内侧髌股韧带重建术中股骨隧道预先定位研究
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摘要
目的在内侧髌股韧带(medial patellofemoral ligament,MPFL)重建术前预先使用C臂X线机和皮外固定器定位股骨隧道位置,探讨其对复发性髌骨脱位患者术后膝关节功能恢复的影响。方法 2014年1月—2016年1月,采用关节镜下髌股外侧支持带松解+MPFL重建术治疗32例单侧膝复发性髌骨脱位患者,术前在C臂X线机下用皮外固定器预先定位MPFL重建术中股骨隧道位置。其中男8例,女24例;年龄15～37岁,平均23.8岁。受伤至入院时间1～24个月,平均9.7个月。术后于CT三维重建图像上测量等距点距离,评价股骨隧道位置是否等距,并采用Lysholm评分评价膝关节功能;将等距点距离与Lysholm评分行Spearman相关分析。结果 32例患者术后均获随访,随访时间12～18个月,平均14.2个月。随访过程中未出现髌骨半脱位或脱位症状,髌骨外推试验及髌骨外推恐惧试验均为阴性。术后3 d测量等距点距离为1.5～5.9 mm,平均3.44 mm;所有股骨隧道位置均为等距隧道。末次随访时,患者Lysholm评分为(92.8±2.1)分,较术前的(54.4±2.8)分显著改善,差异有统计学意义(t=61.911,P=0.000)。等距点距离与术后Lysholm评分成负相关(r=–0.454,P=0.009)。结论 C臂X线机下皮外固定器辅助定位法可术前简便、准确定位MPFL重建的股骨隧道位置,中短期临床疗效满意,且避免了术中多次透视给患者及术者的电离辐射伤害。
Objective To introduce the method of prior-localization femoral tunnel by using a special positioning tool under the C-arm radiographic machine before surgery, and to study the effect on the knee function recovery after medial patellofemoral ligament(MPFL) reconstruction. Methods Between January 2014 and January2016, 32 patients with recurrent unilateral knee patellar dislocation were treated by arthroscopic patellofemoral lateral retinaculum release and MPFL reconstruction. The femoral tunnel position during MPFL reconstruction was priorlocalizated under C-arm radiographic machine before operation. There were 8 males and 24 females, aged from 15 to 37 years, with an average of 23.8 years. The time from injury to admission ranged from 1 to 24 months, with an average of 9.7 months. Isometric point distance was measured on CT three-dimensional reconstruction image after operation to evaluate whether the position of femoral tunnel was isometric, and knee joint function was evaluated by Lysholm score. Spearman correlation analysis was performed between isometric point distance and Lysholm score. Results All the 32 patients were followed up 12-18 months(mean, 14.2 months). No symptoms of patellar subluxation or dislocation was found during follow-up. Patellar extrapolation test and patellar extrapolation fear test were negative. The isometric point distance was1.5-5.9 mm(mean, 3.44 mm) at 3 days after operation. All femoral tunnels were located in equidistant tunnels. At last follow-up, the Lysholm score of the patients was 92.8±2.1, which was significantly improved when compared with preoperative score(54.4±2.8)(t=61.911, P=0.000). Isometric point distance was negatively correlated with Lysholm score(r=–0.454, P=0.009). Conclusion C-arm radiographic machine can locate the femoral tunnel position of MPFL easily and accurately before operation. The short-term and medium-term effectiveness are satisfactory, and the ionizing radiation injury caused by multiple fluoroscopy during operation is avoided.
Objective To introduce the method of prior-localization femoral tunnel by using a special positioning tool under the C-arm radiographic machine before surgery, and to study the effect on the knee function recovery after medial patellofemoral ligament(MPFL) reconstruction. Methods Between January 2014 and January2016, 32 patients with recurrent unilateral knee patellar dislocation were treated by arthroscopic patellofemoral lateral retinaculum release and MPFL reconstruction. The femoral tunnel position during MPFL reconstruction was priorlocalizated under C-arm radiographic machine before operation. There were 8 males and 24 females, aged from 15 to 37 years, with an average of 23.8 years. The time from injury to admission ranged from 1 to 24 months, with an average of 9.7 months. Isometric point distance was measured on CT three-dimensional reconstruction image after operation to evaluate whether the position of femoral tunnel was isometric, and knee joint function was evaluated by Lysholm score. Spearman correlation analysis was performed between isometric point distance and Lysholm score. Results All the 32 patients were followed up 12-18 months(mean, 14.2 months). No symptoms of patellar subluxation or dislocation was found during follow-up. Patellar extrapolation test and patellar extrapolation fear test were negative. The isometric point distance was1.5-5.9 mm(mean, 3.44 mm) at 3 days after operation. All femoral tunnels were located in equidistant tunnels. At last follow-up, the Lysholm score of the patients was 92.8±2.1, which was significantly improved when compared with preoperative score(54.4±2.8)(t=61.911, P=0.000). Isometric point distance was negatively correlated with Lysholm score(r=–0.454, P=0.009). Conclusion C-arm radiographic machine can locate the femoral tunnel position of MPFL easily and accurately before operation. The short-term and medium-term effectiveness are satisfactory, and the ionizing radiation injury caused by multiple fluoroscopy during operation is avoided.
引文
1 Lind M, Enderlein D, Nielsen T, et al. Clinical outcome after reconstruction of the medialpatellofemoral ligament in paediatric patients with recurrent patella instability. Knee Surg Sports Traumatol Arthrosc, 2016, 24(3):666-671.
2 Schottle PB, Schmeling A, Rosenstiel N, et al. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med, 2007, 35(5):801-804.
3 Servien E, Fritsch B, Lustig S, et al. In vivo positioning analysis of medial patellofemoral ligament reconstruction. Am J Sports Med,2011,39(1):134-139.
4 Koh JL, Stewart C. Patellar instability. Orthop Clin North Am,2015,46(1):147-157.
5李小建,付战利,吕昌伟.关节镜下滑膜下髌骨外侧支持带松解联合内侧髌股韧带重建治疗髌骨脱位.中国修复重建外科杂志,2018,32(2):169-173.
6 Balcarek P, Rehn S, Howells NR, et al. Results of medial patellofemoral ligament reconstruction compared with trochleoplasty plus individual extensor apparatus balancing in patellar instability caused by severe trochlear dysplasia:a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc, 2017, 25(12):3869-3877.
7 Warren JF, Marshall JL. The supporting structures and layers on the medial side of the knee:An anatomical analysis. J Bone Joint Surg(Am), 1979, 61(1):56-62.
8 Singhal R,Rogers S,Charalambous CP. Double-bundle medial patellofemoral ligament reconstruction with hamstring tendon autograft and mediolateral patellar tunnel fixation:a meta-analysis of outcomes and complications. Bone Joint J, 2013, 95-B(7):900-905.
9 Ahmad CS, Brown GD, Shubin Stein BE. The docking technique for medial patellofemoral ligament reconstruction surgicaltechnique and clinical outcome. Am J Sports Med, 2009, 37(10):2021-2027.
10 Thaunat M, Erasmus PJ. Management of overtight medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc,2009,17(5):480-483.
11 Redfern J,Kamath G,Burks R. Anatomical confirmation of the use of radiographic landmarks in medial ptellofemoral ligament reconstruction. Am J Sports Med, 2010, 38(2):293-297.
12 Smirk C, Morris H. The anatomy and reconstruction of the medial patellofemoral ligament. Knee, 2003,10(3):221-227.
13 Tuxoe JI, Teir M, Winge S, et al. The medial patellofemoralligament:a dissection study. Knee Surg Sports Traumatol Arthrosc,2002,10(3):138-140.
14 Panagiotopoulos E, Strzelczyk P, Herrmann M, et al. Cadaveric study on static medial patellar stabilizers:the dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament.Knee Surg Sports Traumatol Arthrosc, 2006,14(1):7-12.
15阿依丁·夏哈太,张克远,刘阳.内侧髌股韧带重建术后股骨隧道位置对膝关节功能的影响研究.中国修复重建外科杂志,2015,29(8):951-954.
2 Schottle PB, Schmeling A, Rosenstiel N, et al. Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction. Am J Sports Med, 2007, 35(5):801-804.
3 Servien E, Fritsch B, Lustig S, et al. In vivo positioning analysis of medial patellofemoral ligament reconstruction. Am J Sports Med,2011,39(1):134-139.
4 Koh JL, Stewart C. Patellar instability. Orthop Clin North Am,2015,46(1):147-157.
5李小建,付战利,吕昌伟.关节镜下滑膜下髌骨外侧支持带松解联合内侧髌股韧带重建治疗髌骨脱位.中国修复重建外科杂志,2018,32(2):169-173.
6 Balcarek P, Rehn S, Howells NR, et al. Results of medial patellofemoral ligament reconstruction compared with trochleoplasty plus individual extensor apparatus balancing in patellar instability caused by severe trochlear dysplasia:a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc, 2017, 25(12):3869-3877.
7 Warren JF, Marshall JL. The supporting structures and layers on the medial side of the knee:An anatomical analysis. J Bone Joint Surg(Am), 1979, 61(1):56-62.
8 Singhal R,Rogers S,Charalambous CP. Double-bundle medial patellofemoral ligament reconstruction with hamstring tendon autograft and mediolateral patellar tunnel fixation:a meta-analysis of outcomes and complications. Bone Joint J, 2013, 95-B(7):900-905.
9 Ahmad CS, Brown GD, Shubin Stein BE. The docking technique for medial patellofemoral ligament reconstruction surgicaltechnique and clinical outcome. Am J Sports Med, 2009, 37(10):2021-2027.
10 Thaunat M, Erasmus PJ. Management of overtight medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc,2009,17(5):480-483.
11 Redfern J,Kamath G,Burks R. Anatomical confirmation of the use of radiographic landmarks in medial ptellofemoral ligament reconstruction. Am J Sports Med, 2010, 38(2):293-297.
12 Smirk C, Morris H. The anatomy and reconstruction of the medial patellofemoral ligament. Knee, 2003,10(3):221-227.
13 Tuxoe JI, Teir M, Winge S, et al. The medial patellofemoralligament:a dissection study. Knee Surg Sports Traumatol Arthrosc,2002,10(3):138-140.
14 Panagiotopoulos E, Strzelczyk P, Herrmann M, et al. Cadaveric study on static medial patellar stabilizers:the dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament.Knee Surg Sports Traumatol Arthrosc, 2006,14(1):7-12.
15阿依丁·夏哈太,张克远,刘阳.内侧髌股韧带重建术后股骨隧道位置对膝关节功能的影响研究.中国修复重建外科杂志,2015,29(8):951-954.