Carstensen S Evan, Feeley Scott M, Diduch David R
Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA.
School of Medicine, University of Virginia, Charlottesville, Virginia, USA.
Orthop J Sports Med. 2019 Aug 23;7(8):2325967119864868. doi: 10.1177/2325967119864868. eCollection 2019 Aug.
Sulcus-deepening trochleoplasty has been established as an effective treatment for patellar instability due to trochlear dysplasia. However, arthrofibrosis is a known complication following trochleoplasty, which may require manipulation under anesthesia (MUA) with or without lysis of adhesions (LOA) to increase the knee range of motion (ROM), especially flexion.
To prospectively follow patients for ROM improvements and subsequent complications after undergoing MUA with or without LOA in the setting of sulcus-deepening trochleoplasty.
Case series; Level of evidence, 4.
A total of 76 knees with severe trochlear dysplasia were prospectively enrolled and underwent sulcus-deepening trochleoplasty, with a mean (±SD) follow-up of 32.5 ± 19.3 months. Concomitant procedures included medial patellofemoral ligament reconstruction, lateral retinacular release, and tibial tubercle osteotomy. Physical examination including ROM and findings of recurrent patellar instability were collected for all patients. Arthrofibrosis was defined as active and passive flexion less than 90° within 3 months of surgery combined with a plateau in progress with physical therapy. Paired-samples and independent-samples tests were used. A value less than .05 was considered significant.
A total of 62 knees met inclusion and exclusion criteria and were included in the study. Of these patients, 11 experienced arthrofibrosis as a complication and underwent MUA within 3 months of their index procedure. Of these 11 patients, 9 subsequently underwent arthroscopic LOA following MUA because acceptable ROM could not be achieved with manipulation alone. Patients with arthrofibrosis had a premanipulation mean ROM that was significantly different from those without arthrofibrosis (77.3° ±18.6° vs 133.3° ± 12.7°, respectively; < .001). In the arthrofibrotic group, postoperative ROM increased significantly after MUA and/or LOA compared with the preoperative ROM (127.3° ± 12.5° vs 77.3° ± 18.6°, respectively; < .001). ROM in the arthrofibrotic group after MUA/LOA was not significantly different from that in the nonarthrofibrotic group (flexion, 127.3° ± 12.5° vs 133.3° ± 12.7°, respectively; = .156). No complications from the MUA or LOA were reported at subsequent follow-up visits.
When indicated in the setting of severe trochlear dysplasia, sulcus-deepening trochleoplasty is a treatment for disabling recurrent patellar instability with a known complication of arthrofibrosis. Initiation of postoperative physical therapy within 3 days of surgery may reduce the incidence of arthrofibrosis. If arthrofibrosis is encountered after a sulcus-deepening trochleoplasty, MUA without LOA is not as effective as when following other procedures of the knee, whereas MUA with LOA is an effective procedure likely to result in ROM and patient outcome scores similar to those of a nonarthrofibrotic knee after the same procedure. Both MUA and LOA appear to be safe based on the limited number of patients in this study without complication.
加深滑车成形术已被确立为治疗因滑车发育不良导致的髌骨不稳定的有效方法。然而，关节纤维化是滑车成形术后已知的并发症，这可能需要在麻醉下进行手法操作（MUA），无论是否进行粘连松解（LOA），以增加膝关节活动范围（ROM），尤其是屈曲角度。
前瞻性地随访在加深滑车成形术背景下接受或未接受LOA的MUA治疗的患者的ROM改善情况及随后的并发症。
病例系列；证据等级，4级。
前瞻性纳入76例严重滑车发育不良的膝关节，均接受加深滑车成形术，平均（±标准差）随访32.5±19.3个月。同期手术包括内侧髌股韧带重建、外侧支持带松解和胫骨结节截骨术。收集所有患者的体格检查结果，包括ROM及复发性髌骨不稳定的表现。关节纤维化定义为术后3个月内主动和被动屈曲均小于90°，且物理治疗进展停滞。采用配对样本和独立样本检验。P值小于0.05被认为具有统计学意义。
共有62例膝关节符合纳入和排除标准并纳入研究。在这些患者中，11例出现关节纤维化并发症，并在初次手术后3个月内接受了MUA。在这11例患者中，9例在MUA后因单纯手法操作无法获得可接受的ROM而随后接受了关节镜下LOA。有关节纤维化的患者手法操作前的平均ROM与无关节纤维化的患者有显著差异（分别为77.3°±18.6°和133.3°±12.7°；P<0.001）。在关节纤维化组中，与术前ROM相比，MUA和/或LOA后术后ROM显著增加（分别为127.3°±12.5°和77.3°±18.6°；P<0.001）。MUA/LOA后关节纤维化组的ROM与非关节纤维化组无显著差异（屈曲角度分别为127.3°±12.5°和133.3°±12.7°；P=0.156）。在随后的随访中未报告MUA或LOA的并发症。
在严重滑车发育不良的情况下，加深滑车成形术是治疗导致残疾的复发性髌骨不稳定的一种方法，且已知有关节纤维化并发症。术后3天内开始物理治疗可能会降低关节纤维化的发生率。如果在加深滑车成形术后出现关节纤维化，单纯MUA不如在膝关节其他手术中那样有效，而MUA联合LOA是一种有效的方法，可能会使ROM和患者结局评分与同一手术的非关节纤维化膝关节相似。基于本研究中有限数量患者且无并发症的情况，MUA和LOA似乎都是安全的。
