Kodi mukudziwa zimenezo? Zowopsa ndi chithandizo cha kusakhazikika kwa mgwirizano wa patellofemoral mwa ana

Kusakhazikika kwa Patellofemoral (PFI) kumaphatikizapo matenda angapo, kuyambira kufooka pang'ono mpaka kutayika koonekeratu kwa patella (LPD). LPD ndiyofala, ndipo milandu 50 mwa ana 100,000 aliwonse. Kusuntha koyamba kumachitika pakati pa zaka 15 ndi 19. LPD ndi matenda ofooketsa, ndipo chiwopsezo cha kusuntha pambuyo pa chithandizo chokhazikika kapena chithandizo chamankhwala chimakhala chokwera mpaka 70%. Kukonzanso kwapakati pa patellofemoral ligament ndi mankhwala opangira opaleshoni omwe amagwiritsidwa ntchito kwambiri. Komabe, pafupifupi 16% ya odwala amakhala ndi zovuta, kuphatikizapo kusunthanso. Kuonjezera apo, gawo limodzi mwa magawo atatu a odwala amafunikira opaleshoni yotsatila pamagulu ena a mawondo omwe sachitidwa opaleshoni. Chiwopsezo chanthawi yayitali cha kuvulala kwapang'onopang'ono kwa cartilage ndi OA pambuyo pa LPD ndi nthawi ya 6 kuposa yomwe itatha kusuntha koyamba, zomwe zimapangitsa odwala ambiri achichepere kukumana ndi chiopsezo cha OA m'zaka zawo za 30 ndi 40. Kupanda kumvetsetsa bwino kwa PFI ndi chimodzi mwa zopinga zazikulu zobwezeretsanso kugwirizana kwa mgwirizano wa patellofemoral.

RISK FACTOR

Ziwopsezo za PFI zitha kugawidwa m'magulu awiri: kusakhazikika kwachilengedwe komanso kusakhazikika bwino. The femoral trochlear dysplasia ndiye chinthu chofunikira kwambiri cha anatomical abnormality, ndipo kusalongosoka kumaphatikizapo kukwera kwa patellar, patellar roll ndi subluxation. Kuwonongeka kwa Patellofemoral kumayambitsidwa ndi kusintha kwa biomechanical chifukwa cha kuvulala kwa stabilizer yapakati, kuwonjezeka kwa Q angle, kusinthika kwa femur ndi lateralization ya patellar tendon kulowetsa. Zowopsa za PFI zafotokozedwa mwachidule Chithunzi 1.

• femoral trochlea dysplasia

• angle ya kupendekera kwa pulley yopingasa

• mbali ya asymmetry ya pulley

• kuzama kwa pulley

• kulondola kwachilendo

• mkulu patella

• mtunda wochokera ku tibia kupita ku trochlear groove (tt-tg) unawonjezeka

• kuwonjezera q angle

• kukhumudwa kwachikazi

  
  

MAKHALIDWE WOYENZA AMAGANGIZO

Zotsatira za MRI za PFI zimasiyana ndi kuuma komanso kusakhazikika kwa matendawa. Milandu yofatsa ya PFI ikhoza kudziwika ndi patellar dyskinesia, yomwe imadziwika ndi edema ya kumtunda ndi kumbali ya Hoffa fat pad (yomwe imadziwikanso kuti patellofemoral fat impact). Mafuta a Patellofemoral amagwirizana kwambiri ndi zinthu zina zoopsa za PFI, kuphatikizapo femoral condyle dysplasia, kutalika kwa patellar, kuwonjezeka kwa TT-TG mtunda, lateral patellar tilt ndi subluxation. Kutalika kwa nthawi yayitali patellar dyskinesia kumabweretsa kuvulala kwa cartilage komanso kuwonongeka koyambirira kwa mgwirizano wa patellofemoral.

Acute dislocation of patella (APLD) ndiye mtundu wowopsa kwambiri wa PFI. Mafilimu a X-ray akuwonetsa kuvulazidwa koopsa, komwe kungaphatikizepo kuphatikizika kwa mgwirizano, nthawi zina lipid mlingo wa mafuta arthropathy, fracture of medial patella osteochondral, lateral tilt / subluxation of patella (Chithunzi 8A), ndi chizindikiro chakuya cha sulcus chozama chifukwa cha kuvulala kwa lateral femoral condylar cartilage. Mawonetseredwe enieni a MRI a LPD ovuta kwambiri amaphatikizapo kuvulala kwapakati (kuwonedwa mu 96%), lateral patellar tilt kapena subluxation, kuvulala kwa osteochondral ndi kuphatikizika pamodzi (Chithunzi 2B, C). Nthawi zambiri, patella imasinthidwa zokha pambuyo pa kusuntha koyamba.

Kufikira 70% ya odwala amakumana ndi kusuntha kobwerezabwereza, ndipo kusokonezeka kosalekeza kungachitike. Pachifukwa ichi, MRI ingasonyeze misozi yosatha ya stabilizer yapakati, kusokonezeka kwapakati patellar, ossification ya patella yapakati, mafuta a patellar-femoral, kuvulala kwa cartilage ndi kuwonongeka kwa mgwirizano wa patellofemoral (Chithunzi 3).

MANKHWALA

1. Chithandizo chosapanga opaleshoni:

• Zowonongeka zambiri za patellar ndizokhalitsa ndipo zidzasinthidwa zokha. Nthawi zina, odwala, achibale, abwenzi, makochi kapena ophunzitsa amakhazikitsanso patella pomwepo. Ngati wodwalayo apita ku dipatimenti yodzidzimutsa chifukwa cha kusokonezeka kwa patellar, amapatsidwa mankhwala osokoneza bongo. Kuchepetsa kutsekedwa kwa patella kumatheka mwa kutambasula pang'onopang'ono miyendo. Mukayambiranso, yang'anani bondo kuti muwone kuvulala kwina.

• Chithandizo chokhazikika cha kusokonezeka koyamba kwa patella ndi chithandizo chopanda opaleshoni, ndipo kukhazikika kwa nthawi yochepa (masabata a 2-4) muzitsulo zopangira mawondo kapena mawondo amatha kulamulira ululu ndi machiritso oyambirira a minofu pambuyo pa kuukira koopsa. Panthawi imeneyi, ndodo zimaloledwa kunyamula kulemera. Pambuyo pake, mabatani okhazikika a patella amagwiritsidwa ntchito pazochita, ndipo chithandizo chamankhwala chimachitidwa kuti abwezeretse kuyenda, mphamvu ndi kuwongolera miyendo.

• Odwala nthawi zambiri amayambiranso kuchita masewera olimbitsa thupi pafupifupi miyezi itatu pambuyo pa kuukira koyamba. Kupatula apo, kuvala stent ndikosankha.

2. Chithandizo cha opaleshoni:

• Oposa 30% ya odwala, kusokonezeka koyamba kwa patellar kumakhudzana ndi kuchuluka kwa mawondo ophatikizana. Pankhaniyi, m'pofunika kuchita MRI kuti mudziwe ngati pali osteochondral fractures. Malo odziwika kwambiri a fractures awa ndi patella yapakati kapena lateral femoral condyle, ndipo chithandizo cha opaleshoni nthawi zambiri chimalimbikitsidwa pamaso pa fractures ya intra-articular.

• Panthawi ya opaleshoni, zidutswa za osteochondral fracture zimachotsedwa kapena kukhazikitsidwa molingana ndi kukula kwa zidutswa zosweka komanso mtundu wa cartilage. Pamene kukula kwa osteochondral fracture ndi ≥ 15 mm, kukonza fracture m'malo mwa excision kumaganiziridwa. Kukonzekera uku kumachitidwa ndi njira yotseguka pogwiritsa ntchito zomangira zachitsulo, zikhomo za bioabsorbable kapena sutures.

• Pochiza fractures, mchitidwe wa kukhazikika kwapang'onopang'ono kwa patella kumatheka ndi kukonzanso kwapakati kapena kukonzanso kwa MPFL. Ngati zitsulo zachitsulo zimagwiritsidwa ntchito pokonza fracture, zikhoza kuchotsedwa ndi njira zina za opaleshoni m'tsogolomu.

• Pali masukulu awiri oganiza za njira yabwino kwambiri yokhazikitsira patellar. Njira yoyamba ndiyo kupanganso kukonzanso kwakutali kwa MPFL. MPFL ndiye chinthu chachikulu chomwe chimalepheretsa kusinthika kwa patella, kotero kumangidwanso kwake kumapereka kukhazikika kofunikira kwa patella. Kumanganso kwa MPFL nthawi zambiri kumachitika ndi quadriceps tendon autograft, hamstring tendon autograft kapena allograft. Kupambana kwa kumangidwanso kwakutali kwa MPFL kuti kubwezeretse kukhazikika kwa patellar kumapitilira 95%, zomwe sizikugwirizana ndi kusankha kwa graft. Zovuta zofala kwambiri pakumanganso kwa MPFL ndi kuuma kwa mawondo, kupasuka kwa patellar ndi kusakhazikika kwapang'onopang'ono.

• Njira yachiwiri imathetsa zovuta zowonongeka kwa patellar, ndi kukonzanso kwa MPFL. Mu njira iyi, anatomical chiopsezo zinthu za patellar kusakhazikika anatsimikiza pa X-ray filimu ndi CT/MRI, kuphatikizapo trochlear dysplasia, kuchuluka patellar kutalika ndi TT-TG mtunda. Zikatsimikiziridwa, zina kapena zonse zowopsa zidzakonzedwa ndi opaleshoni.

• The trochlear dysplasia imathetsedwa ndi trochleoplasty, momwe trochlear groove imazama (Chithunzi 12A). Trochlear plasty si yotchuka kwambiri ku United States chifukwa imaphatikizapo kuukira kwa cartilage ya articular, ndipo mwachidziwitso pali chiopsezo cha tsogolo la ischemic necrosis kapena nyamakazi.

• Kutalika kwa Patella kapena kuwonjezeka kwa kutalika kwa patella kumathetsedwa ndi distal tibial tubercle. Pofuna kuonjezera mtunda wa TT-TG, tubercle yapakati kapena ya anteromedial tibial imachitidwa (Chithunzi 12B). Zovuta za tibial tuberosity osteotomy zimaphatikizapo nonunion, kupweteka kwa hardware, kutaya kwa kuchepa kwa tuberosity ndi kupasuka.

• Pakugwedezeka kwa retina kumbuyo, kutulutsidwa kwa retina kumbuyo kumachitika, zomwe zikuwonetsa kupendekeka kwa patella. Zovuta za kumasulidwa kwapambuyo kumaphatikizapo kutupa kosalekeza ndi kusakhazikika kwapakati pa iatrogenic kwa patella.

• Odwala omwe ali ndi mafupa osakhwima, maopaleshoni ena amatsutsana kapena kusinthidwa chifukwa cha epiphysis.

• Malo olumikizirana ndi akazi a MFPL ali pansi pa epiphysis ya distal femur. Chifukwa chake, kukonzanso kwa MPFL kwa odwala omwe ali ndi mafupa osakhwima kuyenera kuchitidwa motsogozedwa ndi fluoroscopy kuti atsimikizire kubowola kotetezeka kwa ngalande yachikazi.

• Kuvulala kwa distal femur kungayambitse kupunduka, komwe kungafune kapena kusafuna kuwongolera opaleshoni. Mofananamo, kuvulala kwa proximal tibial protrusion kungayambitse kuwonongeka, makamaka pa bondo lapakati. Choncho, osteotomy ya tibial tuberosity ndiyoletsedwa kwa odwala omwe ali ndi proximal proximal tibial protrusion.

• M'malo mwake, tendon ya patellar imatha kusamutsidwa kwathunthu kapena pang'ono. Pamene theka lakunja la tendon la patellar limasamutsidwa kumbali yapakati, opaleshoniyi imatchedwa opaleshoni ya Roux-Goldthwait (Chithunzi 12C).

• Odwala onse omwe akuchitidwa opaleshoni ayenera kuyesedwa kuti asasunthike patellar mu dongosolo la mitsempha ya mitsempha ndi miyendo yozungulira. Kuwonjezeka kwa genu valgus, kuwonjezereka kwachikazi kwachikazi komanso kuwonjezeka kwa kunja kwa tibial torsion ndizomwe zimayambitsa kusakhazikika kwa patellar.

• Kwa odwala omwe ali ndi mafupa osakhwima, kutsogolera kukula kuyenera kuganiziridwa pochita ndi genu valgus. Zomangira za epiphyseal kapena tension band plates zimatha kupitilira mbali yapakati ya distal end of femoral epiphysis kuti ikonze pang'onopang'ono. Osteotomy ndiyofunikira kuti akonze odwala omwe ali ndi mafupa okhwima chifukwa cha kuwonongeka kwa mitsempha kapena kuzungulira. Chizindikiro chowongolera cha genu valgus ndi> madigiri a 10, ndipo chizindikiro chowongolera cha kusuntha kozungulira chimaposa madigiri 20.

• Ana (ochepera zaka 10) adzakumana ndi zovuta za kusakhazikika kwa patellar, zomwe zimaphatikizapo kusasunthika kosasunthika kapena chizolowezi cha patellar. Ma syndromes angapo monga Down syndrome, nail-patellar syndrome, Kabuki syndrome ndi Rubinstein Taybi syndrome amapangidwa ndi kusakhazikika kwa patellar.

• Nkofunika kuzindikira kuti akutali kumangidwanso kwa MPFL sikokwanira kuthetsa ndondomeko zovuta zimenezi, chifukwa matenda chachikulu ili laterally, ndipo nthawi zina limagwirira quadriceps femoris ndi adzafupikitsidwa, amene amafuna lonse lateral kumasulidwa ndi quadriceps femoris plasty kuthetsa mavutowa.

• Mu quadriceps femoris plasty, njira ya quadriceps femoris imayendetsedwanso ndi / kapena kutalika. Pankhani ya kunyalanyaza kapena kulandira chithandizo mochedwa, zovuta zosakhazikika izi zikhoza kukumana m'tsogolo.

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