Frosch S, Balcarek P, Walde T A, Schüttrumpf J P, Wachowski M M, Ferleman K-G, Stürmer K M, Frosch K-H
Unfallchirurgie, Plastische und Wiederherstellungschirurgie, Universitätsmedizin Göttingen, Robert-Koch-Strasse 40, Göttingen.
Z Orthop Unfall. 2011 Dec;149(6):630-45. doi: 10.1055/s-0030-1250691. Epub 2011 May 3.
The diagnosis and treatment of patellar dislocation is very complex. The aim of this study is to give an overview of the biomechanics of the patellofemoral joint and to point out the latest developments in diagnosis and treatment of patellar dislocation.
The authors electronically searched Medline, Cochrane and Embase for studies on the biomechanics of the patellofemoral joint and for conservative and surgical treatments after patellar dislocation. We extracted baseline demographics, biomechanical, conservation and surgical details.
Understanding the biomechanics of the patellofemoral joint is necessary to understand the pathology of patellar dislocation. The patellofemoral joint consists of a complex system of static, active and passive stabilising factors. Patellar instability can result from osseous and soft-tissue abnormalities, such as trochlear dysplasia, patella alta, a high tibial tuberosity trochlear groove (TTTG) distance, weaknesses of the vastus medialis obliquus or a lesion of the medial retinaculum. Recent studies have focused on the medial patellofemoral ligament (MPFL) and have shown that the MPFL is the most significant passive stabiliser of the patella. Following patellar dislocation, an MRI should be standard practice to detect an MPFL rupture, osteochondral lesions or other risk factors for redislocation. An acute first-time patellar dislocation without osteochondral lesions and without severe risk factors for a redislocation should follow a conservative treatment plan. If surgical treatment is required, the best postoperative results occur when the MPFL is reconstructed, leading to a redislocation rate of 5%, this includes cases that have a dysplastic trochlea. Duplication of the medial retinaculum show very inconsistent results in the literature, possibly due to the fact that the essential pathomorphology of patellar dislocation is not addressed. Addressing the exact location of the rupture of the MPFL with a suture is possibly more convenient, especially after first-time dislocation with associated risk factors for a redislocation. Recent literature does not encourage the use of lateral release, since this can increase patellar instability. Indications for lateral release include persistent patellar instability or pain reduction in an older arthritic subject. For correcting a patellofemoral malalignment, the TTTG distance should be measured and a medial transposition of the anterior tibial tubercle hinged on a distal periosteal attachment should be considered. Cartilage lesions on the medial facet of the patella are a contra-indication for medial tubercle transposition. For cartilage lesions of the lateral facet, antero-medialization of the tibial tubercle can be successful. A tubercle osteotomy can be efficiently combined with MPFL reconstruction. We believe that patients with open epiphyseal plates should be treated with duplication of the medial retinaculum. In the presence of patellar maltracking, an additional subperiostal soft tissue release with medialisation of the distal part of the patellar tendon can be performed.
It seems that the predominating factors for patellar dislocation are heterogenic morphology in combination with individual predisposition. Non-surgical treatment is typically recommended for primary patellar dislocation without any osteochondral lesions and in the absence of significant risk factors for redislocation. If surgical treatment is deemed necessary, addressing the essential pathomorphology has become the primary focus.
髌骨脱位的诊断与治疗非常复杂。本研究的目的是概述髌股关节的生物力学，并指出髌骨脱位诊断与治疗的最新进展。
作者通过电子检索Medline、Cochrane和Embase，查找有关髌股关节生物力学以及髌骨脱位后保守和手术治疗的研究。我们提取了基线人口统计学、生物力学、保守治疗和手术细节。
了解髌股关节的生物力学对于理解髌骨脱位的病理情况很有必要。髌股关节由静态、主动和被动稳定因素组成的复杂系统构成。髌骨不稳定可能由骨和软组织异常引起，如滑车发育不良、髌骨高位、胫骨结节 - 滑车沟（TTTG）距离增大、股内侧斜肌薄弱或内侧支持带损伤。最近的研究集中在内侧髌股韧带（MPFL），并表明MPFL是髌骨最重要的被动稳定器。髌骨脱位后，进行MRI检查应成为常规做法，以检测MPFL断裂、骨软骨损伤或其他再脱位危险因素。首次急性髌骨脱位且无骨软骨损伤及严重再脱位危险因素的患者应遵循保守治疗方案。如果需要手术治疗，重建MPFL时术后效果最佳，再脱位率为5%，这包括滑车发育不良的病例。内侧支持带重建在文献中的结果非常不一致，可能是因为未解决髌骨脱位的基本病理形态。用缝线处理MPFL断裂的确切位置可能更方便，特别是在首次脱位伴有再脱位相关危险因素的情况下。最近的文献不鼓励使用外侧松解术，因为这可能会增加髌骨不稳定。外侧松解术的适应证包括持续性髌骨不稳定或老年关节炎患者疼痛减轻。为纠正髌股排列不齐，应测量TTTG距离，并考虑将胫骨结节前内侧移位并固定于远端骨膜附着处。髌骨内侧关节面的软骨损伤是胫骨结节内侧移位的禁忌证。对于外侧关节面的软骨损伤，胫骨结节前内侧移位可能成功。结节截骨术可与MPFL重建有效结合。我们认为骨骺未闭的患者应采用内侧支持带重建治疗。在存在髌骨轨迹异常的情况下，可进行额外的骨膜下软组织松解并将髌腱远端向内侧移位。
髌骨脱位的主要因素似乎是形态异质性与个体易感性相结合。对于无任何骨软骨损伤且无明显再脱位危险因素的原发性髌骨脱位，通常建议非手术治疗。如果认为有必要进行手术治疗，解决基本的病理形态已成为主要关注点。
