骨骼不成熟患者的 "冠状裂开/翻转修复 "髌腱缩短术。

IF 1 Q3 SURGERY JBJS Essential Surgical Techniques Pub Date : 2024-02-23 eCollection Date: 2024-01-01 DOI:10.2106/JBJS.ST.23.00030
Mohamed Kenawey, Emmanouil Morakis, Sattar Alshryda
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引用次数: 0

摘要

背景:"冠状面分割/重叠修复 "髌腱缩短术(PTS)是一种用于治疗髌骨脱位的技术,可与股骨远端外展截骨术(DFEO)结合使用,用于治疗骨骼发育不成熟的脑瘫患者的蹲踞步态:在冠状面上分割髌腱。髌腱腹侧皮瓣从其髌骨附着处松解,并向远端反射到其胫骨附着处,露出背侧皮瓣。两个髌骨/胫骨 No.5 Ethibond (Ethicon) 缝合线穿过两个交叉的髌骨隧道和两个平行的胫骨隧道。然后将髌骨推向远端,直到其远端位于胫股关节的水平。将 Ethibond 缝合线绑扎并张紧至所需水平。膝关节应能被动屈曲至 90°。将完整的髌腱背侧多余皮瓣连接起来。最后,将腹侧皮瓣向近端推进,缝合到髌骨前表面和背侧皮瓣边缘,不要缩短。术后使用铰链式膝关节支架,活动范围为 0° 至 30°,6 周后达到 90°。头 3 周内禁止股四头肌抵抗性收缩:对于骨骼不成熟的患者,可通过松解胫骨附着物进行髌腱前移,然后将游离端前移至 T 形胫骨骨膜瓣深部1-3。其他 PTS 技术可分为以下几类:(1) 髌骨肌腱嵌顿术4;(2) 髌骨肌腱分离术,即将肌腱从髌骨附着处分离,或在肌腱中段切开并缩短2,5-7;(3) 髌骨肌腱半分离术,制作髌骨肌腱瓣并缩短8,9。理由:目前所描述的技术是一种半脱髌技术,既保留了大部分髌腱,又避免了伸肌机制的完全开裂。此外,2 处髌骨/胫骨缝合可保护髌骨肌腱修复,并允许早期康复和膝关节活动范围锻炼:预期结果:有报道称,在使用或不使用DFEO的PTS技术矫正脑瘫患者同时伴有的固定屈曲畸形时,髌骨外翻的矫正效果令人满意。此外,有报告称,通过在站立阶段恢复膝关节的充分伸展,膝关节的整体活动范围得到了改善1,3,8。据报道,该技术的并发症主要是表皮感染:重要提示:任何严重的膝关节固定性屈曲畸形(>10°)都应在 PTS 之前通过腘绳肌延长术或 DFEO 进行矫正。为避免髌骨缝线交叉困难,应始终将直针留在第一条隧道内,直到第二条隧道形成并通过相应的缝线。为了使髌骨远端化,将髌骨/胫骨缝线打一个简单的结,并用蚊形夹夹住,以便重新拉紧,直到达到所需的髌骨高度:3DGA=三维步态分析ADL=日常生活活动CP=脑性麻痹CPM=持续被动运动DFEO=股骨远端外展截骨术FAQ=功能评估问卷FMS=功能活动度量表GMFCS=粗大运动功能分类系统GMFM=粗大运动功能测量GPS=步态轮廓评分GVS=步态变量评分K线=Kirschner线PTA=髌腱前移PTS=髌腱缩短SEMLS=单次多层次手术。
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"Coronal Split/Overlap Repair" Patellar Tendon Shortening in Skeletally Immature Patients.

Background: "Coronal split/overlap repair" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy.

Description: The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks.

Alternatives: Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap1-3. Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication4, (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened2,5-7, and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened8,9.

Rationale: The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises.

Expected outcomes: Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase1,3,8. Reported complications with this technique were mainly superficial infection.

Important tips: Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximally and distally with use of 2 mosquito clips.To avoid difficulties with crossing of the patellar sutures, always keep the straight needle inside the 1st tunnel until the 2nd tunnel is created and its respective suture is passed.To distalize the patella, the patellar/tibial sutures are tied in a simple knot and held by a mosquito clip in order to allow retensioning until the desired patellar height is reached.The 2 patellar/tibial suture knots are slid to the proximal and distal ends of the surgical field.

Acronyms and abbreviations: 3DGA = 3-dimensional gait analysisADL = activities of daily livingCP = cerebral palsyCPM = continuous passive motionDFEO = distal femoral extension osteotomyFAQ = Functional Assessment QuestionnaireFMS = Functional Mobility ScaleGMFCS = Gross Motor Function Classification SystemGMFM = Gross Motor Function MeasureGPS = Gait Profile ScoreGVS = Gait Variable ScoreK-wires = Kirschner wiresPTA = patellar tendon advancementPTS = patellar tendon shorteningSEMLS = single event multi-level surgery.

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来源期刊
CiteScore
2.30
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期刊介绍: JBJS Essential Surgical Techniques (JBJS EST) is the premier journal describing how to perform orthopaedic surgical procedures, verified by evidence-based outcomes, vetted by peer review, while utilizing online delivery, imagery and video to optimize the educational experience, thereby enhancing patient care.
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