透射定位法在复发性髌骨脱位重建内侧髌股韧带中的应用

Sch_ ttle method application in medial patellofemoral ligament reconstruction recurrent of patellar dislocation

目的通过回顾性分析术中透射定位法(Sch_ttle法)在复发性髌骨脱位重建内侧髌股韧带(MPFL)的应用,对临床疗效进行总结观察,探讨重建MPFL股骨侧解剖止点的定位法。方法2015年10月至2017年12月间,应用Sch_ttle法确定股骨侧止点19例,男3例,女16例,平均年龄(18. 1±0. 5)岁(15～20岁)。纳入标准:(1)膝关节外伤病史,且有反复髌骨外向脱位病史;(2) X片以及CT测量确定股骨滑车分型属于Dejour B、D型;(3)髌骨外推实验阳性;(4)髌骨外推恐惧试验阳性;(5)胫骨结节过度外偏。排除标准:(1)习惯性髌骨脱位;(2)骨骺未完全闭合;(3)膝关节局部存在感染病灶;(4)对手术期望值过高;(5)膝关节外骨性畸形。所有患者术前均拍摄膝关节正位、屈膝30°髌骨轴位片及CT测量胫骨结节-股骨滑车间距。术中所有病例均进行胫骨结节内移术,直径4. 5 mm金属带线缝合锚作为髌骨侧固定,重建韧带选择同种异体肌腱,Sch_ttle法确定股骨侧髓道。在术前和终末随访时对髌股适合角、外侧髌股角、膝关节功能Lysholm评分进行功能评估。采用配对t检验对数据进行统计分析。结果 19例均获得8个月～27个月,平均(20. 1±1. 3)个月随访,术后末次随访Lysholm评分明显改善,具有统计学意义(t=3. 328,P <0. 05)。术后恐惧试验均阴性,随访期间无髌骨再脱位。末次随访时患膝关节CT测量值:髌股适合角、外侧髌股角与术前比较差异均有统计学意义(t=12. 572、8. 334,P <0. 05)。术后关节活动度有所改善,但与术前比较差异无统计学意义(t=1. 764,P> 0. 05)。结论 Sch_ttle法能准确定位MPFL股骨侧止点位置,重建MPFL,结合胫骨结节内移的手术方法能重建髌股关节的稳定性。

Objective To retrospectively analyze the application of SchOttle method-a X-ray assisted method in the reconstruction of medial patellofemoral ligament(MPFL)in recurrent patellar dislocation,summarize and observe the clinical efficacy,and explore the positioning method of anatomical terminus of equal-length femoral reconstruction of MPFL.Methods From October 2015 to December 2017,SchOttle method was used to identify 19 femoral lateral fixation points,three males and 16 females,with an average age of(18.1±0.5)years(15~20 years old).Inclusion criteria:(1)history of knee joint trauma,and recurrent patellar extraversion dislocation history;(2)X-ray and CT measurements determine that the femoral trochlear classification belongs to Dejour B and D;(3)patella extrapolation test and patella pushout fear test are positive;(4)tibial nodules are excessively external.Exclusion criteria:(1)habitual patella dislocation;(2)epiphyseal is not completely closed;(3)local knee infection lesions;(4)high expectations for surgery;(5)external bone malformation of the knee joint.All the patients accepted anteroposterior and patellar axial X ray examinations with knee joint flexing to 30°,and CT scan for tibial tubercle-trochlear groove distance preoperatively.In all the cases,intraoperative tibial nodules internal transposition was performed.The anchor was sutured with 4.5 mm diameter metal band wire as the lateral fixation of patella,allogeneic tendon was selected for ligament reconstruction,and the lateral femoral medullary tract was determined by SchOttle method.Functional evaluation was performed on the appropriate patellofemoral angle,lateral patellofemoral angle,and Lysholm score of knee joint function before the operation and at the end of the follow-up.Statistical analysis was performed with paired t test.Results All 19 patients were followed up for(20.1±1.3)months on average.Postoperative fear test was negative and no patella redislocation occurred during the follow-up.The Lysholm score of knee joint function were statistically significant improved compared to the preoperative ones(t=3.328,P<0.05).Patellofemoral fitness angle and lateral patellofemoral angle,which were measured by CT scan,were also significantly improved(t=12.572,8.334,both P<0.05).The postoperative range of motion of the joint was improved but without statistically significant difference compared to that before the operation(t=1.764,P>0.05).Conclusion SchOttle′s method can accurately locate the lateral midpoint of MPFL femur,reconstruct MPFL,and reconstruct patellofemoral joint stability with the operation method of tibial nodule internal displacement.