前交叉韧带断裂合并内、外侧半月板后部复杂损伤的修复重建

Repair and Reconstruction of Rupture of Anterior Cruciate Ligament Combined with Complex Injury of Posterior Part of Medial and Lateral Meniscus

目的:探讨前交叉韧带(anterior cruciate ligament,ACL)断裂合并内、外侧半月板后部复杂损伤修复的方法和疗效。方法:回顾性分析2016年10月~2019年10月本院收治的33例接受ACL重建手术的患者,且术中同时重建修复了外侧半月板后根部(LMPR)损伤及内侧半月板RAMP区(RAMP)损伤。根据术前患膝的轴移分度分为两组:低度轴移组25例,其中男18例、女7例,年龄16~41岁(平均26.6±8.19岁);高度轴移组8例,其中男6例、女2例,年龄17~43岁(平均25.4±9.64岁)。记录两组的手术时间、术后并发症情况,术前、术后1年、术后2年的Lysholm膝关节评分、国际膝关节文献委员会(IKDC)评分以及术后2年的轴移分度和患膝MRI,评估ACL及内、外侧半月板后部损伤的愈合情况。结果:所有患者均获随访24~60个月(平均32.8±16.6个月)。手术时间为98±21.4 min。两组术后1年、术后2年的Lysholm膝关节评分、IKDC评分均显著优于术前(P均<0.001)。术前轴移分度:低度轴移组25例(1度15例,2度10例),高度轴移组8例(3度);术后2年轴移分度:低度轴移组1度降为0度15例、2度降为0度3例、2度降为1度7例,高度轴移组3度降为0度1例、3度降为1度4例、3度降为2度3例;术后2年低度轴移组MRI评估RAMP损伤愈合率为92%,LMPR损伤愈合率为88%;高度轴移组RAMP损伤愈合率为75%,LMPR损伤愈合率为75%。并发症情况:无手术部位感染及血管神经损伤情况,下肢肌间静脉血栓形成5例,经3月抗凝治疗后好转,无肺栓塞或死亡发生。结论:针对ACL断裂同时合并RAMP及LMPR损伤的患者,可通过重建ACL的同时修复内、外侧半月板后部复杂撕裂,可恢复膝关节稳定性,改善轴移分度,提升功能评分,达到满意的临床疗效。但手术时间相对较长,且操作复杂,需配合专用修复工具,故需要重视术前的评估和准备工作。

Objective To explore the method and effect of simultaneous repair of rupture of anterior cruciate ligament(ACL)combined with complex injury of posterior part of medial and lateral meniscus.Methods Thirty-three patients who underwent ACL reconstruction in Wuhan Fourth Hospital between October 2016 to October 2019 were retrospectively analyzed,and their posterior root injury of lateral meniscus(LMPR)and medial meniscus RAMP area(RAMP)were reconstructed and repaired at the same time.They were randomly divided into a low degree group(n=25)and a high degree group(n=8)according to the degree of pivot shift before operation.The low degree group included 18 males and 7 females,with an average age of 26.6±8.19(16~41),while the high degree group insisted of 6 males and 2 females,with an average age of 25.4±9.64(17~43).The operation time,postoperative complications,Lysholm knee joint score and International Knee Documentation Committee(IKDC)score before the operation,as well as 1 and 2 years after the operation,the degree of pivot shift and knee MRI 2 years after operation were recorded to evaluate the healing of ACL and posterior medial and lat⁃eral meniscus injuries.Results All patients were followed up for 24 to 60 months(mean 32.8±16.6 months).The operation time was 98±21.4 min.The Lysholm knee score and IKDC score of the two groups at 1 year and 2 years after the operation were significantly better than those before the opera⁃tion(P<0.001).Before the operation,the low degree group was of 151-degree and 102-degree pivot shift while the high degree group were all of the 3-degree.However,2 years after the operation,in the low degree group,only 7 cases were of 1-degree pivot shift,while in the high degree group,on⁃ly 3 cases were of 1-and 2-degree shift,respectively.Meanwhile,according to MRI,the healing rate of RAMP area and LMPR of the low degree group was 92%and 88%,respectively,while the values of the high degree group were 75%and 75%respectively.There was no infection at the opera⁃tive site and vascular and nerve injury.Intermuscular venous thrombosis of lower extremities was ob⁃served among 5 patients.Then after 3 months of anticoagulation therapy,no pulmonary embolism or death occurred.Conclusion For the patients with ACL rupture complicated with RAMP and LMPR tear,reconstruction of ACL and complete repair of medial and lateral meniscus tears at the same time can significantly improve the grade of the pivot shift,and the knee joint function,with satisfactory clinical results.However,such method demands a relatively long-time and complex operation,so it needs special meniscus repair tools,and requires accurate preoperative evaluation and good surgical planning.