后十字韧带单束重建联合小切口切开胭腓韧带重建治疗严重膝关节不稳定

Single bundle posterior cruciate ligament reconstruction and mini-open popliteofibular ligament reconstruction for with severe posterior and posterolateral rotation instability of knee

目的评估后十字韧带（posterior cruciate ligament，PCL）单束重建联合小切口切开胭腓韧带（popliteofibular ligament，PFL）重建治疗严重的膝关节后向和后外旋转不稳定的临床结果。方法自2003年7月至2007年4月，共有28例连续的患者接受关节镜下PCL单束重建联合小切口切开PFL重建手术。入选条件：所有患者均为严重的膝关节不稳定，后抽屉试验为3^＋或以上，胫骨后移程度与健侧相比≥12mm，胫骨外旋程度大于健侧10°以上，同时不合并外侧副韧带的损伤。入选的患者接受关节镜下单束PCL重建，使用异体跟腱作为移植物。在膝关节外侧通过两个小切口切开，使用异体胫前肌腱重建PFL。股骨侧切口位于股骨外上髁，长度为2cm；腓骨侧切口位于腓骨头，长度为3cm。结果术后平均随访时间为39．7个月。使用膝关节应力像评估后向稳定性，胫骨后移程度（患侧与健侧的差值）由术前（17．7±4．5）mm减小为术后（4．5±3．9）mm，胫骨外旋程度（患侧与健侧的差值）由术前16．0°±4．7°减小为术后-2．8°±6．4°，术前与术后的差异有统计学意义。IKDC评分：术前28例均为D级，术后A级为10例，B级9例，C级8例和1例D级。结论关节镜下PCL单束重建联合使用小切口切开PFL重建能够有效地改善膝关节后向和后外旋转不稳定。

Objective The aim of this study was to assess the clinical outcomes of arthroscopy assisted posterior cruciate ligament （PCL） reconstruction and mini-open popliteofibular ligament （PFL） reconstruction for severe posterior and posterolateral rotation instability of the knee with lateral collateral ligament （LCL） intact. Methods Arthroscopic PCL reconstruction and Mini-open PFL reconstruction was performed consecutively in 28 patients with chronic posterior and posterolateral rotation instability of the knee. The inclusion criteria for surgery were a posterior drawer test result of 3^＋ or more, posterior translation of more than 12 mm measured with stress radiography, and tibial external rotation of 10° more than the contralateral uninjured knee without varus laxity. The patients underwent single bundle PCL reconstruction with Achilles tendon allografis. A mini-open PFL reconstruction was performed with anterior tibialis allografts. One 2 cm incision was made on the lateral epicondyle to build the femoral tunnel and another 3 cm incision was made near the fibular head for the fibular tunnel. Results The minimum follow-up was two years. Post-operatively the average posterior tibial translation of the patients was reduced from （17.7±4.5） mm to （4.5±3.9） mm. And their tibial external rotation was decreased from an average of 16.0°±4.7° to -2.80±6.4°, as compared with the contralateral uninjured knee. These differences were statistically significant. On IKDC evaluation, 28 patients were grade D pre-operatively while post-operatively 10 patients were grade A, 9 were grade B, 8 were grade C and 1 was grade D. Conclusion In this small clinical series, single bundle PCL reconstruction combined with mini-open PFL reconstruction was proven to correct pathological excessive posterior and posterolateral rotation instability.