游离腓骨长肌腱联合半腱肌腱单束解剖鞘内重建前十字韧带股骨端损伤

目的探讨应用游离腓骨长肌腱联合半腱肌腱单束解剖鞘内重建前十字韧带股骨端损伤的可行性及临床疗效。方法回顾性分析2015年1月至2016年9月于我院骨科运动医学治疗组收治的24例前十字韧带股骨端损伤患者资料,男19例,女5例,年龄(27.88±7.13)岁;受伤至手术时间为(14.83±9.09)d;右侧16例,左侧8例。24例均经关节镜手术证实,前十字韧带自股骨端完全断裂,胫骨侧残端保留完整。取伤侧游离腓骨长肌腱和半腱肌腱分别对折后编织修整成前十字韧带移植物备用;保留前十字韧带残端,移植物穿过残端内部进行单束解剖鞘内重建;前十字韧带移植物股骨侧应用Endobutton固定,胫骨侧应用界面螺钉固定。记录术前和末次随访的Lachman试验、Lysholm评分、Tegner评分和国际膝关节文献委员会(International Knee Documentation Committee,IKDC)膝关节功能主观评估表,进行膝关节稳定性评估和疗效评估;美国矫形外科足踝协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝-后足指数评分,评估切取腓骨长肌腱后足踝功能的影响。应用视觉模拟评分(visual analogue score,VAS)记录腓骨长肌腱取材部位疼痛的变化。结果24例随访时间(34.38±5.40)个月。游离腓骨长肌腱和半腱肌腱制备四股前十字韧带移植物直径(8.88±0.30)mm。术前Lachman试验中B级16例,C级6例,D级2例,无硬性终止点;末次随访A级23例,B级1例,均硬性终止点。术前膝关节Lysholm评分(35.20±11.92)分,末次随访(94.29±2.92)分,差异有统计学意义(t=23.850,P=0.000);术前Tegner评分(3.46±0.93)分,末次随访(8.04±1.00)分,差异有统计学意义(t=16.653,P=0.000);术前IKDC膝关节主观功能评分为(47.63±13.06)分,末次随访(91.71±3.75)分,差异有统计学意义(t=15.972,P=0.000)。术前及末次随访的足踝AOFAS踝-后足指数评分分别为(98.83±2.78)分和(98.17±4.01)分,差异无统计学意义(t=1.850,P=0.076)。术后即刻、术后6个月和终访时腓骨长肌腱取材处疼痛VAS评分为(4.50±1.41)分、(0.54±0.65)分和(0.29±0.55)分,前两者的差异有统计学意义(t=14.900,P=0.001);后两者的差异有统计学意义(t=2.770,P=0.011)。术后无前十字韧带再断裂和关节感染等严重并发症。结论游离腓骨长肌腱联合半腱肌腱单束解剖鞘内重建前十字韧带股骨端损伤具有可行性,可获得良好临床疗效。

Single bundle anatomic intrathecal reconstruction of proximal injury of anterior cruciate ligament with dissociate peroneus longus tendon and semitendinosus tendon

Objective To explore the feasibility and clinical effect of single bundle anatomic intrathecal reconstruction of proximal injury of anterior cruciate ligament(ACL)using dissociate peroneus longus tendon combined with semitendinosus tendon.Methods From January 2015 to September 2016,a total of 24 patients with proximal injury of ACL,confirmed by arthroscopy,were admitted to the sports medicine department of our hospital.The ACL was completely ruptured from the proximal footprint and the tibial side residual remained intact.There were 19 males and 5 females;16 cases on the right side and 8 cases on the left side.The mean age was 27.88±7.13 years old;The interval between injury and surgery was 14.83±9.09 d;The dissociate peroneus longus tendon and semitendinosus tendonfrom the injured extremity were folded in half,then braided and trimmed into ACL graft for use.The ACL remnant was preserved and the graft was pulled through the stump for single bundle anatomic intrathecal reconstruction.The ACL graft was fixed with Endobutton on the femoral side and interference screw on the tibial side.The results of Lachman test,Lysholm scores,Tegner scores and International Knee Documentation Committee(IKDC)subjective scores of knee before operation and at final visit were recorded to evaluate the stability and function of the knee.Visual analogue score(VAS)was used to record the changes of pain at the site where the peroneal longus tendon was harvested.The American Orthopaedic Foot and Ankle Society(AOFAS)Ankle-Hindfoot Scores were recorded before injury and at the final visit to assess the effect of ankle function after peroneal longus tendon resection.Results The diameter of the ACL graft made of dissociate peroneus longus tendon and semitendinosus tendon is 8.88±0.30 mm.All patients were followed up at the outpatient clinic,with an average of 34.38±5.40 months,and no serious complications such as rerupture and joint infection were found.There were 16 grade B,6 grade C and 2 grade D for preoperative Lachman test,none with hard end point.At last vist,there were 23 cases of grade A and 1 grade B,all with hard end points for Lachman test.At the preoperative and final visit,the Lysholm scores of the knee joint were 35.20±11.92 and 94.29±2.92(t=23.850,P=0.000).Tegner scores were 3.46±0.93 and 8.04±1.00(t=16.653,P=0.000).The subjective IKDC scores of knee joint were 47.63±13.06 and 91.71±3.75(t=15.972,P=0.000).At the final visit,all the indicators of the knee were improved compared with those before surgery,and the difference was statistically significant.The AOFAS scores before injury and at the final visit were 98.83(2.78)and 98.17(4.01),respectively,with no statistically significant difference(t=1.850,P=0.076).The VAS scores for the harvest of theperoneus longus tendon were 4.50±1.41,0.54±0.65 and 0.29±0.55 immediately and 6 months after the operation and at the last visit.There was statistically significant difference between the scores immediately and 6 months after the operation(t=14.900,P=0.001).There was statistically significant differences between the scores at 6 months after the operation and the final visit(t=2.770,P=0.011).Conclusion Single bundle anatomic intrathecal reconstruction of proximal injury of ACL using dissociate peroneus longus tendon and semitendinosus tendon is feasible with good clinical effect.