急性滑脱性髌股关节撞击综合征的关节镜下治疗

The arthroscopic diagnosis and treatment of acute patellofemoral joint impingement syndrome

目的 探讨急性滑脱性髌股关节撞击综合征的损伤机制、MRI诊断特征以及关节镜下诊治方法.方法 2005年9月至2012年10月应用改良髌内侧支持带紧缩缝合治疗急性滑脱性髌股关节撞击综合征46例,男9例,女37例;年龄15～31岁,平均21.6岁.术前常规行膝关节X线及MR检查,测量Q角、外侧髌股角及髌骨外移度.MRI髌内侧支持带损伤按照Schweitzer分级标准：Ⅰ度15例、Ⅱ度18例、Ⅲ度8例、Ⅳ度5例.手术于关节镜监视下施行,清除关节内积血,关节内探查,取出游离软骨和骨软骨碎片,软骨成形,修整损伤软骨面.对髌内侧支持带Ⅰ度损伤者行关节镜下清理及髌内侧支持带固缩.对髌内侧支持带Ⅱ～Ⅲ度损伤伴明显髌骨移位者采用改良髌内侧支持带紧缩缝合术,对受伤时间超过2周的9例同时行髌外侧支持带松解.对髌内侧支持带Ⅳ度损伤者行切开加固缝合.结果 急性滑脱性髌股关节撞击综合征的关节镜下表现包括关节内血肿46例、股骨外髁和髌骨内侧骨软骨损伤37例、游离体形成28例及髌内侧支持带撕裂46例.所有病例均获得随访,随访时间12～36个月,平均18.2个月,无感染、神经血管损伤和再脱位等并发症发生.手术前后Lysholm膝关节评分、Tegner膝关节运动水平评分、AAOS膝关节评分、外侧髌股角及髌骨外移度的差异有统计学意义,患者运动功能均较术前有所改善.结论 关节镜下改良髌内侧支持带紧缩缝合辅助髌外侧支持带松解术,是治疗急性滑脱性髌股关节撞击综合征髌内侧支持带Ⅱ～Ⅲ度损伤的有效方法,有利于恢复膝关节功能,近期疗效好.

Objective To explore the mechanism and characteristics of MRI of acute patellofemoral joint impingement syndrome as well as its arthroscopic diagnosis and treatment.Methods There were a total of 46 cases （9 males and 37 females）with acute patellofemoral joint impingement syndrome from September 2005 to October 2012 in our department,and their average age was 21.6 years old （ranging from 15 to 31 years old）.The Q angle,lateral patellofemoral angle （LPA） and lateral shift distance （LSD） of all cases were measured by X-ray and MRI preoperatively.MRI checked the medial patellar retinaculum injury by 4 degrees：15 cases of degree Ⅰ,18 cases of degree Ⅱ,8 cases of degree Ⅲ,and 5 cases of degree Ⅳ.All operations were monitored under arthroscopy.Firstly,the hemarthrosis was cleared,and secondly arthroscopy was used to explore all around inside joints,the free cartilage and osteochondral fragment were taken out,and the impaired surface of cartilage was repaired.Medial patellar retinaculum was treated arthroscopically with radio frequency ablation in degree Ⅰ injury.Lateral patellar retinaculum was released when the time of injury was longer than 2 weeks （9 cases）,and medial capsule and retinaculum structure were reefed with modified arthroscopy assistance for patients with medial patellar retinaculum injury of degree Ⅱ to Ⅲ with obvious patellar shift.The medial capsule and retinaculum structure were strengthened by open surgical method for patients with degree Ⅳ injury.Results Constant findings under arthroscopy were haemarthrosis （46 cases）,chondral lesions involved in the lateral femoral condyle and medial marginal of patella （37 cases）,osteochondral fragments （28 cases）,and tear of the medical retinaculum （46 cases）.All patients were available at follow-up,the average duration of follow-up was 18.2 months （ranging from 12-36 months）.No infection,nerve and blood vessel injury,redislocation or other complications happened.Lysholm,Tegner and AAOS scores were used both preoperatively and postoperatively,and LPA and LSD were compared.Statistically,the difference between these two scores was significant （P〈0.05）.The sport ability was improved among all patients.Conclusion Acute patellofemoral joint impingement syndrome can be treated effectively by modified suture of medial capsule and retinaculum structure combined with release of lateral retinaculum.The function of knee joint recovered well after operation with satisfactory objective and subjective effects.