美国骨科医师协会《前十字韧带损伤治疗循证临床实践指南(2022版)》解读

The interpretation of the American Academy of Orthopaedic Surgeons "management of anterior cruciate ligament injuries evidence-based clinical practice guideline (2022)"

前十字韧带(anterior cruciate ligament,ACL)损伤是一种常见的运动损伤,导致患者膝关节不稳定、阻碍重返运动并引发创伤性关节炎,一直是临床诊治和运动医学研究的重点。美国骨科医师协会于2022年8月在《ACL损伤治疗循证临床实践指南(2014版)》基础上更新并发布了《ACL损伤治疗循证临床实践指南(2022版)》。新版指南涉及ACL损伤的预防、诊断和治疗等方面,并依据循证证据的等级,提出8条推荐与7条可选的诊治建议。与2014版指南相比,新版指南不再推荐异体移植物,将ACL损伤后的重建时间从原来的伤后5个月提前到伤后3个月,新增了ACL重建时可以联合前外侧韧带重建或前外侧关节外肌腱固定,对ACL修补不予推荐。该新版指南与中国《前交叉韧带损伤临床诊疗循证指南(2022版)》有许多相似之处,两个指南均推荐诊断时需询问病史和体格检查、尽早重建、采用自体骨-髌腱-骨或腘绳肌腱移植物、可选择单束或双束重建。美国骨科医师协会的新版指南依据国外循证证据制定,对国内医生关注的人工韧带、骨隧道制作技术与康复方案并未给出明确的推荐建议。因此,国内医生诊治ACL损伤时,在遵循美国新版指南的基础上还需结合中国患者的特点、临床实践与国内相关指南,提高和完善国内ACL损伤的诊治水平。

The anterior cruciate ligament(ACL)injury is a common sports injury,which can lead to the knee unstable,make it difficult for the patient to return to sports,and cause post-traumatic osteoarthritis.The difficulty of its clinical diagnosis and treatment has always been the focus of sports medicine research.In August 2022,the American Association of Orthopaedic Surgeons updated and published"evidence-based clinical practice guideline on management of ACL injuries(2022 version)"based on the"evidence-based clinical practice guideline on management of ACL injuries(2014 version)".In the prevention,diagnosis and treatment of ACL injuries,the new guideline offers 8 recommendations and 7 options according to different evidence strength.To assist clinicians in the diagnosis and treatment of ACL injuries,this article provides an interpretation of the new guideline.In comparison to the 2014 version,the new guideline does not recommend allografts any more,shortens the time for reconstruction after ACL injury from 5 months to 3 months,adds advice that ACL reconstruction can be combined with anterolateral ligament reconstruction or lateral extra-articular tenodesis,and does not recommend ACL repair.The new guideline also shares many similarities with the domestic"clinical evidence-based guideline for the diagnosis and treatment of anterior cruciate ligament injury(2022 version)",both of which advocate history and physical examination at diagnosis,early reconstruction,the use of autologous bone-patellar tendon-bone or hamstring tendon,and either single-bundle or double-bundle ACL reconstruction.The new ACL guidelines of the American Association of Orthopaedic Surgeons lack specific recommendations on artificial ligaments,techniques for bone tunnel creation,and rehabilitation programs,all of which are of concern to domestic physicians because they are based on evidence-based research from abroad.Therefore,in order to improve the diagnosis and treatment of ACL injuries in China,clinicians should not only follow the new ACL guidelines of the American Association of Orthopaedic Surgeons,but also combine the characteristics of Chinese patients,clinical practice,and pertinent domestic guidelines when diagnosing and treating ACL injuries.