髌骨减容术临床应用

髌骨减容术（髌骨修整术）：常用于治疗髌骨关节骨关节炎患者，通过对髌骨骨性组织、髌骨周围软组织（如外侧支持韧带、内侧支持韧带）等处进行修整，达到减轻髌股关节面压力、恢复髌骨正常运动轨迹的目的，从而缓解膝关节前方疼痛症状，延缓髌股关节骨关节炎进展。髌骨减容术概念第一页，共29页。发病率Davies

CORR

2002:

–

在206

例膝关节X线检查中9.6%>

40岁13.6%

女性

>

60岁15.4

%男性>

60岁McAlindon

Ann

Rheum

Dis:

–

24

%

的女性，11%

的男性有骨性关节炎的症状

>

55

岁有单纯性髌股关节炎Curl

Arthroscopy

1997

–

31,516

例关节镜中:

4%

关节面4度损伤.

–

其中21%有髌骨损伤，15%有滑车损伤第二页，共29页。髌股关节炎分级1.根据髌骨轴位片分级：

Ⅰ级：关节间隙变窄，接近3mm；Ⅱ级：关节间隙变窄，<3mm，没有骨性接触；Ⅲ级：关节骨性部分接触；Ⅳ级：整个关节骨性接触第三页，共29页。髌股关节炎分级2.根据关节镜下软骨损伤分级（Outerbridge分级）：

O级：正常关节软骨；Ⅰ级：软骨变软或局部肿胀Ⅱ级：软骨表面纤维化轻，软骨缺损厚度小于50%；Ⅲ级：软骨表面纤维化重，软骨缺损厚度大于50%，但尚未暴露软骨下骨；Ⅳ级：软骨完全缺损，软骨下骨外露。第四页，共29页。髌股关节炎临床表现1.膝关节前方疼痛；2.上下楼梯、爬山、从坐姿站立、跪或蹲可加重；3.有时可因髌骨、滑车之间骨性摩擦出现绞锁症状；体查：1.膝关节屈伸活动受限；2.可触及摩擦音；3.髌周压痛（+）；4.髌骨活动度差；5.髌骨研磨试验（+）；第五页，共29页。髌股关节炎影像学及关节镜下表现第六页，共29页。保守治疗康复治疗

非甾体抗炎药

关节内注射

–

可的松

–

透明质酸支具

氨基葡萄糖?

富含血小板血浆?第七页，共29页。髌骨成形术

髌股关节炎常用手术治疗方法，通过切除髌骨周围增生骨赘，恢复光滑髌骨关节面，减少髌骨和滑车之间骨性摩擦，达到减容目的。优点：最大程度地保留髌骨骨量以及强度，术后疗效可靠，并发症发生率低。第八页，共29页。髌骨钻孔术（微骨折技术/骨髓刺激技术/microfracture技术/nanofracture技术）适用于：局部软骨退变及局部创伤性病变。小面积缺损（0.5-2cm2）或大面积损伤但功能要求低，损伤区边缘软骨质量要好。第九页，共29页。严格选择Microfracture技术修复的手术适应症，平均70%-95%的患者能提高膝关节功能，尤其以股骨髁软骨损伤患者术后效果最好。Steadman等在对233例患者采用Microfracture技术治疗，3年随访结果显示75%患者疼痛改善。但是术后18-24个月临床结果开始向坏的方向发展。CurlWW，KromeJ，GordonES，eta1．Cartilageinjuries：areviewof31516kneearthroscopies．Arthroscopy，1997，13(4)456-460SteadmanJR，BriggsKK，RodrigoJJ，etal．Outcomesofmicrofracturefortraumaticchondraldefectsoftheknee:average11-yearfollowup［J］．Arthroscopy，2003，19:477－484．KnutsenG，EngebretsenL，LudvigsenTC，etal．Autologouschondrocyteimplantationcomparedwithmicrofractureintheknee．Arandomizedtrial［J］．JBoneJointSurgAm，2004，86:455－464．骨髓刺激技术---microfracture技术第十页，共29页。髌骨部分切除术并外侧支持带松解术长期髌骨不稳定，髌骨运动轨迹异常，反复慢性髌骨外侧半脱位或脱位，导致髌骨软骨面压力不平衡，外侧面负荷增加，造成关节面软骨的破坏；髌骨外移可导致外侧支持带挛缩，内外侧力量失衡；可形成髌骨外侧牵拉型骨赘。第十一页，共29页。髌骨部分切除术并外侧支持带松解术适应症：1.严重髌股关节面病变，特别是外侧髌股关节退变；2.存在髌骨外侧半脱位或脱位；3.合并髌骨外侧软组织挛缩。第十二页，共29页。关节面切除术

:结果Poulos:Arthroscopy2008

–88%满意或者非常满意@5yearsMcCarrol:1983CORR:

–75%满意@4yearsMartens:1990ActaOrthopBelg

–65%良好,25%中等,10%差Yercan:CORR2005:

–疼痛减轻@8years第十三页，共29页。第十四页，共29页。第十五页，共29页。第十六页，共29页。关节面切除术:

长期随访Knee.

2012

Aug;19(4):411-5.

Epub

2011

May

18.Patellofemoral

osteoarthritis

treated

by

partial

lateral

facetectomy:

results

at

long-termfollow

up.WetzelsT,

BellemansJ.SourceDepartment

of

Orthopaedic

Surgery,

University

Hospital

Pellenberg,

Katholieke

UniversiteitLeuven,

Weligerveld

1,

3012

Pellenberg,

Belgium.

AbstractExcision

of

the

eroded

lateral

patellar

facet

has

been

suggested

as

an

acceptable

treatmentfor

short-term

pain

reduction

in

patients

with

isolated

patellofemoral

osteoarthritis.

Theoutcome

of

this

procedure

at

long-term

is

however

not

known.

We

therefore

reviewed

theresults

of

155

consecutive

patients

(168

knees)

treated

at

our

institution

with

lateralfacetectomy

at

an

average

follow

up

of

10.9

years

(±

6.9

years

SD).

During

follow

up

62knees

(36.9%)

had

failed

and

were

revised

to

either

TKA

(60

knees),

patellofemoralarthroplasty

(one

case)

or

total

patellectomy

(one

case).

Average

time

to

reoperation

in

thefailure

group

was

8.0

years

(±

6.2

years

SD).

Kaplan-Meier

survival

rates

with

reoperation

asendpoint

were

85%

at

5

years,

67.2%

at

10

years,

and

46.7%

at

20

years

respectively.

Atfinal

follow

up

79

(74.5%)

of

the

knees

that

had

not

been

re-operated

were

rated

as

eithergood

or

fair,

which

corresponds

to

47%

of

the

original

group.

Our

study

thereforedemonstrates

that

asatisfactory

outcome

after

lateral

patellarfacetectomy

for

isolated

patellofemoral

osteoarthritis

can

beexpected

in

approximately

half

of

the

cases

at

10

year

follow

up.第十七页，共29页。外侧支持带松解的生物力学效果:KneeSurgSportsTraumatolArthrosc.

2007

May;15(5):547-54.

Epub

2007

Jan

16.Dynamic

measurement

of

patellofemoral

kinematics

and

contact

pressure

after

lateral

retinacularrelease:

an

in

vitro

study.OstermeierS,

HolstM,

HurschlerC,

WindhagenH,

Stukenborg-ColsmanC.SourceOrthopaedics

Department,

Hannover

Medical

School,

Anna-von-Borries-Str.

1-7,

30625,

Hannover,

Germany.AbstractThe

purpose

of

this

study

was

to

investigate

the

influence

of

lateral

retinacular

release

and

medial

and

lateralretinacular

deficiency

on

patellofemoral

position

and

retropatellar

contact

pressure.

Human

knee

specimens

(n=

8,

mean

age

=

65

SD

7

years,

all

male)

were

tested

in

a

kinematic

knee-simulating

machine.

Duringsimulation

of

an

isokinetic

knee

extension

cycle

from

120

degrees

to

full

extension,

a

hydraulic

cylinder

appliedsufficient

force

to

the

quadriceps

tendon

to

produce

an

extension

moment

of

31

Nm.

The

position

of

the

patellawas

measured

using

an

ultrasound

based

motion

analysis

system

(CMS

100,

Zebris).

The

amount

ofpatellofemoral

contact

pressure

and

its

pressure

distribution

was

measured

using

a

pressure

sensitive

film(Tekscan,

Boston).

Patellar

position

and

contact

pressure

were

first

investigated

in

intact

knee

conditions,

aftera

lateral

retinacular

release

and

a

release

of

the

medial

and

lateral

retinaculum.

After

lateral

retinacular

releasethe

patella

continuously

moved

from

a

significant

medialised

position

at

flexion

(P

=

0.01)

to

a

lateralisedposition

(P

=

0.02)

at

full

knee

extension

compared

to

intact

conditions,the

centre

ofpatellofemoral

contact

pressure

was

significantly

medialised

(0.04)between

120

degrees

and

60

degrees

knee

flexion.

Patellofemoral

contact

pressuredid

not

change

significantly.

In

the

deficient

knee

conditions

the

patella

moved

on

a

significant

lateralised

track(P

=

0.04)

through

the

entire

extension

cycle

with

a

lateralised

centre

of

patellofemoral

pressure

(P

=

0.04)

witha

trend

(P

=

0.08)

towards

increased

patellofemoral

pressure.

The

results

suggest

that

lateral

retinacularrelease

did

not

inevitably

stabilise

or

medialise

patellar

tracking

through

the

entire

knee

extension

cycle,

butcould

decrease

pressure

on

the

lateral

patellar

facet

in

knee

flexion.

Therefore

lateral

retinacular

releaseshould

be

considered

carefully

in

cases

of

patellar

instability.第十八页，共29页。

外侧支持带松解术:

适应症外侧髌股关节退化性病变

Arthroscopy.

2002

Apr;18(4):399-403.

Lateral

release

for

patellofemoral

arthritis.

AderintoJ,

CobbAG.

METHODS:

Fifty

patients

who

underwent

53

lateral

retinacular

release

procedures

between

1995

and

1999

for

the

treatment

ofsymptomatic

patellofemoral

arthritis

were

assessed

by

questionnaire

comprising

the

Oxford

knee

score,

a

visual

analoguescale

(VAS,

0-10)

for

pain,

and

questions

relating

to

level

of

patient

satisfaction.

Patients

were

included

in

this

study

whetheror

not

tibiofemoral

arthritis

was

present,

but

lateral

release

was

performed

only

in

those

for

whom

the

anterior

knee

pain

of

patellofemoral

arthritis

appeared

to

predominate.

RESULTS:The

average

patient

age

was

53

years

(range,

27

to

79

years).

There

were

14

men

(28%)

and

36

women

(72%).

Follow-up

was

a

mean

of

31

months

(range,

12

to

65

months).

Four

patients

underwent

total

knee

replacement

at

7,

14,

16,

and

18

months

after

lateral

release

for

recurrence

of

symptoms.

In

the

remaining

49

knees,

mean

pain

VAS

was

3.8

+/-

2.8.

In

39knees(80%),patients

judged

that

they

had

experienced

a

reduction

in

paincomparedwiththeirpreoperativestate

(2

were

pain

free),

8

(16%)

were

unchanged,

and

2

(4%)

were

worse.

The

average

Oxford

knee

score

was

27

(range,

12-48).

At

follow-up,

33%

of

patients

were

very

satisfied,

26%

satisfied,

and

41%

dissatisfied

with

their

knee.

The

presence

of

tibiofemoral

disease

did

not

affect

any

of

the

outcomemeasures.

Two

patients

developed

superficial

infections

of

the

arthroscopic

port

sites.

There

were

no

cases

of

hemarthrosis.

CONCLUSIONS:

Arthroscopiclateralreleaseiseffectiveinreducingthepainofsymptomaticpatellofemoralosteoarthritisandgivesreasonableratesofpatientsatisfaction

irrespectiveofthepresenceoftibiofemoralarthritis第十九页，共29页。外侧支持带松解+关节面切除术ActaOrthopBelg.

1990;56(3-4):563-7.Facetectomy

of

the

patella

in

patellofemoral

osteoarthritis.MartensM,

DeRyckeJ.Department

of

Orthopaedic

Surgery,

University

Hospital,

Pellenberg,

Belgium.AbstractPatellofemoral

osteoarthritis

is

a

common

disease

which

may

occur

alone

or

in

associationwith

tibiofemoral

gonarthrosis.

In

cases

of

isolated

symptomatic

patello-femoralosteoarthritis

with

typical

lateral

malalignment

and

formation

of

osteophytes

at

the

lateralborder

of

the

patello-femoral

joint

we

perform

a

lateral

facetectomy

of

the

patella

andassociated

lateral

retinaculum

release.

The

results

of

a

prospective

study

of

20

cases

with

amean

follow-up

of

2

years

are

presented.Agood-to-moderateresultwasobtainedin90%.

The

average

age

was

60

years.

We

had

2

failures

with

a

subjectiverating

of

poor.

The

principal

reason

was

tibiofemoral

gonarthrosis

too

far

advanced

at

thetime

of

the

operation,

which

then

progressed

in

the

postoperative

course.

On

the

other

handthis

technique

results

in

marked

improvement

for

many

cases

and

carries

only

a

small

risk.Further

reconstructive

surgery

of

the

knee

is

not

excluded.

Because

of

the

minor

surgeryand

quick

recovery,

this

operation

presents

a

valid

alternative

to

more

involved

operationssuch

as

patellectomy,

Bandi

or

Maquet

reconstructive

procedures,

or

a

patellofemoralprosthesis.第二十页，共29页。髌骨周围去神经化术髌骨周围的神经主要有：1.皮神经；2.隐神经上支；3.伸膝肢关节支；原理：通过射频烧灼髌骨周围神经，起到“去神经化”目的，可以减少疼痛的传导，缓解膝关节前方疼痛。髌骨周围神经彼此分布交叉重叠，即使切断，也不能完全阻断髌丛神经支配，不会影响髌骨周围皮肤感觉，具有快捷、方便、准确以及安全等优点第二十一页，共29页。胫骨结节截骨术:方法前侧:

–

运用移植:

Maquet技术

–

不运用移植:

Cole技术前内侧

–

Fulkerson技术第二十二页，共29页。胫骨结节截骨:

适应症力线不正和不负重的髌骨和股骨滑车软骨缺损提高合并软骨面重建的疗效第二十三页，共29页。文献回顾：胫骨结节截骨术治疗髌股关节骨关节炎Maquet术:

62-96

%–

Schmid:

Long

Term

Results

Maquet

CORR

199380%良好/非常好–

Atkinson:

Ant/AM