摘要
目的:评估接受内侧髌股韧带重建术合并胫骨结节截骨术的复发性髌骨脱位患者的术后临床疗效。分析术前不同严重程度的膝关节J形征对术后重建移植物松弛度的影响及高度J形征的危险因素。方法:回顾性分析165例在北京大学首钢医院骨科接受内侧髌股韧带重建术+胫骨结节截骨术治疗的成人复发性髌骨脱位患者。术前对髌骨运动轨迹进行评估，根据膝关节J形征的严重程度进行分组：3度组、2度组及1度组。分别比较3组术前及末次随访时的移植物稳定性（麻醉下髌骨外推应力指数）、移植物失效率、CT参数（髌骨-股骨滑车沟距离、股骨前倾角、胫骨外旋角、膝关节旋转角）、髌骨高度、股骨滑车分型及膝关节功能评分［国际膝关节文献委员会（IKDC）评分、髌股关节功能Kujala评分及Lysholm评分］。同时分析造成术前高度J形征可能的危险因素。结果:随访时间（38.2±5.9）个月（范围36~45个月），97.1%（134/138）患者髌骨无再发脱位。术前J形征3度组17例，2度组24例，1度组97例。3组患者年龄、性别、受伤侧别、受伤至接受手术时间窗、随访时间及术前膝关节功能评分的差异无统计学意义（P＞0.05）。末次随访时膝关节“J”形征3度组患者术后麻醉应力下髌骨外推指数（36.4%±19.6%）大于2度（23.5%±8.1%）和1度组（22.9%±9.8%），差异有统计学意义（P＜0.05）；3度组术后髌骨-股骨滑车沟距离（-1.7±8.2）mm大于2度（-6.6±8.0）mm和1度组（-9.4±7.4）mm，差异有统计学意义（P＜0.05）；3度组股骨前倾角（28.2°±11.6°）大于2度（20.4°±12.6°）和1度组（19.6°±10.7°），差异有统计学意义（P＜0.05）；3度组胫骨外旋角（30.4°±20.0°）大于2度（16.5°±17.5°）和1度组（19.8°±16.2°），差异有统计学意义（P＜0.05）；3度组膝关节旋转角（14.6°±5.4°）大于2度（8.3°±3.9°）和1度组（9.2°±5.2°），差异有统计学意义（P＜0.05），而上述指标在2度和1度组间无差异（P＞0.05）。其他影像学参数3组间差异无统计学意义（P＞0.05）。3度组中，随访时移植物失效率（23.5%）大于2度（0%）和1度组（0%），差异有统计学意义（P＜0.05）。3度组IKDC评分由术前（53.3±2.5）分提高至（77.2±6.1）分（P＜0.001），Kujala评分由术前（63.2±9.7）分提高至（76.1±3.3）分（P=0.003），Lysholm评分由术前（66.7±6.7）分提高至（84.7±5.6）分（P＜0.001）；2度组IKDC评分由术前（49.2±4.6）分提高至（87.3±8.7）分（P=0.002），Kujala评分由术前（61.5±6.6）分提高至（84.4±4.8）分（P=0.045），Lysholm评分由术前（59.6±7.0）分提高至（91.6±8.0）分（P＜0.001）；1度组IKDC评分由术前（54.5±3.2）分提高至（86.4±6.5）分（P=0.017），Kujala评分由术前（65.7±3.6）分提高至（85.3±1.2）分（P=0.055），Lysholm评分由术前（63.8±4.3）分提高至（93.1±4.3）分（P＜0.001）。Logistic回归分析示术前髌骨-股骨滑车沟距离（OR=1.44）、股骨前倾角（OR=1.37）及膝关节旋转角（OR=1.24）均为高度J形征（3度）的危险因素（P＜0.05）。结论:复发性髌骨脱位患者接受内侧髌股韧带重建术＋胫骨结节截骨术治疗可获得较满意的髌骨稳定性及膝关节功能，但术前若合并高度J形征（3度）则可造成术后移植物残存松弛甚至失效。过大的髌骨-股骨滑车沟距离、股骨前倾角及膝关节旋转角为高度J形征的危险因素。
Abstract
Objective:To report the clinical outcomes of recurrent patellar dislocation (RPD) patients after medial patellofemoral ligament reconstruction (MPFLR) combined with tibial tubercle osteotomy (TTO), to evaluate the impact of preoperative J sign severity on postoperative residual graft laxity correction, and to identify the predisposing factors of high grade J sign.Methods:A total of 165 adult consecutive RPD patients who underwent MPFL reconstruction and TTO at the Orthopedic Department of Peking University Shougang Hospital and were followed for more than 2 years were analyzed retrospectively in this study. All the patients were classified into three groups based on the severity of pre-operative knee J sign: grade 1+, grade 2+, and grade 3+. Computed tomography (CT) examination was performed in all patients at 0° extension of the knee, and true lateral X-ray films of the knee were obtained at 20° flexion. The patellar laxity index measured by patellar glide test (PGT) under anesthesia and the radiographic parameters (tibial tuberosity-trochlear groove distance, patellar height, trochlear groove classification, patella trochlear-groove distance, femoral anteversion angle, tibial external angle, and knee rotational angle), as well as the pre/postoperative knee functional scores including International Knee Documentation Committee (IKDC) score, Kujala score, and Lysholm score, were assessed. Furthermore, the postoperative residual J sign and surgical failure rate were compared among the three groups at the final follow-up.Results:Totally, 138 (83.6%, 138/165) patients participated in the final follow up. The average follow-up duration was (38.2±5.9) months (range, 36~45 months), and most of the patients (97.1%, 134/138) did not suffer from RPD during the follow-up period except for 4 patients in the grade 3+ group. Seventeen patients had grade 3+ J sign, 24 had grade 2+, and 97 had grade1+ preoperatively. There was no significant difference among the three groups in age, gender, injury side, time from injury to surgery, follow-up duration, and preoperative knee function scores (P＞0.05). At the final follow-up, the patellar laxity index was (36.4±19.6) % in the grade 3+ J sign group, (23.5±8.1)% in the grade 2+ group, and (22.9±9.8)% in the grade 1+ group; there was a significant difference in the patellar laxity index among the three groups (P＜0.05). The patella trochlear-groove distance in the grade 3+, grade 2+, and grade 1+ groups was (-1.7±8.2) mm, (-6.6±8.0) mm, and (9.4±7.4) mm, respectively; there was a significant difference among three groups (P＜0.05). The femoral anteversion angle in the grade 3+, grade 2+, and grade 1+ groups was (28.2±11.6)°, (20.4±12.6)°, and (19.6±10.7)°, respectively; there was a significant difference in the femoral anteversion angle among the three groups (P＜0.05). The tibial external angle in the grade 3+, grade 2+, and grade 1+ groups was (30.4±20.0)°, (16.5±17.5)°, and (19.8±16.2)°, respectively; there was a significant difference in the tibial external angle among the three groups (P＜0.05). The knee rotational angle in the grade 3+, grade 2+, and grade 1+ groups was (14.6±5.4)°, (8.3±3.9)°, and (9.2±5.2)°, respectively; there was a significant difference in the knee rotational angle among the three groups (P＜0.05). The three groups had no significant difference in patellar height or trochlear groove classification (P＞0.05). The IKDC, Kujala, and Lysholm scores were (77.2±6.1), (76.1±3.3), and (84.7±5.6) in the grade 3+group, (87.3±8.7), (84.4±4.8), and (91.6±8.0) in the grade 2+group, and (86.4±6.5), (85.3±1.2), and (93.1±4.3) in the grade 1+group, respectively; all were significantly improved compared with the preoperative scores (P＜0.05).The failure rate in the grade 3+ group was 23.5%, which was significantly higher compared with those in the grade 2+ (0%) group and grade 1+ group (0%) (P＜0.05). The odds ratio of high grade J sign (3+) with patella trochlear-groove distance was 1.44, that with femoral anteversion angle was 1.37, and that with knee rotational angle was 1.24 (P＜0.05).Conclusion:MPFL reconstruction combined with TTO is effective for most of RPD patients during the 2-year follow-up period except for patients with preoperative high grade J sign (grade 3+). However, the morbidity of postoperative positive residual patellar J sign was 26% and the positive J sign might increase the laxity of the patella. Preoperative high grade patellar J sign may lead to postoperative residual graft laxity and even failure, and high grade J sign appears to be associated with increased patella trochlear-groove distance, femoral anteversion angle, and tibial external angle.
基金项目
北京大学首钢医院“首颐医疗科技发展基金”青年基金(SGYYQ202103)
首都卫生发展科研专项自主创新项目(首发2022-2-6041)
北京市科技新星计划交叉合作课题(20220484178)
万方数据