基于后十字韧带的膝关节多发韧带损伤两种重建技术的对比研究

目的 比较采用关节镜下经胫骨隧道技术和切开胫骨镶嵌骨块技术重建基于后十字韧带的多发韧带损伤患者术后的后向稳定性和临床疗效.方法 自2005年4月至2009年12月,共连续完成基于后十字韧带的多发韧带损伤重建修复手术135例,2年以上随访者88例.后十字韧带采用关节镜下经胫骨隧道技术重建57例(64.8％),切开镶嵌骨块技术重建31例(35.2％),合并损伤予同期重建或修复.随访时间平均(45.9±17.0)个月(24～77个月).采用KT-1000和Telos应力装置测量手术前后膝关节后向稳定性.采用Tegner、Lysholm、AAOS评分评价临床疗效.结果 两组患者的性别、年龄、受伤至手术时间、合并损伤和主观评分比较,差异均无统计学意义.经胫骨隧道组术前KT-1000两侧差值为(13.5±4.8) mm,术后为(2.4±3.4)mm;术前Telos两侧差值为(14.9±7.1) mm,术后为(4.6±4.0) mm.切开胫骨镶嵌骨块组术前KT-1000两侧差值为(13.7±5.2) mm,术后为(2.2±3.6)mm;术前Telos两侧差值为(14.9±5.9) mm,术后为(4.3±3.9) mm.两组患者KT-1000和Telos两侧差值手术前后组内比较差异均有统计学意义,而组间比较差异均无统计学意义.两组患者术后Tegner、Lysholm、AAOS评分的差异均无统计学意义.结论 采用两种技术重建基于后十字韧带的多发韧带损伤,两组患者术后的后向稳定性及功能评分差异均无统计学意义,且均可明显恢复膝关节后向稳定性.     

巨大肩袖损伤的手术修复结果

Objective To evaluate the clinical results of arthroscopic repair of massive rotator cuff tear. Methods The study involved 16 patients with massive rotator cuff tears treated arthroscopically from September 2007 to June 2009. There were 6 males and 11 females at average age 61.5 years (45-75 years). The rotator cuff tears was repaired with arthroscopic double-row reconstruction. The range of motion, pain, strength of flexed elevation and function evaluation score were all recorded before operation and at final follow-up. The results were evaluated by t test and compared according to age and course of disease. Results All patients were healed without complications and the outcome was improved significantly ( P < 0.01 ). The mean VAS score was improved from preoperative 5.6 to postoperative 1.7,the average forward flexion from 69. 1°to 151.2°, the average external rotation from 14.7° to 32.2°, and internal rotation from L1 level to T10, the mean Constant-Murle from 39 to 85, the mean UCLA from 10.4 to 28, the mean SST from 2.8 to 8.8 and the strength of flexed elevation from 10.7% of normal side to 65.0%. Compared with preoperation, there was statistical difference in aspects of pain, range of motion, muscle strength and function in postoperation (P < 0.01 ). Conclusion Arthroscopic doublerow fixation can attain satisfactory results in repair of massive rotator cuff tear.     

膝关节置换术后感染病原菌分布及耐药性分析

目的探讨膝关节置换术后关节腔感染的病原菌、耐药性以及影响患者预后的危险因素,以降低感染率。方法对医院收治的膝关节置换术后感染的98例患者作为试验组,选择同期未发生感染的200例患者作为对照组,并对感染患者的病原菌、耐药性及危险因素进行分析。结果分离出病原菌131株,其中革兰阴性菌占45.04%、革兰阳性菌占46.56%、真菌占8.40%;革兰阴性菌对亚胺培南、头孢哌酮/舒巴坦、美罗培南等耐药率<10.0%;金黄色葡萄球菌和凝固酶阴性葡萄球菌对万古霉素的耐药率分别为10.71%、6.25%;备皮时间、术后引流、年龄、异体输血、住院时间、白蛋白含量、尿管滞留时间等是导致患者发生感染的独立危险因素。结论对于膝关节置换术患者发生感染时应及时进行病原学分析,并选择合理抗菌药物进行治疗,以提高患者预后。     

腘肌腱与腘腓韧带重建对控制膝关节外旋不稳定的作用

 目的 探讨腘肌腱与腘腓韧带重建对控制膝关节外旋不稳定的作用。方法 取6个非配对下肢标本,分别对腘肌腱和腘腓韧带进行选择性切断和重建。在屈膝0°、30°、45°、60°、90°和120°时向胫骨施加5 N?m的外旋力矩,使用导航系统测量完整状态、不同切断状态和不同重建状态下胫骨相对股骨的外旋角度。结果 单纯切断腘腓韧带导致屈膝30°到屈膝120°时胫骨外旋增加2.1°±0.7°(2.0°~2.3°),单纯切断腘肌腱导致屈膝30°到屈膝120°时胫骨外旋增加1.3°±1.2°(0.5°~2.0°),两组比较差异无统计学意义;同时切断腘肌腱与腘腓韧带导致胫骨外旋增加4.1°±1.6°(2.8°~5.0°),与单纯切断腘腓韧带及单纯切断腘肌腱比较差异有统计学意义。腘肌腱重建或腘肌腱+腘腓韧带联合重建后,从屈膝30°到屈膝90°胫骨外旋角度与完整膝关节及腘腓韧带重建比较差异有统计学意义。结论 对于外侧副韧带完整的膝关节后外复合体损伤,腘肌腱和腘腓韧带作为一个整体发挥着控制膝关节外旋稳定性的作用。三种重建技术均能恢复膝关节的外旋稳定性,腘腓韧带重建与膝关节正常状态无异,而包含腘肌腱的重建技术会造成外旋受限。     

外侧沟通过试验诊断膝关节后外旋转不稳定的可靠性研究

目的 检验关节镜下外侧沟通过(LGDT)试验诊断膝关节后外旋转不稳定的可靠性.方法 前瞻性选取2009年10月至2012年2月由同一手术医生完成的关节镜手术的连续病例,排除存在双侧膝关节后外复合体损伤、膝关节僵硬、膝关节内侧副韧带损伤及多发韧带松弛的患者.共有115例患者符合入选标准,其中病例组35例,对照组80例.对所有入选患者在手术前麻醉下进行外旋拨号试验作为诊断外旋不稳定的金标准,在手术中进行LGDT试验记录阳性或阴性结果.在病例组中,使用x2检验比较不同损伤类型的LGDT试验阳性率,并使用Logistic回归分析,检验外旋不稳定程度与LGDT试验阳性率的相关性.结果 LGDT试验的敏感度为91.4％,特异度为93.8％,ROC曲线下面积为0.913.急性损伤和陈旧损伤患者的LGDT试验阳性率分别为9/10和92.0％(x2=0.036,P=0.849);腘肌腱股骨侧撕脱伤病例和腘肌腱其他部位损伤病例LGDT试验阳性率分别为100％和87.0％(x2=1.712,P=0.536);单纯外旋不稳定和外旋合并内翻不稳定的LGDT阳性率分别为90.5％和13/14(x2=0.062,P =0.805).LGDT试验的敏感度与胫骨外旋角度增加具有相关性(r =1.000,P=0.011).结论 LGDT试验是一种诊断膝关节后外旋转不稳定的可靠方法,对于诊断腘肌腱股骨侧撕脱的病例敏感度高于其他损伤类型.LGDT试验的敏感度与后外旋转不稳定的程度相关.     

关节镜下治疗肩袖损伤合并肱二头肌长头腱病变的临床随访研究

目的 评估经皮关节内肌腱固定技术在关节镜下肩袖损伤重建患者中,治疗合并肱二头肌长头腱损伤的临床效果.方法 2006年3月-2008年3月,对30例肩袖损伤合并肱二头肌长头腱损伤的患者,采用经皮关节内肌腱固定技术进行肌腱固定治疗.按照肩关节ASKS评分、Constant-Murley评分和YAS疼痛评分,并对肱二头肌肌力、外观进行评估.结果 术后随访时间平均为23个月(12～37个月).30例肩关节ASKS评分术前平均为43.8分,术后平均为94.7分;Constant-Murley评分术前平均为52.8分,术后平均为94.1分;VAS疼痛评分术前平均为5.5分,术后平均为0.6分;三种评分术前和术后差异均有统计学意义(P<0.01).术后均未出现Popeye畸形和二头肌痉挛症状,屈肘肌力测量患侧与健侧基本相同,差异无统计学意义.29例对手术效果满意.结论 经皮关节内肌腱固定技术是治疗肱二头肌长头腱损伤的有效方法,术后肩关节功能和疼痛改善明显,可以较好地维持肱二头肌的肌力并且避免肱二头肌出现肌腹膨隆畸形.     

早期和延期关节镜修复急性膝关节脱位韧带损伤的疗效分析

目的探讨早期和延期关节镜修复手术对急性膝关节脱位的疗效的影响。方法对2009年1月至2012年1月在该院就诊的42例急性膝关节脱位患者进行回顾性分析,按照手术方法分为早期组和延期组。早期组在2~3周内行关节镜修复术,延期组在3周后行关节镜修复术。对两组患者术后疗效和关节稳定性进行随访。结果早期组双股部周径差优于延期组,差异有统计学意义(P<0.05)。两组关节活动度、Lysholm评分、Irgang评分和Larson评分差异无统计学意义(P>0.05)。早期组胫骨前后移动距离不高于5mm的比例为72.7%(16/22),延期组胫骨前后移动距离不高于5mm的比例为55.0%(11/20),两组比较差异无统计学意义(P>0.05)。早期组查体伸膝和屈膝检查结果和延期组差异无统计学意义(P>0.05)。结论急性膝关节脱位可以通过早期手术在关节镜下修复和重建韧带,不会增加术后关节僵硬的风险。     

Hill-Sachs Remplissage手术治疗骨缺损性复发性肩关节前脱位

目的 探讨关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术治疗存在明显骨缺损的复发性肩关节前脱位的疗效.方法 回顾性分析随访2年以上的应用关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术治疗的复发性肩关节前脱位49例患者的病例资料,男42例,女7例;接受手术时年龄16.7～54.7岁,平均28.4岁.49例均为单向不稳定,合并明显的肩盂骨性损伤及巨大的Hill-Sachs损伤.术中采用金属缝合锚钉行Bankart修补,辅助后方冈下肌腱固定填充Hill-Sachs损伤.全部病例随访24～35个月,平均29.0个月,随访时采用ASES评分、Constant-Murley评分、Rowe评分进行功能评估,观察肩关节活动度变化.结果 术前及终末随访时肩关节平均前屈上举162.9°±17.1°和170.9°±7.4°(P=0.007),平均体侧外旋56.0°±17.6°和54.1°±17.1°(P=0.511);ASES评分为(84.7±11.3)分和(96.0±3.4)分(P=0.000),Constant-Murley评分为(93.3±8.7)分和(97.8±3.6)分(P=0.005),Rowe评分为(36.8±8.5)分和(89.8±12.5)分(P=0.000).终末随访时1例患者出现复发脱位,3例患者出现半脱位,失效率8.2%(4/49).此4例患者恐惧试验阳性.结论 肩关节镜下Bankart重建术辅助Hill-Sachs Remplissage手术是治疗存在明显骨缺损的复发性肩关节前脱位的有效方法之一.手术适应证的正确选择、熟练的关节镜下操作技术以及术后长期、严格的功能康复锻炼是手术成功的关键.

Abstract：

Objective The purpose of our study was to report the results of using arthroscopic Remplissage and Bankart repair in patients who had an engaging Hill-Sachs lesion with significant glenoid bone loss. Methods We retrospectively reviewed 49 consecutive patients who underwent arthroscopic Remplissage and Bankart repair for anterior shoulder instability with a mean duration of follow-up of 29.0 months (24-35 months). At the time of surgery the mean age of 42 men and 7 women was 28.4 years. All patients were diagnosed as recurrent anterior shoulder dislocation with a bony lesion of glenoid and an engaging HillSachs lesion. An arthroscopic Remplissage and Bankart repair using metal anchor was performed in all cases.ASES score, Constant-Murley score and Rowe score were used to evaluate the stability and the function of the shoulder. Results Patients' active forward elevation significantly(P=0.007) improved from 162.9°±17.1°preoperatively to 170.9°±7.4° at final follow-up. The external rotation was 56.0°±17.6° before the surgery compared with the 54.1°±17.1° postoperatively(P=0.511 ). The ASES score, Constant-Murley score and Rowe score was 84.7±11.3, 93.3±8.7 and 36.8±8.5 preoperatively compared with 96.0±3.4, 97.8±3.6 and 89.8±12.5 postoperatively. Significant difference could be found with regard to ASES score (P=0.000), ConstantMurley score (P=0.005) and Rowe score (P=0.000). One redislocation happened and a subluxation was noticed in three patients (8.3%). Conclusion Arthroscopic Remplissage combined with Bankart repair can achieve satisfactory for recurrent anterior shoulder dislocation accompany with engaging Hill-Sachs lesion.     

巨大肩袖损伤的手术修复结果

目的 探讨关节镜治疗巨大肩袖损伤的临床效果及影响因素.方法自2007年9月至2009年6月接受手术治疗的巨大肩袖损伤患者16例,男6例,女10例;平均年龄61.5岁.采取关节镜下双排重建对损伤肩袖进行修复.记录术前及最终随访时的疼痛、活动范围、前屈上举的肌肉力量以及功能评分,进行配对t检验;并按不同年龄、病程进行分组,进行统计学分析.结果 所有患者均顺利愈合,术前疼痛视觉模拟评分(visual analogue score,VAS)为5.6,前屈上举为69.1°,外旋为14.7°,内旋达L1水平,Constant-Murley评分为39,加州大学洛杉矾分校评分(UCLA)为10.4,肩关节简单评分(SST)为2.8,前屈上举的肌力相当于健侧的10.7%.术后VAS为1.7,前屈上举为151.2°,外旋为32.2°,内旋达T10水平,Constant-Murley评分为85.6,UCLA为28,SST为8.8,前屈上举的肌力为健侧的65.0%.术后与术前在疼痛、活动范围、肌力及功能方面差异均有统计学意义(P<0.01).不同性别和不同病程在手术前后的差异均无统计学意义.结论通过关节镜手术对损伤的肩袖进行双排重建可获得较为满意的临床治疗结果.

Abstract：

Objective To evaluate the clinical results of arthroscopic repair of massive rotator cuff tear. Methods The study involved 16 patients with massive rotator cuff tears treated arthroscopically from September 2007 to June 2009. There were 6 males and 11 females at average age 61.5 years (45-75 years). The rotator cuff tears was repaired with arthroscopic double-row reconstruction. The range of motion, pain, strength of flexed elevation and function evaluation score were all recorded before operation and at final follow-up. The results were evaluated by t test and compared according to age and course of disease. Results All patients were healed without complications and the outcome was improved significantly ( P < 0.01 ). The mean VAS score was improved from preoperative 5.6 to postoperative 1.7,the average forward flexion from 69. 1°to 151.2°, the average external rotation from 14.7° to 32.2°, and internal rotation from L1 level to T10, the mean Constant-Murle from 39 to 85, the mean UCLA from 10.4 to 28, the mean SST from 2.8 to 8.8 and the strength of flexed elevation from 10.7% of normal side to 65.0%. Compared with preoperation, there was statistical difference in aspects of pain, range of motion, muscle strength and function in postoperation (P < 0.01 ). Conclusion Arthroscopic doublerow fixation can attain satisfactory results in repair of massive rotator cuff tear.