前交叉韧带重建术保留残端韧带的方法及意义

目的探讨保留残端韧带进行前交叉韧带重建的方法及意义。方法2005年6月至2011年6月，我院共收治前交叉韧带损伤178例，其中运动伤63例，军事训练伤61例，交通伤54例；部分断裂35例，韧带松弛16例。男119例，女59例，年龄为17～46岁，平均28岁。所有病例经关节镜检查证实，其中前交叉韧带完全断裂127例，部分束支断裂35例，韧带松弛16例。前交叉韧带胫骨定位器定位于原前交叉韧带胫骨附着残迹的中心点偏内、偏后，即外侧半月板前角游离缘的延长线、胫骨内棘前方2mm，关节外定位于胫骨结节内侧2cm，胫骨骨道定位器标定45°方向，钻入导针，根据移植肌腱的直径选择相应的胫骨钻头，沿导针钻孔建立胫骨隧道。膝关节屈曲90°，通过胫骨隧道放置合适股骨隧道定位器，于右膝10～11点左膝1～2点位置打入导针，选择与移植肌腱直径相同的钻头钻取股骨隧道，深度为3cm。前交叉韧带完全断裂者不对胫骨端或股骨端的残端进行清理，移植的肌腱穿过胫骨或股骨残端，残余韧带似套袖样包裹于重建韧带的表面。前交叉韧带单束支损伤者除了保留断裂束支的残端外，对因受损而出现松弛的另一束支也予以保留。对于前交叉韧带明显松弛者，将移植的肌腱穿过松弛韧带胫骨或股骨附着点附近，使移植的肌腱与原韧带重叠或缠绕。股骨端采用Rigidfix固定，胫骨端采用Intrafix固定。术后采用Lysholm膝关节功能评分对手术效果进行评价。结果所有患者术后均随访12～24个月，平均19个月。术后膝关节稳定性增强，Lysholm膝关节功能评分：术前平均（68.6±5.1）分，其中完全断裂组（67.4±6.2）分，部分束支断裂组（71.1±4.6）分，韧带松弛组（72.7±4.1）分；术后平均（94.9±0.9）分，其中完全断裂组（94.6±5.5）分，部分束支断裂组（95.3±3.8）分，韧带松弛组（96.4±4.2）分。术后较术前平均提高26.3分。对手术前后Lysholm膝关节功能评分进行统计学分析，结果有统计学意义（P＝0.0000）。结论保留残端重建前交叉韧带，有助于移植肌腱再血管化、本体感觉的建立和减少关节液渗入骨隧道，有利于维持膝关节的稳定性，从而获得满意的临床疗效。

Technique and significance of anterior cruciate ligament reconstruction with ligament remnants preserved

Objective To investigate the technique and signiifcance of anterior cruciate ligament （ ACL ） reconstruction with ligament remnants preserved. Methods From 2006 to 2009 a total of ACL injuries in 178 patients, which included 119 males and 59 females with an average age of 28 years old （ ranged, 17 to 46 ） were treated at our institution. The ACL injuries including complete disruption of ACL in 127 cases, partial disruption of ACL in 35 cases and laxity of ligament in 16 cases were conifrmed by arthroscopy. The ACL tibial aimer was in a medial and posterior position from the center of the remnants attached to the original ACL tibia. The tibial tunnel aimer was set at an angel of 45°, and the tibial tunnel was created by the guide pin. The suitable femoral tunnel aimer was placed through the tibial tunnel at 90° knee lfexion. The guide pin was drilled to a depth of 3 cm at the 10 to 11 o’clock position in the right knee and the 1 to 2 o’clock position in the left knee. The tibial or femoral remnants of ACL with complete disruption were not removed, and the tendon graft was pulled through the tibial or femoral remnants. The reconstructed ligaments were wrapped by the ligament remnants in a sleeve-like fashion. As to the ACL with a single bundle branch injured, the remnants of the ruptured bundle branch were preserved, and the other impaired and lax bundle branch should also be retained. For the obviously lax ACL, the tendon graft was pulled through the tibial or femoral attachment points with lax ligaments, which was then overlapped and twisted with the original ligament. Tendons were ifxed by the Rigidifx system at femoral extremities and the Intraifx system at tibial extremities. The Lysholm knee rating score was used to assess the surgical results after the surgery. Results All patients were followed up for a mean period of 19 months （ range;12-24 months ）, and the stability of the knee joints was increased postoperatively. The Lysholm knee score was increased from （ 68.6±5.1 ） points preoperatively （ complete disruption：67.4±6.2, partial disruption：71.1±4.6, laxity of ligament：72.7±4.1 ） to （ 94.9±0.9 ） points postoperatively （ complete disruption：94.6±5.5, partial disruption：95.3±3.8, laxity of ligament：96.4±4.2 ） on average, with a growth of 26.3 points. A statistical analysis was done for the preoperative and postoperative Lysholm knee scores, and the results were statistically signiifcant （ P=0.0000〈0.05 ）. Conclusions ACL reconstruction with remnants preserved is conducive to the revascularization of the tendon graft, recovery of the proprioceptive sense, decrease of the amount of the synovial lfuid penetrating into the bone tunnel and the stability of the knee joint, so as to achieve satisfactory outcomes.