关节镜下改良三入路技术定位前交叉韧带胫骨骨道的临床研究

Arthroscopic anterior cruciate ligament reconstruction via tibial tunnel made by three-portal technique

目的探讨关节镜下改良三入路技术定位前交叉韧带(anterior cruciate ligament,ACL)胫骨骨道的疗效。方法 2015年7月—2016年12月,收治45例ACL断裂患者。男29例,女16例;年龄18~42岁,平均27.5岁。左膝18例,右膝27例。运动伤28例,交通事故伤13例,其他伤4例。受伤至手术时间5~36 d,平均21.6 d。单纯ACL损伤25例,合并内侧副韧带或内、外侧半月板损伤20例。Lachman试验均为阳性;轴移试验均为阳性,其中Ⅰ度27例、Ⅱ度13例、Ⅲ度5例。国际膝关节文献委员会(IKDC)评分为(70.28±6.12)分,Lysholm评分为(63.27±7.62)分。患者均接受关节镜下ACL单束重建,术中通过前外侧、高位前内侧及附加低位前内侧入路建立胫骨骨道。结果术后切口均Ⅰ期愈合。45例均获随访,随访时间14~32个月,平均18.7个月。术后3 d三维CT测量胫骨骨道中心点位于矢状面胫骨平台前后径36.81%~43.35%处,冠状面上胫骨骨道内缘位于胫骨内侧髁间隆起外侧。术后3例出现下肢肌间静脉血栓形成,2例关节肿胀及疼痛,3例膝关节僵硬,均对症处理。末次随访时,患者Lachman试验均为阴性;42例轴移试验阴性,3例阳性(均为Ⅰ度)。IKDC评分为(92.59±4.36)分,Lysholm评分为(93.15±5.53)分,均较术前明显提高(t=11.35,P=0.00;t=12.27,P=0.00)。结论关节镜下ACL重建时采用改良三入路技术定位胫骨骨道操作简便、定位准确,术后早期关节功能恢复较好。

Objective To evaluate the effectiveness of arthroscopic anterior cruciate ligament(ACL)reconstruction via tibial tunnel made by three-portal technique. Methods Between July 2015 and December 2016, 45 patients with ACL ruptures were treated. There were 29 males and 16 females with an average age of 27.5 years(range, 18-42 years). There were 18 cases in the left side and 27 cases in the right side. There were 28 cases of sports injuries, 13 cases of traffic accidents, and 4 cases of other injuries. The average time from injury to operation was 21.6 days(range, 5-36 days). There were 25 cases of simple ACL injury and 20 cases of ACL complicated with medial collateral ligament, medial meniscus or lateral meniscus injuries. The Lachman tests of all patients were positive. The pivot shift tests of all patients were positive with grade Ⅰ in 27 cases, grade Ⅱ in 13 cases, and grade Ⅲ in 5 cases. The preoperative International Knee Documentation Committee(IKDC) score was 70.28±6.12, and the Lysholm score was 63.27±7.62. All patients underwent arthroscopic single-bundle ACL reconstruction, and the tibial tunnel was created through the anterolateral, high anteromedial, and additional low anteromedial approaches. Results All incisions healed by the first intention. All patients were followed up 18.7 months on average(range, 14-32 months). The three-dimensional CT at 3 days after operation showed that the tibial tunnel positions were accurate and the middle points were located in the 36.81%-43.35%of tibial plateau on sagittal plane. The medial borders of the tibial tunnel on coronal plane were located at the lateral to the medial eminence of the tibia. There were 3 cases of thrombosis of intermuscular vein of lower limbs, 2 cases of joint s welling and pain, and 3 cases of stiffness of knee joint. At last follow-up, the Lachman tests of all patients were negative and the pivot shift test were negative in 42 patients and positive in 3 patients(grade Ⅰ). The IKDC score(92.59±4.36) and Lysholm score(93.15±5.53) were significantly higher than preoperative scores(t=11.35, P=0.00;t=12.27, P=0.00).Conclusion Arthroscopic ACL reconstruction via tibial tunnel made by three-portal technique, which was simple and accurate, can obtain the satisfactory function of the knee in the early stage after operation.