3D打印导向器辅助关节镜下前交叉韧带重建术骨隧道准确性的对比研究

A comparative study of the accuracy of bone tunnel reconstruction of anterior cruciate ligament reconstruction with 3D-printing localizer under arthroscope

目的依据膝关节影像学定制前交叉韧带重建3D打印定位导向器(专利号:201620246858.0),研究3D打印定制前交叉韧带重建导向器辅助关节镜下行前交叉韧带重建的股骨、胫骨隧道定位可行性及准确性。方法 2015年1月—2017年6月,在陆军军医大学附属大坪医院骨科诊断急性前交叉韧带断裂的患者中,随机数字表法分成3D打印组与传统手术组,两组患者均50例。3D打印组男性38例,女性12例,平均年龄(28.8±7.3)岁,采用自行研制的3D打印前交叉韧带重建定位导向器,辅助关节镜下进行前交叉韧带重建术定位关节内股骨、胫骨隧道口位置;传统手术组男性40例,女性10例,平均年龄(30.0±7.8)岁,采用传统经胫骨隧道重建前交叉韧带方法关节镜下定位关节内股骨、胫骨隧道口位置,胫骨隧道端采用羟基磷灰石挤压螺钉固定,股骨隧道端微孔钢板(Endobutton)悬吊固定。术后常规照射膝关节正侧位X线片,采用Klos测量法评估胫骨隧道,Amis测量法评估股骨隧道,并对两组患者进行平均随访1年,最少随访时间6个月,记录术前及术后膝关节活动范围,术前与术后Lachman试验,评估术前及术后Lysholm评分、Tegner评分,并进行统计学分析。结果 3D打印组中Amis测量法评估股骨隧道位置测量平均值为(45.6±1.5)%,传统手术组测量平均值(41.4±1.4)%;Klos测量法对胫骨隧道位置测量评估,3D打印组测量平均值(62.7±3.3)%,传统手术组测量平均值(57%±2.6)%,差异均有统计学意义(P<0.05);Lysholm评分3D打印组由术前(57.36±5.76)分提高至术后(96.42±1.39)分,传统手术组由术前(57.06±5.61)分提高至术后(96.12±1.39)分,Tegner评分3D打印组由术前(3.44±0.5)分提高至术后(5.96±0.8)分,传统手术组由术前(3.5±0.5)分提高至术后(6.1±0.78)分;膝关节活动范围3D打印组由(88.6±14.2)°提高至术后(117.3±5.7)°,传统手术组由(87.4±9.2)°提高至术后(119.3±5.3)°。结论基于CT和磁共振等影像学分析设计的3D打印前交叉韧带重建导向器辅助关节镜下进行前交叉韧带重建定位关节内股骨、胫骨隧道口位置比传统经胫骨隧道进行前交叉韧带重建的隧道内口更接近前交叉韧带止点解剖位置,但两组患者术后临床膝关节活动度及功能评分差异无统计学意义。

Objective To observe the accuracy and feasibility for bone tunnel in the arthroscopic reconstruction of anterior cruciate ligament（ ACL）,with the three-dimensional printing localizer based on the imageological examination. Methods A total of 100 patients with acute ruptured ACL from Jan. 2015 to Jun. 2017 were involved in the study. A randomized control method was used to divide patients into two groups. Fifty cases were assigned in experimental group that underwent the reconstruction of anterior cruciate ligament with the three-dimensional printing guider,and 50 cases were assigned into conventional group that treated with traditional technology by hydroxyapatite interference screws and Endobutton. Tunnel positions were measured by Klos＇ s method in femoral side and Amis＇ s method in tibial side according to X-ray films of the postoperative knee. Both groups underwent an average of 1 year postoperative follow-up,at least 6 months follow-up,and the range of motion（ ROM）,Lachman test,Lysholm score,and Tegner score were evaluated between these two groups. Results For femoral side measurement,the average tunnel position in the experimental group was 45. 6% ± 1. 5%,and 41. 4% ± 1. 4% in the conventional arthroscopic group. For tibial side measurement,in the experimental group,the average position was 62. 7% ±3. 3%,and 57% ± 2. 6% in the conventional group. Statistical analysis was performed between the two groups. All data had statistically significant difference（ P 0. 05）. Lysholm score of experimental group was increased from（ 57. 36 ±5. 76） points to（ 96. 42 ±1. 39） points after the operative period,as for conventional arthroscopic group the score was increased from（ 57. 06 ± 5. 61） points to（ 96. 12 ± 1. 39） points. Tegner score of the experimental group was increased from（ 3. 44 ± 0. 5） points to（ 5. 96 ± 0. 8） points after operation,as for conventional arthroscopic group the score was increased from（ 3. 5 ± 0. 5） points to（ 6. 1 ± 0. 78） points. ROM of experimental group was increased from（ 88. 6° ± 14. 2°） to（ 117. 3° ± 5. 7°）,contrast to conventional arthroscopic group in which the ROM was increased from（ 87. 4° ± 9. 2°） to（ 119. 3° ± 5. 3°）. Conclusion Compared with the conventional arthroscopic group,both femoral and tibial tunnel positions in experimental group with the 3 D printed guider are more closed to the anatomic position of ALC. While the ROM of knee and knee function scores have no significant difference between the two groups.