22髌骨软化症

髌骨软化症广州中医药大学一附院关节中心DOCTORWANG髌骨软化症是髌软骨面及与其相对的股骨髌面的关节软骨由于损伤而引起的退行性变。【病因病机】本病多发生于运动员，常由慢性或急性损伤引起，如膝的长期猛烈屈伸活动，使髌股之间发生长期猛烈的摩擦。DefinitionChondromalaciapatella,Softeninganddegenerativechangesintheposteriorsurfaceofthepatella.PathologyFirstusedbyAlemanin1917,chondromalaciapatellawasthenamegiventoadegenerationofthepatellararticularcartilage(KipnisandScuderi,1995).Truechondromalaciapatellainvolvesthedegenerationofthearticularfacetsofthepatella,withresultingraggedfrondededges,(WelshandHutton,1990),andisaverycommoninjuryamongstbothmenandwomenofoursportingpopulation(Williams,1990).Alongwithosteoarthritis,chondromalaciapatellaisatypeofcartilagedamageresultinginanteriorkneepain.Itisalsonamedasacauseofthesymptomsofpatellofemoralpainsyndrome(Reid,1992).Whencomparedtothenumberofpatientswhoareseenwithpatellofemoralpain,andthosewithactualchangestothearticularcartilageofthepatella,chondromalaciapatellaisarareconditionthough(Nofthall,1990).Cartilagechangesoccurduetoexcesscompressionwhichdisruptstheintermediateanddeeplayersofcartilageofthepatella’sarticularsurface(Reid,1992).Kulund,1988,alsodescribeschangeswhichoccurtothesubchondralbone–microfracturesandsclerosis–bothofwhichmakethebonelessresilientandleadtogreatershocktothecartilage.Mostchondromalacicchangesareseenalongthemedianridgeofthepatella,andherecartilageisthickest(Kulund,1988).PatellatraumaAfractureinvolvingthefullthicknessofthepatellainachildisextremelyrare.Howeverfracturesofthepatellararticularfacetsarelessuncommon.PATELLA:Medialcontactoffemurinextremeflexion(rose)FacetformedialfemoralcondyleFacetforlateralfemoralcondyleAttachmentofpatellarligamentLateralrelease4x’sbodyweightwithkneeflexed70-80degreesofflexionPatellaPathologiesPatellofemoralStressSyndromeMechanismS/SHistoryInspectionPalpationAROMPROMRROMSpecialTestsAnatomyPatellarRetinaculumLongitudinaltendinousfibersPatellofemoralligamentsBloodSupplyPrimarilyderivedfromgeniculatearteriesBiomechanicsThepatellaundergoesapproximately7cmoftranslationfromfullflexiontoextensionOnly13-38%ofthepatellarsurfaceisincontactwiththefemurthroughoutitsrangeofmotionBiomechanicsThepatellaincreasesthemomentarmaboutthekneeContributesupto30%increaseinforcewithextensionPatellawithstandscompressiveforcesgreaterthan7XbodyweightwithsquattingBiomechanicsTwiceasmuchtorqueisneededtoextendthekneethefinal15degreesthantoextendfromafullyflexedpositionto15degreesofflexionModifiedTensionBandWiringTransverse,noncomminutedfracturesAfterreduction,fractureisfixedwithtwoparallel,1.6mmKirschnerwiresplacedperpendiculartothefracture18gaugewirepassedbehindproximallyanddistallyModifiedTensionBandWiringWireconvertsanteriordistractiveforcestocompressiveforcesatthearticularsurfaceTwotwistsareplacedonoppositesidesofthewireTightensimultaneouslytoachievesymmetrictensionRepairanyretinaculartears分级OuterbridgeChondralDefectClassification:OuterbridgeChondralDefectClassification:Grade0:normalcartilageGradeI:cartilagewithsofteningandswelling;OuterbridgeChondralDefectClassification:GradeII:apartial-thicknessdefectwithfissuresonthesurfacethatdonotreachsubchondralboneorexceed1.5cmindiameter;OuterbridgeChondralDefectClassification:GradeIII:fissuringtothelevelofsubchondralboneinanareawithadiametermorethan1.5cm;OuterbridgeChondralDefectClassification:GradeIV,exposedsubchondralbone.【诊断】（一）临床表现患者初为膝部不适，继而有髌骨后方疼痛，膝内侧隐痛，活动时或活动后疼痛加重，上、下楼梯尤为明显。自觉髌股之间有摩擦感，压迫髌骨有疼痛，尤以膝外侧压痛明显，膝关节活动度正常，但有细小摩擦音。（二）检查1．髌骨压磨试验2．单腿下蹲试验患肢单腿站立（三）X线检查RadiographicAppearancePlainradiographyofthekneeisoflimiteduse,onaskylineaxialprojectionthesmallfissuresmaybevisibleandinthefinalgrade4stagesosteoarthritic-scleroticchangestakeplaceandosteophytesarevisibleMRisabletoprovidesagittalandaxialreconstructionstoaidearlydiagnosis.龟裂关节镜MRI等信号isointensity.混合信号heterogeneousintensity低信号hypointensity；高信号hyperintensity（四）鉴别诊断【辨证论治】（一）手法治疗（二）药物治疗（三）功能锻炼（四）其他疗法treatment