可吸收缝合线固定髌骨骨软骨骨折的诊治体会
摘要
目的髌骨骨软骨骨折临床少见，属于关节内骨折，严重影响关节功能，临床上诊断困难，容易漏诊误诊，治疗不当可引起创伤性关节炎等严重并发症，本文探讨髌骨骨软骨骨折的诊断、可吸收缝合线固定髌骨软骨骨折的体会。
方法通过一组使用关节镜确诊髌骨骨软骨骨折，并用可吸收线固定骨折块治疗前后得到的临床数据资料进行回顾性分析研究。吉林大学中日联谊医院骨科2009年10月-2011年10月诊治髌骨软骨骨折患者4例，男性1例，女性3例；年龄15～40岁，平均21.25岁。左侧1例，右侧3例。术前误诊3例，确诊1例。下楼梯摔倒扭伤1例，穿高跟鞋扭伤1例，急速奔跑屈曲摔倒受伤2例。其中1例伴有髌骨习惯性脱位。受伤时间3-18天，平均8天。骨折快大小（2.0-3.0）cm×(2.0-2.5)cm。每例患者手术前后均进行国际上认可的Lysholm和Tegnen膝关节功能评分，同时对患者的恢复后症状，对工作及生活的影响进行评价。
结果所有患者术后均无早期并发症发生。所有患者术后均获得随访，3例行门诊随访，1例行电话随访。随访时间8.1~28.3(18.1±8.3)个月。截至写稿时，所有随访患者膝关节稳定，膝关节肿胀疼痛、绞索等症状消失，活动度同健侧12周后关节活动度全面恢复，恢复正常生活、工作或学习。Lysholm评分术前（31.00±11.60）分，术后3个月（84.00±6.92）分，术后6个月（97.75±2.62）分； Tegner评分术前（3.00±0.81）分，术后3个月（8.25±0.96）分，术后6个月（9.25±0.50）分。术后6个月疗效优4例，占100%;总优良率为100%。
结论髌骨骨软骨骨折术前误诊率高。关节镜可以确诊并辅助手术治疗。可吸收缝合线固定髌骨骨软骨骨折块可避免软骨缺损，术中操作简便、安全，固定可靠，术后风险小，短期内症状改善明显，优良率100%，远期疗效需要进一步观察。
Objective： To sum up diagnosis of Patella osteochondralfracture and treatment experience of fixation with dissolvablesutures, which is Belong to intra-articular fractures, easily causemisdiagnosis or missed diagnosis due to clinical rare and difficult todiagnose,also adversely affects joint function even lead to severecompications such as traumatic arthritis.
Methods: a set of clinical data analysis were retrospectivelyreviewed and obtained before and after arthroscopic diagnosis asPatella osteocondral fracture and fixation with dissolvable sutures.China-Japan Union Hospital in October2009on October-2011diagnosed as Patella osteochondral fracture were screened，4caseswere included,1males and3females; The mean age is21.25years(15-40years),7left and3right knee were examined. Preoperatively3cases were misdiagnosed and1case was diagnose.Among thesepatients1case twisted knee as walking down stairs,1case sprainher knee with high-heeled shoes,2cases fell down and hurt kneeswith flexion posture while fastly running.one of4cases complainedof habitual dislocation of patella.The mean time between traumahappening and clinic visiting is8days(3-18days).The sizes offractures varied:(2.0-3.0)cm×(2.0-2.5)cm. Each patient before andafter surgery was rated with Tegner and Lysholm knee score whichwere internationally recognized.Meanwhile,the postoperativesymptoms and signs,effects on life and work were assessed.
Results: All patients had no early complications. Allpatients were followed up after surgery,3patients for outpatientfollow-up,1patients received telephone follow-up.Follow-up timeis8.1~28.3(18.1±8.3). At press time,all patients have good kneejoint stability and return to normal life and work.Ache,swelling andlocking symptoms of joints disappear moreover range of motionafter12weeks recovers as well as the one of contralateral side.Lysholm score mproved from（31.00±11.60）before surgery to(84.00±6.92) after3months and （97.75±2.62）after6months.Tegner score mproved from（3.00±0.81）before surgery to(8.25±0.96) after3months and（9.25±0.50）after6months.After6months all patients gained excellent efficacy which account for100%.
Conclusions: Although preoperative misdiagnosis rate israther high, Patella osteocondral fracture could be diagnosed byarthroscopy which also can aid in healing. fracture fixed withdissolvable sutures could avoid osteochondral defect,otheradvantages are safe,easy to operate,well fixation,low risk,obviousimprovement of symptoms with a100%excellent and good rate inshort term. The clinical efficacy of long-term treatment requiresfurther observation.
方法通过一组使用关节镜确诊髌骨骨软骨骨折，并用可吸收线固定骨折块治疗前后得到的临床数据资料进行回顾性分析研究。吉林大学中日联谊医院骨科2009年10月-2011年10月诊治髌骨软骨骨折患者4例，男性1例，女性3例；年龄15～40岁，平均21.25岁。左侧1例，右侧3例。术前误诊3例，确诊1例。下楼梯摔倒扭伤1例，穿高跟鞋扭伤1例，急速奔跑屈曲摔倒受伤2例。其中1例伴有髌骨习惯性脱位。受伤时间3-18天，平均8天。骨折快大小（2.0-3.0）cm×(2.0-2.5)cm。每例患者手术前后均进行国际上认可的Lysholm和Tegnen膝关节功能评分，同时对患者的恢复后症状，对工作及生活的影响进行评价。
结果所有患者术后均无早期并发症发生。所有患者术后均获得随访，3例行门诊随访，1例行电话随访。随访时间8.1~28.3(18.1±8.3)个月。截至写稿时，所有随访患者膝关节稳定，膝关节肿胀疼痛、绞索等症状消失，活动度同健侧12周后关节活动度全面恢复，恢复正常生活、工作或学习。Lysholm评分术前（31.00±11.60）分，术后3个月（84.00±6.92）分，术后6个月（97.75±2.62）分； Tegner评分术前（3.00±0.81）分，术后3个月（8.25±0.96）分，术后6个月（9.25±0.50）分。术后6个月疗效优4例，占100%;总优良率为100%。
结论髌骨骨软骨骨折术前误诊率高。关节镜可以确诊并辅助手术治疗。可吸收缝合线固定髌骨骨软骨骨折块可避免软骨缺损，术中操作简便、安全，固定可靠，术后风险小，短期内症状改善明显，优良率100%，远期疗效需要进一步观察。
Objective： To sum up diagnosis of Patella osteochondralfracture and treatment experience of fixation with dissolvablesutures, which is Belong to intra-articular fractures, easily causemisdiagnosis or missed diagnosis due to clinical rare and difficult todiagnose,also adversely affects joint function even lead to severecompications such as traumatic arthritis.
Methods: a set of clinical data analysis were retrospectivelyreviewed and obtained before and after arthroscopic diagnosis asPatella osteocondral fracture and fixation with dissolvable sutures.China-Japan Union Hospital in October2009on October-2011diagnosed as Patella osteochondral fracture were screened，4caseswere included,1males and3females; The mean age is21.25years(15-40years),7left and3right knee were examined. Preoperatively3cases were misdiagnosed and1case was diagnose.Among thesepatients1case twisted knee as walking down stairs,1case sprainher knee with high-heeled shoes,2cases fell down and hurt kneeswith flexion posture while fastly running.one of4cases complainedof habitual dislocation of patella.The mean time between traumahappening and clinic visiting is8days(3-18days).The sizes offractures varied:(2.0-3.0)cm×(2.0-2.5)cm. Each patient before andafter surgery was rated with Tegner and Lysholm knee score whichwere internationally recognized.Meanwhile,the postoperativesymptoms and signs,effects on life and work were assessed.
Results: All patients had no early complications. Allpatients were followed up after surgery,3patients for outpatientfollow-up,1patients received telephone follow-up.Follow-up timeis8.1~28.3(18.1±8.3). At press time,all patients have good kneejoint stability and return to normal life and work.Ache,swelling andlocking symptoms of joints disappear moreover range of motionafter12weeks recovers as well as the one of contralateral side.Lysholm score mproved from（31.00±11.60）before surgery to(84.00±6.92) after3months and （97.75±2.62）after6months.Tegner score mproved from（3.00±0.81）before surgery to(8.25±0.96) after3months and（9.25±0.50）after6months.After6months all patients gained excellent efficacy which account for100%.
Conclusions: Although preoperative misdiagnosis rate israther high, Patella osteocondral fracture could be diagnosed byarthroscopy which also can aid in healing. fracture fixed withdissolvable sutures could avoid osteochondral defect,otheradvantages are safe,easy to operate,well fixation,low risk,obviousimprovement of symptoms with a100%excellent and good rate inshort term. The clinical efficacy of long-term treatment requiresfurther observation.
引文
[1]郭世绂.关节软骨的形态、生理、生化特征及损伤修复.骨与关节损伤杂志，1995,10(1):63.
[2]孙沪霞，钱国正，张春才，等.镍钛-聚髌器（NT-PC）治疗髌骨骨折的生物力学性研究，中华骨科杂志，1922，12（5）：361-363.
[3]王胜.髌股关节疾病.骨与关节损伤杂志，1989，4（1）：51
[4]王以进、王介麟.骨科生物力学第一版.北京：人民军医出版社1989.
[5] Goode fellow J, H ungerford DS, Zinde lM (1976) Pate llo-fem ora ljo int mechan ics and patho logy1. Func tiona l anatom y o f the pate llo-femora l jo int[J]. J bone jo int Surg[Br];58(3):287-299.
[6]李德达，李世民，尚天裕。关节软骨愈合和再生研究的现代进展（一）。中国骨伤。2001，14（8）：497-500
[7]娄思权.骨关节炎的病理与发病因素.中华骨科杂志.1996，16（1）：56
[8] Toupin JM, Lechevallier. Osteochondral fractures of the externFemoral condyle after traumatic patellar dislocation during physical execise inchildren.Rev Chir Orthop Reparatrice Appar Mot,1997,83:540-550.
[9]郭世绂.临床骨科解剖学[M].天津：天津科技技术出版社，1988，814-818
[10]王植王林森胡永成等.急性滑脱性髌股关节撞击症的认识与MRI诊断.中华骨科杂志.2003.23：408-413
[11]郭世绂.临床骨科解剖学[M].天津：天津科技技术出版社，1988，814-818
[12] Loredo R,Sanders TG.Imaging of Osteechondral in juried Ost[J].ClinSport S Med.2001,20(2):249-278
[13]李宏键，王革，杨召等.髌骨软骨骨折5例诊治体会.山东医药.2010，59（19）：63-64
[14] Pope TL J r. MR imaging of patel la rdiSlocation andrelocation[J].Semin Ult rasound CT MR,2001,22(4):371-382
[15] Buckwalter JA,Martin JA,Olmstead M,et al.Ostebchondralrepair of primate knee fernomal Orthop,2003,23(1):66-74
[16]卢世璧,杨贵勇,王继芳,等.在连续被动活动作用下自体骨膜游离移植修复髋、膝关节软骨大面积缺损的临床应用.中华骨科杂志,1996,16(8):475
[17]王曹河,黄法泽,汤国才,等.游离软骨膜移植重建股骨头软骨面.中华骨科杂志,1997,17(2):149
[18]李稔生,韩一生,张毅,等.自体骨膜游离移植修复髌骨全层软骨缺损的初步观察中华骨科杂志,1997,17(2):100
[19] Cheung HS, Cott rell WH, St ephenson K, et al. In vit rocollagenbiosynthesis in healing and normal rabbit articular cartilage. J Bon eJoint Surg (Am),1978,60:1076.
[20] Behrans F, Kraf t T R. Biochemical Ohanges in art icular cartilage af t er joint immobilizat ion by casting or ext ernal fixation. J Orthop Res,1989,7:335.
[21]顾延,戴克戎,裘世静,等.应力降低导致关节软骨退变机理的形态学研究.中华骨科杂志,1995,15(9):631.
[22]陆裕朴,胥少汀,葛宝丰,等.实用骨科学.北京:人民军医出版社,1991，1587.
[1] Toupin JM, Lechevallier. Osteochondral fractures of the externFemoral condyle after traumatic patellar dislocation during physical execise inchildren.Rev Chir Orthop Reparatrice Appar Mot,1997,83：540-550.
[2] Toupin JM, Lechevallier. Osteochondral fractures of the externFemoralcondyle after traumatic patellar dislocation during physical excise inchildren. Rev Chir Orthop Reparatrice Appar Mot,1997,83:540--550.
[3]郭世绂.关节软骨的形态、生理、生化特征及损伤修复.骨与关节损伤杂志，1995,10(1):63.
[4]孙沪霞，钱国正，张春才，等.镍钛-聚髌器（NT-PC）治疗髌骨骨折的生物力学性研究，中华骨科杂志，1922，12（5）：361-363.
[5]王胜.髌股关节疾病.骨与关节损伤杂志，1989，4（1）：51
[6]王以进、王介麟.骨科生物力学第一版.北京：人民军医出版社1989.
[7] Goode fellow J, H ungerford DS, Zinde lM (1976) Pate llo-fem ora ljo int mechan ics and patho logy1. Func tiona l anatom y o f the pate llo-femora l jo int[J]. J bone jo int Surg[Br];58(3):287-299.
[8]白希北，王星锋.实验性骨关节炎中关软骨钙化层厚度测定及其意义.中华骨科杂志，1996，16（1）：40.
[9]李德达，李世民，尚天裕.关节软骨愈合和再生研究的现代进展（一）.中国骨伤.2001，14（8）：497-500
[10]娄思权.骨关节炎的病理与发病因素.中华骨科杂志.1996，16（1）：56
[11] Nomura E, Inoue M,Kurlmura M.Chondra I and osteochondral in juriesassociated with acute patel lar di slocation[J]. Arthroscooy,2003,19(7):717-21.
[12]郭世绂.临床骨科解剖学[M].天津：天津科技技术出版社，1988，814-818
[13]王植王林森胡永成等.急性滑脱性髌股关节撞击症的认识与MRI诊断.中华骨科杂志.2003.23：408-413
[14]郭世绂.临床骨科解剖学[M].天津：天津科技技术出版社，1988，814-818
[15] Loredo R,Sanders TG.Imaging of Osteechondral in juried Ost[J].ClinSport S Med.2001,20(2):249-278
[16]李宏键，王革，杨召等.髌骨软骨骨折5例诊治体会.山东医药.2010，59（19）：63-64
[17] Pope TL J r. MR imaging of patel la rdiSlocation andrelocation[J].Semin Ult rasound CT MR,2001,22(4):371-382
[18] Buckwalter JA,Martin JA,Olmstead M,et al.Ostebchondralrepair of primate knee fernomal Orthop,2003,23(1):66-74
[19]卢世璧,杨贵勇,王继芳,等.在连续被动活动作用下自体骨膜游离移植修复髋、膝关节软骨大面积缺损的临床应用.中华骨科杂志,1996,16(8):475
[20]王曹河,黄法泽,汤国才,等.游离软骨膜移植重建股骨头软骨面.中华骨科杂志,1997,17(2):149
[21]李稔生,韩一生,张毅,等.自体骨膜游离移植修复髌骨全层软骨缺损的初步观察中华骨科杂志,1997,17(2):100
[22] Cheung HS, Cott rell WH, St ephenson K, et al. In vit rocollagenbiosynthesis in healing and normal rabbit articular cartilage. J Bon eJoint Surg (Am),1978,60:1076.
[23] Behrans F, Kraf t T R. Biochemical Ohanges in art icular cartilage af t er joint immobilizat ion by casting or ext ernal fixat ion.J Orthop Res,1989,7:335.
[24]顾延,戴克戎,裘世静,等.应力降低导致关节软骨退变机理的形态学研究.中华骨科杂志,1995,15(9):631.
[25]陆裕朴,胥少汀,葛宝丰,等.实用骨科学.北京:人民军医出版社,1991.1587.
[2]孙沪霞，钱国正，张春才，等.镍钛-聚髌器（NT-PC）治疗髌骨骨折的生物力学性研究，中华骨科杂志，1922，12（5）：361-363.
[3]王胜.髌股关节疾病.骨与关节损伤杂志，1989，4（1）：51
[4]王以进、王介麟.骨科生物力学第一版.北京：人民军医出版社1989.
[5] Goode fellow J, H ungerford DS, Zinde lM (1976) Pate llo-fem ora ljo int mechan ics and patho logy1. Func tiona l anatom y o f the pate llo-femora l jo int[J]. J bone jo int Surg[Br];58(3):287-299.
[6]李德达，李世民，尚天裕。关节软骨愈合和再生研究的现代进展（一）。中国骨伤。2001，14（8）：497-500
[7]娄思权.骨关节炎的病理与发病因素.中华骨科杂志.1996，16（1）：56
[8] Toupin JM, Lechevallier. Osteochondral fractures of the externFemoral condyle after traumatic patellar dislocation during physical execise inchildren.Rev Chir Orthop Reparatrice Appar Mot,1997,83:540-550.
[9]郭世绂.临床骨科解剖学[M].天津：天津科技技术出版社，1988，814-818
[10]王植王林森胡永成等.急性滑脱性髌股关节撞击症的认识与MRI诊断.中华骨科杂志.2003.23：408-413
[11]郭世绂.临床骨科解剖学[M].天津：天津科技技术出版社，1988，814-818
[12] Loredo R,Sanders TG.Imaging of Osteechondral in juried Ost[J].ClinSport S Med.2001,20(2):249-278
[13]李宏键，王革，杨召等.髌骨软骨骨折5例诊治体会.山东医药.2010，59（19）：63-64
[14] Pope TL J r. MR imaging of patel la rdiSlocation andrelocation[J].Semin Ult rasound CT MR,2001,22(4):371-382
[15] Buckwalter JA,Martin JA,Olmstead M,et al.Ostebchondralrepair of primate knee fernomal Orthop,2003,23(1):66-74
[16]卢世璧,杨贵勇,王继芳,等.在连续被动活动作用下自体骨膜游离移植修复髋、膝关节软骨大面积缺损的临床应用.中华骨科杂志,1996,16(8):475
[17]王曹河,黄法泽,汤国才,等.游离软骨膜移植重建股骨头软骨面.中华骨科杂志,1997,17(2):149
[18]李稔生,韩一生,张毅,等.自体骨膜游离移植修复髌骨全层软骨缺损的初步观察中华骨科杂志,1997,17(2):100
[19] Cheung HS, Cott rell WH, St ephenson K, et al. In vit rocollagenbiosynthesis in healing and normal rabbit articular cartilage. J Bon eJoint Surg (Am),1978,60:1076.
[20] Behrans F, Kraf t T R. Biochemical Ohanges in art icular cartilage af t er joint immobilizat ion by casting or ext ernal fixation. J Orthop Res,1989,7:335.
[21]顾延,戴克戎,裘世静,等.应力降低导致关节软骨退变机理的形态学研究.中华骨科杂志,1995,15(9):631.
[22]陆裕朴,胥少汀,葛宝丰,等.实用骨科学.北京:人民军医出版社,1991，1587.
[1] Toupin JM, Lechevallier. Osteochondral fractures of the externFemoral condyle after traumatic patellar dislocation during physical execise inchildren.Rev Chir Orthop Reparatrice Appar Mot,1997,83：540-550.
[2] Toupin JM, Lechevallier. Osteochondral fractures of the externFemoralcondyle after traumatic patellar dislocation during physical excise inchildren. Rev Chir Orthop Reparatrice Appar Mot,1997,83:540--550.
[3]郭世绂.关节软骨的形态、生理、生化特征及损伤修复.骨与关节损伤杂志，1995,10(1):63.
[4]孙沪霞，钱国正，张春才，等.镍钛-聚髌器（NT-PC）治疗髌骨骨折的生物力学性研究，中华骨科杂志，1922，12（5）：361-363.
[5]王胜.髌股关节疾病.骨与关节损伤杂志，1989，4（1）：51
[6]王以进、王介麟.骨科生物力学第一版.北京：人民军医出版社1989.
[7] Goode fellow J, H ungerford DS, Zinde lM (1976) Pate llo-fem ora ljo int mechan ics and patho logy1. Func tiona l anatom y o f the pate llo-femora l jo int[J]. J bone jo int Surg[Br];58(3):287-299.
[8]白希北，王星锋.实验性骨关节炎中关软骨钙化层厚度测定及其意义.中华骨科杂志，1996，16（1）：40.
[9]李德达，李世民，尚天裕.关节软骨愈合和再生研究的现代进展（一）.中国骨伤.2001，14（8）：497-500
[10]娄思权.骨关节炎的病理与发病因素.中华骨科杂志.1996，16（1）：56
[11] Nomura E, Inoue M,Kurlmura M.Chondra I and osteochondral in juriesassociated with acute patel lar di slocation[J]. Arthroscooy,2003,19(7):717-21.
[12]郭世绂.临床骨科解剖学[M].天津：天津科技技术出版社，1988，814-818
[13]王植王林森胡永成等.急性滑脱性髌股关节撞击症的认识与MRI诊断.中华骨科杂志.2003.23：408-413
[14]郭世绂.临床骨科解剖学[M].天津：天津科技技术出版社，1988，814-818
[15] Loredo R,Sanders TG.Imaging of Osteechondral in juried Ost[J].ClinSport S Med.2001,20(2):249-278
[16]李宏键，王革，杨召等.髌骨软骨骨折5例诊治体会.山东医药.2010，59（19）：63-64
[17] Pope TL J r. MR imaging of patel la rdiSlocation andrelocation[J].Semin Ult rasound CT MR,2001,22(4):371-382
[18] Buckwalter JA,Martin JA,Olmstead M,et al.Ostebchondralrepair of primate knee fernomal Orthop,2003,23(1):66-74
[19]卢世璧,杨贵勇,王继芳,等.在连续被动活动作用下自体骨膜游离移植修复髋、膝关节软骨大面积缺损的临床应用.中华骨科杂志,1996,16(8):475
[20]王曹河,黄法泽,汤国才,等.游离软骨膜移植重建股骨头软骨面.中华骨科杂志,1997,17(2):149
[21]李稔生,韩一生,张毅,等.自体骨膜游离移植修复髌骨全层软骨缺损的初步观察中华骨科杂志,1997,17(2):100
[22] Cheung HS, Cott rell WH, St ephenson K, et al. In vit rocollagenbiosynthesis in healing and normal rabbit articular cartilage. J Bon eJoint Surg (Am),1978,60:1076.
[23] Behrans F, Kraf t T R. Biochemical Ohanges in art icular cartilage af t er joint immobilizat ion by casting or ext ernal fixat ion.J Orthop Res,1989,7:335.
[24]顾延,戴克戎,裘世静,等.应力降低导致关节软骨退变机理的形态学研究.中华骨科杂志,1995,15(9):631.
[25]陆裕朴,胥少汀,葛宝丰,等.实用骨科学.北京:人民军医出版社,1991.1587.