Ngaba uyayazi loo nto? Izinto ezinobungozi kunye nokunyangwa kwe-patellofemoral joint instability kubantwana

Ukungazinzi kwePatellofemoral (PFI) kubandakanya uluhlu lwezifo, ukusuka kwi-malaise epholileyo ukuya kwi-dislocation ebonakalayo yepatella (LPD). I-LPD iqhelekile ngokwentelekiso, kunye neemeko ezingama-50 kubantwana abali-100,000. Ukukhutshwa kokuqala ngokuqhelekileyo kwenzeka phakathi kwe-15 kunye ne-19 leminyaka ubudala. I-LPD sisifo esiphazamisayo, kwaye izinga lokuchithwa emva konyango olulondolozayo okanye unyango lomzimba luphezulu njenge-70%. Ukwakhiwa ngokutsha kwe-patellofemoral ligament ye-medial yonyango olusetyenziswa kakhulu. Nangona kunjalo, uninzi lwe-16% yezigulane zineengxaki, kubandakanywa ukuchithwa kwakhona. Ukongezelela, ikota yezigulane zidinga ukuhlinzwa okulandelwayo kwelinye idolo elingaphathwa ngotyando. Umngcipheko wexesha elide lokulimala kwe-cartilage eqhubekayo kunye ne-OA emva kwe-LPD ngamaxesha e-6 aphezulu kunokuba emva kokuchithwa kokuqala, okwenza izigulane ezininzi ezincinci zijongene nomngcipheko we-OA kwi-30 kunye ne-40. Ukungabikho kokuqonda ngokubanzi kwe-PFI yenye yeengxaki eziphambili zokubuyisela ukuhambelana kwesiqhelo se-patellofemoral joint.

RISK FACTOR

Imiba yomngcipheko yePFI inokwahlulwa ibe ngamacandelo amabini: ukungaqhelekanga kwe-anatomical kunye nokungahambi kakuhle kolungelelwaniso. I-femoral trochlear dysplasia yeyona nto ibalulekileyo ye-anatomical abnormality, kwaye ukungahambi kakuhle kokulungelelaniswa kubandakanya ukuphakama kwe-patellar, i-patellar roll kunye ne-subluxation. I-Patellofemoral deformity ibangelwa utshintsho lwe-biomechanical olubangelwa ukulimala kwe-stabilizer medial, ukwanda kwe-angle ye-Q, i-anteversion of femur kunye ne-lateralization yokufakwa kwe-tendon patellar. Imiba yengozi yePFI ishwankathelwe kuMfanekiso 1.

• i-femoral trochlea dysplasia

• i-engile yokuthambekela kwepuli enqamlezileyo

• I-facet asymmetry ye-pulley

• ubunzulu bepuli

• ulungelelwaniso olungaqhelekanga

• patella ephezulu

• umgama ukusuka kwi-tibia ukuya kwi-trochlear groove (tt-tg) yanda

• ukwandisa i-engile q

• ukuxhatshazwa kwabasetyhini

  
  

IIMPAWU ZOVIWO LWEMIFANEKISO

Iziphumo zeMRI zePFI ziyahluka ngobunzima kunye nesimo esingapheliyo sesi sifo. Iimeko ze-PFI ezinobunzima zingabonakaliswa yi-patellar dyskinesia, ebonakaliswa yi-edema yecala eliphezulu kunye ne-lateral ye-Hoffa fat pad (eyaziwa ngokuba yi-patellofemoral fat impact). Impembelelo yamafutha e-Patellofemoral ihambelana ngokusondeleyo neminye imingcipheko ye-PFI, kuquka i-femoral condyle dysplasia, ukuphakama kwe-patellar, ukunyuka kwe-TT-TG umgama, i-lateral patellar tilt kunye ne-subluxation. I-patellar dyskinesia yexesha elide ikhokelela ekulimazeni kwe-cartilage kunye nokuwohloka kwangaphambili kwe-lateral patellofemoral joint.

I-Acute dislocation yepatella (APLD) lolona hlobo lunzima lwePFI. Ifilimu ecacileyo ye-X-ray ibonisa ukufunyanwa kokulimala okunamandla, okunokuthi kubandakanye ukuxutywa kwe-joint, i-lipid level ye-fatty arthropathy, i-fracture ye-medial patella osteochondral, i-lateral tilt / subluxation ye-patella (Umfanekiso we-8A), kunye ne-deep lateral sulcus sign ebangelwa ukulimala kwempembelelo ye-lateral femoral condylar cartilage. Ukubonakaliswa kwe-MRI ethile ye-LPD enzima ibandakanya ukulimala kwe-stabilizer ye-medial (ebonwa kwi-96%), i-lateral patellar tilt okanye i-subluxation, ukulimala kwe-osteochondral kunye ne-joint effusion (Figure 2B, C). Kwiimeko ezininzi, i-patella isetwa kwakhona ngokuzenzekelayo emva kokukhutshwa kokuqala.

Ukuya kuthi ga kwi-70% yezigulane ziya kufumana ukuchithwa okuphindaphindiweyo, kwaye ukuchithwa okungapheliyo okungapheliyo kunokwenzeka. Kule meko, i-MRI inokubonisa ukukrazula okungapheliyo kwe-stabilizer medial, i-medial patellar deformity, i-ossification ye-patella ye-medial, impembelelo ye-patellar-femoral fat, ukulimala kwe-cartilage kunye nokuncipha kwe-lateral patellofemoral joint (Umfanekiso 3).

IZINYANGO

1. Unyango olungasebenzisi utyando:

• Uninzi lwee-acute patellar dislocation zexeshana kwaye ziyakusetwa ngokutsha ngokuzenzekelayo. Ngamanye amaxesha, izigulana, amalungu osapho, abahlobo, abaqeqeshi okanye abaqeqeshi baya kusetha ngokutsha ipatella kwangoko. Ukuba isigulane siya kwisebe likaxakeka ngenxa ye-patellar dislocation, siya kunikwa i-sedation sedation. Ukunciphisa i-patella evaliweyo kufezekiswa ngokuthe ngcembe ukunweba imilenze. Emva kokuba usethe kwakhona, jonga ngeklinikhi idolo elihlangeneyo kwezinye iingozi.

• Unyango oluqhelekileyo lwe-dislocation yokuqala ye-patella yonyango olungenalo utyando, kunye nexesha elifutshane (iiveki ze-2-4) ukulungiswa kwi-splint okanye i-knee joint fixator inokulawula intlungu kunye nokuphulukiswa kokuqala kwezicubu emva kokuhlaselwa ngokukrakra. Ngeli xesha, iintonga zivumelekile ukuba zithwale ubunzima. Emva koko, izibiyeli zokuzinzisa i-patella zisetyenziselwa imisebenzi, kwaye unyango lomzimba lwenziwa ukubuyisela ukunyakaza, amandla kunye nokulawulwa kwemilenze.

• Izigulane zidla ngokuphinda ziphinde zisebenze malunga neenyanga ze-3 emva kokuhlaselwa kokuqala. Ngaphandle koko, ukunxiba i-stent kukhetho.

2. Unyango lotyando:

• Ngaphezulu kwe-30% yezigulane, i-patellar dislocation yokuqala ihambelana nomthamo omkhulu we-knee joint effusion. Kule meko, kuyimfuneko ukwenza i-MRI ukuchonga ukuba kukho i-osteochondral fractures. Eyona ndawo ixhaphakileyo kwezi ziqhekeza yi-patella yangaphakathi okanye i-condyle ye-femoral ye-lateral, kwaye unyango lotyando ludla ngokucetyiswa phambi kwe-intra-articular fractures.

• Ngethuba lokusebenza, iziqwenga ze-osteochondral fracture ziyasuswa okanye zilungiswe ngokobungakanani beqhekeza kunye nomgangatho we-cartilage. Xa ubungakanani be-osteochondral fracture ≥ 15 mm, ukulungiswa kwe-fracture endaweni yokucima kuqwalaselwa. Olu lungiso lwenziwa ngendlela evulekileyo ngokusebenzisa izikhonkwane zetsimbi, izikhonkwane ze-bioabsorbable okanye i-sutures.

• Kunyango lweefractures, umkhwa wokuzinzisa utyando ngaxeshanye lwepatella ufezekiswa ngokulungiswa kwe-medial okanye ukwakhiwa kwakhona kweMPFL. Ukuba izikrufu zetsimbi zisetyenziselwa ukulungiswa kokuqhekeka, kunokufuneka ukuba zisuswe ngezinye iinkqubo zotyando kwixesha elizayo.

• Kukho izikolo ezibini zokucinga malunga neyona ndlela ilungileyo yokuzinzisa ipatellar. Indlela yokuqala kukwenza ulwakhiwo olulodwa lweMPFL. I-MPFL iyona nto iphambili yokunyanzeliswa kwe-lateral subluxation yepatella, ngoko ke ukwakhiwa kwayo kwakhona kuya kunika uzinzo olufunekayo kwipatella. Ukwakhiwa kwakhona kwe-MPFL ngokuqhelekileyo kwenziwa nge-quadriceps tendon autograft, i-hamstring tendon autograft okanye i-allograft. Izinga lempumelelo yokwakhiwa ngokutsha kweMPFL ekwanti ukubuyisela uzinzo kwi-patellar ingaphezulu kwama-95%, nto leyo engenanto yakwenza nokukhethwa kwegrafti. Iingxaki eziqhelekileyo zokwakhiwa kwakhona kwe-MPFL kukuqina kwamadolo, ukuphuka kwe-patellar kunye nokungazinzi okuphindaphindiweyo kwepatellar.

• Indlela yesibini isombulula izinto ezinobungozi bokungazinzi kwepatellar, kunye nokwakhiwa kwakhona kweMPFL. Kule ndlela, imingcipheko ye-anatomical yokungazinzi kwe-patellar inqunywe kwifilimu ye-X-ray kunye ne-CT / MRI, kubandakanywa ne-trochlear dysplasia, ukuphakama kwe-patellar kunye nomgama we-TT-TG. Xa sele kumiselwe, ezinye okanye zonke izinto ezinobungozi ziya kulungiswa ngotyando.

• I-dysplasia ye-trochlear isonjululwa yi-trochleoplasty, apho i-trochlear groove inzulu (Umfanekiso 12A). I-Trochlear plasty ayithandwa kakhulu e-United States kuba ibandakanya ukuhlaselwa kwe-articular cartilage, kwaye ithiyori kukho umngcipheko we-ischemic necrosis okanye isifo samathambo.

• Ukuphakama kwePatella okanye ukunyuka kokuphakama kwepatella kusonjululwa yi-distal tibial tubercle. Ukuze ukwandise umgama we-TT-TG, i-tubercle ye-tibial medial okanye i-anteromedial yenziwa (Umfanekiso 12B). Iingxaki ze-tibial tuberosity osteotomy ziquka i-nonunion, intlungu ye-hardware, ukulahlekelwa kwe-tuberosity yokunciphisa kunye nokuphuka.

• Ngoxinzelelo lwe-retina esecaleni, ukukhutshwa kwe-retinal ye-lateral kuyenziwa, okubonisa ukwanda kwe-patella tilt. Iingxaki zokukhululwa kwecala ziquka ukuvuvukala okuqhubekayo kunye nokungazinzi kwe-iatrogenic medial yepatella.

• Kwizigulane ezinamathambo angavuthwanga, ezinye ii-operation zichaswa okanye zitshintshwe ngenxa ye-epiphysis.

• Indawo yokuncamathela ye-femoral ye-MFPL ifumaneka ngaphantsi kwe-epiphysis ye-distal femur. Ke ngoko, ukwakhiwa ngokutsha kweMPFL yezigulana ezinamathambo angavuthwanga kufuneka kuqhutywe phantsi kwesikhokelo esingqongqo se-fluoroscopy ukuqinisekisa ukugrunjwa okukhuselekileyo kwetonela ye-femoral.

• Ukulimala kwe-Distal femur kunokukhokelela ekukhubazekeni, okunokuthi okanye kungafuneki ukulungiswa kotyando. Ngokufanayo, ukulimala kwe-proximal tibial protrusion kunokukhokelela ekukhubazekeni, ngakumbi kwidolo eliphakathi. Ngoko ke, i-osteotomy ye-tibial tuberosity ayivunyelwe kwizigulane ezine-proximal proximal protrusion protrusion.

• Ngokuchasene noko, i-patellar tendon inokufuduswa ngokupheleleyo okanye ngokuyinxenye phakathi. Xa isiqingatha sangaphandle se-patellar tendon sidluliselwa kwicala le-medial, lo msebenzi ubizwa ngokuba yi-Roux-Goldthwait operation (Figure 12C).

• Zonke izigulane ezenza utyando kufuneka zihlolwe ukungazinzi kwepatellar kwilungiselelo lemilenze ye-coronary kunye nemilenze ejikelezayo. Ukunyuka kwe-valgus ye-genu, ukugqithiswa kwe-femoral anteversion kunye nokunyuka kwangaphandle kwe-tibial torsion yizinto ezinobungozi bokungazinzi kwepatellar.

• Kwizigulane ezinamathambo angavuthwanga, ukukhula okukhokelayo kufuneka kuthathelwe ingqalelo xa ujongene ne-valgus ye-genu. Izikrufu ze-Epiphyseal okanye iipleyiti ze-tension band zinokuvula icala eliphakathi kwi-distal end ye-femoral epiphysis ukwenzela ukulungiswa ngokuthe ngcembe. I-Osteotomy iyadingeka ukulungisa izigulane ezinamathambo aqolileyo ngenxa ye-coronary or rotational deformity. Isibonakaliso sokulungiswa kwe-valgus ye-genu> 10 degrees, kwaye isalathisi sokulungiswa kokujikeleza okujikelezayo kudlula i-20 degrees.

• Abantwana (<iminyaka eyi-10 ubudala) baya kuhlangabezana neepatheni ezinzima zokungazinzi kwepatellar, ezibandakanya ukuchithwa okusisigxina okanye okuqhelekileyo kwepatellar. I-syndromes ezininzi ezifana ne-Down syndrome, i-nail-patellar syndrome, i-Kabuki syndrome kunye ne-Rubinstein Taybi syndrome iqulethwe ukungazinzi kwe-patellar.

• Kubalulekile ukuqaphela ukuba ukwakhiwa ngokutsha okuzimeleyo kweMPFL akwanelanga ukusombulula ezi patheni zinzima, kuba i-pathology yokuqala ibekwe ecaleni, kwaye ngamanye amaxesha indlela ye-quadriceps femoris ifinyeziwe, efuna ukukhululwa kwecala elibanzi kunye ne-quadriceps femoris plasty ukusombulula ezi ngxaki.

• Kwi-quadriceps femoris plasty, indlela ye-quadriceps femoris iphinda iqhelaniswe kunye / okanye ixesha elide. Kwimeko yokungahoywa okanye unyango olusemva kwexesha, ezi patheni zinzima ezingazinzanga zinokuqubisana nazo kamva ebomini.

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