关节镜辅助一期自体肌腱重建KD-Ⅲ-MC型多发韧带损伤临床观察

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摘要目的评估关节镜辅助一期自体肌腱重建KD-Ⅲ-MC型多发韧带损伤的临床疗效，为膝关节多发韧带损伤的治疗提供数据支持。方法我们选取甘肃中医药大学第一附属医院关节骨二科2015年7月至2018年7月，依据华西-膝关节脱位多发韧带损伤分期分型诊治体系标准收治符合KD-Ⅲ-MC型的患者32例，男24例，女8例；年龄16～70岁，平均(35.42±7.86)岁。致伤原因：交通事故伤14例，扭伤8例，砸伤6例，高处坠落伤4例。损伤至手术时间14～21 d，平均(16.25±2.87)d。所有患者国际膝关节文献委员会(international knee documentation committee，IKDC)评分均为D级，手术前、后抽屉试验均≥Ⅱ度，Lachman试验均为Ⅲ度，终末点消失，内侧副韧带(medial collateral ligament，MCL)损伤采用美国医学会三度分类法均为Ⅱ度以上。Tilos应力位X线检查提示：前向应力胫骨前移(8.15±3.46)mm、后向应力胫骨后移(12.51±3.98)mm、外翻应力内侧间隙(8.46±3.91)mm。术中均一期关节镜下取同侧自体肌腱进行前、后交叉韧带单束重建，内侧结构均采用带线锚钉固定加强缝合、关节囊紧缩必要时内侧解剖型自体肌腱修复。结果术后所有患者切口均一期愈合，无感染；深静脉血栓1例。所有患者均获得随访，随访时间12～18个月，平均(14.18±2.45)个月。末次随访所有患者前、后抽屉试验及Lachman试验转阴，2例患者MCL损伤分级Ⅱ度，1例膝关节僵硬。IKDC综合评分：A级10例，B级16例，C级6例；与术前比较，差异有统计学意义(P＜0.05)。同时将KD-Ⅲ-MC型中不同损伤类型的患者进行统计分组，观察相应时间段的Lysholm功能评分，结果发现术后末次膝关节Lysholm评分较术前相比差异有统计学意义(P＜0.05)。术前各种损伤类型组间比较，差异无统计学意义(P＞0.05)，术后末次随访软骨损伤组膝关节Lysholm功能评分低于其他组，说明韧带损伤组恢复欠佳与关节软骨损伤有一定关系。各组患膝术后3个月Lysholm评分均有明显的提高，差异相对较大，术后6个月、12个月相比术后3个月差异较小。结论在KD-Ⅲ-MC型多发韧带损伤中，一期关节镜下取自体肌腱单束解剖重建前交叉韧带(anterior cruciate ligament，ACL)、后交叉韧带(posterior cruciate ligament，PCL)，带线锚钉固定加强缝合、关节囊紧缩内侧解剖型自体肌腱分步重建固定可获得良好的近期疗效。

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	李帅 1
	李玉吉 2*
	常旭东 2
	于瑞霞 3

关键词 ：膝关节脱位, 关节镜, 自体肌腱, KD-Ⅲ-MC型

Abstract：Objective To evaluate the clinic outcome of KD-Ⅲ-MC multiple ligament injuries by using arthroscope assisting the with first period reconstruction of ligament and provide data aid for the treatment of multiple ligament of knee-joint.Methods According to the standard of Hua Xi Knee Dislocation and Multiple Ligament，32 KD-Ⅲ-MC examples were selected from in the Second Joint Department of 1st hospital of Gansu TCM Univ.from July 2015 to July 2018，which included 24 males and 8 females，with an average age of (35.42±7.86)years.The causes of injury were 14 cases of traffic accidents，8 cases of sprains，6 cases of smashing injuries，and 4 cases of fall injuries.The time from injury to operation was 14~21 days，with an average of (16.25±2.87) days.All patients had an international knee documentation committee (IKDC) score of grade D.The pre and post-drawer tests were ≥Ⅱ degrees，the Lachman test was Ⅲ degrees，the end point disappeared，and the medial collateral Ligament (MCL) injuries were classified as Grade Ⅱ or higher using the American Medical Association’s three-degree classification.X-ray examination of the Tilos stress site showed：forward stress tibial advance (8.15±3.46) mm，backward stress tibial advance (12.51±3.98) mm，and medial valgus stress medial gap (8.46±3.91) mm.Unilateral autologous tendons were taken under arthroscopy for single-beam reconstruction of the anterior and posterior cruciate ligaments during the same period of surgery.The medial structures were fixed with suture anchors and the capsular contraction was repaired if necessary.Results The incisions of all patients healed in one stage without infection；one case had deep vein thrombosis.All patients were followed up for 12 to 18 months，with an average of (14.18±2.45) months.At the last follow-up，all patients turned negative before and after the drawer test and Lachman test.Two patients had grade Ⅱ MCL injury and one had stiff knee.According to IKDC comprehensive score，there were 10 cases of grade A，16 cases of grade B，6 cases of grade C.Compared with preoperative，the difference was statistically significant (P＜0.05).At the same time，patients with different injury types in the KD-Ⅲ-MC type were statistically grouped，and the Lysholm function score of the corresponding period was observed.As a result，the last knee Lysholm score was significantly different from that before surgery (P＜0.05).There was no significant difference between the various types of injury before surgery (P＞0.05).The Lysholm function score of the knee joint in the cartilage injury group was lower than that in the other groups after the last follow-up，indicating that poor recovery in the ligament injury group was related to articular cartilage injury.The Lysholm scores of the knees in all groups increased significantly at 3 months after surgery，and the differences were relatively large.The differences at 6 and 12 months after surgery were smaller than the 3 months after surgery.Conclusion In KD-Ⅲ-MC multiple ligament injury，a single bundle of autologous tendon which was used to reconstruct anterior cruciate ligament (ACL)，posterior cruciate ligament (PCL) under arthroscope，with line anchor Nail fixation and enhanced sutures，joint capsule tightening and medial anatomical autogenous tendon reconstruction can achieve good short-term results.

Key words： knee dislocation arthroscopy autogenous tendon KD-Ⅲ-MC type

基金资助:四川大学华西医院学科卓越发展135工程项目(ZY2017301)

通讯作者: 李玉吉

作者简介: 李帅(1990－ )，男，医师，甘肃中医药大学中医骨伤研究生院，730000。

引用本文:

李帅 1，李玉吉 2*,常旭东 2，于瑞霞 3. 关节镜辅助一期自体肌腱重建KD-Ⅲ-MC型多发韧带损伤临床观察[J]. 实用骨科杂志, 2020, 26(2): 118-123.
Li Shuai 1，li Yuji 2*,Chang Xudong 2，et al. Clinical Observation of Multiple Ligament Injuries of Medial Rotatory Ddislocation with Autogenous Tendon Reconstruction Assisted by Arthroscopy in The First Stage. sygkzz, 2020, 26(2): 118-123.

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http://www.sygkzz.com/CN/ 或 http://www.sygkzz.com/CN/Y2020/V26/I2/118

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