关节镜下三入路与传统前内侧入路重建前交叉韧带股骨骨道的比较及早期疗效分析

Comparison of femoral tunnel and early curative effect analysis between arthroscopic three approach and traditional anteromedial portal for reconstruction of anterior cruciate ligament

目的:研究三入路和传统前内侧技术确立股骨骨道的位置、长度和冠状面角度以及前交叉韧带重建的早期疗效。方法:2018年12月到2019年6月收集36例诊断为单纯前交叉韧带断裂而且接受手术的患者,患者均有明确膝关节扭伤史,共分为两组,其中16例采用三入路技术钻取股骨骨道重建前交叉韧带,其中男11例,女5例,平均年龄(30.13±6.54)岁,受伤时间7~60(30.19±15.78) d;20例采用传统前内侧入路技术钻取股骨骨道重建前交叉韧带,其中男15例,女5例,平均年龄(30.80±8.60)岁,受伤时间7~60(27.35±15.50) d。通过CT三维重建技术评估钻取的股骨骨道,采用膝关节Lysholm评分评估患者膝关节功能。结果:所有患者手术切口术后都达到Ⅰ期愈合,术中均未出现股骨骨道破裂,血管神经损伤、移植物通过困难及静脉血栓等情况。36例患者获得门诊随访,随访时间9~15(12.00±2.83)个月。采用CT三维重建评估两组患者股骨骨道,股骨骨道位置运用四分法描述为,三入路组:股骨外髁的下(27.83±1.97)%,后(25.57±3.20)%;传统入路组:股骨外髁的下(28.38±3.21)%,后(26.23±3.20)%。骨道长度,三入路组:全长(35.20±5.52) mm,粗骨道长(23.20±2.07) mm;传统入路组:全长(34.60±4.26) mm,粗骨道长(22.56±2.50) mm。冠状面角度,三入路组(47.93±5.98)°;传统入路组(41.78±6.62)°。膝关节Lysholm评分,三入路组:术前57.81±6.23;末次随访97.00±2.48;传统入路组:术前57.15±8.76,末次随访97.30±2.68,手术前后差异有统计学意义,组间差异无统计学意义。结论:两种方式所钻取的股骨骨道的位置均在前交叉韧带的解剖止点范围内,三入路法钻取的股骨骨道相对传统前内侧入路法来说冠状面角度较大,形成的骨道长度、两种手术方式的术后早期疗效、手术时间均无差异,但是三入路法的手术视野更宽阔清晰,而且对于术中钻取股骨骨道时需要的屈膝角度要明显小于传统入路技术,降低了手术的难度。

Objective:To study the three-approach and traditional anterior medial technique to establish the femoral tunnel of position,length,and coronal angle and the early efficacy of anterior cruciate ligament reconstruction.Methods:Through retrospective research,from December 2018 to June 2019,a total of 36 patients diagnosed with simple anterior cruciate ligament tear and undergoing surgery were collected.All patients had a clear history of knee sprains and were divided into two groups.A group of 16 patients,including 11 males and 5 females,with an average age of(30.13±6.54)years and an injury time of 7 to 60(30.19±15.78)days,three-approach technique was used to drill the femoral tunnel to reconstruct the anterior cruciate ligament.Another group of 20 patients,including 15 males and 5 females,with an average age of(30.80±8.60)years,and an injury time of 7 to 60(27.35±15.50)days,the traditional anterior medial approach was used to drill the femoral tunnel to reconstruct anterior cruciate ligament.CT 3D reconstruction technique was used to evaluate the femoral tunnel and the knee joint function was evaluated by Lysholm score of the knee joint.Results:All patients achieved primary healing after the surgical incision.No femoral tunnel fracture,vascular and nerve damage,difficulty in graft passage during the operation,and venous thrombosis occurred.All 36 patients were followed up on an outpatient basis,with a follow-up period of 9 to 15(12.00±2.83)months.Three-dimensional CT reconstruction was used to evaluate the femoral tunnel of the patients.The position of the femoral tunnel was described using the quartile method as the three-approach group:the lower(27.83±1.97)%of the femoral condyle and the posterior(25.57±3.20)%;the traditional approach group:the lower(28.38±3.21)%of the femoral condyle and the posterior(26.23±3.20)%.Bone tunnel length,three-approach group:(35.20±5.52)mm in total length,(23.20±2.07)mm in thick bone tunnel;traditional approach group:(34.60±4.26)mm in total length,(22.56±2.50)mm in thick bone tunnel.Coronal plane angle,three-approach group:(47.93±5.98)°;traditional approach group:(41.78±6.62)°.Knee joint Lysholm score,three-approach group:48.67±4.18 before surgery;97.00±2.48 at last follow-up;traditional approach group:49.75±5.33 before surgery,97.30±2.68 at last follow-up,there were significant differences before and after surgery,no significant statistical difference between two groups.Conclusion:The positions of the femoral tunnel drilled by the two methods were within the range of the anatomic stop of the anterior cruciate ligament,and there was no statistical difference.Compared with the traditional anterior medial approach,the coronal plane angle of the femoral tunnel drilled by the three-approach approach is relatively large,and there were no statistical differences in the length of the tunnel,the early postoperative effect of the two surgical methods,and the operation time.But the three approach has a wider and clearer vision.In addition,the knee flexion angle required for drilling the femoral tunnel during surgery is significantly smaller than that of traditional approach technology,which reduces the difficulty of surgery.