前交叉韧带重建中内侧半月板桶柄样撕裂的缝合:全内和由内向外的比较研究

Repair techniques of all-inside and inside-out during arthroscopic anterior cruciate ligament reconstruction for bucket-handle tears of the medial meniscus

目的探讨前交叉韧带损伤合并内侧半月板桶柄样撕裂患者一期关节镜下自体腘绳肌腱重建前交叉韧带并分别选用全内技术或由内向外技术缝合半月板的临床指标、关节功能评分及术后并发症的差异。方法回顾性分析2015年1月—2021年1月兰州大学第二医院骨科收治的交叉韧带断裂合并内侧半月板桶柄样撕裂患者65例,其中采用关节镜下前交叉韧带重建和半月板的全内缝合技术(全内缝合组)37例(男性30例,女性7例;年龄18~36岁,平均26.1岁),采用关节镜下前交叉韧带重建和半月板的由内向外缝合技术(由内向外缝合组)28例(男性25例,女性3例;年龄19~37岁,平均27.6岁)。记录两组患者的手术时间、平均住院日。所有患者予以≥6个月的随访,记录临床症状和阳性体征,采用Lysholm评分和Tegner评分及关节活动度评价关节功能。结果全内缝合组患者手术时间(84.1±6.2)min,由内向外缝合组(92.6±8.5)min,差异有统计学意义(P<0.05);两组患者住院日分别为9(8,10)d和9(8,11)d,差异无统计学意义(P>0.05)。末次随访Lysholm评分,全内缝合组为91(87,94)分,由内向外缝合组为90(88,94)分,差异无统计学意义(P>0.05);全内缝合组术后Tegner评分为5(5,6)分,由内向外缝合组为5(5,6)分,差异无统计学意义(P>0.05);全内缝合组关节活动度为130°(130°,135°),由内向外缝合组为130°(130°,135°),差异无统计学意义(P>0.05);全内缝合组9例(24%)发现少量关节积液,由内向外缝合组6例(21%),差异无统计学意义(P>0.05);全内缝合组7例(19%)关节间隙压痛,由内向外缝合组3例(11%),差异无统计学意义(P>0.05)。全内缝合组患者轴移试验0度患者27例(73%)、Ⅰ度7例(19%)、Ⅱ度3例(8%);由内向外缝合组0度22例(78%)、Ⅰ度5例(18%)、Ⅱ度1例(4%),两组均无Ⅲ度轴移试验阳性患者,差异无统计学意义(P>0.05)。全内缝合组患者Lachman试验0度松弛20例(54%),Ⅰ度松弛12例(32%),Ⅱ度松弛5例(14%);由内向外缝合组0度松弛16例(57%),Ⅰ度松弛9例(32%),Ⅱ度松弛3例(11%),两组均无Ⅲ度松弛患者,差异无统计学意义(P>0.05)。由内向外缝合组有5例(18%)术后出现较为明显的髌骨内下区域局限性麻木症状,两组患者神经症状发生比较差异有统计学意义(P<0.05)。结论关节镜下前交叉韧带重建并内侧半月板桶柄样撕裂的缝合,全内缝合较由内向外缝合手术时间更短,术后关节功能和阳性症状发生率比较没有差异,而由内向外缝合存在隐神经髌骨下支损伤的风险。

Objective To investigate the clinical indicatiors,joint function socre and complications of all-inside and inside-out repair techniques during arthroscopic anterior cruciate ligament(ACL)reconstruction of bucket-handle tears of the medial meniscus.Methods From Jan.2015 to Jan.2021,patients with cruciate ligament rupture and bucket-handle tears of the medial meniscus in the Department of Orthopedics,Lanzhou University Second Hospital,who met the research criteria,were retrospectively studied.All the 65 cases underwent arthroscopic ACL reconstruction.Based on the repair techniques used for meniscus tears,patients were divided into all-inside group(37 cases,including 30 males and 7 females aged 18-36 years,mean 26.1 years)and inside-out group(28 cases,including 25 males and 3 females aged 19-37 years,mean 27.6 years).The operation time and average length of hospital stay were recorded.All patients were followed up for at least 6 months.Clinical symptoms and positive signs were observed.Lysholm score,Tegner score and range of motion were used to evaluate the joint function.Results The operation time(min)of the all-inside group(84.1±6.2)was significantly shorter than that of the inside-out group(92.6±8.5,P<0.01).No significant difference was observed regarding the length of hospital stay(days)[9(8,10)vs.9(8,11)],Lysholm score[91(87,94)vs.90(88,94)]and Tegner score[5(5,6)vs.5(5,6)],and range of motion[130°(130°,135°)vs.130°(130°,135°)]at the last follow-up[data were expressed as median(P25,P75);all P>0.05].As for complications,both the rate of joint effusion(24%,9/37 vs.21%,6/28)and joint space tenderness(19%,7/37 vs.11%,3/28)revealed no significant difference.The pivot-shift test in the all-inside group showed 73%(27/37)Grade 0,19%(7/37)Grade I,and 8%(3/37)Grade Ⅱ;while in the inside-out group,there were 78%(22/28)Grade 0,18%(5/28)Grade Ⅰ,and 4%(1/28)GradeⅡ,revealing no significant difference between two groups.There was no positive Grade-Ⅲresult.The Lachman test of laxity also showed no significant difference(P>0.05)between the all-inside group(54%,20/37 negative;32%,12/37 grade Ⅰ and 14%,5/37 GradeⅡ)and the inside-out group(57%,16/28 negative;32%,9/28 grade Ⅰ and 11%,3/28 Grade Ⅱ).None of the patients had positive GradeⅢLachman test result.Five patients in the all-inside group had obvious localized numbness in the lower patella region postoperatively,and the onset of neurological symptoms in the two groups was statistically different(P<0.05).Conclusion During arthroscopic ACL reconstruction and repair of bucked-handle tears of the medial meniscus,the all-inside technique requires a shorter operation time,but similar postoperative complications and joint functions,compared with inside-out technique.Notably,the latter has the risk of injuring the inferior patellar branch of the saphenous nerve.