支持带松解联合外侧成形治疗髌骨外侧过度挤压综合征

doi:10.3877/cma.j.issn.1674-134X.2024.02.005

中华关节外科杂志(电子版) ›› 2024, Vol. 18 ›› Issue (02) : 186 -192. doi: 10.3877/cma.j.issn.1674-134X.2024.02.005

临床论著

支持带松解联合外侧成形治疗髌骨外侧过度挤压综合征

蔡雨琦¹, 史尉利², 陶立元³, 曹建夫⁴, 崔国庆², 杨渝平²^,^†(

)

^1. 100191　北京大学第三医院运动医学科；100029　首都医科大学附属北京安贞医院
^2. 100191　北京大学第三医院运动医学科
^3. 100191　北京大学第三医院临床流行病学研究中心
^4. 100038　北京，首都医科大学附属复兴医院

收稿日期:2023-02-10 出版日期:2024-04-01
通信作者: 杨渝平
基金资助:
2023年度北医三院临床重点项目及队列建设项目(BYSYDL2023013)

Retinacular release combined with lateral patellafemoplasty in treatment of lateral patellar compression syndrome

Yuqi Cai¹, Weili Shi², Liyuan Tao³, Jianfu Cao⁴, Guoqing Cui², Yuping Yang²^,^†()

^1. Department of Sports Medicine, Peking University Third Hospital, Beijing 100191, China; Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
^2. Department of Sports Medicine, Peking University Third Hospital, Beijing 100191, China
^3. Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing 100191, China
^4. Fu Xing Hospital, Capital Medical University, Beijing 100038, China

Received:2023-02-10 Published:2024-04-01
Corresponding author: Yuping Yang

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引用本文：

蔡雨琦, 史尉利, 陶立元, 曹建夫, 崔国庆, 杨渝平. 支持带松解联合外侧成形治疗髌骨外侧过度挤压综合征[J/OL]. 中华关节外科杂志(电子版), 2024, 18(02): 186-192.

Yuqi Cai, Weili Shi, Liyuan Tao, Jianfu Cao, Guoqing Cui, Yuping Yang. Retinacular release combined with lateral patellafemoplasty in treatment of lateral patellar compression syndrome[J/OL]. Chinese Journal of Joint Surgery(Electronic Edition), 2024, 18(02): 186-192.

目的

总结和分析外侧支持带松解联合髌骨外侧成形治疗髌骨外侧过度挤压综合征的手术效果。

方法

本研究为回顾性病例系列报告。纳入2015年7月至2019年10月由北京大学第三医院运动医学科同一组医师行关节镜下联合手术治疗髌骨外侧挤压综合征34例患者的临床资料。纳入保守治疗无效膝前疼痛、外侧支持带紧张、影像学检查提示髌骨向外倾斜且存在髌骨外侧骨赘、髌骨呈Wiberg Ⅲ型或Ⅳ型且关节镜下外侧间隙狭窄的患者，排除髌骨不稳、髌骨脱位、类风湿性关节炎症、髌股关节发育异常和髌股关节骨关节炎的患者。手术方式为外侧支持带L型松解联合髌骨外侧成形。采用配对t检验比较术前和末次随访时Lysholm膝关节评分、国际膝关节文献委员会(IKDC)膝关节主观评分、视觉模拟评分(VAS)以及膝关节轴位30°X光片的髌骨外侧曲率角(LPCA)和髌骨外侧倾斜角(PTA)。采用配对t检验和Wilcoxon符号秩检验比较同一患者术中镜下所见内侧、外侧髌骨软骨损伤情况。

结果

34例患者随访12～53个月，平均(23±11)个月，术后病人均未发生感染、神经损伤等并发症。Lysholm膝关节评分、IKDC膝关节主观评分、VAS评分以及LPCA和PTA均优于术前，差异具有统计学意义(t＝7.08、5.77、10.08、10.80，Z＝13.28，均为P<0.05)。

结论

关节镜下外侧支持带松解联合髌骨外侧成形具有良好的手术效果，可以改善疼痛症状并提高关节运动功能。

关键词: 关节镜检查, 关节囊松解, 髌股关节, 膝关节

Objective

To summarize and analyze the surgical effect of lateral retinacular release combined with lateral patellafemoplasty in the treatment of lateral patella compression syndrome.

Methods

This study was a retrospective clinical trial. The clinical data of 34 patients who underwent arthroscopic combined surgery to treat lateral patella compression syndrome from July 2015 to October 2019 by the same surgeon team from the Department of Sports Medicine of Peking University Third Hospital were included. Patients with anterior knee pain who had failed conservative treatment, tension of the lateral support band, and imaging findings indicating outward patellar tilting with lateral patellar osteophyte, Wiberg type III or IV patella, and arthroscopic lateral space stenosis were included. Patients with patellar instability, patellar dislocation, rheumatoid joint inflammation, patellofemoral joint development abnormalities, and patellofemoral osteoarthritis were excluded.The surgical method was L-shaped release of the lateral retinaculum combined with lateral patellafemoplasty. Paired t test was used to compare the Lysholm knee score, International Knee Documentation Committee knee subjective score (IKDC), visual analogue score (VAS), and patellar lateral curvature angle (LPCA) on 30° axial knee X-rays and lateral patellar tilt angle (PTA) before surgery and at the last follow-up. The paired t test and Wilcoxon signed rank test were used to compare the medial and lateral patellar cartilage damage seen under the intraoperative microscope in the same patient.

Results

A total of 34 patients were followed up for 12 to 53 months, (23±11)months on average. No postoperative complication such as infection or nerve damage occurred. Scores and angles were better than those before surgery, and the differences were statistically significant (t=7.08, 5.77, 10.08, 10.80, Z=13.28, all P <0.05).

Conclusion

Arthroscopic lateral retinacular release combined with lateral patella molding has good surgical results and can improve pain symptoms and joint motion function.

Key words: Arthroscopy, Joint capsule release, Patellofemoral joint, Knee joint

图1 关节镜下髌骨外侧判断支持带紧张度分级。图A为镜下可见髌股关节间隙宽度大于5 mm，并有压痛症状为1度；图B为镜下不可见完整刨刀头为2度；图C为镜下不可见刨刀头为3度；图D～F为镜下支持带紧张度1、2、3度术后情况，示镜下关节间隙宽度明显增加，宽度大于1 cm

Figure 1 The tension grade evaluation of the lateral patellar support band under arthroscope. A shows that width of patellafemoral joint space is larger than 5 mm and with tenderness symptoms, the tension grade is grade one; B shows that the planer head is not completely presented, and this is defined as grade two; C shows that planer head is totally invisible, and this is defined as grade three; D, E and F are patellafemoral joint space of grade one to grade three after surgery, showing that the width of space significantly increases to a width larger than one centimeter

图2 膝关节屈曲30°轴位X线片的各影像学角度测量。图A为术前片，可见外侧明显弯钩；图B为髌骨外侧成形手术后，示髌骨外侧面平坦光滑；图C示外侧PTA(髌骨倾斜角)，为穿过髌骨最宽横轴线与过股骨内外侧髁前表面之间的夹角；图D示LPCA(髌骨外侧曲率角)，为经过髌骨最低点髌骨的外侧切线与髌骨最低点与外侧关节面最外侧连线的夹角

Figure 2 Measurements of X-ray image angles at axial view of knee at flexion 30 ° position. A is image before surgery, showing a prominent lateral hook; B is image after patellofemoral plasty, showing that the lateral surface of the patella is flat and smooth; C is the lateral PTA (patellar tilting angle) , the angle lies between the line passing through the widest transverse axis of the patella and the line passing through the anterior surface of the medial and lateral condyles of the femur; D is LPCA (the lateral patellar curvature angle), the angle lies between the lateral tangent of the patella through the nadir of the patella and the line connecting the nadir of the patella and the outermost area of the lateral articularsurface

表1 手术前后角度、评分对比

Table 1 Comparison of angles and scores before and after operation

时间Time point	LPCA [°，(±s)]	PTA [°，(±s)]	Lysholm评分Lysholm score (±s)	IKDC评分IKDC score (±s)	VAS评分VAS score M(P₂₅，P₇₅)
术前Before operation	18.7±5.0	15.9±6.6	46.7±21.6	39.2±17.0	6.0(4.7，7.0)
术后After operation	12.6±4.6	10.4±6.0	88.8±14.1	75.8±15.8	0(0，1.0)
统计值Statistical value	t＝7.08	t＝5.77	t＝10.08	t＝10.80	Z＝13.28
P值	<0.001	<0.001	<0.001	<0.001	<0.001

表1 手术前后角度、评分对比

Table 1 Comparison of angles and scores before and after operation

时间Time point	LPCA [°，(±s)]	PTA [°，(±s)]	Lysholm评分Lysholm score (±s)	IKDC评分IKDC score (±s)	VAS评分VAS score M(P₂₅，P₇₅)
术前Before operation	18.7±5.0	15.9±6.6	46.7±21.6	39.2±17.0	6.0(4.7，7.0)
术后After operation	12.6±4.6	10.4±6.0	88.8±14.1	75.8±15.8	0(0，1.0)
统计值Statistical value	t＝7.08	t＝5.77	t＝10.08	t＝10.80	Z＝13.28
P值	<0.001	<0.001	<0.001	<0.001	<0.001

图3 1例随访评分不满意的联合外侧成形术患者左膝关节30°轴位片。图A为术前片，示LPCA(髌骨外侧曲率角)为22.3°，图B为术后3年，示LPCA为16.1°

Figure 3 X ray images of left knee joint at 30° axial view of the patient undergone lateral patellar retinaculum release combined with lateral patellofemoplasty with unsatisfactory follow-up score. A is the image before surgery, showing that LPCA was 22.3°；B is the image surgery three years after surgery, showing that LPCA was 16.1°

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Retinacular release combined with lateral patellafemoplasty in treatment of lateral patellar compression syndrome