基于胫腓骨重建的单股骨隧道技术治疗Fanelli C型后外侧复合体损伤的疗效

Efficacy of tibiofibular-based reconstruction technique with single femoral tunnel for Fanelli type C posterolateral complex injury

目的探讨采用基于胫腓骨重建的单股骨隧道技术治疗Fanelli C型后外侧复合体(PLC)损伤的疗效。方法采用回顾性病例系列研究分析2016年7月至2019年7月天津市天津医院收治的16例Fanelli C型PLC损伤患者的临床资料,其中男10例,女6例;年龄20~61岁[(36.5±13.9)岁]。采用基于胫腓骨重建的单股骨隧道技术重建PLC,移植物均为自体股薄、半腱肌腱。若合并后/前交叉韧带(PCL/ACL)断裂,同期行关节镜下单束重建。若合并后内侧角(PMC)损伤,同期行PMC修复或重建手术。记录手术时间和术中出血量。术中钻入PLC股骨隧道导针并扩孔时,在关节镜下经交叉韧带的股骨隧道监视隧道间是否干扰。术前及术后6、12个月,通过双膝外侧关节间隙宽度差值和国际膝关节文献委员会(IKDC)膝关节内翻稳定性客观分级评估膝关节内翻稳定性;通过双膝胫骨外旋角度差值及IKDC膝关节外旋稳定性客观分级评估膝关节外旋稳定性。术前,术后6、12个月及末次随访时,比较IKDC 2000主观评分、Lysholm评分。观察并发症发生情况。结果患者均获随访12~36个月[24(15,33)个月]。手术时间100~220 min[175.0(111.3,200.0)min],术中出血量30~150 ml[(84.3±36.5)ml]。术中关节镜下证实PLC与交叉韧带的股骨隧道未发生贯通干扰情况。术后6、12个月双膝外侧关节间隙宽度差值分别为0.5(0.2,1.4)mm和0.6(0.2,1.5)mm,均较术前的12.1(10.8,12.6)mm明显改善(P<0.05),而术后6、12个月差异无统计学意义(P>0.05)。IKDC膝关节内翻稳定性客观分级:术前均为D级;术后6、12个月A级13例,B级2例,C级1例(P<0.01)。术后6、12个月双膝胫骨外旋角度差值分别为-2.0(-3.2,1.3)°和-1.4(-3.0,1.7)°,均较术前的16.8(13.9,18.4)°明显改善(P<0.05),而术后6、12个月差异无统计学意义(P>0.05)。IKDC膝关节外旋稳定性客观分级:术前C级14例,D级2例;术后6、12个月A级14例,B级1例,C级1例(P<0.01)。术后6、12个月及末次随访时IKDC 2000主观评分[(76.3±4.7)分、(80.3±4.4)分、(79.9±3.8)分]、Lysholm评分[(76.1±3.9)分、(81.1±4.3)分、(82.8±3.2)分]均较术前[(48.6±3.7)分、(52.6±2.4)分]明显改善(P<0.05);与术后6个月比较,术后12个月及末次随访时IKDC2000主观评分、Lysholm评分均明显改善(P<0.05);与术后12个月比较,末次随访时IKDC2000主观评分、Lysholm评分差异均无统计学意义(P>0.05)。患者术后均未发生伤口感染、血管神经损伤、关节僵硬、异位骨化等主要并发症。结论采用基于胫腓骨重建的单股骨隧道技术治疗Fanelli C型PLC损伤,可减少股骨侧隧道间干扰风险,显著改善膝关节内翻、外旋稳定性及膝关节功能,并发症少,短期临床效果满意。

Objective To investigate the efficacy of tibiofibular-based reconstruction technique with single femoral tunnel for Fanelli type C posterolateral complex(PLC)injury.Methods A retrospective case series study was conducted to analyze the clinical data of 16 patients with Fanelli type C PLC injury admitted to Tianjin Hospital from July 2016 to July 2019,including 10 males and 6 females,aged 20-61 years[(36.5±13.9)years].PLC reconstruction was performed by tibiofibular-based technique with single femoral tunnel using gracilis tendon and semi-tendinosus autografts.If the posterior and anterior cruciate ligaments(PCL/ACL)rupture were combined,arthroscopic single bundle reconstruction was performed simultaneously.If the posteromedial corner(PMC)injury was combined,PMC repair or reconstruction surgery was performed simultaneously.Operation time and intraoperative blood loss were recorded.When the bone needle and tunnel for PLC were drilled during the operation,the interference of the femoral tunnel through the cruciate ligament was observed under the arthroscope.Before and at 6 and 12 months after operation,the varus stability of the knee joint was evaluated with the difference of lateral joint space width of both knees and the International Knee Documentation Committee(IKDC)objective classification of varus stability of the knee joint;the external rotation stability was evaluated with the difference of external rotation angle of both knees and the IKDC objective classification of external rotation stability of the knee joint.Before,at 6 and 12 months after operation and at the last follow-up,IKDC 2000 subjective score and Lysholm score were compared.The occurrence of complications was observed.Results All the patients were followed up for 12-36 months[24(15,33)months].The operation time was 100-220 minutes[175.0(111.3,200.0)minutes],with intraoperative blood loss of 30-150 ml[(84.3±36.5)ml].Intraoperative arthroscopy showed no interference of perforation between PLC and cruciate ligament femoral tunnel.The differences of lateral joint space width of both knees at 6 and 12 months after operation were 0.5(0.2,1.4)mm and 0.6(0.2,1.5)mm respectively,which were both significantly improved compared with 12.1(10.8,12.6)mm before operation(P<0.05),while there was no significant difference at 6 and 12 months after operation(P>0.05).The IKDC objective classification of varus stability of the knee joint was grade A in 13 patients,grade B in two and grade C in one at 6 or 12 months after operation,and showed statistical difference from grade D in all the patients before operation(P<0.01).At 6 and 12 months after operation,the difference of external rotation angle of both knees was-2.0(-3.2,1.3)°and-1.4(-3.0,1.7)°respectively,which were significantly improved compared with 16.8(13.9,18.4)°before operation(P<0.05),while there was no significant difference at 6 and 12 months after operation(P>0.05).IKDC objective classification of external rotation stability of the knee joint was grade A in 14 patients,grade B in one and grade C in one at 6 or 12 months after operation,and showed statistical difference from grade C in 14 patients and grade D in 2 before operation(P<0.01).At 6 and 12 months after operation and at the last follow-up,the IKDC 2000 subjective scores[(76.3±4.7)points,(80.3±4.4)points,(79.9±3.8)points respectively]and the Lysholm scores[(76.1±3.9)points,(81.1±4.3)points,(82.8±3.2)points respectively]were significantly improved compared with those before operation[(48.6±3.7)points and(52.6±2.4)points](P<0.05).The IKDC 2000 subjective scores and Lysholm scores were significantly improved at 12 months after operation and at the last follow-up than those at 6 months after operation(P<0.05).There were no significant differences in the IKDC 2000 subjective scores and Lysholm scores at 12 months after operation and at the last follow-up(P>0.05).There were no complications such as wound infection,vascular and nerve injury,joint stiffness or ectopic ossification.Conclusion For Fanelli type C PLC injury,tibiofibular-based reconstruction technique with single femoral tunnel reduces the interference between the lateral femoral tunnels,significantly improves the varus and external rotation stability and the function of the knee joint,and has few complications and satisfactory short-term clinical efficacy.