髌股关节炎的治疗进展
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摘要
髌股关节炎是最常见的膝关节疾病之一,目前髌股关节炎的诊治尚无明确的临床共识,保守治疗仅对于早期、单一的疾病阶段有一定的价值,随着对发病机制认识的不断进步和手术技术的改进,微创和关节置换技术得到了飞速的发展,可选择的治疗方案越来越多,早期曾采用的胫骨结节截骨、髌骨切除等技术目前已少见临床应用。根据疾病的发展阶段,并结合患者的年龄、经济能力、术后膝关节功能要求等因素综合考虑,关节镜下的软组织平衡和去神经化对于软骨损伤Ⅰ-Ⅲ级的老年患者是较为合适的术式,而软骨损伤Ⅳ级的老年患者,关节置换的效果更理想,早期争论在于全膝关节置换术是否存在过度医疗,随着假体设计的改进,髌股关节置换术满足了单一髌股关节退变的置换需求。由于软骨移植技术的手术难度大,加之髌股关节的解剖特性,目前髌股关节炎的软骨移植应用报道较少,但随着技术的不断改进,软骨移植技术将会是改善临床症状、降低医疗费用、推迟关节置换时间的一种很好的选择方案。
As a common disease of knee joint disease,the diagnosis and treatment of patellofemoral arthritis has not clear clinical consensus at present,conservative treatment only has a certain value for the disease with early stage and single disease.With the continuous improvement of understanding of pathogenesis and advancement of surgical techniques,minimally invasive and joint replacement technology has been rapid development,more and more alternative treatment options could be chosen. Technique of osteotomy of tibial tuberosity and removal of patella at the early stage were seldom used. According to development stage of disease,and combined with age,economic capacity,patients considering knee joint functional requirements and other factors,the balance of soft tissue under arthroscopy and denervation for cartilage injury in elderly patients with gradeⅠto Ⅲ surgery is more appropriate,and joint replacement is effective for cartilage injury in elderly patients with grade IV.Early debate is focus on total knee arthroplasty whether exist excessive medical treatment,patellofemoral joint replacement meet to demand for replacement of single patellofemoral degeneration with improvement of prosthesis design. Due to technical difficulties of cartilage transplantation and anatomical characteristics of patellofemoral joint,report of application of cartilage transplantation for patellofemoral arthritis is less,but with continuous improvement of technology,cartilage transplantation will be a good method for improving clinical symptoms,reducing medical costs,putting off joint replacement time.
As a common disease of knee joint disease,the diagnosis and treatment of patellofemoral arthritis has not clear clinical consensus at present,conservative treatment only has a certain value for the disease with early stage and single disease.With the continuous improvement of understanding of pathogenesis and advancement of surgical techniques,minimally invasive and joint replacement technology has been rapid development,more and more alternative treatment options could be chosen. Technique of osteotomy of tibial tuberosity and removal of patella at the early stage were seldom used. According to development stage of disease,and combined with age,economic capacity,patients considering knee joint functional requirements and other factors,the balance of soft tissue under arthroscopy and denervation for cartilage injury in elderly patients with gradeⅠto Ⅲ surgery is more appropriate,and joint replacement is effective for cartilage injury in elderly patients with grade IV.Early debate is focus on total knee arthroplasty whether exist excessive medical treatment,patellofemoral joint replacement meet to demand for replacement of single patellofemoral degeneration with improvement of prosthesis design. Due to technical difficulties of cartilage transplantation and anatomical characteristics of patellofemoral joint,report of application of cartilage transplantation for patellofemoral arthritis is less,but with continuous improvement of technology,cartilage transplantation will be a good method for improving clinical symptoms,reducing medical costs,putting off joint replacement time.
引文
[1]王庆甫,马玉峰,殷岳杉.重新认识膝骨性关节炎的诊断和防治[J].中国骨伤,2014,29(9):779-781.WANG QF,MA YF,YIN YS.A new understanding of the diagnosis and treatment of knee osteoarthritis[J].Zhongguo Gu Shang/China J Orthop Trauma,2014,29(9):779-781.Chinese with abstact in English.
[2]杜晋强,高耀祖,张志强,等.体重指数对骨关节炎患者术后疗效的影响[J].中国骨伤,2014,27(11):916-919.DU JQ,GAO YZ,ZHANG ZQ,et al.Effect of body index on postoperative outcome in patients with osteoarthritis after total knee arthroplasty[J].Zhongguo Gu Shang/China J Orthop Trauma,2014,27(11):916-919.Chinese with abstact in English.
[3]Ayhan E,Kesmezacar H,Akgun I.Intraarticular injections(corticosteroid,hyaluronic acid,platelet rich plasma)for the knee osteoarthritis[J].World J Orthop,2014,5(3):351-361.
[4]陈家平,张杰.小针刀联合钻孔减压术治疗髌股关节炎的临床研究[J].中医药临床杂志,2013,25(10):891-893.CHEN JP,ZHANG J.Clinical study of small needle knife combined with drilling decompression in the treatment of patellofemoral arthritis[J].Zhong Yi Yao Lin Chuang Za Zhi,2013,5(10):891-893.Chinese.
[5]肖玉莲.小针刀配合手法康复治疗髌股骨性关节炎120例[J].河南中医,2011,31(5):530-531.XIAO YL.One hundred and twenty cases with small needle knife technique of rehabilitation treatment of patellofemoral arthritis[J].He Nan Zhong Yi,2011,31(5):530-531.Chinese.
[6]Atkinson HD,Bailey CA,Anand S,et al.Tibial tubercle advance ment osteotomy with bone allograft for patellofemoral arthritis:a retrospective cohort study of 50 knees[J].Arch Orthop Trauma Surg,2012,132(4):437-445.
[7]刘朝晖,付国建,谢洋,等.关节镜下清理结合髌骨外侧支持带松解术治疗髌股关节骨关节炎[J].临床骨科杂志,2015,18(6):737-739.LIU ZH,FU JG,XIE Y,et al.The efficacy of arthroscopic debridement and lateral patellar retinacular release for the treatment of patellofemoral osteoarthritis[J].Lin Chuang Gu Ke Za Zhi,2015,18(6):737-739.Chinese.
[8]阴峻岭,滕延震,郝文建,等.关节镜下支持带松解、紧缩并关节清理治疗退变性髌股关节炎临床研究[J].临床研究,2015,3:230-231.YIN JL,TENG YZ,HAO WJ,et al.Arthroscopic retinacular release,tightening and clinical study of degenerative joint debridement treatment of patellofemoral arthritis[J].Lin Chuang Yan Jiu,2015,3:230-231.Chinese.
[9]杨丰建,陈聪,黄东辉,等.关节镜下外侧支持带松解的疗效及其受关节软骨退变程度的影响[J].复旦学报,2015,42(5):642-645.YANG FJ,CHEN C,HUANG DH,et al.The efficacy of arthroscopic lateral retinaculum release and its effect on articular cartilage degeneration[J].Fu Dan Xue Bao,2015,42(5):642-645.Chinese.
[10]赵建罡,高志国,马力学,等.膝关节镜下关节清理联合髌骨周围去神经化术治疗髌股关节炎膝前痛[J].中华创伤骨科杂志,2015,17(2):180-182.ZHAO JG,GAO ZG,MA LX,et al.Arthroscopic debridement combined around patella denervation surgery for the treatment of patellofemoral arthritis of knee anterior pain[J].Zhonghua Chuang Shang Gu Ke Za Zhi,2015,17(2):180-182.Chinese.
[11]肇刚,刘玉杰,袁邦拓,等.关节镜下髌骨成形及髌周去神经化治疗髌股关节炎[J].中国骨伤,2015,28(6):542-546.ZHAO G,LIU YJ,YUAN BT,et al.Arthroscopic patellar plasty and peri patella denervation for treatment of patellofemoral arthritis[J].Zhongguo Gu Shang/China J Orthop Trauma,2015,28(6):542-546.Chinese with abstact in English.
[12]张文庆,周湘桂,易化平,等.髌骨软化症病因与治理研究进展[J].中国矫形外科杂志,2010,18(22):1884-1885.ZHANG WQ,ZHOU XG,YI HP,et al.Research Progress on etiology and treatment of patella osteomalacia[J].Zhongguo Jiao Xing Wai Ke Za Zhi,2010,18(22):1884-1885.Chinese.
[13]陈欢,陈康乐,郑康伟,等.膝关节镜微骨折技术治理退行性髌股关节炎的研究[J].浙江创伤外科,2016,21(5):883-885.CHEN H,CHEN KL,ZHENG KW,et al.Study on technology for the treatment of degenerative patellofemoral arthritis arthroscopic microfracture[J].Zhe Jiang Chuang Shang Wai Ke,2016,21(5):883-885.Chinese.
[14]黄维琛,封彦齐,梁伟.利用髌骨钻孔结合带蒂髌下脂肪垫覆盖髌骨关节面治理髌股关节炎的疗效分析[J].贵阳中医学院学报,2010,32(3):59-60.HUANG WC,FENG YQ,LIANG W.The patella drill analysis the curative effect of combined pedicled infrapatellar fat pad covering the articular surface of the patella treatment of patellofemoral arthritis[J].Gui Yang Zhong Yi Xue Yuan Xue Bao,2010,32(3):59-60.Chinese.
[15]Filardo G,Lon E,Perdisa F,et al.Autologous osteochondral trans plantation for the treatment of knee lesions:results and limitations at two years follow up[J].Int Orthop,2014,38(9):1905-1912.
[16]Lonner JH,Bloomfield MR.The clinical outcome of patellofemoral arthroplasty[J].Orthop Clin North Am,2013,44(3):271-280.
[17]Borus T,Brilhault J,Confalonieri N,et al.Patellofemoral joint replacement,an evolving concept[J].Knee,2014,21(Suppl 1):s47-s50.
[18]Hoogervorst P,De Jong RJ,Van Kampen A,et al.A 21%conversion rate to total knee arthroplasty of a first generationpatellofemoral prosthesis at a mean follow up of 9.7 years[J].Int Orthop,2015,39(9):1857-1864.
[19]伍卫刚,何荣新,王翔华,等.髌股关节置换术治理单纯髌股关节骨关节炎[J].中华骨科杂志,2015,35(4):407-513.WU WG,HE RX,WANG XH,et al.Patellofemoral arthroplasty isolated patellofemoral osteoarthritis treatment[J].Zhonghua Gu Ke Za Zhi,2015,35(4):407-513.Chinese.
[20]张启栋,郭万首,刘朝晖,等.髌股关节置换术治理膝关节髌股骨关节炎的中短期疗效观察[J].中华外科杂志,2014,52(5):361-365.ZHANG QD,GUO WS,LIU ZH,et al.To observe the short term effects of patellofemoral arthroplasty treatment of patellofemoral osteoarthritis of the knee[J].Zhonghua Wai Ke Za Zhi,2014,52(5):361-365.Chinese.
[21]Weaver JK,Wieder D,Derkash RS.Patellofemoral arthritis resul ting from malalignment.A long term evaluation of treatment options[J].Orthop Rev,1991,20(12):1075-1081.
[22]黄河,吴迪,王永年,等.髌骨部分切除外侧松解术治理髌股关节炎148例疗效分析[J].骨与关节损伤杂志,2002,17(2):137-138.HUANG H,WU D,WANG YN,et al.Clinical analysis of 148cases of patellar partial resection of lateral lysis treatment of patellofemoral arthritis[J].Gu Yu Guan Jie Sun Shang Za Zhi,2002,17(2):137-138.Chinese.
[23]殷丽华,韩雨芝,余红豆,等.纳米羟基磷灰石复合支架材料生物性能的研究进展[J].华中科技大学学报:医学版,2013,42(6):729-732.YIN LH,HAN YZ,YU HD,et al.Research progress on biological properties of nano hydroxyapatite composite scaffold[J].Hua Zhong Ke Ji Da Xue Xue Bao:Yi Xue Ban,2013,42(6):729-732.Chinese.
[2]杜晋强,高耀祖,张志强,等.体重指数对骨关节炎患者术后疗效的影响[J].中国骨伤,2014,27(11):916-919.DU JQ,GAO YZ,ZHANG ZQ,et al.Effect of body index on postoperative outcome in patients with osteoarthritis after total knee arthroplasty[J].Zhongguo Gu Shang/China J Orthop Trauma,2014,27(11):916-919.Chinese with abstact in English.
[3]Ayhan E,Kesmezacar H,Akgun I.Intraarticular injections(corticosteroid,hyaluronic acid,platelet rich plasma)for the knee osteoarthritis[J].World J Orthop,2014,5(3):351-361.
[4]陈家平,张杰.小针刀联合钻孔减压术治疗髌股关节炎的临床研究[J].中医药临床杂志,2013,25(10):891-893.CHEN JP,ZHANG J.Clinical study of small needle knife combined with drilling decompression in the treatment of patellofemoral arthritis[J].Zhong Yi Yao Lin Chuang Za Zhi,2013,5(10):891-893.Chinese.
[5]肖玉莲.小针刀配合手法康复治疗髌股骨性关节炎120例[J].河南中医,2011,31(5):530-531.XIAO YL.One hundred and twenty cases with small needle knife technique of rehabilitation treatment of patellofemoral arthritis[J].He Nan Zhong Yi,2011,31(5):530-531.Chinese.
[6]Atkinson HD,Bailey CA,Anand S,et al.Tibial tubercle advance ment osteotomy with bone allograft for patellofemoral arthritis:a retrospective cohort study of 50 knees[J].Arch Orthop Trauma Surg,2012,132(4):437-445.
[7]刘朝晖,付国建,谢洋,等.关节镜下清理结合髌骨外侧支持带松解术治疗髌股关节骨关节炎[J].临床骨科杂志,2015,18(6):737-739.LIU ZH,FU JG,XIE Y,et al.The efficacy of arthroscopic debridement and lateral patellar retinacular release for the treatment of patellofemoral osteoarthritis[J].Lin Chuang Gu Ke Za Zhi,2015,18(6):737-739.Chinese.
[8]阴峻岭,滕延震,郝文建,等.关节镜下支持带松解、紧缩并关节清理治疗退变性髌股关节炎临床研究[J].临床研究,2015,3:230-231.YIN JL,TENG YZ,HAO WJ,et al.Arthroscopic retinacular release,tightening and clinical study of degenerative joint debridement treatment of patellofemoral arthritis[J].Lin Chuang Yan Jiu,2015,3:230-231.Chinese.
[9]杨丰建,陈聪,黄东辉,等.关节镜下外侧支持带松解的疗效及其受关节软骨退变程度的影响[J].复旦学报,2015,42(5):642-645.YANG FJ,CHEN C,HUANG DH,et al.The efficacy of arthroscopic lateral retinaculum release and its effect on articular cartilage degeneration[J].Fu Dan Xue Bao,2015,42(5):642-645.Chinese.
[10]赵建罡,高志国,马力学,等.膝关节镜下关节清理联合髌骨周围去神经化术治疗髌股关节炎膝前痛[J].中华创伤骨科杂志,2015,17(2):180-182.ZHAO JG,GAO ZG,MA LX,et al.Arthroscopic debridement combined around patella denervation surgery for the treatment of patellofemoral arthritis of knee anterior pain[J].Zhonghua Chuang Shang Gu Ke Za Zhi,2015,17(2):180-182.Chinese.
[11]肇刚,刘玉杰,袁邦拓,等.关节镜下髌骨成形及髌周去神经化治疗髌股关节炎[J].中国骨伤,2015,28(6):542-546.ZHAO G,LIU YJ,YUAN BT,et al.Arthroscopic patellar plasty and peri patella denervation for treatment of patellofemoral arthritis[J].Zhongguo Gu Shang/China J Orthop Trauma,2015,28(6):542-546.Chinese with abstact in English.
[12]张文庆,周湘桂,易化平,等.髌骨软化症病因与治理研究进展[J].中国矫形外科杂志,2010,18(22):1884-1885.ZHANG WQ,ZHOU XG,YI HP,et al.Research Progress on etiology and treatment of patella osteomalacia[J].Zhongguo Jiao Xing Wai Ke Za Zhi,2010,18(22):1884-1885.Chinese.
[13]陈欢,陈康乐,郑康伟,等.膝关节镜微骨折技术治理退行性髌股关节炎的研究[J].浙江创伤外科,2016,21(5):883-885.CHEN H,CHEN KL,ZHENG KW,et al.Study on technology for the treatment of degenerative patellofemoral arthritis arthroscopic microfracture[J].Zhe Jiang Chuang Shang Wai Ke,2016,21(5):883-885.Chinese.
[14]黄维琛,封彦齐,梁伟.利用髌骨钻孔结合带蒂髌下脂肪垫覆盖髌骨关节面治理髌股关节炎的疗效分析[J].贵阳中医学院学报,2010,32(3):59-60.HUANG WC,FENG YQ,LIANG W.The patella drill analysis the curative effect of combined pedicled infrapatellar fat pad covering the articular surface of the patella treatment of patellofemoral arthritis[J].Gui Yang Zhong Yi Xue Yuan Xue Bao,2010,32(3):59-60.Chinese.
[15]Filardo G,Lon E,Perdisa F,et al.Autologous osteochondral trans plantation for the treatment of knee lesions:results and limitations at two years follow up[J].Int Orthop,2014,38(9):1905-1912.
[16]Lonner JH,Bloomfield MR.The clinical outcome of patellofemoral arthroplasty[J].Orthop Clin North Am,2013,44(3):271-280.
[17]Borus T,Brilhault J,Confalonieri N,et al.Patellofemoral joint replacement,an evolving concept[J].Knee,2014,21(Suppl 1):s47-s50.
[18]Hoogervorst P,De Jong RJ,Van Kampen A,et al.A 21%conversion rate to total knee arthroplasty of a first generationpatellofemoral prosthesis at a mean follow up of 9.7 years[J].Int Orthop,2015,39(9):1857-1864.
[19]伍卫刚,何荣新,王翔华,等.髌股关节置换术治理单纯髌股关节骨关节炎[J].中华骨科杂志,2015,35(4):407-513.WU WG,HE RX,WANG XH,et al.Patellofemoral arthroplasty isolated patellofemoral osteoarthritis treatment[J].Zhonghua Gu Ke Za Zhi,2015,35(4):407-513.Chinese.
[20]张启栋,郭万首,刘朝晖,等.髌股关节置换术治理膝关节髌股骨关节炎的中短期疗效观察[J].中华外科杂志,2014,52(5):361-365.ZHANG QD,GUO WS,LIU ZH,et al.To observe the short term effects of patellofemoral arthroplasty treatment of patellofemoral osteoarthritis of the knee[J].Zhonghua Wai Ke Za Zhi,2014,52(5):361-365.Chinese.
[21]Weaver JK,Wieder D,Derkash RS.Patellofemoral arthritis resul ting from malalignment.A long term evaluation of treatment options[J].Orthop Rev,1991,20(12):1075-1081.
[22]黄河,吴迪,王永年,等.髌骨部分切除外侧松解术治理髌股关节炎148例疗效分析[J].骨与关节损伤杂志,2002,17(2):137-138.HUANG H,WU D,WANG YN,et al.Clinical analysis of 148cases of patellar partial resection of lateral lysis treatment of patellofemoral arthritis[J].Gu Yu Guan Jie Sun Shang Za Zhi,2002,17(2):137-138.Chinese.
[23]殷丽华,韩雨芝,余红豆,等.纳米羟基磷灰石复合支架材料生物性能的研究进展[J].华中科技大学学报:医学版,2013,42(6):729-732.YIN LH,HAN YZ,YU HD,et al.Research progress on biological properties of nano hydroxyapatite composite scaffold[J].Hua Zhong Ke Ji Da Xue Xue Bao:Yi Xue Ban,2013,42(6):729-732.Chinese.