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中图分类号:R684

文献标识码:A

文章编号:2096-8965(2021)04-0093-08

DOI:10.12287/j.issn.2096-8965.20210413

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目录contents

    摘要

    髌骨脱位是一种常见的青少年关节疾病。在我国基层医院往往存在患者就诊意识不强、治疗方法选择不当、延误治疗时机、甚至漏诊、误诊等问题。为解决相关短板,并提升该疾病的分级诊疗能力,由甘肃省骨科质量控制中心牵头, 甘肃省医学会骨科分会、甘肃省医学会运动医疗分会、甘肃省医师协会骨科分会、甘肃省骨科临床医学研究中心、甘肃省骨科3D打印工程研究中心、甘肃省智能骨科行业技术中心、 甘肃省骨关节疾病研究重点实验室和国家骨科与运动康复临床医学研究中心甘肃分中心共同协助,遴选甘肃省专家进行详细论证、并经国内骨科及运动医学专家审查完善,制定了甘肃省髌骨脱位诊疗专家共识。该共识力求简易、合理、实用、易于被基层医师接受和应用,以便髌骨脱位患者得到及时、准确、规范诊疗并从中受益。

    Abstract

    Patellar dislocation is a common joint disease among adolescents. The situation of the diagnosis and treatment of patellar dislocation in primary hospitals is still grave, and there are many problems that need to be addressed, such as poor visit adherence, delay in treatment, missed diagnosis, misdiagnosis, or inappropriate treatment. To resolve this dilemma and improve the graded diagnosis and treatment system, the Gansu expert consensus of the diagnosis and treatment for patellar dislocation, which was led by the Quality Control Center of Orthopedics of Gansu Province, assisted by the Gansu Orthopaedic Association Attached to Chinese Medical Association, Gansu Sports Medicine Association Attached to Chinese Medical Association, Gansu Orthopaedic Association Attached to Chinese Medical Doctor Association, Orthopaedic Clinical Research Center of Gansu Province, Orthopaedics 3D-Print Engineering Research Center of Gansu Province, Intelligent Orthopaedics Specialty Technical Center of Gansu Province, Gansu Provincial Key Laboratory of Bone and Joint Diseases, and Gansu Orthopaedics and Sports Rehabilitation Association Attached to Chinese National Clinical Medical Research Center, argued carefully by the expert group of Gansu Province, reviewed and refined by the domestic experts in the field of orthopaedics and sports medicine, is developed. This article aims to provide a simple, reasonable, practical, acceptable, and applicable expert consensus for primary care physicians, promote the diagnosis and treatment of patellar dislocation in primary hospitals to be timely, accurate, and standardized, and benefit the patients with patellar dislocation.

  • 1 使用范围

  • 面向甘肃省一级和二级医疗机构的基层医务人员使用,包括骨科医师、康复科医师、疼痛科医师和专科护理人员等。

  • 2 专家共识形成背景及过程

  • 髌骨脱位的发生率较高,尤其在10~17岁人群之间的发生率高达29/10万,会导致严重的活动受限和远期的关节炎[1]。甘肃省地处西部经济欠发达地区,髌骨脱位患者就诊意识薄弱,加之基层医师对髌骨脱位了解和认识程度不够,易出现延误治疗、治疗方法选择不当,甚至漏诊、误诊。总体上,甘肃省髌骨脱位患者的诊疗存在明显短板。

  • 为解决该困局并提升相关疾病的分级诊疗能力,由甘肃省骨科质量控制中心牵头组织,甘肃省医学会骨科分会、甘肃省医学会运动医疗分会、甘肃省医师协会骨科分会、甘肃省骨科临床医学研究中心、甘肃省骨科3D打印工程研究中心、甘肃省智能骨科行业技术中心、甘肃省骨关节疾病研究重点实验室和国家骨科与运动康复临床医学研究中心甘肃分中心共同协助,成立甘肃省髌骨脱位诊疗专家共识编写委员会和专家组,专家组成员由甘肃省骨科、运动医学、康复医学、专科护理学的一线专家等联合组建,覆盖甘肃省大部分地市 (州) 的综合或专科医院。同时,也聘请该领域国内知名专家进行审查和评议。

  • 由于当前国内并没有髌骨脱位的专家共识或指南,国外的相关指南或专家共识内容繁杂且专业性过强,对于基层医师来说要做到全面了解,并在临床工作中加以应用难度很大。该共识在编写过程中对各项内容的选择和编写尽量简洁,在保证推荐意见的合理性前提下,对各个推荐意见进行了简化,删减了争议性大、不宜基层推广应用或技术要求过高的内容。力求突出其简易性、实用性、可操作性,更易于推广使用。

  • 该专家共识经过专家组成员前期详细论证,于2021年甘肃省骨科质量控制中心年会专家组讨论通过,由国内知名专家审查完善后公开发布,这也是甘肃骨科历史上形成的第一部专家共识。同时,组织基层医院和规培医师进行线上、线下学习,以便髌骨脱位患者得到及时、准确、规范诊疗并从中受益。

  • 3 定义和分类

  • 根据髌骨脱位流行病学特点,该专家共识重点阐述初次髌骨脱位和复发性髌骨脱位的诊断与治疗。

  • 常见的与髌骨脱位有关的定义和分类解释及总结 (见表1)。

  • 表1 与髌骨脱位有关的定义和分类解释

  • 4 主要危险因素相关问题、推荐意见和解释说明

  • 4.1 髌骨脱位的解剖危险因素有哪些?

  • 推荐意见:与髌股关节不稳定相关的因素分为骨性和软组织因素。发育性骨性解剖异常因素,主要包括:滑车发育不良、高位髌骨、胫骨结节外偏、髌骨倾斜。内侧髌股韧带 (Medial Patellofemo⁃ ral Ligament,MPFL) 则是最主要的软组织稳定结构,限制髌骨向外侧脱位。我们推荐基层医师必须评估滑车发育异常、胫骨结节-股骨滑车沟距离 (Tibial Tubercle to Trochlear Groove Distance, TT-TG) 值、髌骨高度和斜度以及内侧髌股韧带4个项目。

  • 说明:髌骨脱位的危险因素已经广泛形成了共识,相关研究较多。各类指南或共识[2-7] 也进行相关报道,相关内容异议较少,在此不再赘述。为了适宜基层推广应用和简化流程,本共识推荐以下危险因素作为必须评估项目:滑车发育异常、TT-TG值、髌骨高度和斜度和髌股内侧韧带。

  • 4.2 如何进行滑车发育异常的分型?

  • 推荐意见:使用Dejour分型方法对滑车发育异常进行分型。

  • 说明:滑车发育异常的分型自2007年Dejour等[8, 9] 提出后,得到了广泛的应用和推广[2, 10, 11],该分型系统分为4型,可以很好的指导临床做出诊断和治疗决策。A型:交叉征和浅的滑车 (滑车夹角> 145°);B型:交叉征、滑车上凸起征及平的滑车; C型:交叉征、滑车上凸起征和双廓征;D型:交叉征、滑车上凸起征、双廓征、滑车面不对称并内侧和外面垂直链接 (悬崖征)。

  • 4.3 如何简易评估髌骨脱位的再脱位风险?

  • 推荐意见:使用RIP (Recurrent Instability of the Patella) 评分标准评估初次髌骨脱位再脱位风险 (见表2)。

  • 说明:为了寻找适用于基层医师使用的髌骨再脱位风险评估标准,通过文献检索建议使用RIP评分标准评估再脱位率[12]。该评分标准含4个风险因素:年龄、骨骼发育成熟度、滑车发育情况和TTTG/髌骨长度 (MRI)。通过该评分系统可以将初次髌骨脱位再脱位风险分为3个等级:低风险 (0~1)、中风险 (2~3) 和高风险 (4~5)。该方法具有简易、快速、易于基层医师使用的特点。

  • 表2 RIP评分标准[12]

  • 5 诊断相关的主要问题、推荐意见和解释说明

  • 5.1 主要的体格检查包括哪些内容?

  • 推荐意见:至少进行的体格检查包括:J形征、恐惧试验和髌骨外推试验。

  • 说明:髌骨脱位与下肢力线有关,包括股骨前倾角增大、胫骨外旋增大和外翻膝,可以较为清晰的看到髌骨的倾斜,是重要且简单的视诊内容[13, 14],但是其专业性较强,部分基层医院难以完成,可作为次要检查项目;Q角的测量存在很大争议,而且其在内侧松弛的情况下测量也是不准确的,尤其是在股四头肌紧张和松弛情况下测量偏差较大,不建议其作为必须检查项目[10, 15],但可以作为次要检查进行;许多患者会在主动伸膝关节时出现髌骨外移,即J形征[2, 11],该检查简单易行,高度J形征可能会导致重建的MPFL失效或残存松弛,需要进一步评估导致J形征的骨性发育异常的因素,进行针对性治疗;恐惧试验是经典的髌骨脱位体格检查方法,在此不再赘述。髌骨外推试验根据髌骨向外滑行时髌骨外移位置分为4级,分级越高,脱位程度越重[16]。推荐基层医师进行查体时至少检查J形征、恐惧试验和髌骨外推试验。

  • 5.2 需要进行哪些影像学检查?

  • 推荐意见:建议进行X线、CT和MRI检查。

  • 说明:X线检查是基本检查,需要进行膝关节正位、侧位和髌股关节入口位 (Merchant位,屈膝30°~45°) 的检查,屈膝超过90°的髌骨轴位片投照区域非入口位,对评估复发性髌骨脱位无实际意义,但是对于评估习惯性髌骨脱位具有诊断意义。有条件的医院可以加拍下肢全长片,其中有判定和分型价值的是纯侧位片检查,如果识别到交叉征、滑车上凸起征、双廓征和悬崖征等时具有诊断价值,同时可以测量髌骨高度 (Carton指数),轴位片可以测量髌骨斜度和观察髌骨滑车的接触情况。 MRI是髌骨脱位诊断的金标准,如有条件须进行患侧膝关节MRI的检查,其可以识别髌股内侧支持带的损伤、其他软组织的损伤、髌骨股骨骨髓水肿、也可进行TT-TG的测量以及X线上的大部分测量内容[6]。TT-TG通过CT测量更加准确,对于评估有无软骨损伤及软骨骨折范围有诊断价值。

  • 6 治疗相关的主要问题、推荐意见和解释说明

  • 6.1 哪些患者可以进行保守治疗?

  • 推荐意见:初次髌骨脱位者,未合并软骨损伤、其他韧带损伤、骨折或其他并发症者,经风险评估,再脱位几率低,可以尝试进行保守治疗,同时要告知其再次脱位的可能。

  • 说明:髌骨脱位的保守治疗包括:石膏、夹板或支具固定、制动、理疗、中医药治疗、适应性训练等,其中制动和固定是最为重要的治疗方法。保守治疗的适应症应当严格要求,存在多次脱位、软骨损伤、骨折、合并其他韧带损伤者应进行手术治疗。保守治疗的再脱位率在15%~44%[17],当前循证医学证据和临床研究证实手术治疗比保守治疗效果好、复发率低且功能评分更佳[18-29]。因此,在临床实践中选择保守治疗应当严格把握适应症。

  • 6.2 哪些患者需要进行内侧髌股韧带的重建?

  • 推荐意见:复发性髌骨脱位者应该考虑内侧髌股韧带重建。

  • 说明:2021年,Hurley等[30] 在 《美国运动医学杂志》上发表一项基于随机对照试验的循证医学研究,该证据表明相较保守治疗和MPFL修复来说, MPFL重建的复发率最低,且可以获得更好的膝关节功能。Previtali等[31] 进行的一项Meta分析也表明MPFL重建可以获得更好的短期和长期的随访结果。对于复发性髌骨脱位患者来说,循证医学证据和临床研究结果表明单独MPFL重建也可以获得满意的疗效[32-35]。其他的相关临床研究也证实MPFL重建结果可靠、手术过程简单、术后康复快以及患者的满意度高的特点[36-46]。因此,对于复发性髌骨脱位患者,MPFL重建是一项非常有效的手术,可以单独实施,必要时可联合其他手术进行。

  • 6.3 需要进行髌骨外侧髌股支持带松解吗?

  • 推荐意见:不推荐常规行外侧髌股支持带松解,该术式应用缺乏高等级循证医学证据支持。

  • 说明:关于髌骨外侧结构松解的高等级循证医学证据缺乏,相关方面的内容存在较大的争议。就目前文献研究来看,在复发性髌骨脱位治疗中,外侧髌股支持带松解单独使用或联合使用,其疗效均缺乏高等级循证医学证据支持。而且外侧髌股支持带松解使用不当会导致医源性髌骨内脱位。

  • 6.4 哪些患者需要联合胫骨结节移位术?

  • 推荐意见:TT-TG>20mm可考虑联合胫骨结节移位术。

  • 说明:对于联合胫骨结节移位术治疗髌骨脱位的临床证据一致性较弱。Servien等[46] 认为胫骨结节移位能够重新排列伸肌装置,并提高髌骨的稳定性,该文献认为TT-TG>20mm可以进行联合手术。 Middleton等[47] 认为TT-TG≥20mm需要矫正到10mm左右。但是Boutefnouchet等[48] 进行了一项关于MPFL重建联合胫骨结节移位术治疗有效性的循证医学研究,结果表明,并没有足够的证据支持联合胫骨结节移位术,TT-TG大小标准也缺乏一致性。因此,对于联合胫骨结节移位术来说,应当严格限制适应症的选择,对于TT-TG>20mm患者可以予以考虑,对于预防再脱位有一定帮助。

  • 6.5 滑车成形术可靠吗?

  • 推荐意见:滑车成形术是一种可靠的治疗髌骨脱位的手段,但应严格选择适应症。

  • 说明:2021年,Tan等[49] 进行的一项循证医学研究结果表明,MPFL重建联合髁间窝成形术与单独MPFL重建相比功能评分并没有区别,但是MPFL重建存在再脱位风险。Longo等[50] 发表的一项系统综述也表明滑车成形术可以提供好的临床结果。最新的循证医学研究证据表明在滑车发育不良的情况下,采用滑车成形术治疗复发性髌骨不稳,当单独进行或与其他稳定手术联合进行时均可改善Kujala评分和降低再脱位率[51-53]。滑车成形术技术要求较高,需要非常完善的采集病史、严格的术前查体以及详细的影像学评估。当患者存在J形征、反复脱位、高位髌骨、滑车发育异常以及TT-TG明显增加等情况下可以选择进行滑车成形术[54]

  • 6.6 髌骨脱位的简化处理流程

  • 推荐意见:将初次髌骨脱位和复发性髌骨脱位的诊疗流程进行合理简化,使其更加贴合基层医院使用。

  • 说明:见图1。

  • 图1 髌骨脱位简易诊疗流程图

  • 7 术后康复

  • 推荐意见:术后6个月可以返回运动,积极的康复训练很有必要。

  • 说明:对于髌骨脱位术后康复相关的循证医学证据较少,临床研究证据一致性也较差。2018年, Smith等[55] 在 《美国运动医学杂志》 发表了一项循证医学研究,结果显示,11.32%的文献支持在术后3个月可以返回运动,33.96%的文献支持在术后6个月以上返回运动,18.87%的文献支持在4-6个月内返回运动,仅有1篇文献支持在10-12个月返回运动。2021年,Manjunath等[56] 也在 《美国运动医学杂志》发表循证医学证据指出髌骨脱位术后平均返回运动的时间在7个月左右。因此,为保证手术和康复效果,髌骨脱位患者不宜在术后短期内返回剧烈活动,返回正常运动至少应在术后6个月后。由于术后短期内的康复训练方案争议较大,也没有循证医学证据支持,临床医师应当根据患者情况制定个性化康复方案,促进患者早期康复。术后康复训练方法包括术后负重练习、活动度训练、股四头肌锻炼等,必要的制动也是需要的[55, 56]

  • 8 总结

  • 该专家共识选择了一些适宜于甘肃省基层医院专科医师传播学习的内容进行总结,对一些专业性过强、内容过于繁复和不宜基层医院推广应用的内容进行了必要的删减,相关证据的解读力求简洁,选择关键性证据进行阐述,避免不必要的重复和繁杂文献堆砌,力求言语简单、内容充实、阐述内容易于一、二级医院医师使用和学习。通过该专家共识的基层推广,将提升甘肃省相关疾病的分级诊疗能力,做到真正的释放和提升基层医院相关疾病的处置能力,提升基层医疗资源质量和百姓的就诊满意度。

  • 编写专家组成员:夏亚一(兰州大学第二医院骨科);韵向东(兰州大学第二医院骨科);吴萌(兰州大学第二医院骨科);汉华(兰州大学第二医院骨科);汪玉良(兰州大学第二医院骨科);刘林 (甘肃省人民医院骨科);郭士方(甘肃省人民医院骨科);宋建民(甘肃省人民医院骨科);王文己 (兰州大学第一医院骨科);王勇平(兰州大学第一医院骨科);甄平(中国人民解放军联勤保障部队第940医院骨科);李慎松(中国人民解放军联勤保障部队第940医院骨科);张晓刚(甘肃中医药大学附属医院骨科);董万涛(甘肃中医药大学附属医院骨科);戴刚(甘肃省中医院骨科);李玉吉(甘肃省中医院骨科);李晶(甘肃省肿瘤医院骨科);袁治国(甘肃省第二人民医院骨科);谢兴文(甘肃省第二人民医院骨科);马才英(甘肃省第三人民医院骨科);王经韬(兰州市第二人民医院骨科); 梁建科(甘肃医学院附属医院,平凉市人民医院骨科);张生志(甘肃医学院附属医院,平凉市人民医院骨科);高琪(庆阳市人民医院骨科);孙效虎(庆阳市人民医院骨科);刘瑾(天水市第一人民医院骨科);赵天云(天水市第一人民医院骨科);高发旺(酒泉市人民医院骨科);张浩(酒泉市人民医院骨科);闫沛云(武威市人民医院骨科);张长彪(武威市中医院骨科);徐长德(嘉峪关市第一人民医院骨科);韩福源(金昌市中心医院,金川集团公司职工医院骨科);钱军(张掖市人民医院骨科);杜敏(陇南市第一人民医院骨科);王永平(临夏州中医院骨科);赵来绪(武山县人民医院骨科);朱承善(山丹县人民医院骨科);张芳(兰州大学第二医院康复科);尹晓莉(兰州大学第二医院骨科护理部)

  • 特邀国内外审专家组成员:张辉(北京积水潭医院骨科);吕松岑(哈尔滨医科大学附属第二医院骨科);郑江(西安市红会医院骨科);温鹏(宁夏回族自治区人民医院骨科);张克远(新疆医科大学第一附属医院骨科);张广源(青海大学附属医院骨科)

  • 编写委员会成员:夏亚一韵向东吴萌耿彬邓福仓

  • 秘书与执笔:耿彬(兰州大学第二医院骨科)

  • 利益冲突:所有专家组成员及编写委员会成员均声明不存在利益冲突。

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