内侧髌股韧带重建术

1、移植肌腱准备：通常用股薄肌肌腱，直径应在4mm以上，最小长度18cm，两端10mm编织留线。A gracilis autograft is used, as the size and strength has been shown to be sufficient for MPFL reconstruction (approximately 4 mm in diameter). Minimum graft length is 18 cm, whipstitched 10 mm at both ends. The graft should be tapered at each end to facilitate insertion of the graft into the patella。

2、髌骨的准备：触及髌骨内侧缘，在髌骨上内侧角作2cm长皮肤切口，分离至髌骨内侧缘，在距离髌骨内上角下方3mm处，用2.4钻头平行髌骨，打入第1枚导针，深度约25mm。在下方15-20mm平行于第一枚导针打入第二枚导针。沿导针用4.5mm空心钻头扩孔。Palpate the medial patellar border and make a 2 cm skin incision from the superomedial corner, extending to the center of the medial edge of the patella. Dissect down and expose the medial edge of the patella. Under fluoroscopic guidance, at a point 3 mm distal to the proximomedial corner of the patella, drill a 2.4 mm drill tip Guide Pin in a transverse fashion across the patella to a minimum depth of 25 mm. Place a second 2.4 mm Guide Pin 15-20 mm distal and parallel to the first one. Over- drill the 2 guide pins with a 4.5 mm cannulated reamer to a depth of 25 mm. (Note: Remove both guide pins after overreaming is complete.

3、移植肌腱固定于髌骨：将肌腱线从专用改锥孔穿过并拉紧，将挤压螺钉拧入髌骨，移除改锥。第二个同前。Pass the tails of one graft end through the eyelet of the first 4.75 mm SwiveLock? and push the graft/anchor into the proximal drill hole until the eyelet is fully seated. Maintain tension on the suture limbs and screw the SwiveLock Anchor into the patella. After removal of the driver, the SwiveLock suture should be removed or tied to the graft sutures to reinforce the fixation. Repeat this procedure with the second graft end.

4、准备股骨隧道：准确的股骨定位对于MPFL整个运动范围生物力学功能发挥非常重要，使用MPFL模板可以帮助确定其位置。从侧位看，止点位于股骨后方皮质骨延长线前方1mm处(a)，距离股骨后内侧关节面（b）2.5mm，接近股骨髁间窝顶线水平处，用2.4mm导针打入，由于移植肌腱双股直径在4-5mm，股骨用6mm钻头钻孔。The proper position of the femoral insertion of the MPFL is very important to maintain proper biomechanics of the patello-femoral joint throughout the entire range of motion. The use of the MPFL template can help establish the position of the guide pin. The insertion point is approximately 1 mm anterior to the posterior cortex extension line (a),  2.5 mm distal to the posterior articular border of the medial femoral condyle (b), and proximal to the level of the posterior point of Blumensaat’s line. The template is placed on the area of the medial epicondyle on the distal femur and, under fluoroscopic guidance, a 2.4 mm guide pin is drilled across the femur and out through the lateral epicondyle. As the diameter of the doubled gracilis graft is predictably between 4 mm and 5 mm, the femur is drilled with a 6 mm Low Profile Reamer .

5、牵引移植肌腱：找到股内侧肌与膝关节囊之间间隙，并将其钝性分离，保持关节囊完整，用直角钳从髌旁切口进入，从股骨内侧髁处引出，引入1枚导线。Drill to the far cortex. Maintain the 2.4 mm guide pin in the femur, as it will be used to pass the graft into the femur.Identify the space between the vastus medialis and the capsule, and bluntly dissect towards the femoral insertion area with a scissor, leaving the capsule intact. A right angle clamp is inserted into the prepared layer down to the medial epicondyle and the tip of the clamp is turned towards the skin. Make a 1 cm longitudinal incision and, using the clamp, pass a looped #2 FiberWire? back to the patellar insertion area。

6、如上图所示，把移植肌腱从下方切口中引出，注意保持两股肌腱相同的紧张度。Loop the graft through the passing suture and pass the suture from the patellar origin to the insertion point at the medial femoral epicondyle. It is very important to maintain equal tension on both graft bundles during this step to ensure proper biomechanics of the patellofemoral joint. Deliver the sutures out of the medial incision, and, with equal tension on both graft bundles, pull the graft down to the medial epicondyle.

7、将肌腱从股骨外侧拉出，调整好张力，在膝关节屈曲30°用6mm*23mm挤压螺钉固定。Place a 1.1 mm Nitinol guide wire into the drill hole next to the femoral guide wire to facilitate insertion of the 6 mm x 23 mm Bio-Interference Screw. Loop the graft sutures into the eyelet of the K-wire and deliver the suture tails out of the lateral femur prior to the graft entering the femoral socket. Using a clamp as a pulley, pretension the graft and insert it into the socket with equal tension on both graft bundles. Manually fixate the lateral patellar facet flush with the lateral femoral condyle with the knee at 30? of flexion. The isometry of the MPFL may be provisionally evaluated at this time by maintaining adequate tension on the graft and cycling the knee through the ROM. Once the proper isometry of the construct has been confirmed, final fixation can be accomplished. While maintaining tension on the graft, insert the 6 mm x 23 mm screw into the femur.  Note: Evaluate the tracking and laxity of the patella throughout the knee ROM. If any adjustments need to be made, back out the femoral screw, make any tension or positioning adjustments and reinsert the screw.
8、术后护理：术后支具固定膝关节在0-90°进行屈伸活动，固定6周。12周后正常活动。The Arthrex anatomical double bundle MPFL Reconstruction technique offers immediate, stable tendon-to-bone fixation and allows active quadriceps exercises between  0? and 90? of flexion at postoperative day one. A postoperative brace locked at 0?-90? of flexion should be worn for a period of 6 weeks. Weight-bearing is limited to partial weight-bearing crutch ambulation until wound healing is complete and at that point can be increased according to the pain tolerance of the patient. Full ROM is allowed after 6 weeks with light jogging or cycling. The patient can resume full activity at 12 weeks.

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