Gruskay Jordan A, Gomoll Andreas H, Arendt Elizabeth A, Dejour David H, Strickland Sabrina M
Instr Course Lect. 2020;69:671-692.
Patellar instability is a common problem seen by the orthopedic surgeon. Surgery is indicated in recurrent dislocation to improve patellar tracking and ligamentous restraint in order to decrease risk of recurrence, osteochondral injury, and eventual progression to arthritis. Preoperative imaging studies identify anatomic risk factors that increase risk of patellar dislocation to inform surgical decision making. Surgical management starts with medial patellofemoral ligament reconstruction, which is effective in many cases. Tibial tubercle osteotomy realigns the extensor mechanism and is useful in cases of lateralized tibial tubercle or patella alta. For patients with trochlear dysplasia, both tibial tubercle osteotomy and trochleoplasty are options to prevent recurrent dislocation. Chondral lesions are common and, depending upon symptomology and size, can be addressed with débridement, structural grafting, or cell-based treatment. To maximize outcomes, comprehensive preoperative diagnosis and planning must be combined with meticulous surgical technique. Unfortunately, there is minimal evidence to guide when a soft-tissue ligament reconstruction is sufficient versus when is it necessary to correct and alter the bony anatomy. This chapter covers the individualized decision making and surgical pearls for these techniques to improve outcomes and minimize perioperative complications.
髌骨不稳定是骨科医生常见的问题。复发性脱位时需进行手术，以改善髌骨轨迹和韧带约束，从而降低复发风险、骨软骨损伤风险以及最终发展为关节炎的风险。术前影像学检查可识别增加髌骨脱位风险的解剖学危险因素，为手术决策提供依据。手术治疗首先是内侧髌股韧带重建，这在许多情况下是有效的。胫骨结节截骨术可重新调整伸肌机制，适用于胫骨结节外移或高位髌骨的病例。对于患有滑车发育不良的患者，胫骨结节截骨术和滑车成形术都是预防复发性脱位的选择。软骨损伤很常见，根据症状和大小，可通过清创、结构性移植或基于细胞的治疗来处理。为了使治疗效果最大化，全面的术前诊断和规划必须与精细的手术技术相结合。不幸的是，关于何时软组织韧带重建就足够，何时需要矫正和改变骨骼解剖结构，几乎没有证据可供指导。本章涵盖了这些技术的个体化决策和手术要点，以改善治疗效果并将围手术期并发症降至最低。
