3D打印导板辅助定位与C形臂X线机透视定位股骨隧道重建内侧髌股韧带治疗复发性髌骨脱位的疗效比较

3D printed guide plate assisted and C‑arm X‑ray fluoroscopic positioning for femoral tunnel reconstruction of medial patellofemoral ligament in treating recurrent patellofemoral dislocation:a comparison of efficacies

目的比较3D打印导板辅助定位与C形臂X线机透视定位股骨隧道重建内侧髌股韧带治疗复发性髌骨脱位的疗效。方法采用回顾性队列研究2018年1月至2022年12月昆明医科大学第一附属医院收治的60例复发性髌骨脱位患者的临床资料,其中男29例,女31例;年龄14~40岁[(28.6±7.6)岁]。30例行内侧髌股韧带重建术时使用3D打印导板辅助定位股骨隧道(3D导板组),30例行内侧髌股韧带重建术时使用传统C形臂X线机透视定位股骨隧道(常规透视组)。(1)术后7 d内采集患膝关节CT数据,导入Mimics 19.0软件测量两组患者术后股骨隧道中心至Schöttle点的距离;(2)术前及术后3,6,9,12个月采用膝关节Lysholm评分、Kujala评分评价患者膝关节功能情况;(3)术前及术后3,6,9,12个月通过Opti‑Knee^(TM) 3D膝关节运动学分析系统采集患膝关节的前后位移、上下位移、内外位移、内外翻角、内外旋角及屈伸角,计算各自由度范围并与30名健康人群的该6个自由度进行膝关节运动学分析。结果患者均获随访12~15个月[(12.3±0.7)个月]。(1)术后7 d内所测3D导板组股骨隧道中心至Schöttle点距离为(5.5±2.3)mm,小于常规透视组的(7.6±2.5)mm(P<0.01)。(2)术后3D导板组和常规透视组Lysholm评分、Kujala评分较术前逐渐提高(P均<0.01)。术前、术后12个月3D导板组和常规透视组膝关节Lysholm评分、Kujala评分差异无统计学意义(P均>0.05);术后3,6,9个月3D导板组Lysholm评分[(70.4±4.5)分、(86.4±3.1)分、(91.2±3.2)分]、Kujala评分[(74.2±5.3)分、(80.9±3.5)分、(85.2±3.2)分]高于常规透视组[Lysholm评分:(67.3±5.2)分、(81.8±2.5)分、(86.2±1.9)分;Kujala评分:(69.8±5.2)分、(77.6±2.1)分、(82.7±2.6)分](P<0.05或0.01)。(3)术前3D导板组和常规透视组前后位移[(0.6±0.1)cm、(0.6±0.2)cm]、上下位移[(0.5±0.1)cm、(0.6±0.0)cm]、内外位移[(0.7±0.1)cm、(0.6±0.2)cm]、屈伸角[(50.6±10.3)°、(51.6±8.5)°]小于健康人群[(1.6±0.3)cm、(1.7±0.5)cm、(1.0±0.4)cm、(63.2±5.1)°],而内外翻角[(17.5±4.0)°、(17.1±3.8)°]、内外旋角[(17.9±1.9)°、(17.5±1.5)°]大于健康人群[(11.8±3.6)°、(15.8±4.9)°](P均<0.05)。3D导板组和常规透视组其余各时间点的前后位移、上下位移、内外位移、内外翻角、内外旋角与健康人群的差异无统计学意义(P均>0.05)。术后3个月3D导板组和常规透视组屈伸角小于健康人群(P均<0.05)。术后6,9个月常规透视组的屈伸角[(55.0±3.7)°、(57.7±4.8)°]小于健康人群[(63.2±5.1)°、(63.2±5.1)°](P均<0.05),但3D导板组屈伸角[(61.0±4.8)°、(61.8±4.9)°]与健康人群的差异无统计学意义(P均>0.05)。术后12个月3D导板组和常规透视组屈伸角与健康人群的差异无统计学意义(P均>0.05)。结论与C形臂X线机透视定位股骨隧道比较,3D打印导板辅助定位股骨隧道重建内侧髌股韧带治疗复发性髌骨脱位,可简化内侧髌股韧带重建术,股骨隧道定位更精准;早期膝关节功能恢复更好,患者满意度高;膝关节运动学功能中的屈伸角度恢复更好更快。

Objective To compare the efficacies of 3D printed guide plate assisted positioning and C‑arm X‑ray machine fluoroscopic positioning for femoral tunnel reconstruction of medial patellofemoral ligament in treating recurrent patellofemoral dislocation.Methods A retrospective cohort study was performed on the clinical data of 60 patients with recurrent patellar dislocation admitted to the First Affiliated Hospital of Kunming Medical University from January 2018 to December 2022.The patients included 29 males and 31 females,with age range of 14‑40 years[(28.6±7.6)years].The 3D printed guide plate was used to locate the femoral tunnel in 30 patients for medial patellofemoral ligament reconstruction(3D guide group),and C‑arm X‑ray machine was used for another 30 patients(conventional group).(1)CT data of the knee joint were collected before surgery and at 7 days after surgery.Mimics 19.0 software was introduced to measure the distance between the center of femoral tunnel and Schöttle point after surgery.(2)Knee Lysholm score and Kujala score were used to evaluate the knee function before and at 3,6,9 and 12 months after surgery.(3)At the same time points,Opti‑Knee^(TM) 3D knee kinematics analysis system was used to collect the forward and backward displacement,up and down displacement,internal and external displacement,internal and external flipping angle,internal and external rotation angle,and flexion and extension angle of the affected knee joint.The range of each freedom degree was calculated and 6 freedom degree items of 30 healthy people were subjected to knee kinematics analysis.Results All patients were followed up for 12‑15 months[(12.3±0.7)months].(1)The distance between the center of femoral tunnel and Schöttle point in the 3D guide group was(5.5±2.3)mm,smaller than that in the conventional group[(7.6±2.5)mm](P<0.01).(2)The Lysholm score and Kujala score of the 3D guide group and conventional gruop gradually increased after surgery(all P<0.01).There were no significant differences in the Lysholm score or Kujala score between the 3D guide group and conventional gruop before surgery and at 12 months after surgery(all P>0.05).At 3,6 and 9 months after surgery,the Lysholm score of the 3D guide group[(70.4±4.5)points,(86.4±3.1)points,(91.2±3.2)points]and Kujala score[(74.2±5.3)points,(80.9±3.5)points,(85.2±3.2)points]were higher than those of the conventional group[Lysholm score:(67.3±5.2)points,(81.8±2.5)points,(86.2±1.9)points;Kujala score:(69.8±5.2)points,(77.6±2.1)points,(82.7±2.6)points](P<0.05 or 0.01).(3)Before surgery,the forward and backward displacement in the 3D guide group and conventional group[(0.6±0.1)cm,(0.6±0.2)cm],up and down displacement[(0.5±0.1)cm,(0.6±0.0)cm],internal and external displacement[(0.7±0.1)cm,(0.6±0.2)cm],and flexion and extension angle[(50.6±10.3)°,(51.6±8.5)°]were less than those in the healthy controls[(1.6±0.3)cm,(1.7±0.5)cm,(1.0±0.4)cm,(63.2±5.1)°](all P<0.05),while the internal and external flipping angle[(17.5±4.0)°,(17.1±3.8)°]and internal and external rotation angle[(17.9±1.9)°,(17.5±1.5)°]were greater than those in the healthy controls[(11.8±3.6)°,(15.8±4.9)°](all P<0.05).At other time points,the results of front and back displacement,up and down displacement,internal and external displacement,internal and external rotation angle in the 3D guide group and conventional group were not significantly different compared with the healthy controls(all P>0.05).The flexion and extension angle in the 3D guide group and conventional gruop were smaller than those in the healthy controls at 3 months after surgery(all P<0.05).At 6 and 9 months after surgery,the flexion and extension angle in the conventional group[(55.0±3.7)°,(57.7±4.8)°]were smaller than those in the healthy controls[(63.2±5.1)°,(63.2±5.1)°](all P<0.05),but no significant difference was found between the 3D guide group[(61.0±4.8)°,(61.8±4.9)°]and the healthy controls(all P>0.05).The flexion and extension angle in the 3D guide group and conventional gruop was similar with that in the healthy controls at 12 months after surgery(all P>0.05).Conclusions Compared with the C‑arm X‑ray machine,the 3D printed guide plate assisted positioning of femoral tunnel is more simple and accurate for the medial patellofemoral ligament reconstruction in treating recurrent patellofemoral dislocation,together with better early knee function recovery,better satisfaction of the patients,and better and faster restoration of the flexion and extension angle of knee joint kinematic function.