改良髌骨双骨道法自体股薄肌腱重建髌骨内侧支持带治疗复发性髌骨脱位

摘要

目的 探讨改良髌骨双骨道法自体股薄肌腱重建髌骨内侧支持带(medial patellofemoral ligament,MPFL)治疗复发性髌骨脱位的临床效果,同时探讨解剖高危因素对术后效果的影响. 方法 2007年1月～ 2010年2月,对36例髌骨复发性脱位(单侧31例,双侧5例)采用改良髌骨双骨道法自体股薄肌腱重建MPFL,在髌骨内上缘由后内向前外向髌骨内1/2表面平行钻2个3.5 mm骨道,将股薄肌腱引过骨道,将股薄肌腱的两游离端拉入股骨内侧骨道,屈膝30.位可吸收螺钉固定.对所有患者的Beighton评分,Q角,Insall指数,滑车发育不良分级,胫骨结节-滑车沟距离(TT-TG)等进行测量.临床评分采用Kujala,Lysholm和Tegner评分,同时调查患者的满意度. 结果 32例对手术的效果非常满意,3例满意,1例不满意.Kujala、Lysholm、Tegner评分分别由术前(64.3±15.0)、(65.1±18.6)、(3.2±1.1)分显著提高到术后(92.4±9.2)分(t=4.657,P=0.002),(92.0±10.1)分(t=3.936,P=0.006)和(5.2±1.0)分(t=6.633,P=0.001).80.6％ (29/36)的患者在术后6～8个月恢复到受伤前的运动水平.1例术后1年再次髌骨脱位.97.6％ (40/41)的膝关节存在股骨滑车发育不良,Beighton评分(5.2±2.5)分,Insall指数为1.22±0.14,Q角(13.6±3.9).,TT-TG值(13.7 ±4.4)mm,与功能评分无相关性(P＞0.05). 结论 自体股薄肌腱改良髌骨双骨道法重建MPFL是一种可靠安全经济的手术方法.高危解剖因素如高位髌骨、滑车发育不良、关节松弛等情况广泛存在于髌骨复发性脱位的患者中,虽未发现其严重程度会直接影响手术效果,但当复合因素存在时,仅重建MPFL的软组织手术可能不足以完全防止髌骨脱位复发.%To investigate the efficacy of modified two patellar tunnels in reconstruction of the medialrnpatellofemoral ligament (MPFL) with gracilis tendon autograft for patients with recurrent patellar dislocation, as well as the high-risk anatomical factors for the surgical outcomes. Methods From January 2007 to February 2010, we performed MPFL reconstruction with gracilis tendon autograft by using a modified double-tunnel technique on 36 patients with recurrent patellar dislocation ( unilateral in 31 cases, and bilateral in the other 5). We made two parallel 3. 5-mm channels from the medial upper edge of the patella to the surface ( medial half) of the patella so that to introduce gracilis tendon autograft into the medial femoral channel. The autograft was fixed with absorbable screws with the knee bent at 30°. The Beighton score, Q angle, Insall index, the level of trochlea dysplasia, TT-TG were measured and Kujala, Lysholm, and Tegner scores were employed for clinical evaluation. The satisfaction of the patients were investigated as well. Results Among the patients, 32 patients were very satisfied with the outcomes of the operation, 3 were satisfied, and the other one was not satisfied. The Kujala, Lysholm, and Tegner scores increased from 64. 3 ± 15. 0, 65. 1 ±18.6, and 3.2 ±1. 1 preoperatively to 92. 4 ±9.2 (t =4.657, P =0. 002) , 92. 0 ± 10. 1 (t = 3.936, P =0.006) , and 5.2 ± 1.0 (t = 6. 633 , P =0.001) respectively after the procedure. 80.6% (29/36) of the patients recovered preoperative sports level in 6 to 8 months after operation. One patient had recurrent patella dislocation again in one year after the treatment. In the patients, 97.6 (40/41) of the involved knee .joints showed femoral trochlear dysplasia, the Beighton score, Insall index, Q angle, and TT-TG were 5. 2 ± 2. 5 , 1.22 ±0. 14, (13. 6 ± 3. 9)°, and (13. 7 ± 4. 4) mm, respectively. None of them was related functional scores ( P > 0. 05). Conclusions Modified two patellar tunnels in reconstruction of the medial patellofemoral ligament ( MPFL) with gracilis tendon autograft is a safe, effective, and economic method for recurrent patellar dislocation. High-risk anatomical factors, including high patella, trochlear dysplasia, and joint laxity are common in patients with recurrent patellar dislocation, although their severity does not influence surgical outcomes directly, when the factors exist in a same patient, simple reconstructed MPFL is not adequate for preventingrnrecurrence of patellar dislocation.