Maopopo iā ʻoe kēlā? Nā kumu pilikia a me ka mālama ʻana i ka patellofemoral joint instability i nā keiki

ʻO ka patellofemoral instability (PFI) he mau maʻi maʻi, mai ka malaise māmā a hiki i ka wehe ʻana o ka patella (LPD). He mea maʻamau ka LPD, me 50 mau hihia i kēlā me kēia 100,000 keiki. ʻO ka dislocation mua ma waena o 15 a 19 mau makahiki. He maʻi hoʻonāwaliwali ʻo LPD, a ʻo ka nui o ka dislocation ma hope o ka mālama conservative a i ʻole ka hoʻomaʻamaʻa kino e like me 70%. ʻO ke kūkulu hou ʻana i ka ligament medial patellofemoral ka mea i hoʻohana nui ʻia. Eia nō naʻe, ʻoi aku ka nui o ka 16% o nā maʻi i loaʻa nā pilikia, me ka re-dislocation. Eia kekahi, he hapaha o nā maʻi e pono ai ke ʻoki hope ʻana ma ka hui kuli ʻē aʻe i mālama ʻole ʻia ma ke kaʻe. ʻO ka pilikia lōʻihi o ka hōʻeha cartilage holomua a me ka OA ma hope o ka LPD he 6 mau manawa kiʻekiʻe ma mua o kēlā ma hope o ka wehe mua ʻana, ʻo ia ka mea e hoʻohālikelike ai nā maʻi ʻōpio he nui i ka pilikia OA i ko lākou mau makahiki 30 a me 40. ʻO ka nele o ka hoʻomaopopo piha ʻana i ka PFI kekahi o nā mea pale nui e hoʻihoʻi i ke kūlike o ka hui patellofemoral maʻamau.

PILIKIA

Hiki ke hoʻokaʻawale ʻia nā kumu pilikia o ka PFI i ʻelua mau ʻāpana: anatomical abnormality a me alignment abnormality. ʻO ka femoral trochlear dysplasia ka mea nui anatomical abnormality, a ʻo ka alignment abnormality e pili ana i ka patellar elevation, patellar roll a me ka subluxation. Hoʻokumu ʻia ka deformity Patellofemoral e nā hoʻololi biomechanical ma muli o ka hōʻeha ʻana o ka medial stabilizer, ka hoʻonui ʻana o ka Q angle, anteversion o ka femur a me ka lateralization o ka hoʻokomo ʻana i ka tendon patellar. Ua hōʻuluʻulu ʻia nā kumu pilikia o ka PFI ma ke Kiʻi 1.

• femoral trochlea dysplasia

• kihi o ka inclination o ka pulley transverse

• asymmetry ʻaoʻao o ka pulley

• hohonu pulley

• alignment abnormal

• patella kiʻekiʻe

• ua hoʻonui ʻia ka mamao mai ka tibia a hiki i ka trochlear groove (tt-tg).

• e hoonui i ka huina q

• femoral anteversion

  
  

NA ANO O KA HOIKE KI'I

ʻOkoʻa nā ʻike MRI o ka PFI me ke koʻikoʻi a me ke ʻano maʻi o ka maʻi. Hiki ke hōʻike ʻia nā hihia PFI maʻalahi e ka patellar dyskinesia, kahi i hōʻike ʻia e ka edema o nā ʻaoʻao o luna a me nā ʻaoʻao ʻaoʻao o Hoffa fat pad (i ʻike ʻia ʻo ka patellofemoral fat impact). ʻO ka hopena o ka momona o Patellofemoral e pili kokoke ana i nā mea pilikia'ē aʻe o ka PFI, e like me ka dysplasia femoral condyle, ke kiʻekiʻe o ka patellar, ka hoʻonuiʻana i ka mamao o TT-TG, ka lateral patellar tilt a me ka subluxation. ʻO ka dyskinesia patellar lōʻihi e alakaʻi i ka ʻeha cartilage a me ka hoʻohaʻahaʻa mua ʻana o ka hui patellofemoral lateral.

ʻO ka dislocation acute o patella (APLD) ke ʻano koʻikoʻi o PFI. Hōʻike ke kiʻi ʻoniʻoni X-ray i ka loaʻa ʻana o nā ʻeha ʻeha, ʻo ia hoʻi ka hui pū ʻana, ka pae lipid i kekahi manawa o ka momona arthropathy, ka haʻihaʻi o ka medial patella osteochondral, lateral tilt/subluxation o patella (Figure 8A), a me ka hōʻailona sulcus lateral hohonu ma muli o ka hōʻeha ʻana o ka cartilage condylar femoral lateral. ʻO nā hōʻike MRI kikoʻī o ka LPD koʻikoʻi e pili ana i ka hōʻeha medial stabilizer (ʻike ʻia ma 96%), lateral patellar tilt a subluxation, osteochondral injury and joint effusion (Figure 2B, C). I ka hapanui o nā hihia, hoʻihoʻi ʻia ka patella ma hope o ka dislocation mua.

A hiki i ka 70% o nā maʻi e ʻike i ka dislocation mau, a hiki mai paha ka dislocation mau. I kēia hihia, hiki i ka MRI ke hōʻike i ka waimaka mau o ka medial stabilizer, medial patellar deformity, ossification of medial patella, patellar-femoral fat impact, cartilage injury and degeneration of lateral patellofemoral joint (Figure 3).

NA HANA

1. Ka lāʻau lapaʻau ʻole:

• ʻO ka hapa nui o nā patellar dislocations he transient a e hoʻihoʻi hou ʻia. I kekahi manawa, nā maʻi, nā ʻohana, nā hoaaloha, nā kumu aʻo a i ʻole nā ​​​​mea hoʻomaʻamaʻa e hoʻoponopono hou i ka patella ma kahi. Inā hele ka mea maʻi i ke keʻena pilikia ma muli o ka dislocation o ka patellar, e hāʻawi ʻia ʻo ia i ka sedation noʻonoʻo. Loaʻa ka hoʻohaʻahaʻa paʻa ʻana o ka patella ma ka hoʻolōʻihi ʻana i nā wāwae. Ke hoʻoponopono hou, e nānā pono i ka hui kuli no nā ʻeha ʻē aʻe.

• ʻO ka hoʻomaʻamaʻa maʻamau no ka dislocation mua o ka patella he lāʻau lapaʻau ʻole, a ʻo ka hoʻoponopono ʻana i ka wā pōkole (2-4 mau pule) i ka splint a i ʻole ka hoʻoponopono hui kuli hiki ke hoʻomalu i ka ʻeha a me ka ho'ōla ʻana o ke kino ma hope o ka hoʻouka ʻana. I loko o kēia wā, ʻae ʻia nā koʻokoʻo e amo i ke kaumaha. Ma hope o kēlā, hoʻohana ʻia nā brackets stabilizing patella no nā hana, a hana ʻia ka hoʻomaʻamaʻa kino e hoʻihoʻi i ka neʻe ʻana, ka ikaika a me ka mālama ʻana i nā lālā.

• Hoʻomaka hou nā maʻi i ka hoʻoikaika kino ma kahi o 3 mau mahina ma hope o ka hoʻouka mua ʻana. Ma waho aʻe, he koho ke kau ʻana i kahi stent.

2. Ka lāʻau lapaʻau:

• Ma mua o 30% o nā maʻi, pili ka dislocation patellar mua i ka nui o ka hoʻoheheʻe ʻana o nā kuli. I kēia hihia, pono ia e hana i ka MRI e ʻike inā he mau osteochondral fractures. ʻO ka wahi maʻamau o kēia mau haʻihaʻi, ʻo ia ka medial patella a i ʻole condyle femoral lateral, a ʻo ka hoʻomaʻamaʻa maʻamau e ʻōlelo ʻia ma ke alo o nā haʻihaʻi intra-articular.

• I ka wā o ka hana, hoʻoneʻe ʻia a hoʻopaʻa ʻia paha nā ʻāpana osteochondral e like me ka nui o nā ʻāpana haʻihaʻi a me ka maikaʻi o ka cartilage. Ke ≥ 15 mm ka nui o ka haʻihaʻi osteochondral, e noʻonoʻo ʻia ka hoʻoponopono ʻana i ka haʻihaʻi ma mua o ka excision. Hana ʻia kēia hoʻopaʻa ʻana ma ke ʻano wehe me ka hoʻohana ʻana i nā wili metala, nā pine bioabsorbable a i ʻole sutures.

• I ka mālama ʻana i nā haʻihaʻi, ua hoʻokō ʻia ke ʻano o ka hoʻopaʻa ʻana o ka patella e ka medial repair a i ʻole MPFL reconstruction. Inā hoʻohana ʻia nā wili metala no ka hoʻoponopono ʻana i ka haʻihaʻi, pono paha e wehe ʻia e nā kaʻina hana ʻoki ʻē aʻe i ka wā e hiki mai ana.

• ʻElua mau kula noʻonoʻo e pili ana i ke ala maikaʻi loa o ka hoʻokūpaʻa patellar. ʻO ke ala mua e hana hou i ka MPFL kaʻawale. ʻO MPFL ka mea paʻa nui o ka subluxation lateral o ka patella, no laila ʻo kāna hana hou e hāʻawi i ka paʻa pono no ka patella. Hana ʻia ke kūkulu hou ʻana o MPFL e nā quadriceps tendon autograft, hamstring tendon autograft a i ʻole allograft. ʻO ka helu kūleʻa o ka hoʻokaʻawale ʻana o ka MPFL e hoʻihoʻi i ka paʻa patellar ma luna o 95%, ʻaʻohe mea pili i ke koho ʻana o ka graft. ʻO nā pilikia maʻamau o ka hana hou ʻana o MPFL, ʻo ia ka ʻoʻoleʻa o ka hui kuli, ka haʻi ʻana o ka patellar a me ka patellar instability.

• ʻO ke ala ʻelua e hoʻonā i nā kumu pilikia o ka patellar instability, a me ka kūkulu hou ʻana o MPFL. Ma kēia ʻano, hoʻoholo ʻia nā kumu pilikia anatomical o ka patellar instability ma ka X-ray film a me CT/MRI, me ka trochlear dysplasia, hoʻonui i ke kiʻekiʻe patellar a me ka mamao TT-TG. Ke hoʻoholo ʻia, e hoʻoponopono ʻia kekahi a i ʻole nā ​​mea pilikia a pau e ka ʻoki.

• Hoʻoholo ʻia ka dysplasia trochlear e ka trochleoplasty, kahi i hoʻohonu ʻia ai ke awāwa trochlear (Figure 12A). ʻAʻole kaulana loa ka palaka Trochlear ma ʻAmelika Hui Pū ʻIa no ka mea e pili ana i ka hoʻouka ʻana o ka cartilage articular, a ma ke ʻano manaʻo, aia ka pilikia o ka necrosis ischemic a i ʻole arthritis.

• Hoʻoholo ʻia ke kiʻekiʻe ʻo Patella a i ʻole ka piʻi ʻana o ke kiʻekiʻe o ka patella e ka tubercle tibial distal. No ka hoʻonui ʻana i ka mamao TT-TG, hana ʻia ka medial a i ʻole anteromedial tibial tubercle (Figure 12B). ʻO nā hoʻopiʻi o ka osteotomy tuberosity tibial e pili ana i ka nonunion, ka ʻeha hardware, ka nalowale o ka hoʻemi ʻana o ka tuberosity a me ka haki.

• No ka hoʻopaʻapaʻa ʻana o ka retina lateral, hoʻokuʻu ʻia ka retinal lateral, e hōʻike ana i ka piʻi ʻana o ka patella tilt. ʻO nā pilikia o ka hoʻokuʻu ʻana i ka ʻaoʻao e pili ana i ka pehu mau a me ka iatrogenic medial instability o ka patella.

• I nā poʻe maʻi me nā iwi oʻo, ua contraindicated a hoʻololi ʻia kekahi mau hana ma muli o ka epiphysis.

• Aia ka wahi hoʻopili femoral o MFPL ma lalo pono o ka epiphysis o ka femur distal. No laila, pono e mālama ʻia ka hana hou ʻana o ka MPFL o nā maʻi me nā iwi ʻoi ʻole ma lalo o ke alakaʻi fluoroscopy koʻikoʻi e hōʻoia i ka hoʻopaʻa ʻia ʻana o ka tunnel femoral.

• Hiki i ka ʻeha femur distal ke alakaʻi i ka deformity, a ʻaʻole paha e koi i ka hoʻoponopono ʻana. Pēlā nō, hiki i ka ʻeha o ka proximal tibial protrusion ke alakaʻi i ka deformity, ʻoi aku hoʻi i ke kuli medial. No laila, pāpā ʻia ka osteotomy o ka tuberosity tibial no nā poʻe maʻi me ka hāmama o ka tibial protrusion.

• ʻO ka mea ʻē aʻe, hiki ke hoʻoneʻe ʻia ka tendon patellar i ka medially. Ke hoʻoneʻe ʻia ka hapa waho o ka tendon patellar i ka ʻaoʻao medial, ua kapa ʻia kēia hana ʻo Roux-Goldthwait operation (Figure 12C).

• Pono e loiloi ʻia nā poʻe maʻi āpau e hana ana i ka ʻokiʻoki no ka patellar instability i ka hoʻonohonoho ʻana o nā lālā coronary a me nā lālā ʻōwili. ʻO ka hoʻonui ʻia ʻana o ka genu valgus, ka nui o ka femoral anteversion a me ka hoʻonui ʻana i ka tibial torsion waho nā kumu pilikia no ka patellar instability.

• No nā poʻe maʻi me nā iwi ʻōpiopio, pono e noʻonoʻo ʻia ke alakaʻi ʻana i ka ulu ʻana i ka wā e pili ana i ka genu valgus. Hiki i nā ʻūhā Epiphyseal a i ʻole nā ​​papa hoʻopaʻapaʻa ke hoʻopaʻa i ka ʻaoʻao waena o ka hopena o ka epiphysis femoral no ka hoʻoponopono lohi. Pono ka Osteotomy no ka hoʻoponopono ʻana i nā poʻe maʻi me nā iwi oʻo no ka maʻi coronary a i ʻole rotational deformity. ʻO ka hōʻailona hoʻoponopono o ka genu valgus he> 10 degere, a ʻo ka hōʻailona hoʻoponopono o ka rotational dislocation ma mua o 20 degere.

• Hiki i nā keiki (<10 mau makahiki) ke loa'a i nā hi'ohi'ona pa'akikī o ka patellar instability, e like me ka ho'oka'awale 'ana o ka patellar. ʻO kekahi mau maʻi maʻi e like me Down syndrome, nail-patellar syndrome, Kabuki syndrome a me Rubinstein Taybi syndrome i haku ʻia me ka patellar instability.

• He mea nui ka hoʻomaopopo ʻana ʻaʻole lawa ka hana hou ʻana o MPFL e hoʻoponopono i kēia mau hiʻohiʻona paʻakikī, no ka mea, aia ka pathology mua ma ka ʻaoʻao, a i kekahi manawa ua pōkole ke ʻano o ka quadriceps femoris, e koi ana i ka hoʻokuʻu ākea ākea a me ka quadriceps femoris plasty e hoʻoponopono i kēia mau pilikia.

• I loko o ka quadriceps femoris plasty, hoʻonohonoho hou ʻia ka mīkini quadriceps femoris a hoʻolōʻihi ʻia. Inā mālama ʻole ʻia a mālama ʻole paha, hiki ke ʻike ʻia kēia mau ʻano paʻakikī paʻakikī ma hope o ke ola.

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