Colvin Alexis Chiang, West Robin V
Mount Sinai School of Medicine, 5 East 98th Street, Box 1188, New York, NY 10029, USA.
J Bone Joint Surg Am. 2008 Dec;90(12):2751-62. doi: 10.2106/JBJS.H.00211.
Recurrent patellar instability can result from osseous abnormalities, such as patella alta, a distance of >20 mm between the tibial tubercle and the trochlear groove, and trochlear dysplasia, or it can result from soft-tissue abnormalities, such as a torn medial patellofemoral ligament or a weakened vastus medialis obliquus. Nonoperative treatment includes physical therapy, focusing on strengthening of the gluteal muscles and the vastus medialis obliquus, and patellar taping or bracing. Acute medial-sided repair may be indicated when there is an osteochondral fracture fragment or a retinacular injury. The recent literature does not support the use of an isolated lateral release for the treatment of patellar instability. A patient with recurrent instability, with or without trochlear dysplasia, who has a normal tibial tubercle-trochlear groove distance and a normal patellar height may be a candidate for a reconstruction of the medial patellofemoral ligament with autograft or allograft. Distal realignment procedures are used in patients who have an increased tibial tubercle-trochlear groove distance or patella alta. The degree of anteriorization, distalization, and/or medialization depends on associated arthrosis of the lateral patellar facet and the presence of patella alta. Associated medial or proximal patellar chondrosis is a contraindication to distal realignment because of the potential to overload tissues that have already undergone degeneration.
复发性髌骨不稳定可由骨性异常导致，如高位髌骨（胫骨结节与滑车沟之间距离>20 mm）和滑车发育不良，也可由软组织异常引起，如内侧髌股韧带撕裂或股内侧斜肌薄弱。非手术治疗包括物理治疗，重点是加强臀肌和股内侧斜肌，以及髌骨贴扎或支具固定。当存在骨软骨骨折碎片或支持带损伤时，可能需要进行急性内侧修复。最近的文献不支持单独使用外侧松解术治疗髌骨不稳定。对于复发性不稳定且有或无滑车发育不良、胫骨结节-滑车沟距离正常且髌骨高度正常的患者，可能适合采用自体或异体移植物重建内侧髌股韧带。对于胫骨结节-滑车沟距离增加或高位髌骨的患者，可采用远端重新排列手术。前移、下移和/或内移的程度取决于外侧髌股关节面的相关关节炎以及高位髌骨的存在情况。由于可能会使已经发生退变的组织负荷过重，相关的内侧或近端髌骨软骨病是远端重新排列手术的禁忌证。
