联合半月板移植与前交叉韧带重建的关节镜手术技术及临床效果

目的 探讨全关节镜下联合半月板移植和前交叉韧带（ACL）重建的微创手术技术、围手术期处理及临床效果.方法 对8例膝关节半月板切除伴有ACL损伤的患者,同期实施关节镜下半月板移植与ACL重建微创手术.内侧半月板移植采用前后角骨栓固定方法,外侧半月板移植采用前后角骨桥固定方法.ACL重建术采用自体腘绳肌腱移植,股骨端内纽扣固定、胫骨端可吸收界面钉固定的方法.全部手术过程在关节镜下完成.膝关节功能采用Lysholm记分和IKDC分级评价.关节稳定性检查包括Lachman试验、抽屉试验和轴移试验.膝关节活动度通过测量双膝活动度的差值评价.平均随访20.4个月（5-42个月）.结果 本组病例没有因移植物失败需ACL翻修或取出移植半月板者.患侧膝关节屈曲度较健侧减少9°±6°,伸直度较健侧减少3°±2°.术前患膝Lachman试验Ⅱ°阳性2例,Ⅲ°阳性6例,抽屉试验Ⅱ°阳性3例,Ⅲ°阳性5例,所有患膝轴移试验阳性.术后患膝Lachman试验阴性6例,Ⅰ°和Ⅱ°阳性各1例.前抽屉试验阴性6例,Ⅰ°阳性2例.所有患膝轴移试验阴性.Lysholm记分在手术前后差异有统计学意义（P＜0.01）.IKDC分级正常和接近正常者所占比率在手术前后差异有统计学意义（P＜0.01）.术后随访MRI示ACL移植物位置适当,移植半月板1例前角和1例后角有Ⅱ°损伤信号影,其余半月板外形良好,有内部信号不均匀现象.结论 对适当选择的半月板切除伴有ACL损伤患者,联合半月板移植与ACL重建术可较好地恢复膝关节稳定性,改善功能.虽然其在全关节镜下的微创操作技术上有一定难度,但此术式是一个有实用价值的治疗方法 .

The arthroscopic technique and clinical efficacy of meniscus transplantation combined with anterior cruciate ligament reconstruction

Objective To investigate the minimally invasive technique, preoperative treatment, and the clinical efficacy of meniscus transplantation combined with anterior cruciate ligament （ACL） reconstruction with arthroscopy. Methods A total of 8 patients with their meniscus excised and ACL damaged underwent the one-stage minimally invasive surgery of meniscus transplantation combined with ACL reconstruction with arthroscopy. Of the fixation methods, bone bolt in anterior and posterier angles was applied for medial meniscal allograft transplantation, while the bone bridge in slot was for lateral meniscal allograft transplantation. The ACL reconstrcation was performed through autograft of hamstring tendon, endo-button fixation of femural end, and absorbable bone-screw interface fixation of tibial end. All surgical procedures were done with arthroscopy. The function of knee was assessed by the Lysholm score and IKDC rating scale. The stability of knee was evaluated by Lachman test, Drawer test, and Pivot Shift test. The range of motion of knee was evaluated by measuring the difference of both knees. The average follow-up was 20.4 months （range, 5-42m）. Results No involved patient needed ACL revision or meniscus allograft removal post-operatively, which were resulted from failed transplant. In comparison with the noninvolved knee, the average loss of flexion of the involved knee was 9°±6°, and the average loss of extension of the involved knee was 3°±2°. Preoperatively, the Lachman test results showed 2 cases with positive II, and 6 with positive III; the Drawer test results showed 3 with positive II, 5 with positive III, and all patients were found positive according to the Pivot Shift test. Postoperatively, according to the Lachman test 6 cases were found negative, 1 positive I, and 1 positive II; according to the Drawer test, 6 cases were found negative, an2 positive I; according to the Pivot Shift test, all were found negative. There were significant differences between per-operative and post-operative results in Lyshom score （P〈0.01）, and in the percentage of being normal or nearly normal according to IKDC rating scale （P〈0.01）. Of the post-operative follow-up MRI images, ACL autografts were located properly, but both 1 case in anterior angle of meniscal allograft and 1 case in posterior angle of meniscal allograft were found with 2 degree injury. The remaining meniscal allografts were in normal shape, with ununiformed internal signals. Conclusions For the properly selected patients with meniscus excised and ACL damaged, meniscus transplantation combined with ACL reconstruction can recover knee stability and improve knee function. Although the minimally invasive surgery with arthroscopy is difficult in technique, it is a practical treatment method.