复发性髌骨脱位诊治及治疗选择

Diagnosis and treatment of recurrent dislocation of the patella

复发性髌骨脱位多与髌骨内外侧支持带异常、高位髌骨、滑车发育异常、继发于股骨内侧或胫骨外侧扭转的旋转不良、内侧髌股韧带(MPFL)和股内侧斜肌的破坏或削弱有关。手术方法包括软组织手术、骨性手术或两种方法联合使用。确切的证据表明急性髌骨脱位者首选保守治疗;复发性髌骨脱位通常采用手术干预;MPFL重建需要建立精确的股骨隧道才可以达到解剖修复及最小的移植物张力。在骨骺未闭的患者及翻修手术中,MPFL重建术是安全可行的。远端重排术适用于复发性髌骨脱位伴有胫骨结节滑车沟距离增大的高位髌骨或髌骨外侧及远端有软骨病的患者。截骨术在技术上具有挑战性且并发症发生率高,目前尚无统一有效的术式能够治愈复发性髌骨脱位。

Recurrent instability is often multifactorial and can be the result of a combination of coronal limb malalignment, patella alta, malrotation secondary to internal femoral or external tibial torsion, a dysplastic trochlea, or disrupted and weakened medial soft tissue, including the medial patellofemoral ligament (MPFL) and the vastus medialis obliquus. Surgical treatment includes soft tissue surgery, bone surgery, or the use of two methods. High-level evidence supports nonoperative treatment for first-time lateral acute patellar dislocations. Surgical intervention is often indicated for recurrent dislocations. MPFL reconstruction requires precise graft placement for restoration of anatomy and minimal graft tension. MPFL reconstruction is safe to perform in skeletally immature patients and in revision surgical settings. Distal realignment procedures should be implemented in recurrent instability associated with patella alta, increased tibial tubercle-trochlear groove distances, and lateral and distal patellar chondrosis. In addition, trochleoplasty is technically challenging and has risk of complication. Of all these methods, there is no unique method which can cure the recurrent patella dislocation.