前交叉韧带重建失败的原因分析

目的 探讨前交叉韧带（ACL）重建失败后行翻修手术的主要原因以指导临床。方法 回顾性分析2001年11月至2006年7月收治的因ACL重建失败需要行翻修术的13例患者的临床资料，其中男性9例，女性4例，年龄16～46岁，平均29岁。结合临床病例研究分析ACL重建失败的原因。结果 本组13例患者中，初次手术选用自体骨-髌腱-骨移植物（B-PT-B）7例，自体半腱股薄肌腱（STG）4例，同种异体STG2例。翻修原因上、下两端骨道均偏前4例，单独上骨道偏前4例；同种异体STG重建出现明显排异反应取出移植物1例，骨道明显扩大而失败1例；自体B-PT-B重建固定上骨道内骨块的挤压螺钉位置异常2例；术后感染1例。翻修术中重建的ACL完全断裂和吸收7例，韧带有部分连接但已明显松弛失张力4例，内固定物位置异常2例。行膝关节粘连松解手术1例；因骨道骨质缺损严重而行一期植骨术，准备二期翻修2例；其余10例均行一期翻修手术，其中用同侧STG4例、对侧STG4例、同侧B—PT-B1例、髂胫束1例。结论 前交叉韧带重建手术失败的原因较多，但主要与手术骨道位置异常、固定失效、同种异体腱的排异反应与骨道扩大以及感染和术后粘连等有关。

Factors leading to failure of anterior cruciate ligament reconstruction

OBJECTIVE: To analyze the factors contributing to the failure of primary anterior cruciate ligament (ACL) reconstruction. METHODS: From November 2001 to July 2006, 13 patients underwent ACL reconstruction revision because of pathological instability in daily activities after primary ACL reconstruction, and the data of the patients were retrospectively analyzed. RESULTS: In this group, 7 cases were reconstructed with bone-patellar tendon-bone (B-PT-B) autografts, 4 cases with hamstring tendon autograft and 2 cases with hamstring tendon allograft. There were malpositioned bone tunnels in 8 cases. Among them 4 cases had a femoral tunnel in the front of the predicted one, and in the other 4 cases, both the femoral and tibial tunnels were in the front of the predicted ones. In 2 cases reconstructed with allograft, one had to receive a twice operation to take out the allograft because of serious rejection, and the other claimed a failure because of the obviously enlarged bone tunnel. In the 2 cases reconstructed with B-PT-B autograft, malposition of the interference screw using to fasten the bone block had been founded in the upper bone tunnel. One case suffered from postoperative infection and had been cured by the anti-biotic treatment after arthroscopic debridement. Then the reconstructed ACL in 7 cases had absolutely ruptured and been absorbed. Four cases had obviously loosen but still partly linked reconstructed ligament. Two cases had a malposited interference screw, and both of them had no fastening function. One case received the lytic operation due to knee stiffness. Two cases received primary bone transplantation and needed to receive a secondary revision operation owing to severe incompletion of spongy bone. The other 10 cases received primary revision. Among them 4 cases reconstructed with STG obtained from the same lateral, 4 cases reconstructed with STG obtained from the opposite lateral, 1 case reconstructed with B-PT-B obtained from the same lateral and 1 case reconstructed with iliotibiali tractus. CONCLUSIONS: There are many reasons leading to failure of ACL reconstruction. Nevertheless, malposition of the bone tunnel, invalid fixation, rejection to allograft and other complications such as the enlargement of the bone tunnel, postoperative infection and adhesion are the major factors that predispose the primary construction to failure.