保留与不保留残端重建前十字韧带的前瞻性随机对照研究

A prospective, randomized, controlled study on anterior cruciate ligament reconstruction with or without remnant preservation

目的 评估保留与不保留残端对重建前十字韧带（anterior cruciate ligament,ACL）的意义及临床疗效.方法 2010年1月至2012年10月,收治93例残端存留的ACL损伤患者,前瞻性随机将其分为保留组（保留残端）和不保留组（切除残端）.保留组48例,男34例,女14例;平均年龄30.4岁;左侧25例,右侧23例;损伤至手术时间13.5 d;合并内侧半月板损伤7例,外侧半月板损伤16例,内侧副韧带损伤4例.不保留组45例,男33例,女12例;平均年龄28.8岁;左侧22例,右侧23例;损伤至手术时间14.9 d;合并内侧半月板损伤7例,外侧半月板损伤12例,内侧副韧带损伤2例.两组重建ACL移植物均为自体四股腘绳肌腱.术后两组患者分别行膝关节功能评估、稳定性评估、本体感觉功能测量和二次关节镜手术探查.结果 82例患者完成随访,其中保留组42例,随访时间（25.4±1.9）个月;不保留组40例,随访时间（25.2±1.7）个月.IKDC分级：保留组A级32例,B级9例,C级1例;不保留组A级30例,B级8例,C级2例.Lysholm评分：保留组（95.9±5.2）分,不保留组（95.4±1.7）分.Lachman试验：保留组,阴性38例,1度阳性4例;不保留组,阴性36例,1度阳性4例.轴移试验：保留组,阴性37例,1度阳性5例;不保留组,阴性34例,1度阳性6例.KT-1000测量侧-侧差值：保留组（1.1±1.2） mm,不保留组（1.2±0.9） mm.本体感觉测量关节位置觉侧-侧差值：保留组3.6°±1.8°,不保留组3.9°±2.2°.以上指标两组均无明显差异.二次手术探查移植物滑膜覆盖分型,保留组A型11例,B型6例,C型2例,D型2例;不保留组A型10例,B型5例,C型2例,D型2例.结论 保留较不保留残端并使用自体肌腱移植重建ACL对术后膝关节主观功能、稳定性、本体感觉和移植物滑膜覆盖无促进作用.

Objective To compare the clinical outcomes of patients who underwent remnant-preserved anterior cruciate ligament （ACL） reconstruction with those who underwent conventional ACL reconstruction （ACLR）.Methods From January 2010 to October 2012,93 eligible patients suffered from ACL injuries were randomly allocated into remnant-preserved group （ACLR with remnant preservation;n=48;Male/Female=34/14;Left/Right=25/23） and conventional group （ACLR without remnant preservation;n=45;Male/Female=33/12;Left/Right=22/23）.The mean age of patients,time from injury to surgery,rates of combined meniscal injuries,and medial collateral ligament injury all showed no significant difference between the two groups preoperatively.All the patients underwent ACL reconstruction using 4-strand hamstring autografts.The postoperative assessments included knee functional scales （IKDC grade classification and Lysholm score）,stability examinations （Lachman,pivot-shift,and KT-1000 arthometer）,proprioceptive evaluations,and second-look arthroscopy.Results The average follow-up time was 25.4 months for the remnant-preserved group and 25.2 months for the conventional group.For IKDC grade classification,there were 32 patients with grade A,9 with grade B,1 with grade C in remnant-preserved group,whereas 30 with grade A,8 with grade B,2 with grade C in conventional group,which showed no significant difference between the two groups.Moreover,the Lysholm score （95.9±5.2 vs.95.4±1.7）,Lachman test,pivot-shift test,KT-1000 arthometer （1.1±1.2 mm vs.1.2±0.9 mm）,proprioceptive evaluations （joint position sense：3.6°± 1.8° vs.3.9°±2.2°） all showed no significant differences between the two groups.Additionally,the synovial coverage of grafted tendon under second-look arthroscopy was categorized as grade A in 11,grade B in 6,grade C in 2,grade D in 2 in remnant-preserved group,whereas grade A in 10,grade B in 5,grade C in 2,and grade D in 2 in conventional group,which still showed no significant difference.Conclusion In terms of the knee functional scales,stability examinations,joint position sense and graft synovial coverage,remnant-preserved ACLR group showed no superiority to the conventional ACLR group.