一过性髌骨脱位MRI诊断及评估

目的 认识一过性髌骨脱位发病机制及MRI诊断。方法 回顾性分析2015-2016年间,40例一过性髌骨脱位的MRI表现,男19例,女21例。结果 35例患者均有明确屈曲外翻扭伤病史。13例髌骨内侧骨折或骨软骨骨折。40例在特定部位(股骨外侧髁前外侧面和/或髌骨内下侧面)发现软骨下骨髓水肿,其中34例同时在髌骨内下侧及股骨外侧髁承重面,6例仅在股骨外侧髁承重面。MRI发现40例髌内侧支持带均有损伤,其中11例I度、18例II度、11例III度;3例合并前交叉或后交叉韧带损伤。15例可见髌骨外侧半脱位。所有患者均可见关节腔积液。结论MRI能较好地显示一过性髌骨脱位特征部位的骨及髌内侧支持带损伤。     

急性滑脱性髌股关节撞击症的认识与MRI诊断

目的 认识并定义急性滑脱性髌股关节撞击症，探讨其发病机制及MRI诊断。方法 回顾性分析自2001年5月～2002年7月，34例经MRI诊断的急性滑脱性髌股关节撞击症的MRI表现，并结合临床资料、X线片、CT及关节镜所见进行分析。从矢状、冠状及横断三个平面行MR扫描，扫描方法采用：(1)三维快速梯度回波序列(FE3D)T1及T2加权像．该序列可较好地显示关节软骨及软骨下骨的损伤程度；(2）脂肪抑制梯度回波反转恢复序列(STIR)PD加权像，该序列对骨及软骨损伤有非常高的敏感性；(3)脂肪抑制快速自旋回波反转恢复序列(TSHIRT)T2加权像，该序列可显示韧带损伤情况。结果34例外伤后膝关节MRI均显示髌骨内下部及股骨外髁前外侧部对应的软骨下骨质异常信号改变。表明为骨损伤．与关节镜相比，34例中MRI可见20例髌骨内下部软骨骨折．其中15例为骨软骨骨折；8例股骨外髁前外侧部软骨骨折，其中6例为骨软骨骨折；11例关节囊内可见游离软骨或骨软骨碎片影。27例MRI显示不同程度髌内侧支持带损伤，其中Ⅰ度8例，Ⅱ度12例，Ⅲ度7例。所有患者均可见关节积液，其中单纯积液6例，血性积液18例．脂肪血性积液10例。23例可见髌骨外侧半脱位，结论 急性滑脱性髌股关节撞击症拟定义为当膝盖节急性屈曲外翻时．髌骨在向外侧滑脱或脱位后再自行复位的过程中．髌骨内侧面与股骨外髁相互撞击或挤压．并随之产生的一系列膝关节各解剖结构的损伤，主要包括髌骨内侧面骨软骨损伤、股骨外髁前外侧部骨软骨损伤、髌骨脱位或半脱位、髌内侧支持带损伤，关节囊积液。MRI提高对该症的检出率，并可全面而准确地表现各解剖结构的损伤程度。     

急性滑脱性髌股关节撞击综合征的关节镜下治疗

 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。     

自体半腱肌腱游离移植重建内侧支持带治疗复发性髌骨脱位

目的探讨关节镜下外侧髌股支持带松解和自体肌腱游离移植重建内侧髌股支持带治疗复发性髌骨脱位的疗效。方法复发性髌骨脱位18例,男6例,女12例。年龄17～24岁,平均20岁。关节镜下软骨Ⅳ度损伤者7例采用刨削打磨后微骨折术,软骨损伤Ⅱ度6例和Ⅲ度5例采用射频气化清理。外侧髌股支持带充分松解后,采用自体半腱肌腱游离移植重建内侧髌股支持带,关节镜下动态调整移植肌腱在不同角度下屈伸活动时的张力和髌骨运动轨迹,观察股骨滑车与髌骨的对应关系。采用可吸收界面螺钉将肌腱端固定于股骨内收肌结节的骨道内。结果所有患者术后均获随访,平均13个月(9～19个月)。术后膝关节稳定性增加,无髌骨再脱位发生。恐惧试验阴性,髌骨倾斜试验对称,髌股关节研磨试验阴性16例,阳性2例。1例术后髌骨下极骨折,经手术后功能恢复正常。髌骨轴位X线片和MRI显示髌股关节解剖关系恢复正常15例,髌骨轻度半脱位3例。Lysholm评分术前平均(78.0±4.5)分,术后(94.0±3.5)分。结论关节镜下外侧髌股支持带松解与自体肌腱游离移植重建内侧髌股支持带治疗复发性髌骨脱位,方法简便,对于维持髌骨的运动轨迹具有重要作用。     

伴软骨损伤的Hoffa骨折1例

患者,男,31岁,2019年11月29日因扭伤致右膝部疼痛肿胀、膝关节活动受限,于当地医院诊断为右股骨外侧髁骨折。为进一步治疗,于2019年12月3日至山东省中医院就诊,诊断为右Hoffa骨折。CT检查显示:右股骨外侧髁骨折,右膝关节积液。MRI显示:①右膝关节积液;②右股骨远端外髁骨折,右胫骨近段及髌骨有骨挫伤表现;③右髌骨轻度脱位表现,髌内外侧支持带损伤;④右膝前交叉韧带断裂,胫腓侧副韧带、后交叉韧带损伤;⑤右膝内侧半月板后角、外侧半月板前角损伤,外侧前角部分撕裂可能。2019年12月10日在腰硬联合麻醉下行关节镜下右膝探查清理术+半月板损伤修补缝合术+股骨外侧髁骨折切开复位内固定术。患者仰卧位,取膝关节前内、前外侧切口,建立关节镜观察及工作通道。置入关节镜观察关节腔内髌上囊、髁间窝、内外侧间室等结构,见髌骨内侧支持带损伤,髌骨轻度脱位,刨刀清理髌骨内侧支持带游离缘,内侧间室股骨髁边缘骨赘未予特殊处理。     

自体半腱肌腱游离移植重建内侧髌股韧带治疗儿童复发性髌骨脱位

[目的]探讨自体半腱肌腱游离移植重建内侧髌股韧带治疗儿童复发性髌骨脱位的疗效和安全性.[方法]2008年2月～ 2010年2月治疗复发性髌骨脱位患儿7例.术中关节镜探查髌骨轨迹,处理合并损伤.行外侧支持带松解,自体半腱肌腱游离移植重建内侧髌股韧带.股骨侧避开骺软骨放置3.5 mm锚钉,髌骨内缘钻2个4.5 mm骨道,髌骨复位后将肌腱穿入骨道打结固定.[结果]随访12 ～24个月(平均17个月),手术效果满意,无复发脱位,无骨骺早闭,术后X线片示髌股关节解剖关系恢复正常.[结论]关节镜探查结合外侧支持带松解和自体半腱肌腱游离移植重建内侧髌股韧带治疗儿童复发性髌骨脱位,方法简单安全,疗效可靠.     

急性髌骨脱位的关节镜下诊断与治疗

目的 探讨急性髌骨脱位的关节镜下表现,评价关节镜下治疗方法对其的疗效.方法 2001年2月至2003年12月,共收治急性髌骨脱位16例17膝,女12例,男4例,1例女性患者为双侧发病.年龄14～31岁,平均21.9岁.从发生髌骨脱位到手术的时间间隔为3～25 d,平均13.6 d.术前对所有患者进行放射学检查,观察髌骨的形态和位置、股骨滑车角、髌骨外侧半脱位和下肢对线的状况.临床测量Q角和全身关节松弛度.全部手术均在关节镜监视下施行.首先引流关节内血肿,而后进行全面的关节内探查,取出游离的软骨和骨软骨碎片,施行软骨成形术,修整损伤的软骨面,最后松解外侧支持带以及紧缩缝合内侧支持带.结果 关节镜下表现包括关节内血肿,股骨外侧髁和髌骨内侧骨软骨损伤,游离体形成以及内侧支持结构撕裂.所有病例均获得随访,随访时间1.5～3.5年,平均2.1年,均未发生感染等严重并发症,也无关节内大量血肿和髌骨缺血性坏死发生.全部病例膝关节活动度恢复正常,恢复至术前的活动水平,未发生再脱位.5例患者术后早期主诉髌骨内侧存在牵拉感和弹响.所有病例均未出现重度髌股关节退行性改变.结论 关节镜手术是诊断和治疗急性髌骨脱位的优良方法,操作简便,疗效可靠.     

MRI对滑脱性髌股关节撞击综合征的诊断价值分析研究

目的研究分析3.0T MRI检查滑脱性髌股撞击综合征的诊断准确性及临床应用性。方法选取2018年1月至2019年7月医院收治的64例滑脱性髌股撞击综合征患者,对其进行3.0T MRI检查,所有患者的影像学资料均有两名影像科副主任医师按照双盲法进行分析、诊断。结果 64例患者均为髌骨挫伤,挫伤位置为髌骨内侧缘的皮质下方,有12例挫伤延至髌骨嵴。有52例患者伴有股骨的外侧髁损伤,损伤位置为外侧髁的前侧外缘的皮质下方或者外侧缘的前部、中部,有8例损伤延至后部。韧带损伤中,所有患者均伴有内侧支持带受损,另有16例患者同时伴有外侧支持带受损,64例患者中,有11例伴有前交叉韧带受损,6例伴有后交叉韧带受损,14例内侧副韧带受损,5例外侧副韧带受损。有12例半月板撕裂,64例患者均存在关节腔积液,其中22例为血性积液。结论应用3.0T MRI检查滑脱性髌股关节撞击综合征,可以有效观察骨挫伤、韧带受损等情况,为临床医师对此类疾病的诊断提供重要的参考基础,另外,对韧带损伤严重度的评估,利于判断患者是否进行手术治疗。     

髌骨横轴-股骨通髁线角在评估髌股关节排列紊乱中的作用

目的 探讨MRI上髌骨横轴-股骨通髁线角在评估髌股关节排列紊乱中的作用.方法 从2005年1月至2006年12月行膝关节镜手术的病例中选取主诉膝前痛、膝关节镜检查证实存在髌股关节软骨损伤的患者111例为损伤组;无膝前痛、膝关节镜检查证实髌股关节完好、仅有单纯半月板损伤的患者124例为对照组.所有研究对象均行膝关节MR检查,在MRI轴位图像上测量外侧髌股角、髌骨倾斜角(前)(以股骨前髁连线为参考)、髌骨倾斜角(后)(以股骨后髁连线为参考)及髌骨横轴-股骨通髁线角.为排除年龄与性别对结果的影响,损伤组与对照组按照性别相同、年龄相差3岁以内随机进行1:1配对,配对后采用配对没计资料t检验分析各参数在评估髌股关节排列紊乱中的作用.结果 配对后外侧髌股角、髌骨倾斜角(前)、髌骨倾斜角(后)及髌骨横轴-股骨通髁线角在损伤组依次为18.94°±7.35°、6.89°±7.58°、6.89°±7.55°、6.55°±7.14°,在对照组依次为20.55°±6.25°、4.11°±4.02°、3.86°4±2.95°、3.76°±2.84°.两组外侧髌股角差异无统计学意义,而髌骨倾斜角(前、后)及髌骨横轴-股骨通髁线角差异有统计学意义.损伤组中股骨前髁骨缺损15例,股骨后髁骨缺损8例,未见股骨内、外上髁骨缺损.对照组骨质良好无缺损.结论 髌骨横轴-股骨通髁线角是评估髌股关节排列紊乱的有效参数.     

急性滑脱性髌股关节撞击征的MRI诊断价值

目的探讨急性滑脱性髌股关节撞击征诊疗过程中MRI的应用价值。方法对72例该类损伤的影像学检查结果进行详细分析、总结。结果常规X线检查对存在髌骨脱位或半脱位及发生骨折时有一定诊断价值,但不能确诊该病症。应用MRI检查,对软骨损伤、骨软骨骨折、骨挫伤、撕脱骨片损伤部位、支持带损伤及关节囊积液等情况均可单期明确诊断。结论MRI扫描应作为本病症的首选检查,以早期及时确诊和治疗。     

Isolated osteochondral fracture of the patella without patellar dislocation

Chondral fractures of the patella are associated with acute dislocation of the patella. Osteochondral fracture in patellar dislocation is located in the medial facet of the patella. This article presents a case of a 15-year-old female ballerina with isolated displaced osteochondral fracture of the patella without patellar dislocation. She had no history of trauma. A Merchant's view of both knees showed mild subluxation of the patella, a small fragment on the lateral aspect of the knee, and a small defect of the centromedial patella. Axial magnetic resonance imaging (MRI) revealed an osteochondral fragment measuring 13 mm medial to the patella. However, the medial patellofemoral ligament and medial retinaculum were intact. An effusion on the medial side of the patella consistent with hemarthrosis was observed. An absence of a contusion or bone bruise on the lateral femoral condyle was shown. The loose body was removed arthroscopically. Intraoperative findings included a 1.5×2 cm osteochondral fragment. It is unusual that the osteochondral patellar defect site in this patient was in the inferior and central areas of the patella. Patellar chondral fractures without dislocation or patella fracture are rare. Therefore, the possibility of a trivial trauma leading to an osteochondral fracture should be kept in mind in adolescent and young adults who present with knee pain and hemarthrosis.     

Why do orthopaedic surgeons ignore the medial patellofemoral ligament?

The medial patellofemoral ligament (MPFL) is a condensation of the medial capsule of the knee joint. In the past two decades dissection studies have shown that it extends from the superomedial border of the patella to the femoral epicondyle, at or immediately above the adductor tubercle. MRI and operative studies have revealed that it is almost invariably damaged by lateral patellofemoral dislocation. Current surgical management of such dislocations may involve imbricating the torn medial capsule and parapatellar retinaculum back onto the medial border of the patella. If the medial patellofemoral ligament is torn at or near the femoral attachment, as the latest MRI and operative studies demonstrate it frequently is, then this medial reefing procedure will not be successful in restoring normal anatomy and function. Here we review the anatomy and function of the MPFL, its role in patellar dislocation and as well as surgical treatment for patellar dislocation.     

急性滑脱性髌股关节撞击综合征的关节镜诊断与治疗

目的探讨急性滑脱性髌股关节撞击综合征的发生机制、病理改变及其关节镜下诊断和治疗方法。方法2000年1月至2003年5月,在关节镜下诊断和治疗急性滑脱性髌股关节撞击综合征25例,均为膝关节急性屈曲外翻扭伤。根据撞击后肌肉松弛状态下髌股关节的稳定性将其分为3型:无脱位型9例,半脱位型11例,脱位型5例。关节镜检查25例均存在软骨损伤、髌骨内侧支持带损伤及关节囊积血,18例有关节内游离体。根据分型及关节镜下检查结果采用不同的手术方式:无脱位型患者行关节清理术;半脱位型患者中髌骨内侧支持带Ⅰ度损伤者,行关节清理术 外侧支持带松解术;半脱位及脱位型患者中,轻者行关节清理术 髌骨内侧支持带缝合术 外侧支持带松解术,严重者或存在滑车发育异常者同时行胫骨结节移位术。结果所有患者均获随访,时间6～46个月,平均17个月。优18例,良4例,可2例,差1例,优良率88%。1例术后1年发生再脱位,2例有关节僵直。结论关节镜检查对急性滑脱性髌股关节撞击综合征的诊断具有极高的价值,可以明确诊断,并对损伤情况作出全面评估及制定合理的治疗方案,修复须紧急处理的结构。对于急性滑脱性髌股关节撞击征早期诊断、早期合理治疗,均可获得良好的效果。     

A new minimally invasive surgical technique for medial retinaculum repair following traumatic patellar dislocation

A new surgical method is introduced offering a less invasive approach to reattach the medial retinaculum following acute patellar dislocation. This retrospective analysis comprised 12 cases of medial retinacular repair in 10 patients. The surgical technique achieved reinforced reattachment of the torn region of the medial retinaculum for improved patellar support and stabilization. During follow-up, no recurrent patellar dislocations occurred, except where one patient reported a subjective feeling of patellar dislocation. The average Kujala score for our sample group after 2 years was 89.2. A plethora of methods are described in the literature to repair a tear to the medial patellofemoral ligament, which attaches at the superomedial patella. However, it is our contention that traumatic patellar dislocation invariably results in osteochondral avulsion at the inferomedial patella, refuting medial patellofemoral ligament involvement, and, rather, implicating the inferior aspect of the deep layer of medial retinaculum. Our surgical technique enables stable fixation of the region, decreasing the rate of recurrent dislocations. No grafts are used, permitting tendinous and ligamentous anatomy to remain intact. We further postulate that performing a CT examination preoperatively may reduce time between diagnosis and surgery, in addition to locating fracture sites more precisely.     

关节镜辅助下小切口微创治疗急性髌骨脱位

目的探讨关节镜辅助下小切口微创治疗急性髌骨脱位的方法和疗效。方法 2008年7月至2011年9月,我科收治急性髌骨脱位14例,男9例,女5例;年龄16~28岁,平均(21.8±5.3)岁。患者入选条件:所有患者均有明确膝关节暴力外伤史,排除关节松弛和髌股关节发育异常。从发生髌骨脱位到手术的时间间隔为3~14 d,平均5.6 d。术中先行关节镜检查并清理关节腔内积血和处理关节软骨损伤后,在髌骨内侧做1个1.5 cm长纵行小切口,通过上下推移皮肤,在髌骨中上部拧入带线锚钉,使用过线方法折叠缝合髌内侧支持带,视髌骨复位情况行外侧支持带松解。结果 14例患者获得随访,术后随访24~60个月,平均36.1个月。全部病例未再次发生脱位,恐惧试验全部阴性。关节活动度均在正常范围,3例关节早期过屈时有轻度紧张感,随访患者均恢复伤前的生活状态。所有病例均未出现重度髌股关节退行性改变。结论关节镜辅助下小切口治疗急性髌骨脱位安全、可行,疗效显著。     

复发性髌骨脱位的治疗进展

复发性髌骨脱位主要表现为髌骨反复性脱位、"打软腿"等,大多有外伤史或膝关节发育不良的基础。传统治疗方法包括内侧支持带紧缩、外侧支持带松解、胫骨结节移位、股骨滑车成型术等。近年来随着对内侧髌股韧带(MPFL)解剖结构及生物力学的研究逐渐深入,MPFL防止髌骨脱位的作用越来越被重视,通过重建MPFL来恢复髌骨正常轨迹日益增多。目前尚无一种术式能够完全治疗复发性髌骨脱位,具体治疗根据患者的解剖及生物力学情况,选择合适的术式联合治疗,恢复患者的髌骨稳定性、下肢力线及尽可能恢复膝关节功能。     

Weight-bearing osteochondral lesions of the lateral femoral condyle following patellar dislocation in adolescent athletes

In patients with patellar dislocation, osteochondral injury is often an indication for early surgical intervention. However, no studies have identified a relationship between injury to the weight-bearing surface of the lateral femoral condyle following a patellar dislocation and the eventual need for surgical treatment. The authors hypothesized that a significant number of patients sustain injury to the weight-bearing surface of the lateral femoral condyle following an acute patellar dislocation.Radiographs and magnetic resonance images were retrospectively reviewed and the patterns of injury were evaluated for 80 patients with a diagnosis of acute patellar dislocation, including the presence of osteochondral damage, the location of the medial patellofemoral ligament injury, and concomitant meniscal pathology. Magnetic resonance imaging identified a 27.5% incidence of osteochondral injury involving the articular, weight-bearing region of the lateral femoral condyle following an acute lateral patellar dislocation. Surgical intervention was performed in more than 60% of these injuries, and most were not identified with plain radiographs. Injury to the weight-bearing surface of the lateral femoral condyle following patellar dislocation was 3.6 times more common in boys in the current study population.Osteochondral injury to the weight-bearing surface of the lateral femoral condyle may occur in a high percentage of patients following a lateral patellar dislocation and in a higher percentage of boys than girls. Patients with tenderness over the lateral femoral condyle following an acute lateral patellar dislocation should undergo magnetic resonance imaging.     

Chondral and osteochondral injuries associated with acute patellar dislocation

Purpose: The purpose of this study was to evaluate the frequency and precise pathology of articular cartilage injuries after acute patellar dislocation. Type of Study: Case series. Methods: In 39 consecutive knees with initial lateral patellar dislocation, the articular cartilage injuries were examined using arthroscopy or macroscopic observation. Results: Thirty-seven knees (95%) had articular cartilage injuries of the patellofemoral joint and 2 knees (5%) had no cartilage injury. In all 37 knees (95%), articular cartilage injuries were observed in the patella. The appearances were categorized into 3 groups: cracks alone (9 knees), cartilage defect caused by osteochondral or chondral fracture (7 knees), and cartilage defects caused by osteochondral or chondral fracture associated with cracks (21 knees). The main site of osteochondral fracture was the medial facet, and the main site of cracks was the central dome. Twelve knees (31%) had cartilage injury of the lateral femoral condyle. Conclusions: From this study, articular cartilage injuries, especially of the patella, seem to be common occurrences after acute patellar dislocation. Chondral and osteochondral injuries of the patella were classified into 3 groups.     

关节镜辅助下小切口重建内侧髌股韧带治疗创伤性复发性髌骨脱位

目的探讨关节镜辅助下小切口同种异体肌腱重建内侧髌股韧带(MPFL)治疗创伤性复发性髌骨脱位的临床效果。方法回顾性分析自2006年1月～2010年4月共收治28例创伤性复发性髌骨脱位,所有患者在第一次脱位均为膝关节外伤所致,伤后患膝明显肿胀及髌骨脱位-复位感,此后出现髌骨脱位3次以上者。手术方法:先行关节镜检查,髌骨外侧支持带紧张者行松解术,关节镜监视下调整MFPL的张力并于其解剖止点以同种异体肌腱重建MFPL,术后接受正规功能康复锻炼。结果术后平均随访26个月(12～36个月)。重建术后无髌骨再次脱位发生,髌股关节稳定。术前、术后均采用Lysholm和Kujala膝关节评分标准,手术前后评分差异有统计学意义(P<0.05)。结论选择适当的病例,重建内侧髌股韧带是治疗创伤性复发性髌骨脱位的有效方法。