一期前、后交叉韧带及后外侧复合体重建联合内侧副韧带修复治疗KD-Ⅳ型膝关节脱位的近期疗效

Short-term effectiveness of one-stage anterior and posterior cruciate ligaments and posterolateral complex reconstruction combined with medial collateral ligament repair for KD-Ⅳknee dislocation

目的探讨一期前交叉韧带(anterior cruciate ligament,ACL)、后交叉韧带(posterior cruciate ligament,PCL)及后外侧复合体(posterolateral complex,PLC)重建联合内侧副韧带(medial collateral ligament,MCL)修复治疗KD-Ⅳ型膝关节脱位的近期疗效。方法2018年1月—2020年6月,收治9例KD-Ⅳ型膝关节脱位患者。其中,男7例,女2例;年龄23~43岁,平均32.3岁。致伤原因:高处坠落伤6例,交通事故伤3例。损伤侧别:左膝2例,右膝7例。受伤至手术时间为14~24 d,平均19 d。术前国际膝关节文献委员会(IKDC)评分为(45.6±4.2)分、Lysholm评分为(42.4±7.0)分,膝关节主动屈曲活动度为(75.2±12.3)°;后抽屉试验、轴移试验、胫骨外旋试验、0°外翻应力试验均为阳性。关节镜下以自体肌腱重建PCL、同种异体跟腱重建ACL、同种异体胫前肌腱Larson后外侧加强重建PLC,带线锚钉或单纯缝线缝合修复MCL。结果手术时间2~3 h,平均2.5 h。术后切口均Ⅰ期愈合。所有患者均获随访,随访时间12~25个月,平均16.1个月。术后出现2例屈膝障碍及疼痛,1例膝关节僵硬。末次随访时,IKDC评分为(76.9±7.4)分、Lysholm评分为(81.6±6.4)分、膝关节主动屈曲活动度为(122.9±7.2)°,均较术前明显改善(P<0.05)。随访期间移植物均无失效,末次随访时后抽屉试验、轴移试验、胫骨外旋试验以及0°外翻应力试验均较术前改善,差异有统计学意义(P<0.05)。影像学复查显示骨隧道位置均满意,1年后可见韧带移植物成活,MCL连续性良好。结论一期ACL、PCL及PLC重建联合MCL修复治疗KD-Ⅳ型膝关节脱位,能有效恢复膝关节稳定性、改善关节松弛程度,并提高关节运动能力。

Objective To investigate the short-term effectiveness of one-stage anterior cruciate ligament(ACL),posterior cruciate ligament(PCL),and posterolateral complex(PLC)reconstruction combined with medial collateral ligament repair for KD-Ⅳknee dislocation.Methods Between January 2018 and June 2020,9 patients with KD-Ⅳknee dislocation were treated.Of 9 cases,7 were male and 2 were female with an average age of 32.3 years(range,23-43 years).The knee dislocation was caused by falling from height in 6 cases and traffic accident in 3 cases.The injury located at left knee in 2 cases and right knee in 7 cases.The time from injury to operation was 14-24 days,with an average of 19 days.The preoperative International Knee Joint Documentation Committee(IKDC)score was 45.6±4.2,Lysholm score was42.4±7.0,and the knee joint active flexion range of motion was(75.2±12.3)°.The posterior drawer test,pivot-shift test,Dial test,and 0°valgus stress test were all positive.Under arthroscopy,PCL was reconstructed with the autologous tendons,ACL with allogeneic Achilles tendon,PLC with the allogeneic anterior tibial tendon by Larson enhanced reconstruction method,and MCL was repaired with anchor or simple suture.Results The operation time was 2-3 hours(mean,2.5 hours).All incisions healed by first intention after operation.All patients were followed up12-25 months(mean,16.1 months).After operation,2 cases developed knee flexion disorder and pain,and 1 case had knee joint stiffness.At last follow-up,the IKDC score was 76.9±7.4,the Lysholm score was 81.6±6.4,and the knee active flexion range of motion was(122.9±7.2)°,all of which significantly improved when compared with preoperative ones(P<0.05).During follow-up,there was no failure of the grafts.At last follow-up,there were significant differences in the posterior drawer test,pivot-shift test,Dial test,and 0°valgus stress test between pre-and post-operation(P<0.05).The imaging review showed that the positions of the bone tunnels were satisfactory,the reconstructed ACL,PCL,and PLC structures were continuous,and MCL insertions were restored.Conclusion One-stage ACL,PCL,and PLC reconstruction combined with MCL repair to treat KD-Ⅳknee dislocation can effectively restore knee joint stability,improve joint laxity,and improve joint movement.