内侧髌股韧带功能束和功能区的解剖学研究及其临床意义
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摘要
1内侧髌股韧带功能束和功能区的解剖学测量?
目的:正常的髌骨运动轨迹,既受到髌骨、股骨滑车等骨性结构的维持,更重要的是髌骨内外侧支持带及其周围软组织结构的调控。近年来研究发现内侧髌股韧带是髌内侧支持带中的主要解剖结构,是调控髌骨轨迹的主要软组织力量。目前内侧髌股韧带修复或重建成为治疗髌骨脱位的主要方法,但恢复正确的解剖学结构仍然是手术成功的关键。本研究对内侧髌股韧带进行了解剖学研究,进一步探讨生理状态下内侧髌股韧带的生理特点和病理情形中的损伤类型,为临床内侧髌股韧带解剖重建奠定解剖学基础。
方法:河北医科大学解剖教研室提供的冷冻低温保存的新鲜膝关节标本7具(12膝),其中男性5具,女性2具;左侧5具,右侧7具,平均死亡年龄50岁(30-65岁)。将标本仰卧固定于解剖实验台上,去除膝关节内侧面的皮肤和皮下组织,完整暴露股内侧肌斜束的远端附着部分和肌腹。沿着股内侧肌下缘切开,在股内侧肌的深面即可发现内侧髌股韧带的上缘,去除表面的软组织,可辨认大收肌腱、内侧髌股韧带上缘和股内侧肌斜束三者组成的三角形结构,将组织钳沿着内侧髌股韧带的下面钝性分离,可解剖和辨认其股骨和髌骨止点。仔细辨认并记录内侧髌股韧带的股骨和髌骨侧解剖止点。测量内侧髌股韧带的长度,宽度等,双功能束的长度,两功能区的长度等。所有的测量在标记针进行标记后,用游标卡尺测量二点之间的距离,测量三次取平均值,数据以均数±标准差来表示,数据分析采用SPSS13.0版软件完成。
结果:所有的标本上均发现了内侧髌股韧带。内侧髌股韧带位于膝关节内侧软组织结构的第二层,当切开股内侧肌斜束的下缘并将其肌腹向前反折后,可明显发现内侧髌股韧带附着于其深面。由于股骨侧纤维的纤细,其股骨止点不是很明确。本研究中其股骨止点位于股骨内上髁和大收肌结节之间的区域,以股骨内上髁为标志,其股骨止点与股骨内上髁之间的垂直和水平距离分别为8.90±3.27mm和13.47±3.68 mm。其在走形过程中变得越来越宽,在股内侧肌斜束结合点水平的宽度为13.71±4.03mm,在髌骨附着处的宽度为22.28±2.92mm。髌骨的长度测量为49.73±3.84mm,因此髌骨附着处的宽度约为髌骨宽度的1/2。内侧髌股韧带起源于股骨内侧髁,在其走形过程中逐渐变宽,形成了纤维逐步集中的两功能束:上斜束和下直束。上斜束沿着内侧髌股韧带的上缘,止于髌骨的上内侧角,其在髌骨止点附近,附着于股内侧肌的深面,其部分纤维超过髌骨的上内侧角,融入股四头肌腱之中。下直束几乎水平沿着内侧髌股韧带的下缘走形,止于髌骨内侧缘的中点。两功能束的长度分别为73.67±5.40mm和71.78±5.5 mm。内侧髌股韧带的两功能束以及其宽大的髌骨止点使得其解剖结构形成独特的三角形,但其韧带纤维并没有完全分开,内侧髌股韧带仍是一完整的韧带整体。内侧髌股韧带在近髌骨止点的过程中附着于股内侧肌斜束的深面。依据股内侧肌斜束在内侧髌股韧带附着点的下缘,我们将内侧髌股韧带进行了功能分区:独立区和结合区。韧带从股骨起点到股内侧肌斜束的附着点下缘之间的部分仅有韧带纤维称为独立区,而股内侧肌斜束的附着点下缘到髌骨内侧缘之间的韧带纤维得到了股内侧肌斜束的加强并与深层的组织相互交织结合称为结合区。二者大致的长度分别为44.72±5.32mm和25.67±5.03mm。
小结:内侧髌股韧带是膝关节内侧关节囊外的一独立横行韧带结构,在本研究中的出现率为100%。起源于股骨内侧髁,以股骨内上髁为参考点,其股骨止点与股骨内上髁之间的垂直和水平距离分别为8.90±3.27mm和13.47±3.68mm,这将为临床MPFL重建术中经皮股骨骨道确定提供了选择参数。
根据内侧髌股韧带与股内侧肌斜束的关系,首次提出将内侧髌股韧带分为股骨侧的独立区和髌骨侧的结合区。韧带从股骨起点到股内侧肌斜束的附着点下缘之间的部分仅有韧带纤维称为独立区,而股内侧肌斜束的附着点下缘到髌骨内侧缘之间的韧带纤维得到了股内侧肌斜束的加强并与深层的组织交织愈合称为结合区。二者大致的长度分别为44.72±5.32mm和25.67±5.03mm。不同的功能区由于解剖学的特点可以在急性髌骨脱位中表现出不同的损伤类型以及不同的预后。
内侧髌股韧带在其走形过程中逐渐变宽,根据其解剖学特点首次提出内侧髌股韧带的双功能束概念:上斜束和下直束。上斜束沿着内侧髌股韧带的上缘,止于髌骨的上内侧角,其在髌骨止点附近,附着于股内侧肌的深面,其部分纤维超过髌骨的上内侧角,融入股四头肌腱之中。下直束几乎水平沿着内侧髌股韧带的下缘走形,止于髌骨内侧缘的中点。并提出MPFL上斜束,联合股内侧肌斜束是维持髌骨稳定性的动态力量,而MPFL下直束是稳定髌骨的静力性结构。MPFL功能束的概念必将为内侧髌股韧带解剖重建提供重要的理论基础。
2急性内侧髌股韧带的损伤类型和临床治疗选择?
目的:髌骨脱位可分为急性和复发性。对于急性髌骨脱位,目前治疗的主要选择仍然是保守治疗。复发率是治疗急性髌骨脱位首要关注的问题。临床报道急性髌骨脱位的复发率普遍很高,有学者提出未能准确地辨认内侧髌股韧带的损伤的部位以及完全恢复其功能可能是导致急性髌骨脱位复发的主要原因之一。基于我们解剖学研究中提出的内侧髌股韧带的功能区概念,本部分将急性内侧髌股韧带损伤分为三种类型:独立区损伤,结合区损伤,联合损伤。本研究将探讨急性髌骨脱位中内侧髌股韧带损伤的类型以及不同损伤类型的治疗方式的选择。
方法:准确的初次急性髌骨脱位的诊断依赖于详细地病史询问和体格检查。常规拍摄患膝关节正侧位X线片。常规行膝关节MRI检查用来检测可能的骨软骨损伤和明确内侧髌股韧带损伤的部位。膝关节MRI由两名骨科专科医师来分析。MPFL损伤根据MPFL和股内侧肌斜束的关系被分为三类:(1)结合区损伤,指内侧髌股韧带与股内侧肌斜束结合点下缘至髌骨内侧缘之间的韧带损伤;(2)独立区损伤,指内侧髌股韧带股骨止点到与股内侧肌斜束结合点下缘之间的韧带损伤;(3)联合损伤,指广泛的MPFL的损伤。其中,独立区和结合区损伤包括各自的止点撕脱损伤。从2003年1月到2009年12月,我科共收治初次髌骨脱位98例患者的MRI进行了统计分析。根据入选和排除标准,本研究共分析了85例进行了保守治疗的患者资料:其中髌骨侧损伤组33例,股骨侧损伤组52例。本研究中的保守治疗主要包括尽量创伤性小的手法复位,抽取关节积血等,如果有必要,进行关节镜探查和去除关节内积血及骨软骨骨折片形成的游离体。膝关节支具固定至少三周,三周内膝关节活动度限制在0度～60度之间。患者可进行早期的康复和锻炼,包括股四头肌等张、等长练习,直腿抬高锻炼等。患者可拄着拐杖下地负重,膝关节负重控制在患者的可耐受范围之内。治疗的时间大致为2-4个月,直到患者的疼痛消失,重新获得肌力。随访期间根据恐惧试验结果确定髌骨的稳定性,髌股关节功能采用Kujala评分来评估,用VAS评分来评估患者的主观疼痛。数据采用SPSS13.0软件进行统计学分析,P≤0.05认为有统计学意义。
结果:98例患者按照我们的MPFL损伤的类型分成3类:独立区损伤组56例(57.1%),结合区损伤组36例(36.7%),联合损伤组6例(6.1%)。在MRI表现上,骨软骨骨折的发生率为32(32.7%),游离体的发生率为14(14.3%),半月板损伤的发生率为19(19.4%),内侧副韧带损伤的发生率为9(9.2%),髌骨撕脱的发生率为10 (10.2%)。到随访末为止,2例(6.1%)结合区损伤患者和11例(21.2%)独立区损伤患者发生了复发性髌骨脱位,组间比较有统计学意义(P=0.060);3例(9.1%)结合区损伤患者和9例(17.3%)独立区损伤患者发生了疼痛性髌骨半脱位,组间比较没有统计学意义(P=0.289);总共5例(15.2%)结合区损伤侧患者和20例(38.5%)独立区损伤患者发生了复发性髌骨不稳,组间比较具有统计学意义(P=0.022)。两组之间的VAS疼痛评分分别为15.6和28.3,组间具有统计学差异(P=0.026);两组平均的Kujala评分分别为91.1和82.6,组间具有统计学差异(P=0.009);优良率分别为81.8%和57.7%,组间具有统计学差异(P=0.021)。
小结:本研究中基于前期解剖学研究提出的内侧髌股韧带的功能分区的概念,提出了与股内侧肌斜束相关的急性MPFL损伤分型:(1)结合区损伤,指内侧髌骨韧带与股内侧肌斜束结合点下缘至髌骨内侧缘之间的韧带损伤;(2)独立区损伤,指内侧髌股韧带股骨止点到与股内侧肌斜束结合点下缘之间的韧带损伤;(3)联合损伤,指广泛的MPFL的损伤。其中,结合区和独立区损伤包括各自的止点撕脱损伤。
本研究通过对33例MPFL结合区损伤患者和52例MPFL独立区损伤患者进行保守治疗后的回顾性分析,术后的髌骨不稳的复发率存在统计学差异。MPFL独立区损伤容易导致继发性的髌骨不稳,保守治疗并不能恢复MPFL独立区损伤后功能,推荐对于急性髌骨脱位中的MPFL独立区损伤,应早期进行手术治疗。而MPFL结合区损伤有其强大的愈合能力,在我们的随访发现结合区损伤不易导致复发性脱位的发生,可以首选保守治疗。
3内侧髌股韧带解剖重建的临床研究
目的:初次髌骨脱位极易由于治疗不当而导致复发性脱位,对于复发性髌骨脱位,目前主要进行内侧髌股韧带重建手术治疗。随着对内侧髌股韧带解剖学的深入研究,临床MPFL重建经历了非解剖重建向解剖重建的转变,单束重建向双束重建转变,以及与股内侧肌斜束联合重建的转变和发展。本文随访我们临床手术重建MPFL治疗的复发性髌骨脱位患者的资料,按不同的时期治疗方式的不同分为单束重建,联合重建和双束重建等,对比评估术后髌骨不稳的发生率和膝关节的功能。
方法:回顾性分析2003年1月至2009年12月中应用内侧髌股韧带重建手术治疗复发性髌骨脱位的131例患者的资料。根据手术方式分为3组:单束重建组28例,男10例,女18例,平均年龄29岁(19-39岁)。单束重建联合股内侧肌斜束重建组41例,男20例,女21例,平均年龄31岁(21-42岁)。双束重建联合股内侧肌斜束重建组62例,男22例,女40例,平均年龄30岁(20-43岁)。手术采用自体半腱肌腱-股薄肌腱,单束重建直接将自体半腱肌腱-股薄肌腱修整后,正中折叠返折端编织缝合2.5cm,另一端呈单股状态缝合,而双束重建正中折叠成两股,返折端编织缝合2.5cm,另一端两股肌腱分别缝合牵引线。将股骨内侧髁之最高点和股骨内收肌结节的中点稍后侧初步定为股骨止点,髌骨内缘中上1/3处初步定为髌骨止点,测量二者之间的距离并适当调整选取等长点。股骨侧以7mm钻钻取30mm深的骨隧道,将肌腱反折端导入隧道内,以7mm×23mm的可吸收界面螺钉固定。将移植肌腱另一端经股骨切口,紧贴关节囊外侧面经皮下筋膜隧道导出至髌骨侧切口。此两束肌腱移植物分别重建MPFL的两个功能束,下束重建MPFL的下直束,固定于髌骨内侧缘的中点;上束固定点接近于髌骨的上内侧角,重建MPFL的上斜束。首先在屈膝60度状态下应用一枚锚钉固定下直束。上斜束在保持与下直束相同张力条件下固定于接近髌骨上极处缝合固定。而进行单束重建时的固定方法与双束重建中的下直束固定方法相同。最后将股内侧肌斜束在髌内侧附着点的腱性组织连同肌肉切开后向下及内侧移位缝合于重建的髌股韧带上斜束靠近髌骨止点的位置。术后不放置引流,使用膝关节支具保护。按照常规的康复程序进行康复锻炼。随访期间髌骨的稳定性根据恐惧试验评价:屈曲膝关节30度向外推移髌骨,髌骨移动度大于1.5cm,如为硬性止点,诊断为髌骨过度活动;如果为软点或没有明显止点,诊断为髌骨脱位。术后所有患者行屈膝30度的膝关节CT检查测量下列指标:髌骨适合角,髌骨倾斜角和髌骨外移度等指标。髌股关节功能采用Kujala评分来评估。数据采用SPSS13.0软件进行统计学分析,P≤0.05认为有统计学意义。
结果:单束重建组和单束重建联合股内侧肌斜束重建组比较:单束重建组8例患者(28.6%)和3例(7.3%)联合股内侧肌斜束重建组患者髌骨外推恐惧试验大于1.5cm,但均为硬性止点,组间比较有统计学意义(P=0.042);术后病人行屈膝300的膝关节CT平扫,两组之间的髌骨适合角,髌骨倾斜角和髌骨外移度等指标组间比较没有统计学差异。两组平均的Kujala评分分别为79.9±6.2和83.9±6.5,组间比较没有统计学差异(P=0.074);优良率分别为67.9%和87.8%,组间具有统计学差异(P=0.035)。单束重建联合股内侧肌斜束重建组和双束重建组比较:单束联合重建组3例患者(7.3%)髌骨外推恐惧试验大于1.5cm,但均为硬性止点,双束重建组髌骨外推恐惧试验均为阴性,组间比较有统计学意义(P=0.031);术后病人行屈膝300的膝关节CT平扫,两组之间的髌骨适合角,髌骨倾斜角和髌骨外移度组间比较没有统计学差异。两组平均的Kujala评分分别为83.9±6.5和95.9±5.4,组间比较没有统计学差异(P=0.046);优良率分别为87.8%和98.4%,组间具有统计学差异(P=0.024)。
小结:本研究通过临床随访对比MPFL单束重建,单束MPFL联合股内侧肌斜束重建和双束重建联合股内侧肌斜束重建,指出双束MPFL重建较单束重建可以降低术后髌骨不稳的发生率,提高膝关节的功能;联合股内侧肌斜束更能较好地恢复髌骨的稳定性,提高膝关节功能。
本研究提出了内侧髌股韧带解剖重建的原则:保持重建韧带等长性的基础上,解剖定位MPFL的股骨附着点,重建MPFL的上斜束和下直束,并且在重建过程中需要恢复内侧髌股韧带上斜束和股内侧肌斜束之间的“联合纤维”结构。
1. An anatomical study for the functional bundles and functional regions of the medial patellofemoral ligament
Objective: The normal trajectory of the patella was maintained by both the bone structure such as patella, femoral block, and, more importantly, the lateral retinaculum and surrounding soft tissue structures. Of which, the medial patellofemoral ligament (MPFL) is the primary structure. Anatomy has described the MPFL as a distinct structure in the second layer of the medial soft tissues above the knee coursing from the medial femoral epicondyle to the supra-medial two-thirds of the patella. However, there have been some debates about the exact location of the femoral attachment. Now, MPFL reconstruction has been the main choice for patellar dislocation, and understanding of the anatomy of MPFL is critical to the success of the MPFL reconstruction. The present study was to explore the anatomical features of the MPFL to build the base to the MPFL reconstruction in clinical practice.
Method: Twelve knees (5 left and 7 right) from 7 (5 men and 2 women) fresh-frozen cadavers in the department of anatomy of Hebei Medical University were dissected in the present study. The specimens were frozen at -210C and thawed to room temperature the night prior to dissection. The mean age was 50 years (range from 30 to 65). The skin and subcutaneous tissue of the medial side of the knee were removed, and the distal insertion of the vastus medialis obliquus (VMO) and its muscle belly were entirely exposed. Along the inferior border of the VMO, dissection was performed until the upper margin of MPFL was fully exposed. The soft tissue over the MPFL was blunt dissected and removed, where the VMO, combined with the tendon of adductor magnus (TAM), served as reference to identify and dissect the MPFL. With a forceps under the MPFL, the femoral attachment and patellar insertion were blunt identified and dissected. General feature of the MPFL and its femoral and patellar insertions were observed. All anatomical landmarks were carefully identified and marked. All data were obtained, described, and analyzed in the form of mean±SD. All measurements were taken with a sliding caliper by the same person in order to reduce the interobserver variation. The accuracy of the sliding caliper is 0.1 mm.
Results: The MPFL was found in all specimens we dissected. Among all knee specimens, the MPFL was found to locate in the second layer of the medial side of the knee. When the distal part of the VMO was reflected anteriorly along its lower margin, the upper margin of the MPFL was observed to adhere to the deep aspect of the VMO In the present study, the center of the area where fibers of the MPFL originated was carefully identified as the initiation point of the MPFL, which was not located at the adductor tuberosity or the MFE in knee specimens of this dissection. Referring to the MFE, the position of the initiation point was located: the paralleled and perpendicular distance relative to the long axis of femur between it and MFE was 8.90±3.27 and 13.47±3.68 mm, respectively. Along its course, fibers of the MPFL become wider, the width was 13.71±4.03mm at the level of the insertion of the VMO, of 22.28±2.92mm at the patellar insertion. It is as fan-sharp along its trip, forming two relative centered fiber bundles. The lower fiber bundle, named as inferior-straight bundle (ISB), attaches the medial aspect of the patella nearly horizontally, and its length equal to the distance between the femur initiation point and the medial edge of patella was 71.78±5.51 mm. The upper fiber bundle, named as superior-oblique bundle (SOB), also attaches the superior-medial aspect of patella, with some fibers merging into the patellar quadriceps fibers, and its length from the femur initiation point to the superior pole of patella measured was 73.67±5.40 mm. The angle formed by the two fiber bundles was 15.10±2.10. Although the inferior-straight bundle insertion is in the inferior part of the patellar MPFL footprint and the superior-oblique bundle in the superior part, the bundles are not separated completely. This makes the MPFL the intact structure, where its patellar footprint was 22.28±2.92 mm. The total height of patella was 49.73±3.84 mm, and the percentage of the MPFL footprint was calculated to be about 1/2. Closed to the patellar insertion, it adheres to the deep surface of the VMO. Due to the VMO, the MPFL is divided into two functional regions. Closed to the patellar insertion, it is called the combined region, with the VMO overlaied. From the femoral origin, it is defined as the isolated region, without the the VMO overlaied. Anatomically, the MPFL was measured to be 58.8 mm, with the combined and isolated region of 44.72±5.32mm and 25.67±5.03 mm.
Conclusion: MPFL as a distinct structure in the second layer of the medial soft tissues above the knee coursing from the medial femoral epicondyle to the supra-medial two-thirds of the patella. Referring to the MFE, the position of the initiation point was located: the paralleled and perpendicular distance relative to the long axis of femur between it and MFE was 8.90±3.27 and 13.47±3.68 mm, respectively. Closed to the patellar insertion, it adheres to the deep surface of the VMO. Due to the VMO, the MPFL is divided into two functional regions. Closed to the patellar insertion, it is called the combined region, with the VMO overlaied. From the femoral origin, it is defined as the isolated region, without the the VMO overlaied. Approximately from the origination, fibers of the MPFL become wider as fan-sharp along its trip, forming two relative centered fiber bundles.The lower fiber bundle, named as inferior-straight bundle (ISB), attaches the medial aspect of the patella nearly horizontally, and its length equal to the distance between the femur initiation point and the medial edge of patella was 71.78±5.51mm. The upper fiber bundle, named as superior-oblique bundle (SOB), also attaches the superior-medial aspect of patella, with some fibers merging into the patellar quadriceps fibers, and its length from the femur initiation point to the superior pole of patella measured was 73.67±5.40 mm. Patellofemoral contact begins with the distal part of the patella at approximately 200 of flexion, and it progresses to the proximal pole of the patella at 900 of flexion.With the flexion of the knee, the VMO starts to contract, the superior-oblique bundle is pulled proximally and appears shorter due to the tension through fibers attached to the VMO. As a result, the superior-oblique bundle with VMO provides the major dynamic soft tissue restraints and pulls the patella medially. When the knee is in flexion of 20-30, the patella slips into the femoral trochlea groove, and the resultant lateral force is resisted by the prominent lateral facet of the femoral trochlea. Therefore, the role of the MPFL with the knee in deep flexion remains unknown. The pressure between the patellofemoral joint might be balanced by the tension of the MPFL. So this finding may provide the theoretical foundation for the anatomical reconstruction of the MPFL and shed lights on the future researchers.
2. Clinical treatment the injury of the medical patellofemoral ligament based on the acute injury patterns
Objective: Acute patellar dislocation is a relatively common knee injury that occurs most commonly in adolescents. The recommendation for treatment is initially conservative. In spite of the treatment methods, the recurrence rate has been high in general. It has been hypothesized that failure to identify and correct incompetence of the MPFL at the injury site may contribute to recurrence in the treatment to primary dislocation. With the VMO into consideration, we introduced the simple three-part classification of acute MPFL injury patterns: isolated region injury and combined region injury with the meshing point to divide, and the combined injuries. The purpose of the present study was to analyze clinical results of conservative treatment to primary acute patellar dislocation, with comparion between patellar and femoral MPFL injury types categorized by ourselves.
Method: To be included in the study, precise diagnosis of acute patellar dislocation was based on the history of a laterally displaced patella and on physical examination. The radiographic examination includes anteroposterior, lateral radiographs of the affected knee. Magnetic resonance imaging (MRI) was routinely acquired to detect potential osteochondral or chondral fragments and to confirm and categorize the injury of the MPFL. MR images were analyzed by two experienced orthopedic surgeons. The MPFL injury patterns were assessed and categorized into three types according to the meshing point of the MPFL and VMO: isolated region injury,combined region injury and combined injury. Combined region injury is defined as the injury from that point to the medial patellar margin, to the femoral origin is called the isolated region injury and the combined injury is the coexistence of the combined region and isolated region injury. To facilitate the study, the combined injury was excluded from the analysis. From January 2003 to December 2009, our department were treated 98 cases of primary dislocation of the patella in patients with a statistical analysis of MRI.Based on the inclusion and exclusion criteria, 85 patients were retrospectively reviewed in the present study. Thirty three patients were with the MPFL combined region injury (Group P) and 52 patients were with the isolated region injury (Group F). For the conservative treatment, atraumatic reduction, aspiration of the hemarthrosis If necessary, arthroscopic procedure was performed. early mobilization and rehabilitation should be initiated including quadriceps isometrics, straight leg raises, and single-plane motion exercises and so on, and the patient should be allowed to progress as tolerated. In the follow up, the patellar stability was evaluated with the apprehension test into three groups as stability, subluxation, and redislocation. In addition, the Kujala patellofemoral score was used for subjective knee function. The 100-mm visual analog scale was used to determine the patient’s subjective pain in the affected knee. The statistical analysis was performed with SPSS 13.0 software (SPSS Inc, Chicago, Illinois). Significance was set at P≤.05.
Results: Of 98 MRIs, MPFL injury was divided into 3 patterns: combined region injury was in 36 patients; isolated region injury was 56 patients and combined injury six patients. At final follow-up, 2 patients (6.1%) in group P and 11 patients (21.2%) in group F had patellar redislocation (P=0.060). Painful patellar subluxation occurred in 3 patients (9.1%) in group P and in 9 patients (17.3%) in group F (P=0.289). Overall patellar instability was present in 5 of the 33 patients (15.2%) in group P and in 20 of the 52 patients (38.5%) in group F, with statistical difference between the grooups (P=0.022). The mean visual analog scale for combined region and isolated region injury groups were 15.6 points and 28.3 points, respectively (P=0.026). The mean Kujala score was 91.1 points and 82.6 points (P=0.009), with a good or excellent subjective result recorded for 27 of 33 patients (81.8%) in group P, compared with 30 of 52 patients (57.7%) in group F (P=0.021).
Conclusion: The MPFL injury patterns were assessed and categorized into three types according to the meshing point of the MPFL and VMO: combined region injury, isolated region injury and combined injury. Combined region injury is defined as the injury from that point to the medial patellar margin, to the femoral origin is called the isolated region injury and the combined injury is the coexistence of the combined region and isolated region injury. Some authors have felt that failure to identify the injury site of MPFL may contribute to recurrence in the treatment to primary dislocation, to speak in further, failure to identify the relationship between the MPFL injury site and the VMO may jeopardize the success of the treatment, as showed in the present comparison between the combined region and isolated region injury patterns: patients with combined region injury of MPFL would achieve lower patellar instability rate (15.2% versus 38.5%) and better subjective function (91.1 versus 82.6). The different anatomical characters of MPFL femoral origin and patellar insertion may make an explaination for these differences. Different injury patterns of MPFL in primary acute patellar dislocation have resulted in different clinical results based on the same conservative procedure. Conservative treatment achieved a lower patellar instability rate and better subjective function for combined region injury of MPFL than that for isolated region injury. In future, the injury pattern of MPFL should be considered to choose the treatment methods for the acute patellar dislocation.
3. Clinical study for the anatomical reconstruction of the medial patellofemoral ligament
Objective: The MPFL reconstruction is popular in clinical practice for chronic patellar dislocation. With the anatomy of the medial patellofemoral ligament in-depth research, clinical MPFL reconstruction experienced a non-anatomical reconstruction of the changes to the anatomical reconstruction, single-bundle reconstruction changes to the double-bundle reconstruction, and the combined reconstruction with VMO. The present study aims to compare the clinical results of isolated MPFL reconstruction and those of a combinative reconstruction with vastus medialis advancement, and double-bundles reconstruction, with comparation in the postoperative redislocation rate and knee function.
Method: From January 2003 to December 2009, 131 patients with symptomatic chronic patellar dislocation underwent arthroscopically assisted MPFL reconstruction with or without vastus medialis advancement were retrospective analyzed in the present study. According to the surgical procedure, all the patients were divided into three groups: the isolated single-bundle reconstruction, the single-bundle with the vastus medialis advancement and double-bundle reconstruction group. Autologous semitendinosus -gracilis were choosed for grafts, folded from the middle into two shares. Whip stitches are placed in folding end about 2.5 cm, while pullout sutures wrer in the other two ends. The mid-point between medial femoral epicondyle and adductor tubercle and the upper middle 1/3 of the medial margin of patella were initially selected as the femoral and patellar insertion site to check the isometry of graft. In the selected femur point, the bone tunnel was drilled with 7.0-mm in diameter and 25mm-30mm in depth, the suture end was pulled into the blind tunnel through the pullout line and then fixed with a 7.0×23mm bioabsorbable interference screw. Blunt dissection was carried out to create a soft tissue tunnel from the medial border of patella to the medial epicondyle, deep to the medial retinaculum but superficial to the synovium and the free ends of the graft were then pulled through the soft tissue tunnel. Two transverse tunnels were created beneath the prepatellar aponeurosis at supermedial corner and midpoint of medial border of patella to reconstructe the functianal bundles of MPFL: inferior-straight bundle and superior-oblique bundle. With the tension to the ligament, the knee was placed a range of motion and patellar track was monitored under arthroscopy. At 60 degree of knee flexion, whip sutures were performed between the prepatellar aponeurosis and graft to fix the inferior-straight bundle. With the similar motheds, the superior-oblique bundle was sutured at the supermedial corner with the knee at extension. The surgery was with a complement of vastus medialis advancement. In addition, the lower border of vastus medialis obliquus was advanced 5 to 10 mm distally and laterally and sutured on the surface of the reconstructed superior-oblique bundle about 20 mm. During follow up, the apprehension test was conducted and the redislocation was recorded. The patellofemoral joint was evaluated with CT scans and the knee function determined with the Kujala score and with a subjective questionnaire. Statistical analysis was conducted with the SPSS software. A P value of less than 0.05 was considered statistically significant.
Results: Between the single-bundle renconstruction group and the combination reconstruction group, 8 patients in Group S (28.6%) and 3 cases (7.3%) in Group C were more than 1.5 cm at the apprehension test, with the hard end, with the significant differences between groups (P=0.042).On CT images, all the index were within the normal range without a statistically significant difference between the two groups. The Kujala scores were 79.9±6.2 and 83.9±6.5, without the significant differences between groups (P=0.074). The excellent and good rate were 67.9% and 87.8%, with the significant differences between groups (P=0.035). As the results between the single and double-bundle reconstruction, 3 cases (7.3%) in Group C were more than 1.5 cm at the apprehension test, with the hard end, with the significant differences between groups (P=0.031). On CT images, all the index were within the normal range without a statistically significant difference between the two groups. The Kujala scores were 83.9±6.5 and 95.9±5.4, with the significant differences between groups (P=0.046). The excellent and good rate were 87.8%and 98.4%, with the significant differences between groups (P=0.024).
Conclusion: Patellar dislocation is a common orthopedic clinical disease, with most cases, the medial patellofemoral ligament (MPFL) was found relaxation, torn, or dysfunction in recent years, especially in the cases with the normal development of bone structure. Biomechanical studies have confirmed that MPFL is the primary, also the important soft tissue inhibiting strength for patellar dislocation. Therefore, MPFL is the main surgical choice for the treatment of patellar dislocation, aimed at restoring the normal anatomy and function. With the anatomy of the medial patellofemoral ligament in-depth research, clinical MPFL reconstruction experienced a non-anatomical reconstruction of the changes to the anatomical reconstruction, single-bundle reconstruction changes to the double-bundle reconstruction, and the combined reconstruction with VMO. Although many debates are still on MPFL the reconstruction about the graft, the surgical procedures, the double-bundle anatomical medial patellofemoral ligament reconstructionfor for patellar dislocation, can correct poor patellar track and reduce the subjective symptoms of patients and improve knee function.
目的:正常的髌骨运动轨迹,既受到髌骨、股骨滑车等骨性结构的维持,更重要的是髌骨内外侧支持带及其周围软组织结构的调控。近年来研究发现内侧髌股韧带是髌内侧支持带中的主要解剖结构,是调控髌骨轨迹的主要软组织力量。目前内侧髌股韧带修复或重建成为治疗髌骨脱位的主要方法,但恢复正确的解剖学结构仍然是手术成功的关键。本研究对内侧髌股韧带进行了解剖学研究,进一步探讨生理状态下内侧髌股韧带的生理特点和病理情形中的损伤类型,为临床内侧髌股韧带解剖重建奠定解剖学基础。
方法:河北医科大学解剖教研室提供的冷冻低温保存的新鲜膝关节标本7具(12膝),其中男性5具,女性2具;左侧5具,右侧7具,平均死亡年龄50岁(30-65岁)。将标本仰卧固定于解剖实验台上,去除膝关节内侧面的皮肤和皮下组织,完整暴露股内侧肌斜束的远端附着部分和肌腹。沿着股内侧肌下缘切开,在股内侧肌的深面即可发现内侧髌股韧带的上缘,去除表面的软组织,可辨认大收肌腱、内侧髌股韧带上缘和股内侧肌斜束三者组成的三角形结构,将组织钳沿着内侧髌股韧带的下面钝性分离,可解剖和辨认其股骨和髌骨止点。仔细辨认并记录内侧髌股韧带的股骨和髌骨侧解剖止点。测量内侧髌股韧带的长度,宽度等,双功能束的长度,两功能区的长度等。所有的测量在标记针进行标记后,用游标卡尺测量二点之间的距离,测量三次取平均值,数据以均数±标准差来表示,数据分析采用SPSS13.0版软件完成。
结果:所有的标本上均发现了内侧髌股韧带。内侧髌股韧带位于膝关节内侧软组织结构的第二层,当切开股内侧肌斜束的下缘并将其肌腹向前反折后,可明显发现内侧髌股韧带附着于其深面。由于股骨侧纤维的纤细,其股骨止点不是很明确。本研究中其股骨止点位于股骨内上髁和大收肌结节之间的区域,以股骨内上髁为标志,其股骨止点与股骨内上髁之间的垂直和水平距离分别为8.90±3.27mm和13.47±3.68 mm。其在走形过程中变得越来越宽,在股内侧肌斜束结合点水平的宽度为13.71±4.03mm,在髌骨附着处的宽度为22.28±2.92mm。髌骨的长度测量为49.73±3.84mm,因此髌骨附着处的宽度约为髌骨宽度的1/2。内侧髌股韧带起源于股骨内侧髁,在其走形过程中逐渐变宽,形成了纤维逐步集中的两功能束:上斜束和下直束。上斜束沿着内侧髌股韧带的上缘,止于髌骨的上内侧角,其在髌骨止点附近,附着于股内侧肌的深面,其部分纤维超过髌骨的上内侧角,融入股四头肌腱之中。下直束几乎水平沿着内侧髌股韧带的下缘走形,止于髌骨内侧缘的中点。两功能束的长度分别为73.67±5.40mm和71.78±5.5 mm。内侧髌股韧带的两功能束以及其宽大的髌骨止点使得其解剖结构形成独特的三角形,但其韧带纤维并没有完全分开,内侧髌股韧带仍是一完整的韧带整体。内侧髌股韧带在近髌骨止点的过程中附着于股内侧肌斜束的深面。依据股内侧肌斜束在内侧髌股韧带附着点的下缘,我们将内侧髌股韧带进行了功能分区:独立区和结合区。韧带从股骨起点到股内侧肌斜束的附着点下缘之间的部分仅有韧带纤维称为独立区,而股内侧肌斜束的附着点下缘到髌骨内侧缘之间的韧带纤维得到了股内侧肌斜束的加强并与深层的组织相互交织结合称为结合区。二者大致的长度分别为44.72±5.32mm和25.67±5.03mm。
小结:内侧髌股韧带是膝关节内侧关节囊外的一独立横行韧带结构,在本研究中的出现率为100%。起源于股骨内侧髁,以股骨内上髁为参考点,其股骨止点与股骨内上髁之间的垂直和水平距离分别为8.90±3.27mm和13.47±3.68mm,这将为临床MPFL重建术中经皮股骨骨道确定提供了选择参数。
根据内侧髌股韧带与股内侧肌斜束的关系,首次提出将内侧髌股韧带分为股骨侧的独立区和髌骨侧的结合区。韧带从股骨起点到股内侧肌斜束的附着点下缘之间的部分仅有韧带纤维称为独立区,而股内侧肌斜束的附着点下缘到髌骨内侧缘之间的韧带纤维得到了股内侧肌斜束的加强并与深层的组织交织愈合称为结合区。二者大致的长度分别为44.72±5.32mm和25.67±5.03mm。不同的功能区由于解剖学的特点可以在急性髌骨脱位中表现出不同的损伤类型以及不同的预后。
内侧髌股韧带在其走形过程中逐渐变宽,根据其解剖学特点首次提出内侧髌股韧带的双功能束概念:上斜束和下直束。上斜束沿着内侧髌股韧带的上缘,止于髌骨的上内侧角,其在髌骨止点附近,附着于股内侧肌的深面,其部分纤维超过髌骨的上内侧角,融入股四头肌腱之中。下直束几乎水平沿着内侧髌股韧带的下缘走形,止于髌骨内侧缘的中点。并提出MPFL上斜束,联合股内侧肌斜束是维持髌骨稳定性的动态力量,而MPFL下直束是稳定髌骨的静力性结构。MPFL功能束的概念必将为内侧髌股韧带解剖重建提供重要的理论基础。
2急性内侧髌股韧带的损伤类型和临床治疗选择?
目的:髌骨脱位可分为急性和复发性。对于急性髌骨脱位,目前治疗的主要选择仍然是保守治疗。复发率是治疗急性髌骨脱位首要关注的问题。临床报道急性髌骨脱位的复发率普遍很高,有学者提出未能准确地辨认内侧髌股韧带的损伤的部位以及完全恢复其功能可能是导致急性髌骨脱位复发的主要原因之一。基于我们解剖学研究中提出的内侧髌股韧带的功能区概念,本部分将急性内侧髌股韧带损伤分为三种类型:独立区损伤,结合区损伤,联合损伤。本研究将探讨急性髌骨脱位中内侧髌股韧带损伤的类型以及不同损伤类型的治疗方式的选择。
方法:准确的初次急性髌骨脱位的诊断依赖于详细地病史询问和体格检查。常规拍摄患膝关节正侧位X线片。常规行膝关节MRI检查用来检测可能的骨软骨损伤和明确内侧髌股韧带损伤的部位。膝关节MRI由两名骨科专科医师来分析。MPFL损伤根据MPFL和股内侧肌斜束的关系被分为三类:(1)结合区损伤,指内侧髌股韧带与股内侧肌斜束结合点下缘至髌骨内侧缘之间的韧带损伤;(2)独立区损伤,指内侧髌股韧带股骨止点到与股内侧肌斜束结合点下缘之间的韧带损伤;(3)联合损伤,指广泛的MPFL的损伤。其中,独立区和结合区损伤包括各自的止点撕脱损伤。从2003年1月到2009年12月,我科共收治初次髌骨脱位98例患者的MRI进行了统计分析。根据入选和排除标准,本研究共分析了85例进行了保守治疗的患者资料:其中髌骨侧损伤组33例,股骨侧损伤组52例。本研究中的保守治疗主要包括尽量创伤性小的手法复位,抽取关节积血等,如果有必要,进行关节镜探查和去除关节内积血及骨软骨骨折片形成的游离体。膝关节支具固定至少三周,三周内膝关节活动度限制在0度～60度之间。患者可进行早期的康复和锻炼,包括股四头肌等张、等长练习,直腿抬高锻炼等。患者可拄着拐杖下地负重,膝关节负重控制在患者的可耐受范围之内。治疗的时间大致为2-4个月,直到患者的疼痛消失,重新获得肌力。随访期间根据恐惧试验结果确定髌骨的稳定性,髌股关节功能采用Kujala评分来评估,用VAS评分来评估患者的主观疼痛。数据采用SPSS13.0软件进行统计学分析,P≤0.05认为有统计学意义。
结果:98例患者按照我们的MPFL损伤的类型分成3类:独立区损伤组56例(57.1%),结合区损伤组36例(36.7%),联合损伤组6例(6.1%)。在MRI表现上,骨软骨骨折的发生率为32(32.7%),游离体的发生率为14(14.3%),半月板损伤的发生率为19(19.4%),内侧副韧带损伤的发生率为9(9.2%),髌骨撕脱的发生率为10 (10.2%)。到随访末为止,2例(6.1%)结合区损伤患者和11例(21.2%)独立区损伤患者发生了复发性髌骨脱位,组间比较有统计学意义(P=0.060);3例(9.1%)结合区损伤患者和9例(17.3%)独立区损伤患者发生了疼痛性髌骨半脱位,组间比较没有统计学意义(P=0.289);总共5例(15.2%)结合区损伤侧患者和20例(38.5%)独立区损伤患者发生了复发性髌骨不稳,组间比较具有统计学意义(P=0.022)。两组之间的VAS疼痛评分分别为15.6和28.3,组间具有统计学差异(P=0.026);两组平均的Kujala评分分别为91.1和82.6,组间具有统计学差异(P=0.009);优良率分别为81.8%和57.7%,组间具有统计学差异(P=0.021)。
小结:本研究中基于前期解剖学研究提出的内侧髌股韧带的功能分区的概念,提出了与股内侧肌斜束相关的急性MPFL损伤分型:(1)结合区损伤,指内侧髌骨韧带与股内侧肌斜束结合点下缘至髌骨内侧缘之间的韧带损伤;(2)独立区损伤,指内侧髌股韧带股骨止点到与股内侧肌斜束结合点下缘之间的韧带损伤;(3)联合损伤,指广泛的MPFL的损伤。其中,结合区和独立区损伤包括各自的止点撕脱损伤。
本研究通过对33例MPFL结合区损伤患者和52例MPFL独立区损伤患者进行保守治疗后的回顾性分析,术后的髌骨不稳的复发率存在统计学差异。MPFL独立区损伤容易导致继发性的髌骨不稳,保守治疗并不能恢复MPFL独立区损伤后功能,推荐对于急性髌骨脱位中的MPFL独立区损伤,应早期进行手术治疗。而MPFL结合区损伤有其强大的愈合能力,在我们的随访发现结合区损伤不易导致复发性脱位的发生,可以首选保守治疗。
3内侧髌股韧带解剖重建的临床研究
目的:初次髌骨脱位极易由于治疗不当而导致复发性脱位,对于复发性髌骨脱位,目前主要进行内侧髌股韧带重建手术治疗。随着对内侧髌股韧带解剖学的深入研究,临床MPFL重建经历了非解剖重建向解剖重建的转变,单束重建向双束重建转变,以及与股内侧肌斜束联合重建的转变和发展。本文随访我们临床手术重建MPFL治疗的复发性髌骨脱位患者的资料,按不同的时期治疗方式的不同分为单束重建,联合重建和双束重建等,对比评估术后髌骨不稳的发生率和膝关节的功能。
方法:回顾性分析2003年1月至2009年12月中应用内侧髌股韧带重建手术治疗复发性髌骨脱位的131例患者的资料。根据手术方式分为3组:单束重建组28例,男10例,女18例,平均年龄29岁(19-39岁)。单束重建联合股内侧肌斜束重建组41例,男20例,女21例,平均年龄31岁(21-42岁)。双束重建联合股内侧肌斜束重建组62例,男22例,女40例,平均年龄30岁(20-43岁)。手术采用自体半腱肌腱-股薄肌腱,单束重建直接将自体半腱肌腱-股薄肌腱修整后,正中折叠返折端编织缝合2.5cm,另一端呈单股状态缝合,而双束重建正中折叠成两股,返折端编织缝合2.5cm,另一端两股肌腱分别缝合牵引线。将股骨内侧髁之最高点和股骨内收肌结节的中点稍后侧初步定为股骨止点,髌骨内缘中上1/3处初步定为髌骨止点,测量二者之间的距离并适当调整选取等长点。股骨侧以7mm钻钻取30mm深的骨隧道,将肌腱反折端导入隧道内,以7mm×23mm的可吸收界面螺钉固定。将移植肌腱另一端经股骨切口,紧贴关节囊外侧面经皮下筋膜隧道导出至髌骨侧切口。此两束肌腱移植物分别重建MPFL的两个功能束,下束重建MPFL的下直束,固定于髌骨内侧缘的中点;上束固定点接近于髌骨的上内侧角,重建MPFL的上斜束。首先在屈膝60度状态下应用一枚锚钉固定下直束。上斜束在保持与下直束相同张力条件下固定于接近髌骨上极处缝合固定。而进行单束重建时的固定方法与双束重建中的下直束固定方法相同。最后将股内侧肌斜束在髌内侧附着点的腱性组织连同肌肉切开后向下及内侧移位缝合于重建的髌股韧带上斜束靠近髌骨止点的位置。术后不放置引流,使用膝关节支具保护。按照常规的康复程序进行康复锻炼。随访期间髌骨的稳定性根据恐惧试验评价:屈曲膝关节30度向外推移髌骨,髌骨移动度大于1.5cm,如为硬性止点,诊断为髌骨过度活动;如果为软点或没有明显止点,诊断为髌骨脱位。术后所有患者行屈膝30度的膝关节CT检查测量下列指标:髌骨适合角,髌骨倾斜角和髌骨外移度等指标。髌股关节功能采用Kujala评分来评估。数据采用SPSS13.0软件进行统计学分析,P≤0.05认为有统计学意义。
结果:单束重建组和单束重建联合股内侧肌斜束重建组比较:单束重建组8例患者(28.6%)和3例(7.3%)联合股内侧肌斜束重建组患者髌骨外推恐惧试验大于1.5cm,但均为硬性止点,组间比较有统计学意义(P=0.042);术后病人行屈膝300的膝关节CT平扫,两组之间的髌骨适合角,髌骨倾斜角和髌骨外移度等指标组间比较没有统计学差异。两组平均的Kujala评分分别为79.9±6.2和83.9±6.5,组间比较没有统计学差异(P=0.074);优良率分别为67.9%和87.8%,组间具有统计学差异(P=0.035)。单束重建联合股内侧肌斜束重建组和双束重建组比较:单束联合重建组3例患者(7.3%)髌骨外推恐惧试验大于1.5cm,但均为硬性止点,双束重建组髌骨外推恐惧试验均为阴性,组间比较有统计学意义(P=0.031);术后病人行屈膝300的膝关节CT平扫,两组之间的髌骨适合角,髌骨倾斜角和髌骨外移度组间比较没有统计学差异。两组平均的Kujala评分分别为83.9±6.5和95.9±5.4,组间比较没有统计学差异(P=0.046);优良率分别为87.8%和98.4%,组间具有统计学差异(P=0.024)。
小结:本研究通过临床随访对比MPFL单束重建,单束MPFL联合股内侧肌斜束重建和双束重建联合股内侧肌斜束重建,指出双束MPFL重建较单束重建可以降低术后髌骨不稳的发生率,提高膝关节的功能;联合股内侧肌斜束更能较好地恢复髌骨的稳定性,提高膝关节功能。
本研究提出了内侧髌股韧带解剖重建的原则:保持重建韧带等长性的基础上,解剖定位MPFL的股骨附着点,重建MPFL的上斜束和下直束,并且在重建过程中需要恢复内侧髌股韧带上斜束和股内侧肌斜束之间的“联合纤维”结构。
1. An anatomical study for the functional bundles and functional regions of the medial patellofemoral ligament
Objective: The normal trajectory of the patella was maintained by both the bone structure such as patella, femoral block, and, more importantly, the lateral retinaculum and surrounding soft tissue structures. Of which, the medial patellofemoral ligament (MPFL) is the primary structure. Anatomy has described the MPFL as a distinct structure in the second layer of the medial soft tissues above the knee coursing from the medial femoral epicondyle to the supra-medial two-thirds of the patella. However, there have been some debates about the exact location of the femoral attachment. Now, MPFL reconstruction has been the main choice for patellar dislocation, and understanding of the anatomy of MPFL is critical to the success of the MPFL reconstruction. The present study was to explore the anatomical features of the MPFL to build the base to the MPFL reconstruction in clinical practice.
Method: Twelve knees (5 left and 7 right) from 7 (5 men and 2 women) fresh-frozen cadavers in the department of anatomy of Hebei Medical University were dissected in the present study. The specimens were frozen at -210C and thawed to room temperature the night prior to dissection. The mean age was 50 years (range from 30 to 65). The skin and subcutaneous tissue of the medial side of the knee were removed, and the distal insertion of the vastus medialis obliquus (VMO) and its muscle belly were entirely exposed. Along the inferior border of the VMO, dissection was performed until the upper margin of MPFL was fully exposed. The soft tissue over the MPFL was blunt dissected and removed, where the VMO, combined with the tendon of adductor magnus (TAM), served as reference to identify and dissect the MPFL. With a forceps under the MPFL, the femoral attachment and patellar insertion were blunt identified and dissected. General feature of the MPFL and its femoral and patellar insertions were observed. All anatomical landmarks were carefully identified and marked. All data were obtained, described, and analyzed in the form of mean±SD. All measurements were taken with a sliding caliper by the same person in order to reduce the interobserver variation. The accuracy of the sliding caliper is 0.1 mm.
Results: The MPFL was found in all specimens we dissected. Among all knee specimens, the MPFL was found to locate in the second layer of the medial side of the knee. When the distal part of the VMO was reflected anteriorly along its lower margin, the upper margin of the MPFL was observed to adhere to the deep aspect of the VMO In the present study, the center of the area where fibers of the MPFL originated was carefully identified as the initiation point of the MPFL, which was not located at the adductor tuberosity or the MFE in knee specimens of this dissection. Referring to the MFE, the position of the initiation point was located: the paralleled and perpendicular distance relative to the long axis of femur between it and MFE was 8.90±3.27 and 13.47±3.68 mm, respectively. Along its course, fibers of the MPFL become wider, the width was 13.71±4.03mm at the level of the insertion of the VMO, of 22.28±2.92mm at the patellar insertion. It is as fan-sharp along its trip, forming two relative centered fiber bundles. The lower fiber bundle, named as inferior-straight bundle (ISB), attaches the medial aspect of the patella nearly horizontally, and its length equal to the distance between the femur initiation point and the medial edge of patella was 71.78±5.51 mm. The upper fiber bundle, named as superior-oblique bundle (SOB), also attaches the superior-medial aspect of patella, with some fibers merging into the patellar quadriceps fibers, and its length from the femur initiation point to the superior pole of patella measured was 73.67±5.40 mm. The angle formed by the two fiber bundles was 15.10±2.10. Although the inferior-straight bundle insertion is in the inferior part of the patellar MPFL footprint and the superior-oblique bundle in the superior part, the bundles are not separated completely. This makes the MPFL the intact structure, where its patellar footprint was 22.28±2.92 mm. The total height of patella was 49.73±3.84 mm, and the percentage of the MPFL footprint was calculated to be about 1/2. Closed to the patellar insertion, it adheres to the deep surface of the VMO. Due to the VMO, the MPFL is divided into two functional regions. Closed to the patellar insertion, it is called the combined region, with the VMO overlaied. From the femoral origin, it is defined as the isolated region, without the the VMO overlaied. Anatomically, the MPFL was measured to be 58.8 mm, with the combined and isolated region of 44.72±5.32mm and 25.67±5.03 mm.
Conclusion: MPFL as a distinct structure in the second layer of the medial soft tissues above the knee coursing from the medial femoral epicondyle to the supra-medial two-thirds of the patella. Referring to the MFE, the position of the initiation point was located: the paralleled and perpendicular distance relative to the long axis of femur between it and MFE was 8.90±3.27 and 13.47±3.68 mm, respectively. Closed to the patellar insertion, it adheres to the deep surface of the VMO. Due to the VMO, the MPFL is divided into two functional regions. Closed to the patellar insertion, it is called the combined region, with the VMO overlaied. From the femoral origin, it is defined as the isolated region, without the the VMO overlaied. Approximately from the origination, fibers of the MPFL become wider as fan-sharp along its trip, forming two relative centered fiber bundles.The lower fiber bundle, named as inferior-straight bundle (ISB), attaches the medial aspect of the patella nearly horizontally, and its length equal to the distance between the femur initiation point and the medial edge of patella was 71.78±5.51mm. The upper fiber bundle, named as superior-oblique bundle (SOB), also attaches the superior-medial aspect of patella, with some fibers merging into the patellar quadriceps fibers, and its length from the femur initiation point to the superior pole of patella measured was 73.67±5.40 mm. Patellofemoral contact begins with the distal part of the patella at approximately 200 of flexion, and it progresses to the proximal pole of the patella at 900 of flexion.With the flexion of the knee, the VMO starts to contract, the superior-oblique bundle is pulled proximally and appears shorter due to the tension through fibers attached to the VMO. As a result, the superior-oblique bundle with VMO provides the major dynamic soft tissue restraints and pulls the patella medially. When the knee is in flexion of 20-30, the patella slips into the femoral trochlea groove, and the resultant lateral force is resisted by the prominent lateral facet of the femoral trochlea. Therefore, the role of the MPFL with the knee in deep flexion remains unknown. The pressure between the patellofemoral joint might be balanced by the tension of the MPFL. So this finding may provide the theoretical foundation for the anatomical reconstruction of the MPFL and shed lights on the future researchers.
2. Clinical treatment the injury of the medical patellofemoral ligament based on the acute injury patterns
Objective: Acute patellar dislocation is a relatively common knee injury that occurs most commonly in adolescents. The recommendation for treatment is initially conservative. In spite of the treatment methods, the recurrence rate has been high in general. It has been hypothesized that failure to identify and correct incompetence of the MPFL at the injury site may contribute to recurrence in the treatment to primary dislocation. With the VMO into consideration, we introduced the simple three-part classification of acute MPFL injury patterns: isolated region injury and combined region injury with the meshing point to divide, and the combined injuries. The purpose of the present study was to analyze clinical results of conservative treatment to primary acute patellar dislocation, with comparion between patellar and femoral MPFL injury types categorized by ourselves.
Method: To be included in the study, precise diagnosis of acute patellar dislocation was based on the history of a laterally displaced patella and on physical examination. The radiographic examination includes anteroposterior, lateral radiographs of the affected knee. Magnetic resonance imaging (MRI) was routinely acquired to detect potential osteochondral or chondral fragments and to confirm and categorize the injury of the MPFL. MR images were analyzed by two experienced orthopedic surgeons. The MPFL injury patterns were assessed and categorized into three types according to the meshing point of the MPFL and VMO: isolated region injury,combined region injury and combined injury. Combined region injury is defined as the injury from that point to the medial patellar margin, to the femoral origin is called the isolated region injury and the combined injury is the coexistence of the combined region and isolated region injury. To facilitate the study, the combined injury was excluded from the analysis. From January 2003 to December 2009, our department were treated 98 cases of primary dislocation of the patella in patients with a statistical analysis of MRI.Based on the inclusion and exclusion criteria, 85 patients were retrospectively reviewed in the present study. Thirty three patients were with the MPFL combined region injury (Group P) and 52 patients were with the isolated region injury (Group F). For the conservative treatment, atraumatic reduction, aspiration of the hemarthrosis If necessary, arthroscopic procedure was performed. early mobilization and rehabilitation should be initiated including quadriceps isometrics, straight leg raises, and single-plane motion exercises and so on, and the patient should be allowed to progress as tolerated. In the follow up, the patellar stability was evaluated with the apprehension test into three groups as stability, subluxation, and redislocation. In addition, the Kujala patellofemoral score was used for subjective knee function. The 100-mm visual analog scale was used to determine the patient’s subjective pain in the affected knee. The statistical analysis was performed with SPSS 13.0 software (SPSS Inc, Chicago, Illinois). Significance was set at P≤.05.
Results: Of 98 MRIs, MPFL injury was divided into 3 patterns: combined region injury was in 36 patients; isolated region injury was 56 patients and combined injury six patients. At final follow-up, 2 patients (6.1%) in group P and 11 patients (21.2%) in group F had patellar redislocation (P=0.060). Painful patellar subluxation occurred in 3 patients (9.1%) in group P and in 9 patients (17.3%) in group F (P=0.289). Overall patellar instability was present in 5 of the 33 patients (15.2%) in group P and in 20 of the 52 patients (38.5%) in group F, with statistical difference between the grooups (P=0.022). The mean visual analog scale for combined region and isolated region injury groups were 15.6 points and 28.3 points, respectively (P=0.026). The mean Kujala score was 91.1 points and 82.6 points (P=0.009), with a good or excellent subjective result recorded for 27 of 33 patients (81.8%) in group P, compared with 30 of 52 patients (57.7%) in group F (P=0.021).
Conclusion: The MPFL injury patterns were assessed and categorized into three types according to the meshing point of the MPFL and VMO: combined region injury, isolated region injury and combined injury. Combined region injury is defined as the injury from that point to the medial patellar margin, to the femoral origin is called the isolated region injury and the combined injury is the coexistence of the combined region and isolated region injury. Some authors have felt that failure to identify the injury site of MPFL may contribute to recurrence in the treatment to primary dislocation, to speak in further, failure to identify the relationship between the MPFL injury site and the VMO may jeopardize the success of the treatment, as showed in the present comparison between the combined region and isolated region injury patterns: patients with combined region injury of MPFL would achieve lower patellar instability rate (15.2% versus 38.5%) and better subjective function (91.1 versus 82.6). The different anatomical characters of MPFL femoral origin and patellar insertion may make an explaination for these differences. Different injury patterns of MPFL in primary acute patellar dislocation have resulted in different clinical results based on the same conservative procedure. Conservative treatment achieved a lower patellar instability rate and better subjective function for combined region injury of MPFL than that for isolated region injury. In future, the injury pattern of MPFL should be considered to choose the treatment methods for the acute patellar dislocation.
3. Clinical study for the anatomical reconstruction of the medial patellofemoral ligament
Objective: The MPFL reconstruction is popular in clinical practice for chronic patellar dislocation. With the anatomy of the medial patellofemoral ligament in-depth research, clinical MPFL reconstruction experienced a non-anatomical reconstruction of the changes to the anatomical reconstruction, single-bundle reconstruction changes to the double-bundle reconstruction, and the combined reconstruction with VMO. The present study aims to compare the clinical results of isolated MPFL reconstruction and those of a combinative reconstruction with vastus medialis advancement, and double-bundles reconstruction, with comparation in the postoperative redislocation rate and knee function.
Method: From January 2003 to December 2009, 131 patients with symptomatic chronic patellar dislocation underwent arthroscopically assisted MPFL reconstruction with or without vastus medialis advancement were retrospective analyzed in the present study. According to the surgical procedure, all the patients were divided into three groups: the isolated single-bundle reconstruction, the single-bundle with the vastus medialis advancement and double-bundle reconstruction group. Autologous semitendinosus -gracilis were choosed for grafts, folded from the middle into two shares. Whip stitches are placed in folding end about 2.5 cm, while pullout sutures wrer in the other two ends. The mid-point between medial femoral epicondyle and adductor tubercle and the upper middle 1/3 of the medial margin of patella were initially selected as the femoral and patellar insertion site to check the isometry of graft. In the selected femur point, the bone tunnel was drilled with 7.0-mm in diameter and 25mm-30mm in depth, the suture end was pulled into the blind tunnel through the pullout line and then fixed with a 7.0×23mm bioabsorbable interference screw. Blunt dissection was carried out to create a soft tissue tunnel from the medial border of patella to the medial epicondyle, deep to the medial retinaculum but superficial to the synovium and the free ends of the graft were then pulled through the soft tissue tunnel. Two transverse tunnels were created beneath the prepatellar aponeurosis at supermedial corner and midpoint of medial border of patella to reconstructe the functianal bundles of MPFL: inferior-straight bundle and superior-oblique bundle. With the tension to the ligament, the knee was placed a range of motion and patellar track was monitored under arthroscopy. At 60 degree of knee flexion, whip sutures were performed between the prepatellar aponeurosis and graft to fix the inferior-straight bundle. With the similar motheds, the superior-oblique bundle was sutured at the supermedial corner with the knee at extension. The surgery was with a complement of vastus medialis advancement. In addition, the lower border of vastus medialis obliquus was advanced 5 to 10 mm distally and laterally and sutured on the surface of the reconstructed superior-oblique bundle about 20 mm. During follow up, the apprehension test was conducted and the redislocation was recorded. The patellofemoral joint was evaluated with CT scans and the knee function determined with the Kujala score and with a subjective questionnaire. Statistical analysis was conducted with the SPSS software. A P value of less than 0.05 was considered statistically significant.
Results: Between the single-bundle renconstruction group and the combination reconstruction group, 8 patients in Group S (28.6%) and 3 cases (7.3%) in Group C were more than 1.5 cm at the apprehension test, with the hard end, with the significant differences between groups (P=0.042).On CT images, all the index were within the normal range without a statistically significant difference between the two groups. The Kujala scores were 79.9±6.2 and 83.9±6.5, without the significant differences between groups (P=0.074). The excellent and good rate were 67.9% and 87.8%, with the significant differences between groups (P=0.035). As the results between the single and double-bundle reconstruction, 3 cases (7.3%) in Group C were more than 1.5 cm at the apprehension test, with the hard end, with the significant differences between groups (P=0.031). On CT images, all the index were within the normal range without a statistically significant difference between the two groups. The Kujala scores were 83.9±6.5 and 95.9±5.4, with the significant differences between groups (P=0.046). The excellent and good rate were 87.8%and 98.4%, with the significant differences between groups (P=0.024).
Conclusion: Patellar dislocation is a common orthopedic clinical disease, with most cases, the medial patellofemoral ligament (MPFL) was found relaxation, torn, or dysfunction in recent years, especially in the cases with the normal development of bone structure. Biomechanical studies have confirmed that MPFL is the primary, also the important soft tissue inhibiting strength for patellar dislocation. Therefore, MPFL is the main surgical choice for the treatment of patellar dislocation, aimed at restoring the normal anatomy and function. With the anatomy of the medial patellofemoral ligament in-depth research, clinical MPFL reconstruction experienced a non-anatomical reconstruction of the changes to the anatomical reconstruction, single-bundle reconstruction changes to the double-bundle reconstruction, and the combined reconstruction with VMO. Although many debates are still on MPFL the reconstruction about the graft, the surgical procedures, the double-bundle anatomical medial patellofemoral ligament reconstructionfor for patellar dislocation, can correct poor patellar track and reduce the subjective symptoms of patients and improve knee function.
引文
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1 Kaplan EB. Factors responsible for the stability of the knee joint. Bull Hosp Joint Dis 1957,18:51-59
2 Warren LF, Marshall JL. The supporting structures and layers on medial side of the knee: an anatomical analysis. J Bone Joint Surg, 1979, 61A:56-62
3 Robert N. Steensen, Ryan M, et al. The anatomy and isometry of the medial patellofemoral ligament: implications for reconstruction. Am J Sports Med 2004 32; 1509-1513
4 Nomura E, Horiuchi Y, Kihara M. A mid-term follow-up of medial patellofemoral ligament reconstruction using an artificial ligament for recurrent patellar dislocation. Knee 2000, 7(4):211-215
5 Ellera Gomes JL, Stigler Marczyk LR, Cesar de Cesar P, et al. Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: a follow-up study. Arthroscopy 2004, 20(2):147-151
6 Schottle PB, Fucentese SF, Romero J. Clinical and radiological outcomeof medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc 2005, 13(7):516-521
7 Cossey AJ, Paterson R. A new technique for reconstructing the medial patellofemoral ligament. Knee 2005, 12(2):93-98
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19 Parker DA, Alexander JW, Conditt MA, et al. Comparison of isometric and anatomic reconstruction of the medial patellofemoral ligament: a cadaveric study. Orthopedics 2008, 31(4):339-343
20 Aragāo JA, Reis FP, Vasconcelos DP, et al. Metric measurements and attachments levels of the medial patellofemoral ligament: an anatomical study in cadavers. Clinics 2008, 63:541-544
21 Nomura E, Inoue M, Osada N, et al. Anatomical analysis of the medial patellofemoral ligament of the knee, especially the femoral attachment. Knee Surg Sports Traumatol Arthrosc 2005,13:510-515
22 Tuxoe JI, Teir M, Winge S, et al. The medial patellofemoral ligament: a dissection study. Knee Surg Sports Traumatol Arthrosc 2002, 10: 138-140
23 Panayiotopoulos 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 Tarthrosc 2006, 14: 7-12
1 Nomura E. Classification of lesions of the medial patello-femoral ligament in patellar dislocation.Int Orthop 1999, 23: 260-263
2 Sallay PI, Poggi J, Speer KP, et al. Acute dislocation of the patella. A correlative pathoanatomic study. Am J Sports Med 1996,24:52-60
3 Sch?ttle PB, Fucentese SF, Romero J. Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc 2005,13: 516-521
4 Kaplan EB. Factors responsible for the stability of the knee joint. Bull Hosp Joint Dis 1957,18:51-59
5 Conlan T, Garth WP, Lemons J. Evaluation of the medial soft tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg 1993, 75Am:682-693
6 Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998,26(1): 59-65
7 Larson RL,Cabaud HE,Slocum DB,et al.The patellar compression syndrome:surgical treatment by lateral retinacular release.Clin Orthop 1978, 134:158-167
8 Warren LF, Marshall JL.The supporting structures and layers on medial side of the knee: an anatomical analysis. J Bone Joint Surg 1979, 61A:56-62
9 Reider B, Marshall JL, Koslin B, et al. The anterior aspect of the knee joint: an anatomical study. J Bone Joint Surg 1981, 63Am:351-356
10 Conlan T, Garth WP, Lemons J. Evaluation of the medial soft tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg 1993, 75Am: 682-693
11 Nomura E, Horiuchi Y, Kihara M. Medial patellofemoral ligament restraint in lateral patellar translation and reconstruction. Knee 2000; 7:121-127.Warren LF, Marshall JL. The supporting structures and layers on medial side of the knee: an anatomical analysis. J Bone Joint Surg 1979, 61A: 56-62
12 Smirk C, Morris H. The anatomy and reconstruction of the medial patellofemoral ligament. Knee 2003,10:221-227
13 Tuxoe JI, Teir M, Winge S, et al. The medial patellofemoral ligament: a dissection study. Knee Surg Sports Traumatol Arthrosc 2002, 10: 138-140.Feller JA, Feagin JA, Garrett WE. The medial patellofemoral ligament revisited: an anatomical study. Knee Surg Sports Traumatol Arthrosc 1993, 1: 184-186
14 Aragāo JA, Reis FP, Vasconcelos DP, et al. Metric measurements and attachments levels of the medial patellofemoral ligament: an anatomical study in cadavers. Clinics 2008, 63:541-544
15 Robert N. Steensen, Ryan M. et al. The Anatomy and Isometry of the Medial Patellofemoral Ligament: Implications for Reconstruction. Am. J. Sports Med 2004, 32:1509-1513
16 Hautamaa PV, Fithian DC, Kaufman KR, et al. Medial soft tissue restraints in lateral patellar instability and repair. Clinical orthopaedics and related research, 1998, 349:174-182
17 Nomura E, Horiuchi Y, Kihara M. A mid-term follow-up of medial patellofemoral ligament reconstruction using an artificial ligament for recurrent patellar dislocation. Knee 2000, 7(4): 211-215
18 Kang Huijun, Wang Fei, Chen Baicheng, et al. Functional bundles of themedial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2010, 18:1511-1516
19 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 Tarthrosc 2006, 14:7-12
20 Steensen RN, Dopirak RM, Maurus PB. A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft. Arthroscopy 2005,21:365-70
21 Mountney J, Senavongse W, Amis AA, et al. Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction. J Bone Joint Surg [Br] 2005,87-B:36-40
22 Sanders TG, Morrison WB, Singleton BA, et al. Medial patellofemoral ligament injury following acute transient dislocation of the patella: MR findings with surgical correlation in 14 patients. J Comput Assist Tomogr 2001, 25(6):957-962
23 Parker DA, Alexander JW, Conditt MA,et al. Comparison of isometric and anatomic reconstruction of the medial patellofemoral ligament: a cadaveric study. Orthopedics 2008 , 31(4):339-343
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2 Avikainen VJ, Nikku RK, Seppanen-Lehmonen TK. Adductor magnus tenodesis for patellar dislocation: technique and preliminary results. Clin Orthop Rel Res 1993, 97:12-16
3 Vainionp?? S, Laasonen E, Silvennoinen T, et al. Acute dislocation of the patella: a prospective review of operative treatment. J Bone Joint Surg 1990, 72(3):366-369
4 Nomura E. Classification of lesions of the medial patello-femoral ligament in patellar dislocation.Int Orthop 1999, 23: 260-263
5 Sallay PI, Poggi J, Speer KP, et al. Acute dislocation of the patella. A correlative pathoanatomic study. Am J Sports Med 1996,24:52-60
6 Sch?ttle PB, Fucentese SF, Romero J. Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc 2005,13: 516-521
7 Kaplan EB. Factors responsible for the stability of the knee joint. Bull Hosp Joint Dis 1957,18:51-59
8 Larson RL,Cabaud HE,Slocum DB,et al.The patellar compression syndrome:surgical treatment by lateral retinacular release .Clin Orthop 1978,134:158-167
9 Warren LF,Marshall JL.The supporting structures and layers on medial side of the knee: an anatomical analysis. J Bone Joint Surg 1979, 61A:56-62
10 Kang Huijun, Wang Fei, Chen Baicheng, et al. Functional bundles of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2010,18:1511-1516
11 Colan T, Garth WP, Lemons JE. Evaluation of the medial soft-tissue restraint of the extensor mechanism of the knee. J Bone Joint Surg Am 1993,75:682-693
12 Desio SM,Burks RT,Bachus KN.Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998,26(1):59 65
13 Nomura E,Fujikawa K,Takeda T, et al. Anatomical study of the medial patellofemoral ligament (in Japanese).Bessatsu Seikeigeka1992, 22:2-5
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31 Hautamaa PV,Fithian DC,Kaufman KR,et al. Medial soft tissue restraints in lateral patellar instability and repair. Clinical orthopaedics and relatedresearch 1998, 349:174-182
32 Nomura E, Inoue M. Surgical technique and rationale for medial patellofemarol ligament reconstruction for recurrent patellar dislocation. Arthroscopy 2003,19(5):E47
33 Schottle PB, Hensler D, Imboff AB.Direct anatomic reconstruction of the medial patellofemarol ligament with the double-bundle technique aperture fixation .Arthroskopie 2008,21(3):192-195
34 Christiansen SE, Jacobsen BW, Lund B, et al. Reconstruction of the medial patellofemoral ligament with gracilis tendon autograft in transverse patellar drill holes. Arthroscopy 2008,24(1):82-87
35 Schottle PB, Weiler A, Romeo J. Reconstruction of the patellofemoral ligament in patellofemoral instability. Arthroskopie 2005, 18(5):293-300
36 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 Tarthrosc 2006,14:7-12
2 Fulkerson JP. Diagnosis and treatment of patients with patellofemoral pain. Am J Sports Med, 2002; 30:447-456
3 Conlan T, Garth WP, Lemons J, et al. Evaluation of the medial soft tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg, 1993, 75Am: 682-693
4 Desio SM, Burks RT, Bachus KN, et al. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med, 1998, 26(1): 59- 65
5 Warren LF, Marshall JL. The supporting structures and layers on medial side of the knee: an anatomical analysis. J Bone Joint Surg, 1979, 61A:56-62
6 Aragāo JA, Reis FP, Vasconcelos DP, et al. Metric measurements and attachments levels of the medial patellofemoral ligament: an anatomical study in cadavers. Clinics, 2008, 63:541-544
7 Panayiotopoulos 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 Tarthrosc, 2006, 14: 7-12
8 Nomura E. Classification of lesions of the medial patellofemoral ligament in patellar dislocation. Int Orthop, 1999, 23: 260-263
9 Sallay PI, Poggi J, Speer KP, et al. Acute dislocation of the patella. A correlative path anatomic study. Am J Sports Med, 1996, 24:52-60
10 Sch?ttle PB, Fucentese SF, Romero J, et al. Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc, 2005,13: 516-521
11 Sanders TG, Morrison WB, Singleton BA, et al. Medial patellofemoral ligament injury following acute transient dislocation of the patella: MR findings with surgical correlation in 14 patients. J Comput Assist Tomogr, 2001,25(6):957-962
12 Reider B, Marshall JL, Koslin B, et al. The anterior aspect of the knee joint: an anatomical study. J Bone Joint Surg,1981,63Am:351-356
13 Thaunat M, Erasmus PJ. Management of overtight medial patellofemoral ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2009, 5: 480-483
14 Steensen RN, Dopirak RM, McDonald WG III, et al. The anatomy and isometry of the medial patellofemoral ligament: implications for reconstruction. Am J Sports Med, 2004, 32:1509-1513
15 Philippot R, Chouteau J, Wegrzyn J, et al. Medial patellofemoral ligament anatomy: implications for its surgical reconstruction. Knee Surg Sports Traumatol Arthrosc, 2009, 5:475-479
16 Aragao JA, Reis FP, Vasconcelos DP, et al. Metric measurements and attachments levels of the medial patellofemoral ligament: an anatomical study in cadavers. Clinics, 2008, 63: 541-544
17 Andrikoula S, Tokis A, Vasiliadis HS, et al. The extensor mechanism of the knee joint: an anatomical study. Knee Surg Sports Traumatol Arthrosc, 2006, 3: 214-220
18 Hautamaa PV, Fithian DC, Kaufman KR, et al. Medial soft tissue restraints in lateral patellar instability and repair. Clinical orthopaedics and related research, 1998, 349:174-182
19 Steensen RN, Dopirak RM, Maurus PB. A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft. Arthroscopy, 2005, 21:365-70
20 Tuxoe JI, Teir M, Winge S, et al. The medial patellofemoral ligament: a dissection study. Knee Surg Sports Traumatol Arthrosc, 2002, 10: 138-140.
21 Nomura E, Fujikawa K, Takeda T, et al. Anatomical study of the medial patellofemoral ligament (in Japanese). Bessatsu Seikeigeka, 1992, 22:2-5
22 Nomura E, Inoue M, Osada N, et al. Anatomical analysis of the medial patellofemoral ligament of the knee, especially the femoral attachment. Knee Surg Sports Traumatol Arthrosc, 2005,13: 510-515
23 Smirk C, Morris H. The anatomy and reconstruction of the medial patellofemoral ligament. Knee, 2003,10:221-227
24 Schoettle 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
25 Redfern J, Kamath G, Burks R. Anatomical confirmation of the use of radiographic landmarks in medial patellofemoral ligament reconstruction. Am J Sports Med, 2010, 38(2):293-297
26 Elias JJ, Cosgarea AJ. Technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: a computational analysis. Am J Sports Med, 2006, 9:1478-1485
1 Nikku R, Nietosvaara Y, Kallio PE, et al. Operative versus closed treatment of primary dislocation of the patella: similar 2-year results in 125 randomized patients. Acta Orthop Scand 1997, 68:419-423
2 Palmu S, Kallio PE, Donell ST, et al. Acute patellar dislocation in children and adolescents: a randomized clinical trial. J Bone Joint Surg Am 2008, 90(3): 463 -470
3 Beasly LS, Vidal AF. Traumatic patellar dislocation in children and adolescents: treatment update and literature review. Curr Opin Pediatr 2004, 16:29-36
4 Buchner M, Baudendistel B, Sabo D, et al. Acute traumatic primary patellar dislocation: long-term results comparing conservation and surgical treatment. Clin J Sport Med 2005,15: 62-66
5 Harilainen A, Sandelin J. Prospective long-term results of operative treatment in primary dislocation of the patella. Knee Surg Sports Traumatol Arthrosc 1993,1:100-103
6 Vainionp?? S, Laasonen E, Silvennoinen T, et al. Acute dislocation of patella: a prospective review of operative treatment. J Bone Joint Surg Br. 1990, 72:366-369
7 Cash JD, Hughston JC. Treatment of acute patellar dislocation. Am J Sports Med 1988, 16: 244- 249
8 Cofield RH, Bryan RS. Acute dislocation of the patella: results of conservative treatment. J Trauma 1977,17:526-531
9 Larsen E, Lauridsen F. Conservative treatment of patellar dislocation: influence of evident factors on the tendency to redislocation and the therapeutic result. Clin Orthop. 1982;171:131-136
10 Nikku R, Nietosvaara Y, Aalto K, et al. Operative treatment of primary patellar dislocation does not improve medium-term outcome. A 7-year follow-up report and risk analysis of 127 randomized patients. Acta Orthop 2005, 76: 699-704
11 Dejour H, Walch G, Nove-josserand L, et al. Factors of patellar instability: an anatomic radiographic study. Knee Surg Sports Traumatol Arthrosc,1994, 2: 19-26
12 Hautamaa PV, Fithian DC, Kaufman KR, Daniel DM, Pohlmeyer AM. Medial soft tissue restraints in lateral patellar instability and repair. Clin Orthop. 1998;349:174-182
13 Nomura E. Classification of lesions of the medial patellofemoral ligament in patellar dislocation. Int Orthop 1999; 23:260-263
14 Guerrero P, Li X, Patel K, Brown M, Busconi B. Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study. Sports Med Arthrosc Rehabil Ther Technol. 2009, 30;1(1):17
15 Balcarek P, Walde TA, Frosch S, Schüttrumpf JP, Wachowski MM, Stürmer KM, Frosch KH. Patellar dislocations in children, adolescents and adults: A comparative MRI study of medial patellofemoral ligament injury patterns and trochlear groove anatomy. Eur J Radiol. Doi:10.1016/j.ejrad.2010.06.042
16 Balcarek P, Ammon J, Frosch S, Walde TA, Schüttrumpf JP, Ferlemann KG, Lill H, Stürmer KM, Frosch K-H. Magnetic resonance imaging characteristics of the medial patellofemoral ligament lesion in acute lateral patellar dislocations considering trochlear dysplasia, patella alta, and tibial tuberosity-trochlear groove distance. Arthroscopy 2010;26(7):926-35
17 Tuxoe JI, Teir M, Winge S, et al. The medial patellofemoral ligament: a dissection study. Knee Surg Sports Traumatol Arthrosc, 2002, 10: 138-140
18 Nomura E, Inoue M, Osada N, et al. Anatomical analysis of the medial patellofemoral ligament of the knee, especially the femoral attachment.Knee Surg Sports Traumatol Arthrosc, 2005,13:510-515
19 Nietosvaara Y, Aalto K, Kallio PE. Acute patellar dislocation in children:incidence and associated osteochondral fractures. J Pediatr Orthop. 1994, 14:513-515
20 Fithian DC, Paxton EW, Stone ML, et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med, 2006, 9:1478-1485
21 Sallay PI, Poggi J, Speer KP, et al. Acute dislocation of the patella. A correlative path anatomic study. Am J Sports Med, 1996, 24:52-60
22 Sanders TG, Morrison WB, Singleton BA, et al. Medial patellofemoral ligament injury following acute transient dislocation of the patella: MR findings with surgical correlation in 14 patients. J Comput Assist Tomogr, 2001,25(6):957-962
23 Guerrero P, Li X, Patel K, et al. Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study. Sports Med Arthrosc Rehabil Ther Technol. 2009 Jul 30;1(1):17
24 Ellas D, White L, Fithian D: Acute lateral patellar dislocations at MR imaging: Injury patterns of medial soft tissue restraints and osteochondral injuries of the inferomedial patella. Radiology 2002, 225:736-43
25 Sillanpaa PJ, Maenpaa HM, Mattila VM, Visuri T, Pihlajamaki H: Arthroscopic surgery for primary traumatic patellar dislocation. Am J of Sports Medicine 2008, 36:2301-9
26 Camanho GL, Viegas Ade C, Bitar AC, et al. Conservative versus surgical treatment for repair of the medial patellofemoral ligament in acute dislocations of the patella. Arthroscopy. 2009, 25(6):620-5
27 Sillanp?? PJ, Peltola E, Mattila VM, et al. Femoral avulsion of the medial patellofemoral ligament after primary traumatic patellar dislocation predicts subsequent instability in men: a mean 7-year nonoperativefollow-up study. Am J of Sports Medicine 2009, 37:1513-21
28 Avikainen VJ, Nikku RK, Seppanen-Lehmonen TK. Adductor magnus tenodesis for patellar dislocation: technique and preliminary results. Clin Orthop 1993, 297:12-16
29 Robert N. Steensen, Ryan M, et al. The anatomy and isometry of the medial patellofemoral ligament: implications for reconstruction. Am J Sports Med 2004, 32; 1509-1513
1 Kaplan EB. Factors responsible for the stability of the knee joint. Bull Hosp Joint Dis 1957,18:51-59
2 Warren LF, Marshall JL. The supporting structures and layers on medial side of the knee: an anatomical analysis. J Bone Joint Surg, 1979, 61A:56-62
3 Robert N. Steensen, Ryan M, et al. The anatomy and isometry of the medial patellofemoral ligament: implications for reconstruction. Am J Sports Med 2004 32; 1509-1513
4 Nomura E, Horiuchi Y, Kihara M. A mid-term follow-up of medial patellofemoral ligament reconstruction using an artificial ligament for recurrent patellar dislocation. Knee 2000, 7(4):211-215
5 Ellera Gomes JL, Stigler Marczyk LR, Cesar de Cesar P, et al. Medial patellofemoral ligament reconstruction with semitendinosus autograft for chronic patellar instability: a follow-up study. Arthroscopy 2004, 20(2):147-151
6 Schottle PB, Fucentese SF, Romero J. Clinical and radiological outcomeof medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc 2005, 13(7):516-521
7 Cossey AJ, Paterson R. A new technique for reconstructing the medial patellofemoral ligament. Knee 2005, 12(2):93-98
8 Nomura E, Inoue M. Hybrid medial patellofemoral ligament reconstruction using the semitendinous tendon for recurrent patellar dislocation: minimum 3 years’follow-up. Arthroscopy 2006, 22(7): 787-793
9 Steiner TM, Torga-Spak R, Teitge RA. Medial patellofemoral ligament reconstruction in patients with lateral patellar instability and trochlear dysplasia. Am J Sports Med 2006, 34(8):1254-1261
10 Thaunat M, Erasmus PJ. The favourable anisometry: an original concept for medial patellofemoral ligament reconstruction. Knee. 2007;14(6): 424- 428
11 Nomura E, Inoue M, Kobayashi S. Long-term follow-up and knee osteoarthritis change after medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 2007, 35(11): 1851- 1858
12 SillanpaaP, Mattila VM, Visuri T, et al. Ligament reconstruction versus distal realignment for patellar dislocation. Clin Orthop Relat Res. 2008; 466(6):1475-1484
13 Watanabe T, Muneta T, Ikeda H, et al. Visual analog scale assessment after medial patellofemoral ligament reconstruction: with or without tibial tubercle transfer. J Orthop Sci 2008, 13(1): 32-38
14 Ahmad CS, Brown GD, Stein BS. The docking technique for medial patellofemoral ligament reconstruction: surgical technique and clinical outcome. Am J Sports Med 2009, 37(10):2021-2027
15 Ronga M, Oliva F, Longo UG, et al. Isolated medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 2009, 37:1735-1742
16 Senavongse W, Amis AA. The effects of articular, retinacular, or muscular deficiencies on patellofemoral joint stability. J Bone Joint Surg Br 2005, 87:577-582
17 Higuchi T, Arai Y, Takamiya H, et al. An analysis of the medial patellofemoral ligament length change pattern using open-MRI. Knee Surg Sports Traumatol Arthrosc 2010,18(11):1470-5
18 Steiner TM, Torga-Spak R, Teitge RA. Medial patellofemoral ligament reconstruction in patients with lateral patellar instability and trochlear dysplasia. Am J Sports Med 2006, 34:1254-1261
19 Parker DA, Alexander JW, Conditt MA, et al. Comparison of isometric and anatomic reconstruction of the medial patellofemoral ligament: a cadaveric study. Orthopedics 2008, 31(4):339-343
20 Aragāo JA, Reis FP, Vasconcelos DP, et al. Metric measurements and attachments levels of the medial patellofemoral ligament: an anatomical study in cadavers. Clinics 2008, 63:541-544
21 Nomura E, Inoue M, Osada N, et al. Anatomical analysis of the medial patellofemoral ligament of the knee, especially the femoral attachment. Knee Surg Sports Traumatol Arthrosc 2005,13:510-515
22 Tuxoe JI, Teir M, Winge S, et al. The medial patellofemoral ligament: a dissection study. Knee Surg Sports Traumatol Arthrosc 2002, 10: 138-140
23 Panayiotopoulos 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 Tarthrosc 2006, 14: 7-12
1 Nomura E. Classification of lesions of the medial patello-femoral ligament in patellar dislocation.Int Orthop 1999, 23: 260-263
2 Sallay PI, Poggi J, Speer KP, et al. Acute dislocation of the patella. A correlative pathoanatomic study. Am J Sports Med 1996,24:52-60
3 Sch?ttle PB, Fucentese SF, Romero J. Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc 2005,13: 516-521
4 Kaplan EB. Factors responsible for the stability of the knee joint. Bull Hosp Joint Dis 1957,18:51-59
5 Conlan T, Garth WP, Lemons J. Evaluation of the medial soft tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg 1993, 75Am:682-693
6 Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998,26(1): 59-65
7 Larson RL,Cabaud HE,Slocum DB,et al.The patellar compression syndrome:surgical treatment by lateral retinacular release.Clin Orthop 1978, 134:158-167
8 Warren LF, Marshall JL.The supporting structures and layers on medial side of the knee: an anatomical analysis. J Bone Joint Surg 1979, 61A:56-62
9 Reider B, Marshall JL, Koslin B, et al. The anterior aspect of the knee joint: an anatomical study. J Bone Joint Surg 1981, 63Am:351-356
10 Conlan T, Garth WP, Lemons J. Evaluation of the medial soft tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg 1993, 75Am: 682-693
11 Nomura E, Horiuchi Y, Kihara M. Medial patellofemoral ligament restraint in lateral patellar translation and reconstruction. Knee 2000; 7:121-127.Warren LF, Marshall JL. The supporting structures and layers on medial side of the knee: an anatomical analysis. J Bone Joint Surg 1979, 61A: 56-62
12 Smirk C, Morris H. The anatomy and reconstruction of the medial patellofemoral ligament. Knee 2003,10:221-227
13 Tuxoe JI, Teir M, Winge S, et al. The medial patellofemoral ligament: a dissection study. Knee Surg Sports Traumatol Arthrosc 2002, 10: 138-140.Feller JA, Feagin JA, Garrett WE. The medial patellofemoral ligament revisited: an anatomical study. Knee Surg Sports Traumatol Arthrosc 1993, 1: 184-186
14 Aragāo JA, Reis FP, Vasconcelos DP, et al. Metric measurements and attachments levels of the medial patellofemoral ligament: an anatomical study in cadavers. Clinics 2008, 63:541-544
15 Robert N. Steensen, Ryan M. et al. The Anatomy and Isometry of the Medial Patellofemoral Ligament: Implications for Reconstruction. Am. J. Sports Med 2004, 32:1509-1513
16 Hautamaa PV, Fithian DC, Kaufman KR, et al. Medial soft tissue restraints in lateral patellar instability and repair. Clinical orthopaedics and related research, 1998, 349:174-182
17 Nomura E, Horiuchi Y, Kihara M. A mid-term follow-up of medial patellofemoral ligament reconstruction using an artificial ligament for recurrent patellar dislocation. Knee 2000, 7(4): 211-215
18 Kang Huijun, Wang Fei, Chen Baicheng, et al. Functional bundles of themedial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2010, 18:1511-1516
19 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 Tarthrosc 2006, 14:7-12
20 Steensen RN, Dopirak RM, Maurus PB. A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft. Arthroscopy 2005,21:365-70
21 Mountney J, Senavongse W, Amis AA, et al. Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction. J Bone Joint Surg [Br] 2005,87-B:36-40
22 Sanders TG, Morrison WB, Singleton BA, et al. Medial patellofemoral ligament injury following acute transient dislocation of the patella: MR findings with surgical correlation in 14 patients. J Comput Assist Tomogr 2001, 25(6):957-962
23 Parker DA, Alexander JW, Conditt MA,et al. Comparison of isometric and anatomic reconstruction of the medial patellofemoral ligament: a cadaveric study. Orthopedics 2008 , 31(4):339-343
1 Brantigan OC, Voshell AF. The tibial collateral ligament: its bursae, and its relation to the medial meniscus. J Bone Joint Surg 1943, 25-A: 121-131
2 Avikainen VJ, Nikku RK, Seppanen-Lehmonen TK. Adductor magnus tenodesis for patellar dislocation: technique and preliminary results. Clin Orthop Rel Res 1993, 97:12-16
3 Vainionp?? S, Laasonen E, Silvennoinen T, et al. Acute dislocation of the patella: a prospective review of operative treatment. J Bone Joint Surg 1990, 72(3):366-369
4 Nomura E. Classification of lesions of the medial patello-femoral ligament in patellar dislocation.Int Orthop 1999, 23: 260-263
5 Sallay PI, Poggi J, Speer KP, et al. Acute dislocation of the patella. A correlative pathoanatomic study. Am J Sports Med 1996,24:52-60
6 Sch?ttle PB, Fucentese SF, Romero J. Clinical and radiological outcome of medial patellofemoral ligament reconstruction with a semitendinosus autograft for patella instability. Knee Surg Sports Traumatol Arthrosc 2005,13: 516-521
7 Kaplan EB. Factors responsible for the stability of the knee joint. Bull Hosp Joint Dis 1957,18:51-59
8 Larson RL,Cabaud HE,Slocum DB,et al.The patellar compression syndrome:surgical treatment by lateral retinacular release .Clin Orthop 1978,134:158-167
9 Warren LF,Marshall JL.The supporting structures and layers on medial side of the knee: an anatomical analysis. J Bone Joint Surg 1979, 61A:56-62
10 Kang Huijun, Wang Fei, Chen Baicheng, et al. Functional bundles of the medial patellofemoral ligament. Knee Surg Sports Traumatol Arthrosc 2010,18:1511-1516
11 Colan T, Garth WP, Lemons JE. Evaluation of the medial soft-tissue restraint of the extensor mechanism of the knee. J Bone Joint Surg Am 1993,75:682-693
12 Desio SM,Burks RT,Bachus KN.Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998,26(1):59 65
13 Nomura E,Fujikawa K,Takeda T, et al. Anatomical study of the medial patellofemoral ligament (in Japanese).Bessatsu Seikeigeka1992, 22:2-5
14 Sallay PI, Poggi J, Speer KP, et al. Acute dislocation of the patella : A correlative pathoanatomic study. Am J Sports Med 1996 ,24 :52- 60
15 Nomura E,Inoue M,Osada N. Augmented repair of avulsion tear type medial patellofemoral ligament injury in acute patellar dislocation.Knee Surg Sports Traumatol Arthrosc 2005,13(5):346- 351
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19 Deie M, Ochi M, Sumen Y, et al.A long-term follow-up study after medial patellofemoral ligament reconstruction using the transferredsemitendinosus tendon for patellar dislocation. Knee Surg Sports Traumatol Arthrosc 2005,13(7):522-528
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21 Steensen RN,Dopirak RM,Maurus PB. A simple technique for reconstruction of the medial patellofemoral ligament using a quadriceps tendon graft. Arthroscopy 2005,21(3):365- 370
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25 Paker DA, Alexander JW, Conditt MA, et al. Comparison of isometric and anatomic reconstruction of the medial patellofemoral ligament: a cadaveric study. Orthopedics 2008,31:339-343
26 Schottle P, Schmeling A,Romero J,et al. Anatomical reconstruction of the medial patellofemoral ligament using a free gracilis autograft.Arch Orthop Trauma Surg 2009,129(3):305-309
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30 Smirk C, Morris H. The anatomy and reconstruction of the medial patellofemoral ligament. Knee 2003,10:221-227
31 Hautamaa PV,Fithian DC,Kaufman KR,et al. Medial soft tissue restraints in lateral patellar instability and repair. Clinical orthopaedics and relatedresearch 1998, 349:174-182
32 Nomura E, Inoue M. Surgical technique and rationale for medial patellofemarol ligament reconstruction for recurrent patellar dislocation. Arthroscopy 2003,19(5):E47
33 Schottle PB, Hensler D, Imboff AB.Direct anatomic reconstruction of the medial patellofemarol ligament with the double-bundle technique aperture fixation .Arthroskopie 2008,21(3):192-195
34 Christiansen SE, Jacobsen BW, Lund B, et al. Reconstruction of the medial patellofemoral ligament with gracilis tendon autograft in transverse patellar drill holes. Arthroscopy 2008,24(1):82-87
35 Schottle PB, Weiler A, Romeo J. Reconstruction of the patellofemoral ligament in patellofemoral instability. Arthroskopie 2005, 18(5):293-300
36 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 Tarthrosc 2006,14:7-12