保残重建前交叉韧带对膝关节运动学特征的影响

Kinematic characteristics based on remnant preservation for patients undergoing anterior cruciate ligament reconstruction

目的评估保残与否重建前交叉韧带(ACL)对膝关节术后运动学特征及临床疗效的影响,指导临床治疗及选择更优康复方案。方法选取2017年8月至2018年3月南方医科大学第三附属医院关节外科/运动医学科所收治50例行ACL重建患者,根据术中是否保留ACL胫骨残端分为保残组(25例)与非保残组(25例),以及健康受试者(25例)纳入本研究,纳入标准:年龄≤55岁;身体质量指数(BMI)≤30 kg/m 2;术侧或健侧膝关节无活动受限;无神经系统疾病;不伴同侧膝其他韧带损伤,对侧膝关节亦无损伤;留存术后1年完整资料。排除标准:年龄>55岁;BMI>30 kg/m 2;术侧或健侧膝关节活动受限;伴有膝关节其他韧带损伤或对侧膝关节存在损伤;存在神经系统疾病;临床资料不完全而无法统计者。采用三维膝关节动态功能分析系统(Opti_Knee)计算膝关节6自由度数据及膝关节运动功能评分,并分析患者Lysholm膝关节功能评分、国际膝关节文献委员会(IKDC)评分及Tegner膝关节运动评分、本体感觉(位置觉和运动觉)数据,以及胫骨隧道内口(术前为ACL足迹)中心至外侧半月板前角韧带足迹前后向及内外向距离偏差,其中,各组6自由度统计学差异采用双因素方差分析及t检验,各组基本数据计量资料采用单因素方差分析检测及t检验、计数资料则采用卡方检验,各组运动功能评分、主观评分、本体感觉数据、中心距偏差均采用t检验分析。结果保残组术后3个月内外旋、屈伸范围、术后6个月内外旋范围低于对照组(t=-2.365,P<0.05;t=-3.123,P<0.01;t=-2.419,P<0.05);非保残组术后3个月内外翻、内外旋、屈伸、上下位移、内外位移范围、术后6个月内外旋、屈伸范围低于对照组(F=9.554,P<0.05;t=-5.067,P<0.01;t=-5.119,P<0.01;t=-2.655,P<0.05;t=-2.863,P<0.01;t=-3.516,P<0.01;t=-4.100,P<0.01),术后6月前后位移范围大于对照组(t=2.464,P<0.05),术后12月内外旋范围小于对照组(t=-3.076,P<0.01)。非保残组术后3月内外旋、屈伸角范围、术后6月屈伸角范围低于保残组(t=2.512,P<0.05;t=2.428,P<0.05;t=2.267,P<0.05)。保残组术后3月术侧膝关节运动功能评分高于非保残组(t=2.272,P<0.05)。保残组术后3月及6月Lysholm评分高于非保残组(t=4.706、P<0.01;t=2.106,P<0.05),保残组术后3月IKDC评分高于非保残组(t=2.987,P<0.01),保残组中心内外向距偏差小于非保残组(t=-2.600,P<0.05),保残组术后3月及6月60°位置觉小于非保残组(t=-2.063,P<0.05;t=-2.147,P<0.05)。结论保残重建ACL患者较非保残者在运动学特征上更接近于正常人,而且在术后前中期恢复更优于非保残者。

Objective To evaluate the kinematic characteristics and efficacy of knees following anterior cruciate ligament(ACL)restoration with remnant preservation,and to guide clinical treatments and choose better rehabilitation methods.Methods The clinical data of 50 patients with ACL deficiency and 25 healthy volunteers from August 2017 to March 2018 were analyzed.Inclusion criteria:age less than 55 years old;body mass index(BMI)less than 30 kg/m 2;no limitation of movement of the operated or healthy knee;no nervous system disease;no injury of other ligaments of the ipsilateral knee and no injury of the contralateral knee;complete data were retained one year after operation.Exclusion criteria:age>55 years;BMI>30 kg/m 2;knee joint movement limitation;accompanied by other knee ligament injury or contralateral knee joint injury;existence of nervous system disease;clinical data was incomplete and could not be counted.The six degrees of freedom(6-DOF)ranges of knee joints and kinematic function score were calculated by Opti_Knee.Lysholm score,International Knee Documentation Committee(IKDC)score,Tegner score,proprioceptive(position and motion)data and the distance error from the center of the tibial tunnel inner mouth to the center of the footprint of the anterior horn ligament of the lateral meniscus were also analyzed.The statistical differences of 6-DOF in each group were analyzed by two-way ANOVA and t test.The statistical differences of basic data in each group were analysed by one-way ANOVA and t-test,while the counting units were tested by chi-square test.The kinematic function scores,subjective scores,proprioceptive data and center distance errors were detected by t-test.Results In remnant preservation group,the ranges of internal-external rotation,flexion-extension rotation at three months and the range of internal-external rotation at six months were lower than those in control group(t=-2.365,P<0.05;t=-3.123,P<0.01;t=-2.419,P<0.05).In non-remnant preservation group,the ranges of adduction-abduction rotation,internal-external rotation,flexion-extension rotation,proximal-distal translation,medial-lateral translation at three months,the ranges of internal-external rotation,flexion-extension rotation at six months and the range of internal-external rotation at 12 months were lower than those in control group(F=9.554,P<0.05;t=-5.067,P<0.01;t=-5.119,P<0.01;t=-2.655,P<0.05;t=-2.863,P<0.01;t=-3.516,P<0.01;t=-4.100,P<0.01;t=-3.076,P<0.01),while the range of anterior-posterior translation at six months was larger than control group(t=2.464,P<0.05).Besides,the range of internal-external rotation,flexion-extension rotation at three months and the range of flexion-extension rotation at six months in non-remnant preservation group were also lower than remnant preservation group at the corresponding time(t=2.512,P<0.05;t=2.428,P<0.05;t=2.267,P<0.05).Kinematic function score of operative knees at three months in the remnant preservation group was higher than that in the non-remnant preservation group(t=2.272,P<0.05).The Lysholm score at three months and six months and the IKDC score at three months in the remnant preservation group were higher than the non-remnant preservation group(t=4.706,P<0.01;t=2.106,P<0.05;t=2.987;P<0.01),and the medial-lateral distance error in remnant preservation group was smaller than non-remnant preservation group(t=-2.600,P<0.05).The position perceptions of 60°in the remnant preservation group were smaller than that in the non-remnant preservation group at three and six months after operation(t=-2.063,P<0.05;t=-2.147,P<0.05).Conclusion The kinematic characteristics of the remnant preservation group are closer to those of normal people and the rehabilitation of the remnant preservation group is better than that of non-remnant preservation group in the early and mid-term period.