以改良式脛骨結節截骨術(Elmslie-Trillat手術)治療嚴重的單一非對稱型髕骨股骨退化性關節炎

Modified tibia tubercle osteotomy (Elmslie-Trillat operation) for severe isolated asymmetrical patellofemoral osteoarthritis

林任家(Renn-Chia Lin)

指導教授 ： 呂克修

中山醫學大學/醫學院/醫學研究所/碩士(2014年)

https://doi.org/10.6834/CSMU.2014.00063

摘要

前言
單一關節面之非對稱型臏骨股骨退化性關節炎不常見，臏骨滑行軌道不正(patella maltracking)是主因之一，目前有多種手術治療方式。我們利用改良式遠端截骨術，減輕患者日常生活的疼痛並促進日常生活的功能並逆轉退化性關節炎。
研究方法及對象
共十三位是女性患者(十五個膝關節)，三位男性患者接受這項手術。髕骨股骨關節退化嚴重度是以Merchant評量法，前膝活動及功能評估是使用Kujala評分法，病人整體疼痛以視覺類比量表(visual analogue scale)。所有的患者臏骨股骨關節軟骨退化性損傷程度依照Outerbridge classification分級後，完成關節鏡手術及關節鏡視下外側支持帶解離術，患者接受改良式脛骨結節截骨術。術後立即使用角度限制型膝關節護具，可正常負重踏地行走。
研究結果
共有十二位病患(十四個膝關節)完成追蹤時間平均為70.92個月。在疼痛視覺類比量表分數由7.92分降到2.00分(P值<0.001)，Kujala氏膝關節量表則由44.25分進步到70.36分(P值<0.001)。術前有6個膝關節在臏骨股骨關節面有軟骨下囊狀空洞形成，術後都有軟骨下骨再塑型。依照Merchant評量法，術後X光片追蹤發現所有臏骨股骨關節面均進步到第二級。
討論
這一項手術方式就是重建一個良好對應的關節面，減輕臏骨在股骨髁間切跡不正常的壓力，使關節壓力正常傳遞讓軟骨磨損正常。術後患者關節面有軟骨下骨再塑形及軟骨下囊狀空洞消失。除此之外，本項可因人制宜的手術能促進患者日常生活功能的進步，保留關節面軟骨及X光下發現逆轉退化性關節炎。

關鍵字

髕骨股骨退化性關節炎 ； 改良式脛骨結節截骨術 ； 軟骨下骨再塑形

並列摘要

Introduction
Isolated asymmetric patellofemoral osteoarthritis is not common, and patella maltracking is one of the reasons. Numerous procedures are known to treat patellofemoral osteoarthritis. We used the modified Elmslie-Trillat operation to treat patients, not only improving in knee function but preventing and reversing arthritis changes in radiography.
Materials and methods
A consecutive series of patients, 13 women (15 knees) and 3 men, received the operation. The severity of the patellofemoral osteoarthritis was recorded using the Merchant’s method. The anterior knee function and level of pain was scored using the Kujala knee score and 10 points visual analogue scale. Articular cartilage was graded by Outerbridge classification under arthroscopy. After standard arthroscopic surgery and arthroscopic lateral retinaculum release, all patients received the modified Elmsile-Trillate operation. A knee brace was used to restrict range of motion and to keep the knee in full extension during early ambulation.
Results
A total of 12 patients (14 knees) had completed records with a mean follow-up of 70.92 months. The mean 10-joint VAS score decreased from 7.92 to 2.00 (P<0.001). The mean Kujala knee score improved from 44.25 to 70.36 (P<0.001). Six knees had subchondral bone cysts formation preoperatively and all of them had subchondral bone remodeling postoperatively. According to the Merchant’s method, all of the patients improved to grade 2 postoperatively.
Discussions
The principle treatment for these patients was to restore the patellofemoral joint alignment and unloaded abnormal patellofemoral joint pressure to create an appropriate load transmission for optimal cartilage wear. Subchondral bone remolding with subchondral bone cysts diminished following the modified Elmslie-Trillat operation. Furthermore, the individualized operation also improved daily function, reserved the articular cartilage and reversed the progress of arthritis in radiography.

並列關鍵字

patellofemoral osteoarthritis ； Elmslie-Trillat operation ； subchondral remodeling

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