髌骨脱位成形术dislocation of the patella课件

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1、临床病例1dislocationofthepatella.患者孙某，女,23岁10年前摔伤致左髌骨脱位，自行复位，未给予特殊治疗，近日感左膝关节无力，轻度屈膝关节即出现髌骨脱位。查体：Q角（quadriceps-angle）26°（正常:女性15+5°）变大，恐惧试验，髌骨活动度，J征（J-sign-slight）阳性，髌骨研磨试验。左膝关节查体体格检查视频1Q角LT/LP大于1.2Q角大于20°测量髌骨关节匹配度TT-TGCT测量胫骨结节外移程度大于1.5厘米行结节内移CTMRI诊断？分型？治疗方案？固定方式？初步诊断——？左髌骨脱位急性、复发

2、性和固定性保守和手术单一固定和联合固定手术治疗外侧支持带松解近端内侧重排（支持带紧缩、MPFL重建等）远端重排（胫骨结节内移截骨等）髌骨切除（挽救性手术）内侧髌股韧带重建（MPFL）联合胫骨结节移位和关节镜下髌骨外侧支持带松解术治疗方案——联合方案重建手术方法关节镜检查，取出游离体正常髌股关节在屈膝45度时髌骨归位，位于滑车中心髌骨轨迹不良时外移内侧髌股韧带（MPFL）重建术1.半腱肌切取和处理；2.建立髌骨和股骨隧道；3.肌腱植入固定。MPFL重建外侧支持带松解术关节镜下前内侧入路，松解范围：距髌骨外侧缘1cm，自髌骨尖水平髌腱外侧缘至髌骨外上

3、极的外侧2cm、近侧2cm。Fulkerson-osteotomy方法：沿着胫骨结节外侧做纵形切口，显露胫骨结节及胫骨嵴。胫骨近端外侧面及内侧缘钻孔，成勺形形态，骨刀分离，保留胫骨远侧与胫骨主体的连接。内侧截骨线与冠状面成交45度截入，在松质骨区域做一个较为平整的骨面。将胫骨结节的近端向内侧推移1.5mm,一般用2枚3.5mm螺钉完成固定。Fulkerson-osteotomyPostoperativeX-rayPostoperativefunctionalOperativevsconservative?ConservativeNonsurgic

4、almanagementisgenerallyrecommendedforfirsttimedislocation,withimmobilizationinextensionfor3–6weekswithplacementofabrace.SurgicalA.Recurrentinstabilityfollowinginitialconservativemanagementoccursin15–50%.B.Chronicinstabilityandrecurrentdislocationsmaycausecartilagedamageandeve

5、ntualarthriticchanges.1.ChristinaEarhart.Transientlateralpatellardislocation:reviewofimagingfindings,patellofemoralanatomy,andtreatmentoptions.EmergRadiol.(2013)20:11–232.M.Petri,E.Liodakis,M.Hofmeister,Operativevsconservativetreatmentoftraumaticpatellardislocation:resultsofa

6、prospectiverandomizedcontrolledclinicaltrial.ArchivesofOrthopaedicandTraumaSurgery2013,(133)2,pp209-213Osteochondralfragments骨软骨碎片/loosebodies（游离体）Persistentpatellarsubluxation（持续性髌骨半脱位）Femoralavulsionofmedialstabilizersintheacutesetting急性内侧髌股韧带股骨止点撕脱Chronicpatellarinstabilit

7、y慢性髌骨脱位Ligamentousormeniscalinjury韧带/半月板损伤IndicationsforsurgeryBollierM,FulkersonJP(2011)Theroleoftrochleardysplasiainpatellofemoralinstability.JAmAcadOrthopSurg19(1):8–16Tibialtuberositytransfertoamoremedialposition(TT–TGdistance>20mm)reducesQ-angleanddecreaseslateralstresso

8、nthepatella.Osseousrealignmentprocedures（骨性重建）BollierM,FulkersonJP(2