不同定位方法单双束解剖重建前交叉韧带的疗效比较研究

EFFECTIVENESSES OF SINGLE-BUNDLE AND DOUBLE-BUNDLE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION BY TWO METHODS

目的 比较采用不同定位方法行单、双束重建前交叉韧带（anterior cruciate ligament,ACL）的疗效。方法 2010年5月-2013年4月,将符合选择标准的120例ACL损伤患者纳入研究。根据手术方法不同,患者分为4组（n=30）。A组：按传统定位进行双束重建;B组：在ACL残留足迹上进行个体化解剖定位双束重建;C组：按传统定位进行单束重建;D组：在ACL残留足迹上进行个体化解剖定位单束重建。各组患者性别、年龄、病程、侧别、致伤原因及术前Lysholm评分、国际膝关节文献委员会（IKDC）分级、Lachman试验、前抽屉试验、轴移试验比较,差异均无统计学意义（P〉0.05）,具有可比性。术后即刻行患膝MRI扫描,并建立三维模型,评定ACL移植物与股骨髁间窝是否存在撞击;采用Lachman试验、前抽屉试验、轴移试验以及Lysholm评分、IKDC分级比较组间疗效差异。结果 三维模型分析显示：A组11例（36.7%）出现撞击,B组1例（3.3%）,C组9例（30.0%）,D组无撞击发生。其中,A、C组撞击发生率显著高于B、D组,比较差异有统计学意义（P〈0.05）;A、C组间及B、D组间比较,差异无统计学意义（P〉0.05）。4组患者术后切口均Ⅰ期愈合,无早期相关并发症发生。患者均获随访,随访时间24-30个月,平均26个月。术后24个月4组Lysholm评分、Lachman试验、前抽屉试验及轴移试验比较,差异均无统计学意义（P〉0.05）;组内术后均显著优于术前,差异有统计学意义（P〈0.05）。术后24个月IKDC分级比较,B、D组显著优于A、C组,比较差异有统计学意义（P〈0.05）;A、C组间及B、D组间比较,差异均无统计学意义（P〉0.05）。结论 与传统定位方法相比,按残留足迹进行个体化解剖定位单、双束重建ACL均可降低术后撞击发生率,膝关节功能恢复更好。

Objective To compare the effectiveness of single-bundle and double-bundle anterior cruciate ligament （ACL） reconstruction by two methods. Methods Qualified for the selective standard, 120 patients with ACL injury between May 2010 and April 2013 were divided into 4 groups： double-bundle reconstruction was performed by the conventional procedure in 30 cases （group A）; anatomic double-bundle reconstruction was performed in the original ACL residual footprints in 30 cases （group B）; single-bundle reconstruction was performed by the conventional procedure in 30 cases （group C）; and anatomic single-bundle reconstruction was performed in the original ACL residual footprints in 30 cases （group D）. There was no significant difference in gender, age, disease duration, pathogenesis, injury side, Lysholm scores, International Knee Documentation Committee （IKDC） ratings, Lachman test, anterior drawer test, and pivot shift test among groups （P〉0.05）. The impingement between the ACL implants and intercondylar notch was evaluated with postoperative immediate MRI scan and the three-dimensional digital model. Lachman test, anterior drawer test, and pivot shift test results, Lysholm scores, and IKDC ratings were used to compare the effectiveness among groups after operation. Results Three-dimensional digital model after operation showed impingement in 11 cases （36.7%） of group A, 1 case （3.3%） of group B, 9 cases （30.0%） of group C, and no impingement in group D. The impingement rates of groups A and C were significantly higher than that of groups B and D （P〈0.05）, but no significant difference was found between groups A and C, and between groups B and D （P〉0.05）. All incisions healed by first intention, and no early complication was found. The patients were followed up 24-30 months （mean, 26 months）. Lysholm scores, Lachman test, anterior drawer test, and pivot shift test results at 24 months after operation were significantly better than preoperative ones in 4 groups （P〈0.05）, but no significant difference was shown among groups （P〉0.05）. The IKDC ratings of groups B and D were significantly better than that of groups A and C （P〈0.05）; but there was no significant difference between groups A and C, and between groups B and D （P〉0.05）. Conclusion Compared with the conventional procedure, the individual anatomic single- and double-bundle reconstruction in the original ACL residual footprints has decreased impingement rate and increased IKDC rating.