Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.
Division of Orthopaedic Surgery, The Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
J Bone Joint Surg Am. 2023 Mar 1;105(5):397-409. doi: 10.2106/JBJS.22.00756. Epub 2023 Jan 19.
➤: Patellar instability represents a common problem with an evolving understanding and multifactorial pathoetiology. Treatment plans should be based on the identification of contributing anatomical factors and tailored to each individual patient.
➤: Risks for recurrent instability are dependent on several patient-specific factors including patella alta, increased tibial tubercle-to-trochlear groove (TT-TG) distance, trochlear dysplasia, younger skeletal age, and ligamentous laxity.
➤: Cartilage or osteochondral lesions and/or fractures are commonly observed in first-time patellar dislocation, and magnetic resonance imaging (MRI) should be strongly considered. Advanced imaging modalities, such as computed tomography (CT) or MRI, should also be obtained preoperatively to identify predisposing factors and guide surgical treatment.
➤: Medial patellofemoral ligament (MPFL) reconstruction with anatomical femoral tunnel positioning is associated with lower recurrence rates compared with MPFL repair and has become a common and successful reconstructive surgical option in cases of instability.
➤: Lateral retinacular tightness can be addressed with lateral retinacular release or lengthening, but these procedures should not be performed in isolation.
➤: Tibial tubercle osteotomy is a powerful reconstructive tool in the setting of underlying skeletal risk factors for instability and can be of particular benefit in the presence of increased TT-TG distance (>20 mm), and/or in the setting of patella alta.
➤: The indications for trochleoplasty are still developing along with the clinical evidence, but trochleoplasty may be indicated in some cases of severe trochlear dysplasia. Several surgical techniques have indications in specific clinical scenarios and populations, and indications, risks, and benefits to each are progressing with our understanding.
➤: Combined femoral derotational osteotomy and MPFL reconstruction can be considered for patients with a femoral anteversion angle of >30° to improve patient outcomes and reduce recurrence rates.
髌股关节不稳定是一种常见的问题，其发病机制复杂，认识不断发展。治疗方案应基于确定的致病解剖因素，并根据每个患者的具体情况进行调整。
髌股关节不稳定的复发风险取决于几个患者特定的因素，包括高位髌骨、增加的滑车沟-胫骨结节（TT-TG）距离、滑车发育不良、较小的骨骼年龄和韧带松弛。
初次髌骨脱位常伴有软骨或骨软骨损伤和/或骨折，应强烈考虑进行磁共振成像（MRI）检查。术前还应获得高级影像学检查，如计算机断层扫描（CT）或 MRI，以识别致病因素并指导手术治疗。
与 MPFL 修复相比，解剖学股骨隧道定位的髌股外侧支持带（MPFL）重建与较低的复发率相关，已成为不稳定病例中一种常见且成功的重建手术选择。
外侧支持带紧张可以通过外侧支持带松解或延长来解决，但这些手术不应孤立进行。
胫骨结节截骨术是一种强大的重建工具，适用于不稳定的潜在骨骼危险因素，对于 TT-TG 距离增加（>20mm）和/或高位髌骨的情况尤其有益。
滑车成形术的适应证仍在发展，同时也在积累临床证据，但在某些严重滑车发育不良的情况下，滑车成形术可能是指征。几种手术技术在特定的临床情况下和人群中具有适应证，而对每种手术的适应证、风险和获益的认识也在不断发展。
对于股骨前倾角>30°的患者，可考虑行股骨旋转截骨术和 MPFL 重建，以改善患者的治疗效果，降低复发率。
