| 1.Anatomy of the structure of the medial patellofemoral ligament and f ootprints of the starting and ending pointsObjective: Medial patellofemoral ligament is a major soft tissue that limits the migration of the patella.The medial patellofemoral ligament reconstruction is an important surgical procedure for the treatment of patellar dislocation.More in-depth study of the medial patellofemoral ligament anatomical features and its insertion in patellar side and the femoral side and footprints.To provide a more accurate basis of anatomy for the medial patellofemoral ligament reconstruction.Methods:On the 20 side formalin fixation specimens and 10 sides of fresh frozen adult adult cadaver knee specimens,through the detailed anatomical examination,to observe the layers,composition,types of the medial patellofemoral lig ament,and its patella side and femur side insertions and footprints.Sections 10 um thick were obtained from the paraffin-embedded samples and stained with haematoxylin–eosin,and anti-S100 was applied for recognition of nerve structure.The data of the medial patellofemoral ligament were measured with a vernier caliper.The data were expressed as mean ± standard deviation((?)±sd)and the results were analyzed using Spss16.0 statistical software.Results: According to the relative relationship of medial anatomical structure of the knee,it can be divided into five layers.The MPFL was composed of two layers of different depths.It was observed that there were three types of lining of the superficial MPFL.Type one: The superficial layer of the MPFL from the beginning ran forward along the lower edge of the deep part of the MPFL,then interwoven with the lower edge of the deep layer of MPFL and the latter was strengthened.It ended at the intersection of oblique aponeurosis and patellar tibial medial ligament,and the ratio was 90%?There were many variations in the attachment of the medial patellar ligament on the femoral side,which was roughly divided into three types.The most common form was in the deep MPFL characteriz ed by several narrow,thin fiber bundles attached to the inner adductor tubercle.The rate of this form was 73.3%?They were all located in bone spines on the line between the adductor tubercle and femoral epicondyle,and superficial proximal part of the me dial collateral ligament of the extension line.The MPFL on the side of the patella attachment point was constant and attached to the medial patellar edge projection.The apex of the medial margin of the patella was located at the distal of the midpoint of MPFL patellar attachment,with the distance of 2.01 ± 0.50 mm.In sagittal view,the footprints were located at about the position of the middle 17.5 –43.5% of the patellar height,and accounted for about 26% of the patellar height.MPFL is mainly composed of collagen fibers,rare elastic fibers.Wavy collagen fibers parallel to each other,closely spaced.By S-100 staining,it can be found that the number of type ? mechanical receptors exist in the thin layer of sparse connective tissue on both sides of the ligament.Conclusion : the present study of knee specimens further elaborated the hierarchical distribution of the medial knee structures.We are the first to propose that the MPFL is divided into two layers of different depths.Observation of the position and variation of the footprints of the side of the femur and patella of the MPFL,By microscopic observation revealed that the ligament is mainly composed of regularly arranged collagen fibers,and is rich in mechanoreceptors exist.This part of the research has a better understanding in anatomy of MPFL and has implications for guiding bone tunnel positioning of MPFL reconstruction surgery.2.Isometric study of the distance between the midpoint of the MPFL in the patellar side and the femoral side attachmentObjective: we would based on our early anatomical observation,the length between the midpoint of the MPFL patellar attachment and the midpoint of the femoral attachment(AB)were measured at different angles of the knee,In the course of surgery,we can not actually dissect the MPFL true patellar side and femoral side of the attachment and select the positioning point,so we according to anatomical measurements,select the obvious bone landmark as a reference point,according to the mean value of the anatomical measurements,The midpoint of the MPFL in the patellar side and the femoral side attachment which was decuced was also measured here in the ligament length change(A'B ').To understand if there is a good isometric about ligament length between two points,respectively,and AB and A'B' isometric were compared.To provide the appropriate theoretical support for the clinical study of modified medial patellofemoral ligament reconstruction.Methods: Fresh frozen knee specimens 6,the femoral end of at leas t 20 cm,the distal is completely retained.Thaw at room temperature.All specimens were dissected according to the first part of the study,until the the deep layer of medial patellofemoral ligament was revealed,and the medial epicondyle and adductor tubercle were clearly revealed,and the patellar ends and femoral end points were carefully observed and observedThe knee specimen was fixed on the self-made experimental stent,allowing the distal end to move at 0 ° to 120 °.The bracket was engraved with a compass to record the knee flexion angle,giving a constant 10 N tension to the quadriceps.Knee full extention,the midpoint of MPFL femur insertion,recorded as A point,the the midpoint of MPFL patella insertion as the B point.And then kneel 0 °,3 0 °,45 °,60 °,90 °,120 °,measured AB two points of the length of the connection.The values at which the other angles are measured minus the value of 0 ° are changed based on the length of the extension(0 °).Then,in the femoral side,take the point distal 2.5mm to the adductor tubercle,as A 'point.take the point that proximal 2mm to The apex of the medial margin of the patella as B 'point.Similarly,the length of the A'B 'connection was measured and recorded at knees 0 °,30 °,45 °,60 °,90 °,120 °,respectively.The values at which the other angles are measured minus the value of 0 ° are changed based on the length of the extension(0 °).The entire measurement process by a person to complete independently,each point are measured 3 times,t ake the average.The data were analyzed using SPSS 16.0 statistical software,expressed as mean ± standard deviation((?)±sd).The variance analysis of ligament length at all flexion angles was analyzed by one-way ANOVA with complete random data.The difference between the two groups was statistically significant by LSD method,P <0.05 was statistically significant.Result: the center point of anatomical femoral attachment A and the center point of the anatomical patella attachment points B,between A and B has a good isometric,its length change in the process of knee flexion and extension activities were not more than 2.0mm.then,in the femoral side,take the point distal 2.5mm to the adductor tubercle,as A 'point.take the point that proximal 2mm to The apex of the medial margin of the patella as B 'point.between A 'and B ' has a good isometric too,its length change in the process of knee flexion and extension activities were not more than 3.0mm.There was no significant difference between AB and A'B '(P> 0.05).Conclusion : Ideally,we would take the midpoint of patella and femoral attachment of MPFL in the surgery of ligament reconstruction.Howerer,in the course of surgery,we can not dissect the real patellar side and femoral side attachment of the MPFL and make precise selection of positioning points,so we according to anatomical measurements,select the obvious bone landmark as a reference point,The mean value of the midpoint of the patella side and the femoral side attachment,A 'and B',was estimated.Therefore,in this article also choose to measure the same specimen A'B ' length changes,the results show that both AB and A'B' are good isometric.This study provides a theoretical support for the clinical study of modified single-bundle MPFL reconstruction in this paper.3.Clinical study of medial patellofemoral ligament single bundle reconstruction with arthroscopy assisted and small incision for patellar dislocationObjective:Based on the new anatomical findings of medial patellofemoral ligament,the surgical method and effect of modified single bundle reconstruction medial patellofemoral ligament were studied by using the new bone markers to determine the femoral and patellar punctate of medial patellofemoral ligament more fastly.Methods : Analysis of cases of modified medial patellofemoral ligament reconstruction after 9 patients with recurrent patellar dislocation from October 2015 to December 2016,Department of Sports Medicine,Affiliated Hospital of Qingdao University Hospital.Cut from the autologous 1/2 width peroneal tendon,both ends with Ethibdnd suture weaving suture,and folded back.Perform arthroscopic examination of the knee,remove the exfoliative articular cartilage pieces,flatten the degenerative and rough articular cartilage surface,and deal with meniscus injury.Knee flexion and extension within the range of 0 ° ~ 90 ° dynamic observation of the patella track to confirm the patella dislocation.First,lateral retinacular were released.In the horizontal plane,choose the inner edge of the patella at the highest point of the proximal 2mm as the midpoint of MPFL patellar attachment,At this level,the medial margin of the patella on the sagittal plane to select the thickness of the inner edge of the patella at the top 30% as the Kirschner wire drill point.And at this point using 2mm Kirschner wire to the lateral patellar,and then 6mm hollow drill through the patella.In the line of medial epicondyle and adductor tubecle,selected the point 2mm-3mm distal the apex of adductor tubercle as the femoral bone tunnel center.At this point will be a 2mm guide needle oblique outward,from the lateral condylar,piercing along the guide needle with 6mm hollow drill for the femoral bone tunnel.Using long curved forceps thro ugh medial patellar incision,making soft tissue tunnel.The folded end of grafts suspended with # 2 thread of ?Aesculap AG? was leaded from the inside out patella bone tunnel with the guide pin and penetrated a fixation button,temporarily tied.The preparaed free end of the grafts through the soft tissue tunnel to the direction of adductor tubercle,then pull the ends of the grafts with the guide pin to the femoral bone tunnel,Adjust the length of grafts in the bone tunnels,patella side knot fixation,pull and adjust the grafts tension by flexion and extension of the knee,observe the anatomical relationship and location of the patellofemoral joint under arthroscopic,to avoid tension too tight.Until the patella track return to normal position,test r econstruction ligament isometric,tendon length changes less than 5mm in the motion of 0 °-90 °range of the knee joint,The graft was fixed in the bone tunnel of the femoral condyle with a hydroxyapatite absorbable screw when the joint 30°flexion.suture together the tendon tissue of the VMO in the medial patellofacial attachment and deep tendon of reconstruction the with polyester braided,close the incision.Use a knee brace,perform rehabilitation exercises according to the rehabilitation plan ?Postoperative CT scan of the knee,for measuring the congruence angle,patellar tilting angle;The Lysholm score and the Kujala score were used to evaluate the knee function and compared with the preoperative score.SPSS16.0 statistical software for statistical analysis,the use of paired samples t test,P <0.05 for the difference was statistically significant.Results: All patients were followed up for 3 months.None experienced redislocation,no presence of apprehension with lateralization of the patella.The postoperative congruence angle decreased from 21.11 ° ± 4.01 ° to 12.89 ° ± 2.31 °.The patellar tilting angle was reduced from 19.22 ° ± 1.72 ° to 11.89 ° ± 1.27 °,and the changes were statistically significant before and after operation.Knee function assessment:Kujala score increased from 68.11 ± 9.34 to 78.22 ± 4.17;Lysholm score increased from 66.89 ± 5.92 to 80.33 ± 4.18;all were statistically significant.Conclusion:The application of this kind of medial patellofemoral ligament single bundle reconstruction with arthroscopy assisted and small incision for patellar dislocation,can quickly locate femoral and patella insertion intraoperative,can improve patients' subjective results and restore patellar track,improve knee function.Short-term clinical observation no redislocation occurred,but long-term efficacy still need long-term follow-up. |
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