异体肌腱重建前交叉韧带术后临床效果及关节镜下再探查分析

Second arthroscopic examination after anterior cruciate ligament reconstruction with allogenic tendon graft

[目的]探讨采用异体肌腱重建膝关节前交叉韧带(anterior cruciate ligament,ACL)术后移植物的转归,为术后康复提供指导依据。[方法]2012年1月~2015年12月对行ACL重建术后1年以上的患者58例(58膝)进行随访,同时进行患膝关节镜下再探查(second-look);ACL重建手术时患者年龄18~52岁,平均(30.7±9.9)岁,均采用深冻异体肌腱作为重建移植物。比较手术前后膝关节功能恢复情况(Lysholm评分及International Knee Documentation Committee,IKDC评分)及膝关节前向稳定性(前抽屉试验、Lachman试验变化以及KT-1000侧侧差值);行二次关节镜检查,观察移植物连续性、移植物滑膜覆盖情况以及关节内是否有异生结构等。[结果]所有患者未发生感染、严重排异反应及其他严重并发症。ACL重建术后至末次随访时间为12~33个月,所有患者均行关节镜下再探查。末次随访时除1例患者出现约10°伸直受限,其余患者膝关节活动度基本正常。Lysholm评分由术前的(55.64±9.43)分提高至末次随访时的(86.40±4.78)分,IKDC评分由术前的(55.73±9.97)分提高至末次随访时的(85.75±4.97)分,差异有统计学意义(P<0.05);KT-1000侧侧差值由术前的(6.62±1.28)分提高至末次随访时的(1.57±0.98)分,差异有统计学意义(P<0.05)。关节镜下再探查结果:3例出现移植物完全吸收,连续性不佳;3例出现ACL移植物磨损;2例患者关节腔内可见Cyclops样结节。滑膜覆盖评价:移植物滑膜覆盖优22例,良24例,差12例;滑膜覆盖优良率为79.3%。滑膜覆盖优组和良组其Lysholm评分、IKDC评分、KT-1000侧-侧差值均优于滑膜覆盖差组,差异有统计学意义(P<0.05)。[结论]采用异体肌腱ACL重建术后移植物血管化、滑膜化进程慢,康复计划应相对缓慢;关节镜下再探查所见能够作为术后康复的良好依据。

[Objective] To report the findings of second arthroscopic examination after reconstructed anterior cruciate ligament （ACL） using allogenic tendon graft, for improvement of rehabilitation program. [Methods] From January 2012 to December 20t5, 58 patients who had received complete ACL reconstruction followed up more than one year, and under- went second arthroscopie examination. At the time of ACL reconstruction, the average age of the patients was 30.7 years （range, 18 to 52 years） . The deep-frozen allogenic tendon grafts were used for all these patients. Before second arthroscopic examination, the knee function and stability were checked and compared before and after the surgery. Second arthroscopic evaluation was then performed, and focused on continuity, the synovial coverage, as well as incorporation of the structure. [Results] All patients were followed up for 12 to 33 months after surgery. No infection, rejection reaction, and other seri- ous complication was found. In one case 10° extension limitation was found, while the knee range of motion was normal in all other cases. The Lysholm score improved from preoperative （55.64±9.43） to postoperative （86.40±4.78）, and the IKDC improved from preoperative （55.73 ±9.97） to postoperative （85.75±4.97）, both with statistically significant differenc- es （P〈0.05） . KT- 1000 arthrometer measurement showed that the side-to-side difference improved from preoperative （6.62±1.28） to postoperative （1.57±0.98）, also with statistically significant difference （P〈0.05） . Complete resorp-tion of the graft was seen in 3 cases, graft abrasion was seen in 3 cases, and cyclops-like lesions was found in 2 cases. The excellent and good outcomes rate of the synovial coverage of the graft was 79.3 %. The Lysholm score, IKDC, and side-to-side difference were significantly better in the excellent and good synovial coverage findings group than those in the poor synovial coverage group （P〈0.05） . [Conclusion] The integration and remodeling processes of the allogenic tendon grafts is slow af- ter ACL reconstruction, so the rehabilitation program should also be slower. Second arthroscopic findings is valuable for reha- bilitation program planning.