关节镜下保留前交叉韧带下止点残端重建术的临床疗效探讨
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摘要
目的通过关节镜下应用自体四股腘绳肌腱(semitendinosus/gracilis,ST/G)前交叉韧带(Anterior Cruciate Ligament, ACL)重建术治疗ACL损伤,(1)探讨急性与陈旧性ACL损伤保留ACL下止点残端重建术后临床疗效比较。(2)探讨ACL损伤保留ACL下止点残端重建术与非保残重建术后临床效果对比。(3)探讨自体四股ST/G并保留ACL下止点残端重建ACL的手术方法及影响因素。(4)探讨ACL保残重建手术时机的选择。
方法自2008年10月至2009年10月期间,收治经临床及关节镜检查确诊的ACL损伤患者共60例(60膝),均实施关节镜下自体四股ST/G前交叉韧带重建术治疗,均获得随访。其中非保残重建组20例,急、慢性损伤随机入组,男14例,女6例,年龄18～52岁,平均年龄36.4岁;保残重建慢性损伤组20例,男16例,女4例,年龄18～55岁,平均38.6岁;保残重建急性损伤组20例,男15例,女5例,年龄18～53岁,平均30.2岁。交通事故伤20例,生活扭伤19例,运动伤14例,压砸伤7例。根据临床表现及MRI检查诊断ACL损伤46例,经关节镜检查及手术确诊共60例,损伤部位包括体部断裂36例,韧带缺如11例,股骨端撕脱13例,其中合并半月板损伤20例。受伤至手术时间为伤后5天～1年,平均1个月。关节镜下以自体四股ST/G为ACL重建替代物,等长重建前交叉韧带,保残重建组保留ACL下止点的残端,可作为定位标志物,非保残重建组则清理ACL残端。运用单隧道技术,以带袢钢板悬吊固定股骨端,可吸收界面挤压螺钉固定胫骨端肌腱。所有手术均由一组医师完成。三组术后平均随访时间为13个月。随访时行MRI检查,Lachman试验,膝关节活动度测量,膝关节本体感觉恢复测量,膝关节功能评估:采用Lysholm膝关节评分和国际膝关节文献编制委员会(IKDC)分级评估标准进行术前、术后的疗效评定。
结果
1、一般情况所有手术均顺利完成,60例患者均获得随访。术后所有患者切口均Ⅰ期愈合,患者随访时X片显示移植腱位置良好。三组患者均无关节粘连、切口感染、移植物断裂、内固定螺钉松脱、隧道扩大、髌骨骨折、关节纤维化、滑膜炎、下肢深静脉血栓形成等并发症,同时也无并发独眼畸胎畸形。
2、膝关节稳定性及活动度对比根据术后康复6个月后的康复评定,非保残重建组:Lachman试验(-)17例,(±)3例,2例伸膝角度较对侧差约5°,5例屈膝较对侧差5°;保残重建慢性组:Lachman试验(-)19例,(±)1例,2例伸膝角度较对侧差约5°,4例屈膝较对侧差5°;保残重建急性组:Lachman试验均为(-),1例伸膝角度较对侧差约3°,4例屈膝较对侧差5°,三组间两两比较Lachman试验及关节活动度差异无统计学意义(P>0.05)。原有症状消失或减轻。主观评价膝关节功能明显改善,对治疗效果满意。
3、综合评分根据术后康复2、3、6个月的康复评定,得出Lysholm膝关节评分。术前三组间两两比较Lysholm膝关节评分P>0.05,三组间无显著性差异;非保残重建组术后2个月评分显著高于术前评分(P<0.01),术后3个月评分明显高于术后2个月评分(P<0.01),术后6个月评分显著高于术后3个月评分(P<0.01);与非保残重建组比较,保残重建慢性组和急性组术后2个月及3个月评分均显著增高(P<0.01);与保残重建慢性组比较,急性组术后2个月及3个月评分均明显增高(P<0.05);术后6个月三组间两两比较Lysholm膝关节评分P>0.05,三组间无显著性差异。
根据术后康复6个月后的康复评定,得出IKDC评分活动水平。术后IKDC评级分为A(正常)、B(基本正常)、C(异常)、D(严重异常)四级。非保残重建组,IKDC评分活动水平正常17例(85%),保残重建慢性组,IKDC评分活动水平正常18例(90%),保残重建急性组,IKDC评分活动水平正常19例(95%),三组间两两比较IKDC评分活动水平差异无统计学意义(P>0.05)。患者均无明显的活动受限,绝大部分患者已恢复到伤前的运动状态。
4、膝关节本体感觉恢复测量比较对比测量三组患者重建后膝关节屈膝15°和30°时的被动位置复制试验能力。结果:非保残重建组,完全被动位置复制者10例(50%);保残重建慢性组,完全被动位置复制者14例(70%);保残重建急性组,完全被动位置复制者20例(100%)。保残重建急性组被动位置复制能力明显优于保残重建慢性组(P<0.05),保残重建慢性组被动位置复制能力优于非保残重建组(P<0.05),保残重建急性组被动位置复制能力明显优于非保残重建组(P<0.01)。
屈膝30°时膝关节被动运动察觉阈值测量三组患侧与健侧位置感觉的差异结果:保残重建急性组患侧与健侧位置感觉差异低于保残重建慢性组(P<0.05);保残重建慢性组患侧与健侧位置感觉差异低于非保残重建组(P<0.05);保残重建急性组患侧与健侧位置感觉差异明显低于非保残重建组(P<0.01)。
结论1、急性期进行ACL保残重建术是最佳的手术时机,应及早诊断并实施保残重建手术。
2、保留ACL胫骨残端,可促进移植物的早期再血管化,再韧带化;有利于移植腱神经感受器的长入,恢复本体感觉;指导术中对于韧带解剖止点和隧道的定位,封闭腱体与骨隧道通透,促进腱骨愈合,为ACL的完全重建创造有利条件。
3、陈旧性ACL损伤本体感受依然存在并发挥作用,术中亦应保留残端。
4、关节镜下自体四股ST/G重建ACL是恢复膝关节稳定性较好的方法,是治疗急慢性ACL损伤的有效方法。术中精确的胫骨、股骨隧道定位及移植物的固定是手术成功的关键,术后实施正确合理的功能康复训练也是保证疗效的重要环节。
Objective: To investigate the clinical effcet of the hamstring tendon anterior cruciate ligament reconstruction with remants and remaining bundle preservation.
Methods: Since October 2008~October 2009 in our hospital 60 patients (60 knees) underwent hamstring tendon anterior cruciate ligament reconstruction. And all the patiens allowed a follow-up visit, group of Standard ACL reconstruction(Standard group) includes 14 males and 6 females with the average age of 36.4(from 18 to 52), group of chronic injuries ACL reconstruction with remants and remaining bundle preservation(Chronic group) includes 16 males and 4 females with the average age of 38.6(from 18 to 55), group of acute injuries ACL reconstruction with remants and remaining bundle preservation(Acute group) includes 15 males and 5 females with the average age of 30.2(from 18 to 53). Among that, 20 traffic accidents, 19 sprain injuries, 14 sports injuries, 7 crushing injuries. The basis of clinical performance and MRI diagnosis of anterior cruciate ligament injury in 46 cases, with arthroscopic examination and surgery alone anterior cruciate ligament confirmed 60 cases of injury. Arthroscopic of anterior cruciate ligament body of 41 cases of fracture, ligament absence of 11 cases, femoral avulsion 13 cases of point,20 cases of medial meniscus injury. Injury to surgery 5 days to 1 year, average 1 month. Clinical results were evaluatrd according to MRI, Lachman test, knee function and stability, Lysholm, IKDC.
Results:1、General Condition:All operations were successful, 60 patients were followed up. All patients were stageⅠincision healed, the patients follow-up X ray shows good position of transplanted tendons. Three groups of patients had no joint adhesion, wound infection, graft fracture, internal fixation screw loose, tunnel widening, patella fracture, joint fibrosis, synovitis, deep venous thrombosis and other complications, but also non-concurrent one-eyed abnormal fetal malformation.
2、Comparison of knee joint stability and activity: According to evaluation after 6 months of rehabilitation, Standard group: Lachman test (-) 17 cases, (±) 3 cases, 2 cases compared with the contralateral extensor angle difference of about 5°, 5 cases contralateral knees difference of about 5°; Chronic group: Lachman test (-) 19 cases, (±) 1 cases, 2 cases compared with the contralateral extensor angle difference of about 5°, 4 cases contralateral knees difference of about 5°; Acute group: Lachman test (-)20 cases, 1 cases compared with the contralateral extensor angle difference of about 3°, 4 cases contralateral knees difference of about 5°, between every two of the three groups Lachman test and range of motion was no significant difference(P>0.05). The original symptoms disappeared or reduced. Subjective assessment of knee function improved treatment results were satisfactory.
3、Composite score: According to the rehabilitation evaluation of 2,3,6 months after operation, Lysholm knee score obtained. The preoperative Lysholm score of three groups showed no difference(P>0.05).Standard group 2 months after reconstruction scores were marked higher than preoperative scores(P<0.01), 3 months scores notable higher than 2 months(P<0.01), 6 months scores significantly higher than 3 months(P<0.01); Compared with Standard group, Acute group and Chronic group scores that 2,3 months after reconstruction were significantly higher(P<0.01);Compared with Chronic group, Acute group scores that 2,3 months after reconstruction were marked higher(P<0.05);6 months postoperation scores has no significant difference.
According to the rehabilitation evaluation of 6 months after operation, IKDC score obtained. IKDC ranges from A to D, A(normal), B(nearly normal), C(abnormal), D(severely abnormal). Standard group: IKDC score normal level of activity in 17 patients (85%); Chronic group: IKDC score normal level of activity in 18 patients (90%); Acute group: IKDC score normal level of activity in 19 patients (95%); three groups showed no difference(P>0.05). Patients have no significant limitation of activity, most patients have returned to pre-injury state of motion.
4、Comparison of measure of the recovery knee proprioception: Measurement of three groups compared the ability to copy test of postoperation knee when the flexion in 15°and 30°passive position. Results: Standard group, Completely passive position copied 10 cases (50%); Chronic group, Completely passive position copied 14 cases (70%); Acute group, Completely passive position copied 20 cases (100%); The test showed that Acute group marked better than Chronic group(P<0.05), Chronic group notable better than Standard group(P<0.05), Acute group significantly better than Standard group(P<0.01).
Results among three groups of the differences of the threshold measuremen passive motion detection sensory location of the uninvolved when knee 30°flexion: Acute group lower than Chronic group(P<0.05); Chronic group lower than Standard group(P<0.05); Acute group significantly lower than Standard group(P<0.01). Conclusion: 1、Acute phase of the ACL injury is the best time to implement reconstruction with remants and remaining bundle preservation, it`s necessary to get early diagnosis and implement reconstruction.
2、ACL tibial stump retained can promote early graft revascularization and re-ligament, is conductive to the nerve receptors of migration tendon to grow up and restore proprioception, to guide the ligament anatomical positioning of the tunnel and close the transparent between tendon and tunnel, and promote bone-tendon healing, create favorable conditions for the completely ACL reconstruction.
3、Proprioception of the Chronic group still exists and plays a important role, surgery should also be retained stump.
4、Arthroscopic autologous four shares of ST/G ACL reconstruction is the better way to restore the knee stability and is an effective manner to treat acute and chronic ACL injury. Accurate intraoperative tibial and femoral tunnel position and graft fixation is the key to successful surgery. After the reconstruction, correct and rational functions rehabilitation is an important part to ensure the effection.
方法自2008年10月至2009年10月期间,收治经临床及关节镜检查确诊的ACL损伤患者共60例(60膝),均实施关节镜下自体四股ST/G前交叉韧带重建术治疗,均获得随访。其中非保残重建组20例,急、慢性损伤随机入组,男14例,女6例,年龄18～52岁,平均年龄36.4岁;保残重建慢性损伤组20例,男16例,女4例,年龄18～55岁,平均38.6岁;保残重建急性损伤组20例,男15例,女5例,年龄18～53岁,平均30.2岁。交通事故伤20例,生活扭伤19例,运动伤14例,压砸伤7例。根据临床表现及MRI检查诊断ACL损伤46例,经关节镜检查及手术确诊共60例,损伤部位包括体部断裂36例,韧带缺如11例,股骨端撕脱13例,其中合并半月板损伤20例。受伤至手术时间为伤后5天～1年,平均1个月。关节镜下以自体四股ST/G为ACL重建替代物,等长重建前交叉韧带,保残重建组保留ACL下止点的残端,可作为定位标志物,非保残重建组则清理ACL残端。运用单隧道技术,以带袢钢板悬吊固定股骨端,可吸收界面挤压螺钉固定胫骨端肌腱。所有手术均由一组医师完成。三组术后平均随访时间为13个月。随访时行MRI检查,Lachman试验,膝关节活动度测量,膝关节本体感觉恢复测量,膝关节功能评估:采用Lysholm膝关节评分和国际膝关节文献编制委员会(IKDC)分级评估标准进行术前、术后的疗效评定。
结果
1、一般情况所有手术均顺利完成,60例患者均获得随访。术后所有患者切口均Ⅰ期愈合,患者随访时X片显示移植腱位置良好。三组患者均无关节粘连、切口感染、移植物断裂、内固定螺钉松脱、隧道扩大、髌骨骨折、关节纤维化、滑膜炎、下肢深静脉血栓形成等并发症,同时也无并发独眼畸胎畸形。
2、膝关节稳定性及活动度对比根据术后康复6个月后的康复评定,非保残重建组:Lachman试验(-)17例,(±)3例,2例伸膝角度较对侧差约5°,5例屈膝较对侧差5°;保残重建慢性组:Lachman试验(-)19例,(±)1例,2例伸膝角度较对侧差约5°,4例屈膝较对侧差5°;保残重建急性组:Lachman试验均为(-),1例伸膝角度较对侧差约3°,4例屈膝较对侧差5°,三组间两两比较Lachman试验及关节活动度差异无统计学意义(P>0.05)。原有症状消失或减轻。主观评价膝关节功能明显改善,对治疗效果满意。
3、综合评分根据术后康复2、3、6个月的康复评定,得出Lysholm膝关节评分。术前三组间两两比较Lysholm膝关节评分P>0.05,三组间无显著性差异;非保残重建组术后2个月评分显著高于术前评分(P<0.01),术后3个月评分明显高于术后2个月评分(P<0.01),术后6个月评分显著高于术后3个月评分(P<0.01);与非保残重建组比较,保残重建慢性组和急性组术后2个月及3个月评分均显著增高(P<0.01);与保残重建慢性组比较,急性组术后2个月及3个月评分均明显增高(P<0.05);术后6个月三组间两两比较Lysholm膝关节评分P>0.05,三组间无显著性差异。
根据术后康复6个月后的康复评定,得出IKDC评分活动水平。术后IKDC评级分为A(正常)、B(基本正常)、C(异常)、D(严重异常)四级。非保残重建组,IKDC评分活动水平正常17例(85%),保残重建慢性组,IKDC评分活动水平正常18例(90%),保残重建急性组,IKDC评分活动水平正常19例(95%),三组间两两比较IKDC评分活动水平差异无统计学意义(P>0.05)。患者均无明显的活动受限,绝大部分患者已恢复到伤前的运动状态。
4、膝关节本体感觉恢复测量比较对比测量三组患者重建后膝关节屈膝15°和30°时的被动位置复制试验能力。结果:非保残重建组,完全被动位置复制者10例(50%);保残重建慢性组,完全被动位置复制者14例(70%);保残重建急性组,完全被动位置复制者20例(100%)。保残重建急性组被动位置复制能力明显优于保残重建慢性组(P<0.05),保残重建慢性组被动位置复制能力优于非保残重建组(P<0.05),保残重建急性组被动位置复制能力明显优于非保残重建组(P<0.01)。
屈膝30°时膝关节被动运动察觉阈值测量三组患侧与健侧位置感觉的差异结果:保残重建急性组患侧与健侧位置感觉差异低于保残重建慢性组(P<0.05);保残重建慢性组患侧与健侧位置感觉差异低于非保残重建组(P<0.05);保残重建急性组患侧与健侧位置感觉差异明显低于非保残重建组(P<0.01)。
结论1、急性期进行ACL保残重建术是最佳的手术时机,应及早诊断并实施保残重建手术。
2、保留ACL胫骨残端,可促进移植物的早期再血管化,再韧带化;有利于移植腱神经感受器的长入,恢复本体感觉;指导术中对于韧带解剖止点和隧道的定位,封闭腱体与骨隧道通透,促进腱骨愈合,为ACL的完全重建创造有利条件。
3、陈旧性ACL损伤本体感受依然存在并发挥作用,术中亦应保留残端。
4、关节镜下自体四股ST/G重建ACL是恢复膝关节稳定性较好的方法,是治疗急慢性ACL损伤的有效方法。术中精确的胫骨、股骨隧道定位及移植物的固定是手术成功的关键,术后实施正确合理的功能康复训练也是保证疗效的重要环节。
Objective: To investigate the clinical effcet of the hamstring tendon anterior cruciate ligament reconstruction with remants and remaining bundle preservation.
Methods: Since October 2008~October 2009 in our hospital 60 patients (60 knees) underwent hamstring tendon anterior cruciate ligament reconstruction. And all the patiens allowed a follow-up visit, group of Standard ACL reconstruction(Standard group) includes 14 males and 6 females with the average age of 36.4(from 18 to 52), group of chronic injuries ACL reconstruction with remants and remaining bundle preservation(Chronic group) includes 16 males and 4 females with the average age of 38.6(from 18 to 55), group of acute injuries ACL reconstruction with remants and remaining bundle preservation(Acute group) includes 15 males and 5 females with the average age of 30.2(from 18 to 53). Among that, 20 traffic accidents, 19 sprain injuries, 14 sports injuries, 7 crushing injuries. The basis of clinical performance and MRI diagnosis of anterior cruciate ligament injury in 46 cases, with arthroscopic examination and surgery alone anterior cruciate ligament confirmed 60 cases of injury. Arthroscopic of anterior cruciate ligament body of 41 cases of fracture, ligament absence of 11 cases, femoral avulsion 13 cases of point,20 cases of medial meniscus injury. Injury to surgery 5 days to 1 year, average 1 month. Clinical results were evaluatrd according to MRI, Lachman test, knee function and stability, Lysholm, IKDC.
Results:1、General Condition:All operations were successful, 60 patients were followed up. All patients were stageⅠincision healed, the patients follow-up X ray shows good position of transplanted tendons. Three groups of patients had no joint adhesion, wound infection, graft fracture, internal fixation screw loose, tunnel widening, patella fracture, joint fibrosis, synovitis, deep venous thrombosis and other complications, but also non-concurrent one-eyed abnormal fetal malformation.
2、Comparison of knee joint stability and activity: According to evaluation after 6 months of rehabilitation, Standard group: Lachman test (-) 17 cases, (±) 3 cases, 2 cases compared with the contralateral extensor angle difference of about 5°, 5 cases contralateral knees difference of about 5°; Chronic group: Lachman test (-) 19 cases, (±) 1 cases, 2 cases compared with the contralateral extensor angle difference of about 5°, 4 cases contralateral knees difference of about 5°; Acute group: Lachman test (-)20 cases, 1 cases compared with the contralateral extensor angle difference of about 3°, 4 cases contralateral knees difference of about 5°, between every two of the three groups Lachman test and range of motion was no significant difference(P>0.05). The original symptoms disappeared or reduced. Subjective assessment of knee function improved treatment results were satisfactory.
3、Composite score: According to the rehabilitation evaluation of 2,3,6 months after operation, Lysholm knee score obtained. The preoperative Lysholm score of three groups showed no difference(P>0.05).Standard group 2 months after reconstruction scores were marked higher than preoperative scores(P<0.01), 3 months scores notable higher than 2 months(P<0.01), 6 months scores significantly higher than 3 months(P<0.01); Compared with Standard group, Acute group and Chronic group scores that 2,3 months after reconstruction were significantly higher(P<0.01);Compared with Chronic group, Acute group scores that 2,3 months after reconstruction were marked higher(P<0.05);6 months postoperation scores has no significant difference.
According to the rehabilitation evaluation of 6 months after operation, IKDC score obtained. IKDC ranges from A to D, A(normal), B(nearly normal), C(abnormal), D(severely abnormal). Standard group: IKDC score normal level of activity in 17 patients (85%); Chronic group: IKDC score normal level of activity in 18 patients (90%); Acute group: IKDC score normal level of activity in 19 patients (95%); three groups showed no difference(P>0.05). Patients have no significant limitation of activity, most patients have returned to pre-injury state of motion.
4、Comparison of measure of the recovery knee proprioception: Measurement of three groups compared the ability to copy test of postoperation knee when the flexion in 15°and 30°passive position. Results: Standard group, Completely passive position copied 10 cases (50%); Chronic group, Completely passive position copied 14 cases (70%); Acute group, Completely passive position copied 20 cases (100%); The test showed that Acute group marked better than Chronic group(P<0.05), Chronic group notable better than Standard group(P<0.05), Acute group significantly better than Standard group(P<0.01).
Results among three groups of the differences of the threshold measuremen passive motion detection sensory location of the uninvolved when knee 30°flexion: Acute group lower than Chronic group(P<0.05); Chronic group lower than Standard group(P<0.05); Acute group significantly lower than Standard group(P<0.01). Conclusion: 1、Acute phase of the ACL injury is the best time to implement reconstruction with remants and remaining bundle preservation, it`s necessary to get early diagnosis and implement reconstruction.
2、ACL tibial stump retained can promote early graft revascularization and re-ligament, is conductive to the nerve receptors of migration tendon to grow up and restore proprioception, to guide the ligament anatomical positioning of the tunnel and close the transparent between tendon and tunnel, and promote bone-tendon healing, create favorable conditions for the completely ACL reconstruction.
3、Proprioception of the Chronic group still exists and plays a important role, surgery should also be retained stump.
4、Arthroscopic autologous four shares of ST/G ACL reconstruction is the better way to restore the knee stability and is an effective manner to treat acute and chronic ACL injury. Accurate intraoperative tibial and femoral tunnel position and graft fixation is the key to successful surgery. After the reconstruction, correct and rational functions rehabilitation is an important part to ensure the effection.
引文
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