关节镜下髌骨内侧支持带紧缩术治疗青少年复发性髌骨脱位

TREATMENT OF RECURRENT PATELLAR DISLOCATION WITH ARTHROSCOPIC MEDIAL RETINACULUM PLICATION IN ADOLESCENTS

目的探讨关节镜下髌骨内侧支持带紧缩术(medial retinaculum plication,MRP)治疗青少年复发性髌骨脱位的临床疗效。方法对2000年3月-2007年10月收治的30例符合选择标准的青少年复发性髌骨患者进行前瞻性研究,其中28例获完整随访者纳入研究。男5例,女23例;年龄12～19岁,平均14.7岁。左膝12例,右膝16例。髌骨首次脱位至入院时间4～39个月,平均18.8个月。患者既往髌骨2～4次脱位。患者髌骨外推恐惧试验均为阳性,髌骨外移度为(2.9±0.7)°,髌骨外推无硬性终止点。国际膝关节文献委员会(IKDC)、Lysholm、Kujala以及Tegner评分分别为(47.7±3.7)、(52.6±4.9)、(66.7±5.9)和(3.1±1.3)分。患者均于关节镜下行MRP治疗。结果患者术后切口均Ⅰ期愈合,无感染或神经、血管损伤等早期并发症发生。患者均获随访,随访时间2～7年,平均4.8年。术后随时间延长,髌骨外推恐惧试验阳性患者数逐渐增加,24个月时为12例;髌骨外推有硬性终止点患者逐渐减少,24个月时为3例;髌骨外移度逐渐增加,24个月为(2.3±1.1)°;以上3项指标除髌骨外移度外,与术前比较差异均有统计学意义(P<0.05)。术后6例发生再脱位,23例出现单纯髌骨不稳。术后24个月IKDC、Lysholm、Kujala以及Tegner评分分别为(62.5±6.2)、(70.7±5.1)、(76.6±4.8)和(3.9±0.7)分,均较术前显著提高(P>0.05)。CT检查示,术后即刻患者髌股关节适配角、髌骨外侧角以及髌骨倾斜角均恢复至正常水平,但术后24个月与术前比较差异均无统计学意义(P>0.05);术后24个月髌骨外移距离与术前比较,差异有统计学意义(P<0.05)。结论关节镜下MRP治疗青少年复发性髌骨脱位虽在改善膝关节功能方面有一定疗效,但不能较好维持髌骨矫正后的位置。

Objective To explore the effectiveness of arthroscopic medial retinaculum plication （MRP） for recurrent patellar dislocation in adolescents. Methods Between March 2000 and October 2007, 30 adolescent patients with recurrent patellar dislocation underwent arthroscopic MRP, and 28 of them （12 left knees and 16 right knees） completed the final follow-up and were enrolled. There were 5 males and 23 females with an average age of 14.7 years （range, 12-19 years）. The dislocation duration was 4 to 39 months with an average of 18.8 months. All patients experienced 2-4 episodes of dislocation. Before operation, all the patients showed positive apprehension test; the degree of lateral patellar translation was （2.9 ±0.7）° and there was no hardness termination in lateral translation. The International Knee Documentation Committee （IKDC）, Lysholm, Kujala, and Tegner scores were 47.7±3.7, 52.6±4.9, 66.7±5.9, and 3.1±1.3, respectively. All patients underwent arthroscopic MRP procedure. Results All incisions healed by first intention without complication. All the patients were followed up 2-7 years （4.8 years on average）. During the follow-up, more and more patients showed positive apprehension test, and at 24 months of follow-up, 12 patients showed positive apprehension test; less and less patients had hardness termination in lateral translation, only 3 patients at 24 months of follow-up; the degree of lateral patellar translation increased, （2.3±1.1）° at 24 months of follow-up. There were significant differences in positive apprehension test and hardness termination between preoperation and 24 months of follow-up （P 〈 0.05）. Moreover, 6 patients suffered from redislocation, and 23 patients experienced patella instability. The IKDC, Lysholm, Kujala, and Tegner scores at 24 months of follow-up were 62.5±6.2, 70.7± 5.1, 76.6±4.8, and 3.9±0.7, respectively, showing significant differences when compared with preoperative scores （P 〈 0.05）. CT examination showed that the congruence angle, lateral patellar angle, and patellar tilt angle were recovered to normal level after operation immediately, however, the final patellar position at 24 months of follow-up was not significantly better than that before surgery （P 〉 0.05）. There was significant difference in the lateral patellar displacement between preoperation and 24 months of follow-up （P 〈 0.05）. Conclusion Arthroscopic MRP is not reliable for maintaining the corrected position of the patella for recurrent patellar dislocation in adolescents, though functional improvements are significant.