基于华西分期分型诊治体系治疗膝关节多发韧带损伤脱位的疗效研究

Effectiveness of knee dislocation and multiple ligament injury based on Hua Xi-knee dislocation and multiple ligament injury diagnosis and treatment system

目的探讨基于膝关节多发韧带损伤脱位华西分期分型诊治体系(Hua Xi-knee dislocation and multiple ligament injury,HX-KDMLI)开展个体化精准治疗的临床效果。方法回顾分析2019年2月—2020年9月收治且符合选择标准的36例(36膝)KDMLI患者临床资料。男24例,女12例;年龄21~62岁,平均45.7岁。致伤原因:交通事故伤15例,重物砸伤8例,运动伤7例,高处坠落伤4例,机器切割伤2例。病程1~9周,平均3.6周。术前患者根据HX-KDMLI进行评估:急性期20例、陈旧期16例;脱位分型:HX-Ⅰ-A型3例,HX-Ⅰ-P型1例,HX-Ⅲ-L型10例,HX-Ⅲ-M型13例,HX-Ⅳ-S型4例,HX-Ⅴ-F型3例,HX-Ⅴ-T型2例。患者前抽屉试验及Lachman试验均阳性35例,后抽屉试验阳性31例;内翻应力试验阳性19例,外翻应力试验阳性23例。国际膝关节文献委员会(IKDC)分级:A级1例、B级5例、C级8例、D级22例。基于分期分型评估结果,选择关节镜下、开放或关节镜联合开放手术修复重建韧带,骨折解剖复位固定。术后采取循序渐"激"康复原则进行锻炼。结果术后切口均Ⅰ期愈合,无手术相关并发症发生。患者均获随访,随访时间12~19个月,平均15个月。术后12个月,患肢肌力均恢复至Ⅴ级,膝关节活动范围均能达到伸直0°、屈曲120°以上;影像学复查示膝关节无明显不稳,骨折均愈合,修复及重建的韧带连续性及张力好,关节对位对线好。患者前、后抽屉试验均阴性;Lachman试验Ⅰ度阳性5例,内翻应力试验Ⅰ度阳性2例,外翻应力试验Ⅰ度阳性2例,其余患者均为阴性。术后12个月,膝关节IKDC分级:A级9例、B级19例、C级5例、D级3例,与术前比较差异有统计学意义(Z=-5.328,P=0.000)。IKDC、Lysholm、Tegner评分与术前比较,差异均有统计学意义(P<0.05)。结论HX-KDMLI能指导KDMLI治疗方案的制定,并获得较好疗效。

Objective To investigate the effectiveness of personalized treatment based on Hua Xi-knee dislocation and multiple ligament injury(HX-KDMLI)diagnosis and treatment system.Methods A clinical data of 36 patients(36 knees)with KDMLI met the selective criteria between February 2019 and September 2020 was retrospectively analyzed.There were 24 males and 12 females with an average age of 45.7 years(range,21-62 years).The KDMLI was caused by traffic accident in 15 cases,heavy pound in 8 cases,sports sprain in 7 cases,falling from height in 4 cases,and machine cutting in 2 cases.The interval between injury and operation was 1-9 weeks(mean,3.6 weeks).All patients were categorized according to HX-KDMLI diagnosis and treatment system.Twenty patients were categorized as acute period and 16 patients as chronic period.Three patients were type HX-Ⅰ-A,1 type HX-Ⅰ-P,10 type HX-Ⅲ-L,13 type HX-Ⅲ-M,4 type HX-Ⅳ-S,3 type HX-Ⅴ-F,and 2 type HX-Ⅴ-T.Thirty-five patients were positive in both the anterior drawer test and Lachman test,31 were positive in the posterior drawer test;19 patients were positive in varus stress test,23 were positive in valgus stress test.According to the Internation Knee Documentation Committee(IKDC)grading,there was1 case of grade A,5 cases of grade B,8 cases of grade C,and 2 cases of grade D.Surgical interventions included arthroscopic surgery,open surgery,or arthroscopy combined with open surgery,ligament suture or reconstruction,and internal fixation after anatomical reduction of the fracture.Different rehabilitation protocols were assigned to patients during different postoperative period,according to patient’s individualized classification.Results All incisions healed by first intention with no obvious complications.All patients were followed up 12-19 months(mean,15 months).At 12 months after operation,all patients retained muscle strength of gradeⅤ,and range of motion of the knee joint could reach 0°extension and over 120°flexion.Radiographic examination showed no sign of knee instability,healed fractures,ideal joint alignment,good continuity and tension,and clear image of repaired or reconstructed ligaments.The anterior and posterior drawer tests were all negative.Lachman test was degreeⅠpositive in 5 cases,valgus stress test was degreeⅠpositive in 2 cases,varus stress test was degreeⅠpositive in 2 cases;the other patients were all negative.At 12 months after operation,according to the IKDC grading,there were 9 cases of grade A,19 cases of grade B,5 cases of grade C,and 3 cases of grade D,showing significant differences when compared with the preoperative ones(Z=–5.328,P=0.000).There were significant differences in the IKDC,Lysholm,and Tegner scores between pre-and post-operation(P<0.05).Conclusion The promising effectiveness of KDMLI can obtain under the guidance of HX-KDMLI.