关节镜下髌骨成形、外侧支持带松解及髌周去神经化治疗中、重度髌股关节炎

Effects of arthroscopic patelloplasty combined with lateral patellar retinaculum release and circumpatellar denervation in treatment of moderate and severe patellofemoral osteoarthritis

目的探讨膝关节镜下髌骨成形、外侧支持带松解及髌周去神经化治疗中、重度髌股关节炎的临床疗效。方法采用回顾性病例对照研究分析2013年3月-2015年3月收治的80例中、重度髌股关节炎患者临床资料。根据治疗方法不同分为两组：A组40例，OuterbridgeⅢ级22例，Ⅳ级18例，行单纯关节镜清理术；B组40例，Outerbridgem级22例，Ⅳ级18例，关节镜下清理同时行髌骨成形、外侧支持带松解及应用射频髌周去神经化。比较两组术前及术后Kujula评分及Lysholm评分，评估髌股关节功能。术后3个月屈膝30。摄髌骨轴位X线片，测量外侧髌股角，评估髌股关节功能改善情况。结果80例患者获随访13～36个月，平均19．8个月。术后两组髌股关节功能评分均得到不同程度改善。Ⅲ级髌股关节炎患者，B组术后3个月、末次随访时Kujula评分[（85．1±6．8）分、（86．84-4．6）分]和Lysholm评分[（88．1±1．8）分、（88．4±2．3）分]均高于A组[（78．1±5．7）分、（78．3±5．3）分和（82．4±2．8）分、（82．5±2．5）分]（P〈0．05）；组内术后3个月及末次随访时Kujula评分、Lysholm评分均较术前提高（P〈0．05）；根据Lysholm评分，B组术后优良率（86％）高于A组（55％）（P〈0．05）。1V级髌股关节炎患者，B组术后3个月、末次随访时Kujula评分[（72．3±5．3）分、（72．7±3．6）分]及Lysholm评分[（75．1±1．9）分、（75．3±2．3）分]均高于A组[（70．8±5．2）分、（71．1±4．2）分和（73．4±2．8）分、（73．6±2．5）分]，但差异无统计学意义（P〉0．05）；组内术后3个月及末次随访时Kujula评分、Lysholm评分虽较术前提高，但差异无统计学意义（P〉0．05）；根据Lysholm评分，虽然B组术后优良率（33％）高于A组（28％），但差异无统计学意义（P〉0．05）。无论OuterbridgeⅢ级还是Ⅳ级髌股关节炎患者，A组术后3个月外侧髌股角较术前未见明显改善（P〉0．05），B组术后明显改善（P〈0．01），且较A组改善明显（P〈0．01）。结论与单纯关节镜下清理术相比，联合髌骨成形、外侧支持带松解及髌周去神经化能更好地缓解中度髌股关节炎症状并改善膝关节功能。而对于重度髌股关节炎患者，该手术方法疗效不佳。

Objective To investigate the clinical effects of arthroscopic patelloplasty combined with lateral patellar retinaculum release and circumpatellar denervation for treatment of moderate and severe patellofemoral osteoarthritis. Methods A retrospective case-control study was done on 80 patients with moderate to severe patellofemoral osteoarthritis who were treated in our hospital between March 2013 and March 2015. According to treatment methods, the patients were divided into two groups： Group A including 40 cases （22 cases of Outerbridge grade m degree and 18 cases of Outerbridge grade IV ） undergone arthroscopic debridement, and Group B including 40 cases （22 cases of Outerbridge grade m degree and 18 cases of Outerbridge grade IV ） undergone arthroscopic patelloplasty combined with lateral patellar retinaculum release and circumpatellar denervation. The Kujula scores and Lysholm scores of the patellofemoral joint were compared between the two groups before and after operation. The lateral patellofemoral angle was measured according to patellar axial X-ray performed 3 months after operation to evaluate patellofemoral joint function. Results All patients were followed up for 13-36 months （average 19.8 months）. The patellofemoral joint scores of the two groups was increased at different degrees after operation. In moderate patellofemoral osteoarthritis patients, at 3 months after operation and the last follow-up of Group B, Kujula scores [ （ 85.1 ±6.8 ） points, （ 86.8 ± 4.6） points I and Lysholm scores [ （88. 1 ± 1.8） points, （ 88.4 ± 2.3 ） points were higher than that of Group A I （78.1 ± 5.7） points, （78.3-5.3）points,（82.4 ---2.9）points, and （82.5 ±2.5）points] （P〈0.05）. In each group, the Kujula scores and Lysholm scores at 3 months after operation and the last follow-up were improved to be higher than p, reoperation （ P 〈 0.05 ） , with insignificant statistical difference between the two groups （P 〉 0.05 ）. According to the Lysholm scores, the excellent rate after operation in Group B （86%） was higher than that of Group A （55%） （P 〈0.05）. For patients with severe patellofemoral osteoarthritis, Kujula scores [ （72.3 ± 5.3 ） points, （72.7 ± 3.6） points I and Lysholm scores I （75. 1 ± 1.9） points, （75.3 ± 2.3 ） points ] at 3 months postoperatively and at the last follow-up in Group B were higher than that of Group A [ （70. 8 ± 5.2） points, （71. 1 ± 4. 2） points, （73.4± 2.8）points, and （73.6 ± 2.5 ）pointsl , but the difference was not statistically significant （P 〉 0.05 ）. Within each group, although the Kujula scores and Lyshohn scores at 3 months postoperatively and at the last follow-up were improved compared with befnre operation, but the difference was not statistically significant （ P 〉 0.05 ）. According to the Lysholm scores, although the excellent rate after operation of Group B （33%） was higher than that of Group A （28%）, with insignificant statistical difference （ P 〉 0.05 ）. No matter Outerbridge m or IV patellofemoral osteoarthritis a patient was, the lateral patellofemoral angle of Group A after operation had no significant improvement （ P 〉 0.05 ）, while Group B showed significant improvement after operation （ P 〈0. 01 ）. Group B had better improvements than that of Group A （ P 〈0. 01 ）. Conclusions Compared with simple arthroscopic debridement, patelloplasty combined with lateral patellar retinaculum release and circumpatellar denervation can better relieve the symptoms of moderate patellofemoral osteoarthritis and improve knee function. But for patients with severe patellofemoral osteoarthritis, this method is not effective.