关节镜下"8"字缝线与网兜缝线固定治疗前十字韧带胫骨止点撕脱骨折

Arthroscopic fixation with figure of 8 suture versus ladder mesh suture for anterior cruciate ligament tibial avulsion fracture

目的探讨关节镜下"8"字缝线与网兜缝线固定治疗前十字韧带(anterior cruciate ligament,ACL)胫骨止点撕脱骨折的早期临床疗效。方法回顾性分析2013年8月至2016年11月收治的37例ACL胫骨止点撕脱骨折并获得完整随访的患者,所有患者骨骺均已闭合。Meyers-McKeever-Zaricznyj骨折分型:Ⅱ型10例,Ⅲ型22例,Ⅳ型5例。固定方式采用"8"字缝线法25例,男17例,女8例,年龄(18.91±9.34)岁(范围14~36岁),以两根2号高强度缝线交叉成"8"字经胫骨骨道拉出固定骨折块;采用网兜缝线固定12例,男8例,女4例,年龄(19.63±7.85)岁(范围15~33岁),以三根2号高强度缝线编织成网兜经胫骨骨道拉出固定骨折块。手术前后采用Lysholm及国际膝关节评分委员会(International Knee Documentation Committee,IKDC)评分评价膝关节功能,通过Lachman试验及Pivot-shift试验评价膝关节稳定性,并记录手术时间、膝关节活动度及伸膝阻滞情况。结果"8"字缝线组随访(16.35±5.27)个月(范围10~22个月),网兜缝线组(14.06±7.18)个月(范围10~21个月)。末次随访时,"8"字缝线组的Lysholm、IKDC评分分别为(95.86±5.74)分、(90.53±4.61)分,网兜缝线组分别为(96.53±3.17)分、(92.15±5.54)分,两组差异无统计学意义(t=0.723,P=0.462;t=1.018,P=0.279);"8"字缝线组Lachman试验及Pivot-shift试验阴性率均为92%(23/25),网兜缝线组均为100%(12/12),两组差异无统计学意义(χ^2=0.904,P=0.265);网兜缝线组手术时间为(61.8±6.3)min,较"8"字缝线组的(43.5±5.9)min长,差异有统计学意义(t=2.714,P=0.025);"8"字缝线组伸膝受限(5°或以上伸膝受限)发生率为16%(4/25),网兜缝线组为0,两组差异有统计学意义(χ^2=0.450,P=0.032)。结论关节镜下"8"字缝线固定与网兜缝线固定技术治疗ACL胫骨止点撕脱骨折均可获得良好的早期膝关节功能和稳定性。网兜缝线固定技术可完整复位骨折块,术后伸膝阻滞发生率低,在治疗旋转Ⅲ型和粉碎Ⅳ型骨折中可能更具有优势;但有技术要求高、手术时间长的缺点。

Objective To compare the primary clinical results of arthroscopic figure of 8 suture and ladder mesh suture fixations in treating anterior cruciate ligament(ACL)tibial avulsion fractures.Methods From August 2013 to November 2016,a total of 37 patients with ACL tibial avulsion fracture who had closed epiphyses underwent arthroscopy.By the Meyers-McKeever-Zaricznyj classification,10 cases were type II,22 type III and 5 type IV.There were 25 cases in the figure of 8 suture fixation group with two No.2 high-strength sutures crossed to form a 8 figure to pull out and fix the fracture through the tibial tunnels,including 17 males and 8 females with an average age of 18.91±9.34 years(range 14-36 years).The ladder mesh suture fixation group with three No.2 high-strength sutures woven into a mesh to pull out and fix the fracture through the tibial tunnels had 12 cases,including 8 males and 4 females with an average age of 19.63±7.85 years(range 15-33 years).At the latest follow-up,the Lysholm and International Knee Documentation Committee(IKDC)scores were used to estimate knee joint function,while the Lachman test and Pivot-shift test were used to estimate knee joint instability.The operation duration,knee range of motion(ROM)and the number of case with flexion contracture were evaluated.Results All 37 cases were followed up.The average follow-up duration was 16.35±5.27 months(range 10-22 months)in figure of 8 suture fixation group and 14.06±7.18 months(range 10-21 months)in ladder mesh suture fixation group.In figure of 8 suture fixation group,the Lysholm and IKDC average scores were 95.86±5.74 and 90.53±4.61,respectively.However,they were 96.53±3.17 and 92.15±5.54 in ladder mesh suture fixation group with no significant difference between the two groups after operation(t=0.723,P=0.462;t=1.018,P=0.279).The percentage of negative Lachman test and Pivot-shift test in the figure of 8 suture group was 92%(23/25).There was no significant difference in the negative rate in the ladder mesh suture fixation group 100%(12/12,χ^2=0.904,P=0.265).The average operation duration of ladder mesh suture fixation group was 61.8±6.3 minutes,which was longer than that of figure of 8 suture fixation group 43.5±5.9 minutes(t=2.714,P=0.025).Flexion contracture of≥5°occurred in 4 cases in the figure of 8 suture group and 0 case in the ladder mesh suture fixation group with significant difference between the two groups(χ^2=0.450,P=0.032).Conclusion In treating ACL tibial avulsion fractures,arthroscopic figure of 8 suture fixation and ladder mesh suture fixation can achieve satisfied functional recovery and stability.The ladder mesh suture fixation can effectively achieve reduction of fracture fragments and knee flexion contracture.It may have more advantages in treating rotational type III and type IV comminuted fractures.However,some disadvantages in this technique,such as high technical requirements and long operation time,have to be considered.