Нестабильность надколенника. Помогите определиться с операцией

[Sereda Andrey]

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Figure 72-13 Femoral tunnel drilled with 6.0-mm drill bit.
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Figure 72-14 The 2.0-mm eyelet K-wire is used to pull the femoral end of the graft into the femoral tunnel.

[Sereda Andrey]

6. Graft Tensioning and Fixation

Tension is placed on the free suture ends on the lateral aspect of the knee as the surgeon moves the knee several times through a full range of motion. As the knee flexes and extends, the amount of tension in the graft can be ascertained by the amount of traction felt on the free suture ends ( Fig. 72-15 ). In addition, the graft tension is directly palpated and visualized through the medial incision. It is extremely important not to overconstrain the graft. The knee is placed in full extension, and the patella is translated laterally. An attempt is made to identify the graft length that reproduces the same amount of normal lateral translation noted on the contralateral side. Once the appropriate graft length is identified, graft fixation is obtained by a 7.0-mm bioabsorbable cannulated femoral interference screw ( Fig. 72-16 ). The screw is countersunk below the surface of the bone, and fixation can be augmented by sewing the graft to the adjacent soft tissue at the tunnel opening ( Fig. 72-17 ). It should then be confirmed that the knee has full range of motion, the patella is no longer dislocatable, and the graft provides a firm checkrein preventing pathologic lateral translation.
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Figure 72-15 The knee is ranged through a full flexion arc several times. Graft isometry is determined by assessing tension in the femoral sutures, which are held where they exit the skin on the lateral side of the knee.

[Sereda Andrey]

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Figure 72-16 Femoral fixation is obtained by a 7.0-mm bioabsorbable interference screw with the knee flexed to the angle that was determined to cause the greatest amount of tension in the MPFL graft. An attempt is made to replicate the passive lateral translation of the patella in the normal contralateral knee.
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Figure 72-17 The interference screw is countersunk. Femoral graft fixation may be augmented with sutures.
7. Closure

Subcuticular wound closure offers excellent cosmesis ( Fig. 72-18 ). Cryotherapy devices are routinely used to help control pain and swelling. A compressive dressing is then applied, followed by a thigh-high compression stocking and a postoperative brace locked in full extension.

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Figure 72-18 Subcuticular wound closure allows excellent cosmesis.






Postoperative Considerations

Rehabilitation ( Box 72-2 )

Immediately postoperatively, patients are instructed in quadriceps sets and straight-leg raises. Patients are instructed in crutch ambulation and are allowed touch-down weight bearing. The brace remains locked in full extension for 1 week, at which point patients are encouraged to begin knee range of motion and to progress as tolerated. Weight bearing is also allowed to progress as tolerated. Patients are encouraged to attend formal physical therapy three times per week, where knee range of motion and quadriceps-strengthening exercises are emphasized. The brace is unlocked for ambulation as soon as quadriceps strength is sufficient. Patients are given the goal of achieving 120 degrees of knee flexion by 4 weeks postoperatively, and the brace is generally discontinued by 6 weeks. Patients are encouraged to achieve full knee range of motion by 8 weeks and allowed to progress to jogging and sports-specific drills by 12 weeks. Most patients are able to return to sports by 4 to 5 months.

[easyf]

правильно ли я понял, через некоторое время трансплантант преварщается в нормальную связку (живую), т.е. следов от операции не будет (ну кроме шрама наверно)

[germmed]

Андрей, огромное спасибо на подробную информацию. Век живи - век учись. А что пишут о показаниях к такой операции?
Конечно, надо смотреть пациента очно, чтобы выбрать методику, померять угол Q, оценить соотношение ATT-TS. При такой дисплазии, как у пациента (угол MSL около 160гр), хронический характер патологии, наличие дефекта хряща, наличие достаточно выраженной сублюксации пателлы я бы склонился всё-таки к дистальной коррекции.

[easyf]

И все же, возможно ли безоперационное восстановление (физ. процедуры, восстановительная физкультура и и т.д.) или про это можно забыть и надо делать операцию ту или иную?

[germmed]

Консервативное лечение - это не Ваш случай

[Sereda Andrey]

Сообщение от germmed

А что пишут о показаниях к такой операции?

Показания ИМХО лучше брать такие -
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А раз так, то эта методика не совсем оптимальна для нашего виртуального пациента. Дисплазию тут видимо корректировать (трохлеопластику в спысле) никто не собирается, ИМХО более четкие данные о высоте стояния надколенника не помешали бы. НЕ знаю, как оценить высоту стояния надколенника по МРТ....
Сами же авторы книги, из которой я брал описание методики реконструкции MPFL звучат так:
MPFL reconstruction is indicated in skeletally mature patients with symptomatic recurrent lateral subluxation or dislocation episodes. Attempts at nonoperative treatment, including activity modification, physical therapy, and bracing, have failed in most patients. Femoral fixation can be modified in skeletally immature patients so that the distal femoral growth plate is not at risk. Tibial tuberosity osteotomy procedures like the Elmslie-Trillat, which directly decrease the Q angle, have a theoretical advantage in patients with greater degrees of malalignment. The Fulkerson anteromedialization osteotomy is preferred in patients with malalignment and degenerative changes.[14] MPFL reconstruction or repair can be combined with distal osteotomy if neither alone is sufficient to provide adequate stability. Lateral retinacular release is reserved for patients with excessive lateral patellofemoral pressure and is ineffective as an isolated procedure in patients with instability.

Some authors recommend MPFL repair after first-time patellar dislocation.[23] I usually treat an initial subluxation or dislocation episode nonoperatively but will repair an acute MPFL tear when surgery is indicated for concomitant intraarticular disease (such as a large loose body or meniscus tear). MPFL repair may also be used to treat recurrent instability. With repeated instability episodes, the MPFL becomes attenuated and functionally incompetent. To re-establish the normal checkrein effect, the MPFL is tightened by cutting, shortening, and reattaching it at the patellar or femoral insertion or by midsubstance imbrication.

MPFL repair or reconstruction is contraindicated in patients with medial instability or isolated anterior knee pain. In patients with significant medial patellofemoral degenerative changes, great care should be taken not to overtighten the MPFL as this will result in excessive medial joint pressures and is likely to exacerbate patellofemoral pain.

Так что эти авторы (Brian J. Cole, Jon K. Sekiya 2008) показания очерчивают более обтекаемо.

[easyf]

К сожалению, мне, как не специалисту мало о чем это говорит. Подскажите пожалуйста как мне лучше поступить в этой ситуации, идти к другому врачу либо повторно обратиться к моему, а если пойти на повторный прием то какие вопросы нужно задавать?