoral joint osteoarthritis:the multicenter osteoarthritis study. Arthritis Care Res(Hoboken), 2010, 62(9):1258-1265.
9 Yin L, Liao TC, Yang L, et al. Does patella tendon tenodesis improve tibial tubercle distalization in treating patella alta? A computational study. Clin Orthop Relat Res, 2016, 474(11):2451-2461.
10戴祝,尤迪,廖瑛,等.髌骨复发性脱位伴陈旧性骨软骨骨折的治疗.中国修复重建外科杂志,2016, 30(1):10-14.
11 Weber AE, Nathani A, Dines JS, et al. An algorithmic approach to the management of recurrent lateral patellar dislocation. J Bone Joint Surg(Am), 2016, 98(5):417-427.
12阮文辉,李宏波,谢鹏,等.成人复发性髌骨脱位的术前影像学评估与联合手术.中华骨与关节外科杂志,2016, 9(1):57-61.
13 Dejour D, Le Coultre B. Osteotomies in patello-femoral instabilities. Sports Med Arthrosc Rev, 2018,26(1):8-15.
14高志涛,李彦林,王国梁,等.内侧髌股韧带重建治疗髌骨脱位影响因素研究进展.中国修复重建外科杂志,2018, 32(8):1047-1051.
15 Andrish J. Surgical options for patellar stabilization in the skeletally immature patient. Sports Med Arthrosc Rev, 2017, 25(2):100-104.
16 Simmons E Jr, Cameron JC. Patella alta and recurrent dislocation of the patella. Clin Orthop Relat Res, 1992,(274):265-269.
17 Caton JH, Dejour D. Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop, 2010,34(2):305-309.
18 Duchman K, Bollier M. Distal realignment:indications, technique,and results. Clin Sports Med, 2014, 33(3):517-530.
19 Damasena I, Blythe M, Wysocki D, et al. Medial patellofemoral ligament reconstruction combined with distal realignment for recurrent dislocations of the patella:5-year results of a randomized controlled trial. Am J Sports Med, 2017,45(2):369-376.
20 Hernigou J, Chahidi E, Kashi M, et al. Risk of vascular injury when screw drilling for tibial tuberosity transfer. Int Orthop, 2018, 42(5):1165-1174.
2 Mayer C, Magnussen RA, Servien E, et al. Patellar tendon tenodesis in association with tibial tubercle distalization for the treatment of episodic patellar dislocation with patella alta. Am J Sports Med,2012,40(2):346-351.
3 Clark D, Metcalfe A, Wogan C, et al. Adolescent patellar instability:current concepts review. Bone Joint J, 2017, 99-B(2):159-170.
4 Bartsch A, Lubberts B, Mumme M, et al. Does patella alta lead to worse clinical outcome in patients who undergo isolated medial patellofemoral ligament reconstruction? A systematic review Arch Orthop Trauma Surg, 2018, 138(11):1563-1573.
5 Magnussen RA, De Simone V, Lustig S, et al. Treatment of patella alta in patients with episodic patellar dislocation:a systematic review. Knee Surg Sports Traumatol Arthrosc, 2014, 22(10):2545-2550.
6 Otsuki S, Nakajima M, Fujiwara K, et al. Influence of age on clinical outcomes of three-dimensional transfer of the tibial tuberosity for patellar instability with patella alta. Knee Surg Sports Traumatol Arthrosc, 2017, 25(8):2392-2396.
7 Luyckx T, Didden K, Vandenneucker H, et al. Is there a biomechanical explanation for anterior knee pain in patients with patella alta?:influence of patellar height on patellofemoral contact force, contact area and contact pressure. J Bone Joint Surg(Br),2009,91(3):344-350.
8 Stefanik JJ, Zhu Y, Zumwalt AC, et al. Association between patellaalta and the prevalence and worsening of structural features of patellofemoral joint osteoarthritis:the multicenter osteoarthritis study. Arthritis Care Res(Hoboken), 2010, 62(9):1258-1265.
9 Yin L, Liao TC, Yang L, et al. Does patella tendon tenodesis improve tibial tubercle distalization in treating patella alta? A computational study. Clin Orthop Relat Res, 2016, 474(11):2451-2461.
10戴祝,尤迪,廖瑛,等.髌骨复发性脱位伴陈旧性骨软骨骨折的治疗.中国修复重建外科杂志,2016, 30(1):10-14.
11 Weber AE, Nathani A, Dines JS, et al. An algorithmic approach to the management of recurrent lateral patellar dislocation. J Bone Joint Surg(Am), 2016, 98(5):417-427.
12阮文辉,李宏波,谢鹏,等.成人复发性髌骨脱位的术前影像学评估与联合手术.中华骨与关节外科杂志,2016, 9(1):57-61.
13 Dejour D, Le Coultre B. Osteotomies in patello-femoral instabilities. Sports Med Arthrosc Rev, 2018,26(1):8-15.
14高志涛,李彦林,王国梁,等.内侧髌股韧带重建治疗髌骨脱位影响因素研究进展.中国修复重建外科杂志,2018, 32(8):1047-1051.
15 Andrish J. Surgical options for patellar stabilization in the skeletally immature patient. Sports Med Arthrosc Rev, 2017, 25(2):100-104.
16 Simmons E Jr, Cameron JC. Patella alta and recurrent dislocation of the patella. Clin Orthop Relat Res, 1992,(274):265-269.
17 Caton JH, Dejour D. Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. Int Orthop, 2010,34(2):305-309.
18 Duchman K, Bollier M. Distal realignment:indications, technique,and results. Clin Sports Med, 2014, 33(3):517-530.
19 Damasena I, Blythe M, Wysocki D, et al. Medial patellofemoral ligament reconstruction combined with distal realignment for recurrent dislocations of the patella:5-year results of a randomized controlled trial. Am J Sports Med, 2017,45(2):369-376.
20 Hernigou J, Chahidi E, Kashi M, et al. Risk of vascular injury when screw drilling for tibial tuberosity transfer. Int Orthop, 2018, 42(5):1165-1174.