3Discussion
讨论
Whentheprimaryrepairofthepatellartendonisnotpossible,itisnecessarytoeitherrepairwithautologousaugmentationoruseagrafttoreconstructthetendon.Therearevarioustypesofgraftsanditisofaparamountimportancetochoosewisely.Despitetheirlimitedavailabilityandhigherriskofinfection,syntheticallograftshavebeenusedinpatellartendonreconstruction.AchillestendonandBTBallograftshavealsobeenstudied.SeveralstudiesinvestigatedtheutilizationofcontralateralsemitendinosustendonwithorwithoutthegracilistendonandBTBautograftswithvarioussuccessrates.Nevertheless,webelieveautograftsmaynotbesuitableinthepresenceofrheumatoidarthritissincethediseaseisassociatedwithexcessivelevelsofcollagenasethatarethoughttocontributetothedegenerationofthetendons.Inaddition,systemiccorticosteroids,whichourpatientwastaking,arealsoriskfactorsfortendonrupture.Thus,allograftsarebetteroptionsinpatellartendonreconstructionsurgeriesincasesthataresimilartoours.
如果一期修补无法治愈，则有必要进行自体移植或异体移植来重建髌韧带。移植方案很多，需要谨慎选择。同种异体移植术虽然适用范围受限，且存在感染风险，但已被用于重建髌韧带。有研究报道过跟腱和BTB异体移植。一些研究称，对侧半腱肌肌腱有/无股薄肌肌腱BTB同种异体移植成功率各异，但是我们认为，自体移植不适用于类风湿性关节炎患者，因为该病与胶原酶过多有关，胶原酶过多可能导致肌腱退化。此外，患者正在进行的系统糖皮质激素治疗是肌腱断裂的风险因素。因此，对于与本例患者症状相似的患者，同种异体移植是重建髌韧带的良好选择。
Latepatellartendonreconstructionsurgeriesarechallengingtoorthopedicsurgeonssincethereisaneedtorestorethefunctionofaweakextensormechanismwhilemanagingthepatellaalta.Itisveryimportanttoensurethatthetensiononthegraftisadequate.Otherwise,therewillbeaflexiondeficitifthetensionisexcessiveorinabilitytoproperlyextendifthetensionisinsufficient.Thepersistenceofpatellaaltaaftersurgery,asinourcase,hasbeenreported.Inthisregard,itisadvisabletoassessthenormalsidethroughplainradiographsandtomeasurethepatellarindices,suchastheInsall-SalvatiorBlackburn-Peelindex,beforetheoperation.This,alongwithagraftofanideallength,wouldserveinrestoringthenormalheightofthepatella.Anotherproblemourpatientfacedistheexcessiveextension(?20?)whichcanbeexplainedbytheinappropriatelengthoftheavailableallograftthathadtobeanchoreddistaltotheidealsiteofinsertion.
重建髌韧带手术对于整形科医师来说是一项挑战，因为需要在重建伸肌机制功能的同时管理高位髌骨。确保抑制物张力足够尤为重要，否则，张力过大时可能会出现不能弯曲，张力不足时可能出现伸展困难。本文所述患者术后仍有高位髌骨，因此，术前应进行影像学检查，并测量髌骨指数，如Insall–Salvati指数，Blackburn-Peel指数，这些加之理想长度的移植物，将有助于重建正常高度的髌骨。该患者面临的另一个问题是过度伸展(?20?)，这是由可用的移植物长度不合适所造成的。
4.Conclusion
结论
Latepatellartendonreconstructioninrheumatoidarthritisisachallengingprocedure,andwebelieveitisbestperformedusinganallografttoachievethedesiredout中科与白癜风患者心心相印中国白癜风专家
