腓骨长肌腱重建前交叉韧带结合一期锚钉修复严重内侧副韧带损伤的早期疗效

【摘要】目的探讨腓骨长肌腱重建（anteriorcruciateligament，ACL）结合一期锚钉修复严重（medialcollateralligament，MCL）损伤的早期疗效。方法2008年12月至2012年10月，关节镜下自体同侧腓骨长肌腱和同种异体半腱肌腱重建急性ACL断裂合并III度MCL损伤38例。其中ACL用自体同侧腓骨长肌腱重建18例（A组），同种异体半腱肌腱重建20例（B组），MCL均用带线锚钉固定。术后伸直位支具制动后1周开始练习膝关节屈伸，屈曲角度由小到大，至术后6周至少达到120度。所有患者均进行术后6个月、术后1年客观指标检查，包括膝关节稳定性（KT一1000测量，134N前向拉力），Lachman试验，轴移试验，大腿周径差别，膝关节磁共振检查；并应用Tegner评分表，Lysholm评分表和IKDC膝关节功能评分表对患者运动功能进行主观评估。术前和术后分别进行足部16排CT扫描重建，测量足部横弓的宽度以及内、外纵弓的高度和顶角。将以上结果进行对比。结果术前Tegner评分，Lysholm评分尸值均〉0．05，差异无统计学意义。术后6个月Lachman试验检查A组16例（88．89％）阴性，2例（11．11％）Ⅰ度阳性，无Ⅱ度以上阳性；B组17例（85．00％）阴性，3例（15．00％）I度阳性，无Ⅱ度以上阳性。A组有1例轴移试验阳性，其余均为阴性；B组有1例轴移试验阳性，其余均为阴性。KT一1000在134N前向拉力下测量的双侧膝关节前向松弛度差异，A组：〈2mm者15例（83．33％），～5mm者3例（16．67％），无〉5mm者（0．00％）；B组：〈2mm者16例（80．00％），〉5mm者3例（15．00％），〉5mm者1例（5．00％）。双下肢周径差别A组为（1．06±0．86）cm，B组为（1．04±0．92）cm。Tegner评分A组为（6．00±0．46）分，B组为（6．00±0．57）分。Lysholm评分A组为（94．00±6．02）分，B组为（95．00±2．35）分。IKDC膝关节功能评分A组为（89．45±2．89）分，B组为（90．12±4．56）分。两组患者各指标间差异均无统计学意义（P〉0．05）。术后1年Lachman试验检查A组15例（83．33％）阴性，3例（16．67％）I度阳性，无Ⅱ度以上阳性；B组16例（80．00％）阴性，1例（5．00％）I度阳性，2例（10．00％）II度阳性。A组有2例轴移试验阳性，其余患者均为阴性；B组有2例轴移试验阳性，其余患者均为阴性。KT-1000在134N前向拉力下测量的双侧膝关节前向松弛度差异，A组：〈2mm者14例（77．78％），-5mm者4例（22．22％），无〉5mm者（0．00％）；B组：〈2mm者16例（80．00％），-5mm者3例（15．00％），〉5mm者1例（5．00％）mm。双下肢周径差别A组为（1．01±0．21）cm，B组为（1．03±0．12）cm。Tegner评分A组为（5．00±0．96）分，B组为（6．00±0．03）分。Lysholm评分A组为（94．00±6．67）分，B组为（95．00±3．55）分。IKDC膝关节功能评分A组为（90．48±2．36）分，B组为（90．17±4．32）分。两组患者各指标间差异均无统计学意义（P〉0．05）。术后经过平均18个月的随访，16排CT测量结果显示手术前后足部横弓的宽度以及内、外纵弓的高度和顶角无显著性差异。结论急性ACL断裂合并III度MCL损伤时，应用自体同侧腓骨长肌腱和同种异体半腱肌腱重建ACL结合一期锚钉修复III度MCL损伤，均能取得优良的早期疗效，两者的差异无统计学意义。自体同侧腓骨长肌腱是合并III度MCL损伤时前交叉韧带断裂重建可选择的良好移植物，同时行一期带线锚钉修复MCL损伤的早期疗效可靠。

Early curative effects of anterior cruciate ligament reconstruction with the peroneus longus tendon combined with one-stage repair of severe medial collateral ligament injury using suture anchors

Objective To investigate the early curative effects of anterior cruciate ligament （ ACL ） reconstruction with the peroneus longus tendon combined with one-stage repair of severe medial collateral ligament （ MCL ） injury using suture anchors. Methods From December 2008 to October 2012, a total of 38 patients with acute ACL tears and grade III MCL injuries underwent arthroscopic reconstruction with the ipsilateral autologous peroneus longus tendon and the semitendinosus allograft. There were 18 cases of ACL reconstruction with the ipsilateral autologous peroneus longus tendon （ group A ） and 20 cases with the semitendinosus allograft （ group B ）. The suture anchors were used in all cases of MCL injuries. After the postoperative brace immobilization in the straight position for 1 week, the patients began the practice of knee flexion and extension. The flexion angle was gradually increased, and 6 weeks after the operation it reached more than 120 degrees. All patients were examined in the following objective indexes at 6 and 12 months after the operation respectively, including the stability of the knee （ KT-1000, 134 N forward tension ）, Lachman test, pivot shift test, thigh circumference difference and knee Magnetic Resonance Imaging （ MRI ）. Subjective evaluation of the motor functions in the patients was performed using the Tegner scale, Lysholm scale and International Knee Documentation Committee （ IKDC ） knee function scale. Reconstruction was performed in the foot with a 16-slice CT scanner preoperatively and postoperatively. The width of the transverse arch of the foot and the height and apex angel of the inner and outer longitudinal arches were measured. The above results were compared. Results Based on the preoperative Tegner scores and Lysholm scores, P values were more than 0.05 and the differences were not statistically significant. The Lachman test was negative in 16 cases （ 88.89% ） in the 6th months after the operation and I positive in 2 cases （ 11.11% ） in group A, with no positive cases of more than II degrees. It was negative in 17 cases （ 85.00% ） and I positive in 3 cases （ 15.00% ） in group B, with no positive cases of more than II degrees. The pivot shift test was positive in 1 case in group A, and negative in all the other cases. It was positive in 1 case in group B, and negative in all the other cases. The KT-1000 examination with the forward tension of 134 N showed that the side to side difference of anterior laxity was less than 2 mm in 15 cases （ 88.33% ） and -5 mm in 3 cases （ 16.67% ） in group A, with no cases of more than 5 mm（ 0.00% ）. It was less than 2 mm in 16 cases （ 80.00% ）, -5 mm in 3 cases （ 15.00% ） and more than 5 mm in 1 case （ 5.00% ） in group B. The circumference differences of both lower limbs were （ 1.06~0.86 ） cm in group A and （ 1.04＋0.92 ） cm in group B. The Tegner scores were （ 6.00＋0.46 ） points in group A and （ 6.004-0.57 ） points in group B. The Lysholm scores were （ 94.004-6.02 ） points in group A and （ 95.004-2.35 ） points in group B. The IKDC knee function scores were （ 89.454-2.89 ） points in group A and （ 90.124-4.56 ） points in group B. The differences in each index between the 2 groups were not statistically significant （ P〉0.05 ）. At 1 year after the operation, the Lachman test was negative in 15 cases （ 83.33% ） and I positive in 3 cases （ 16.67% ） in group A, with no positive cases of more than II degrees. It was negative in 16 cases （ 80.00% ）, I positive in 1 case （ 5.00% ） and II positive in 2 cases （ 10.00% ） in group B. The pivot shift test was positive in 2 cases in group A, and negative in all the other cases. It was positive in 2 cases in group B, and negative in all the other cases. The KT-1000 examination with the forward tension of 134N showed that the side to side difference of anterior laxity was less than 2 mm in 14 cases （ 77.78% ） and -5 mm in 4 cases （ 22.22% ） in group A, with no cases of more than 5 mm （ 0.00% ）. It was less than 2 mm in 16 cases （ 80.00% ）, -5 mm in 3 cases （ 15.00% ） and more than 5 mm in 1 case （ 5.00% ） in group B. The circumference differences of both lower limbs were （ 1.014-0.21 ） cm in group A and （ 1.034-0.12 ） cm in group B. The Tegner scores were （ 5.004-0.96 ） points in group A and （ 6.00-4-0.03 ） points in group B. The Lysholm scores were （ 94.004-6.67 ） points in group A and （ 95.004- 3.55 ） points in group B. The IKDC knee function scores were （ 90.484-2.36 ） points in group A and （ 90.174-4.32 ） points in group B. The differences in each index between the 2 groups were not statistically significant （ P〉0.05 ）. After a mean follow-up of 18 months, the measurement results by the 16-slice CT scanner showed that there were not statistically significant differences in the width of the transverse arch and the height and apex angel of the inner and outer longitudinal arches of the foot before and after the operation. Conclusions For the patients with acute ACL tears and grade III MCL injuries, satisfactory early results can be obtained after the ACL reconstruction with the ipsilateral autologous peroneus longus tendon and the semitendinosus allograft combined with the one-stage repair of MCL injury using suture anchors are performed. There are no statistically significant differences between them. The ipsilateral autologous peroneus longus tendon may be a good choice in the ACL reconstruction when grade III MCL injury occur. The early results are good at the same time with the one-stage repair of MCL injuries using suture anchors.