胫骨前方闭合楔形截骨合并前交叉韧带翻修手术治疗胫骨平台后倾角过大的前交叉重建失败的短期疗效

Short-term Clinical Efficacy of Anterior Closed Wedge Osteotomy Combined with Anterior Cruciate Ligament Revision Surgery for Patients with Failed Anterior Cruciate Reconstruction with Excessive Posterior Tibial Slope

目的探讨胫骨近端前方闭合楔形截骨联合前交叉韧带(anterior cruciate ligament,ACL)翻修手术治疗胫骨平台后倾角(posterior tibial slope,PTS)过大的ACL重建术后失败病人的短期临床疗效。方法回顾性分析中部战区总医院骨科在2020年1月至2022年12月收治的5例初次ACL重建术后移植物失效的病人,其中术后再次外伤2例,无明显外伤3例。男4例,女1例;年龄28~41岁。所有病人均有典型的ACL断裂症状和体征,Lachman试验、轴移试验均为阳性,MRI及术中探查证实重建的ACL失效。5例病人均伴有病理性的胫骨平台后倾(PTS>12°),术前PTS为17.2°±1.9°(中位数:17°;范围:15°~20°)。所有病人均接受一期胫骨平台前方闭合楔形截骨合并ACL重建术。比较术前及术后轴移试验、股骨髁后移距离、Lysholm评分、Tegner评分、国际膝关节文献委员会(International Knee Documentation Committee,IKDC)评分。结果本组病人平均随访12个月。术后1年的PTS和股骨髁后移距离分别为6.4°±1.1°(中位数:6°;范围:5°~8°)、(1.8±0.8)mm(中位数:2 mm;范围:1~3 mm),显著低于术前的17.2°±1.9°(中位数:17°;范围:15°~20°)、(11.2±0.8)mm(中位数:11 mm;范围:10~12 mm);术前的Lysholm评分、Tegner评分和IKDC评分分别为(51.2±2.4)分(中位数:51分;范围:48~54分)、(4.2±0.8)分(中位数:4分;范围:3~5分)、(51.0±2.0)分(中位数:51分;范围:48~54分),术后1年显著提高至(87.8±3.1)分(中位数:87分;范围:85~92分)、(7.0±0.7)分(中位数:7分;范围:6~8分)、(85.0±3.5)分(中位数:85分;范围:81~89分)。结论本研究显示存在PTS过大的ACL重建失效的病人,通过胫骨截骨合并一期韧带翻修手术能有效恢复关节稳定性,提高关节功能评分。

Objective To investigate the short⁃term clinical outcomes of the anterior closed wedge osteotomy of the proximal tibia combined with anterior cruciate ligament(ACL)revision surgery in patients with failed ACL reconstruction after excessive posterior tibial slope(PTS).Methods We retrospectively analyzed 5 patients who had undergone initial ACL reconstruction and failed after the initial ACL reconstruction,including 2 cases of postoperative re⁃trauma and 3 cases without significant trauma,who were admitted to Department of Orthopedics,General Hospital of Central Theater Command between January 2020 and December 2022.There were 4 males and one female with age of 28 to 41 years old.All patients had typical signs and symptoms of ACL tear,positive Lachman test and axial shift test,and MRI and intraoperative exploration confirmed the failure of the reconstructed ACL.The pathological posterior tibial slope(PTS>12°)occurred in 5 patients,and the mean angle of PTS was 17.2°±1.9°(median 17°;range 15°⁃20°).All patients underwent a one⁃stage anterior closed wedge osteotomy of the tibial plateau combined with ACL reconstruction.The preoperative and postoperative axial shift tests,posterior femoral condylar shift distance,Lysholm score,Tegner score,and International Knee Documentation Committee(IKDC)score were compared.Results The average follow⁃up period for this group of patients was 12 months.The postoperative PTS and the posterior displacement distance of the femoral condyles at 1st year were 6.4°±1.1°(median 6°;range 5°⁃8°),(1.8±0.8)mm(median 2 mm;range 1⁃3 mm)respectively,significantly lower than the preoperative ones of 17.2°±1.9°(median 17°;range 15°⁃20°),(11.2±0.8)mm(median 11 mm;range 10⁃12 mm);The preoperative Lysholm score,Tegner score,and IKDC score were 51.2±2.4(median 51;range 48⁃54),4.2±0.8(median 4;range 3⁃5),51.0±2.0(median 51;range 48⁃54)respectively,which were significantly improved to 87.8±3.1(median 87;range 85⁃92),7.0±0.7(median 7;range 6⁃8),85.0±3.5(median 85;range 81⁃89)at 1st year after surgery.Conclusion This study shows that in patients with ACL reconstruction failure with excessive PTS,tibial osteotomy combined with one⁃stage ligament revision is effective in restoring joint stability and improving joint function scores.