穿骨原位缝合修复前交叉韧带技术在膝关节多发韧带损伤脱位中的应用

目的探讨膝关节多发韧带损伤脱位(multiple ligament injuries with knee dislocation,MLIKD)中采用穿骨原位缝合修复前交叉韧带(anterior cruciate ligament,ACL)止点撕脱损伤的方法及疗效。方法回顾分析2010年9月—2016年4月收治并符合选择标准的27例(27膝)MLIKD患者临床资料。其中男21例,女6例;年龄24~60岁,平均42岁。致伤原因:交通事故伤9例,重物砸伤9例,运动扭伤6例,高处坠落伤3例。受伤至手术时间1~19 d,平均10.8 d。ACL股骨止点撕脱损伤20例、胫骨止点撕脱损伤7例,后交叉韧带(posterior cruciate ligament,PCL)实质部损伤17例。根据Schenck分型标准:KD-Ⅲ-M型15例,KD-Ⅲ-L型8例,KD-Ⅳ型4例。患者前、后抽屉试验及Lachman试验均为阳性;内翻应力试验Ⅲ度阳性8例,外翻应力试验Ⅲ度阳性15例。膝关节Lysholm评分为(27.6±6.5)分,国际膝关节文献委员会(IKDC)评分为(25.5±6.2)分,膝关节活动度为(45.1±10.2)°。取患者自体腘绳肌腱单束重建PCL、联合有限切开原位双束牵引线穿骨原位缝合修复ACL止点撕脱损伤,同时修复内外侧副韧带、关节囊和其他损伤结构。结果术后切口均Ⅰ期愈合。3例发生关节腔积液,3例膝关节屈曲功能不全。患者均获随访,随访时间12~36个月,平均22个月。X线片复查示膝关节各方向稳定性良好。末次随访时,患者前、后抽屉试验均为阴性;Lachman试验Ⅰ度阳性4例、外翻应力试验Ⅰ度阳性3例、内翻应力试验Ⅰ度阳性1例,其余患者均为阴性。术后1年,膝关节活动度为(119.3±12.6)°,Lysholm评分为(87.2±6.3)分,IKDC评分为(87.9±6.3)分,与术前比较差异均有统计学意义(P<0.05)。结论早期关节镜下有限切开穿骨原位缝合修复ACL撕脱损伤,具有微创、固定牢固、并发症少等优点,能显著改善膝关节稳定性、活动度及功能,近期疗效满意。

Application of transosseous suture in situ technique in repair of anterior cruciate ligament for multiple ligament injuries with knee dislocation

Objective To investigate the method and effectiveness of transosseous suture in situ technique in repairing anterior cruciate ligament(ACL)avulsion injury for the multiple ligament injuries with knee dislocation(MLIKD).Methods The clinical data of 27 patients(27 knees)with MLIKD between September 2010 and April 2016 were analyzed retrospectively.There were 21 males and 6 females,with an average age of 42 years(range,24-60 years).The injury was caused by traffic accident in 9 cases,heavy-weight crushing in 9 cases,sports sprain in 6 cases,falling from height in 3 cases.The interval from injury to operation was 1-19 days(mean,10.8 days).There were 20 cases of femoral avulsion injury of ACL,7 cases of tibial avulsion injury of ACL,and there were 17 cases of posterior cruciate ligament(PCL)injuries.According to the Schenck classification,there were 15 cases of KD-Ⅲ-M type,8 cases of KD-Ⅲ-L type,and4 cases of KD-Ⅳtype.All patients were positive in the posterior drawer test and Lachman test;8 cases were degreeⅢpositive in varus stress test,and 15 cases were degreeⅢpositive in valgus stress test.The Lysholm score of knee was27.6±6.5,the International Knee Documentation Committee(IKDC)score was 25.5±6.2,and the range of motion(ROM)of knee was(45.1±10.2)°.The injured PCL was reconstructed with a single bundle of autologous hamstring tendon.ACL was repaired with double bundle traction by transosseous suture in situ technique.Medial cruciate ligament,lateral cruciate ligament,joint capsule,and other damaged structures were repaired at the same time.Results All incisions healed by first intention.There were 3 cases with joint effusion and 3 cases with incomplete flexion.All patients were followed up 12-36 months(mean,22 months).The X-ray films showed good stability in all directions.At last follow-up,the anterior and posterior drawer tests were all negative;Lachman test was degreeⅠpositive in 4 cases,valgus stress test was degreeⅠpositive in 3 cases,varus stress test was degreeⅠpositive in 1 case;and all tests were negative in the rest patients.At 1 year after operation,the ROM of knee was(119.3±12.6)°,Lysholm score was 87.2±6.3,and IKDC score was87.9±6.3,showing significant differences when compared with the preoperative scores(P<0.05).Conclusion Transosseous suture in situ technique can be used to repair the ACL avulsion injury for MLIKD,which can significantly improve the stability,mobility and function of the knee joint,and obtain satisfied short-term effectiveness.