后交叉韧带胫骨止点骨折两种手术方式疗效比较

doi:10.3877/ cma.j.issn.1674-134X.2024.06.016

目的

探讨关节镜下单隧道缝线套捆固定与切开固定治疗成人后交叉韧带胫骨止点骨折的手术技术及疗效，为临床治疗提供参考。

方法

2018年6月至2023年6月，将在扬州大学建湖临床医学院收治的急性成人后交叉韧带胫骨止点骨折40例患者随机分为两组，关节镜组20例，切开组20例，对其进行临床评价，包括术前、术后第3天、术后1、 6个月视觉模拟评分（VAS）、Lysholm评分、国际膝关节评分委员会（IKDC）评分及膝关节活动度（ROM）评价膝关节的功能，后抽屉试验、Lachman试验评价膝关节的稳定性，术后X线评价骨折复位愈合情况。两组 VAS评分、Lysholm膝关节评分、IKDC评分、膝关节ROM 的总体差异分析采用重复测量资料的方差分析，各时间点的组间差异采用独立样本t检验，计数资料采用卡方检验。

结果

术后随访平均（9.9±1.0）d，所有患者切口均Ⅰ期愈合，无切口感染、腘窝神经血管损伤、下肢深静脉血栓形成等并发症发生，术后6个月X线示骨性愈合，后抽屉试验、Lachman试验均呈阴性。两组 VAS 评分、Lysholm膝关节评分、IKDC评分、膝关节ROM 的差异有统计学意义（VAS 评分F=18.364，Lysholm评分F=49.371，IKDC评分F=14.094，ROM F=174.708，均为P＜0.001），均为关节镜组优于切开组。分组上，术后第3天、1个月关节镜组和切开组的VAS评分、Lysholm评分、IKDC评分、膝关节ROM的差异均有统计学意义（VAS评分t=-3.048、2.1250，均为P＜0.05；Lysholm评分t=6.725、6.280，均为P＜0.05；IKDC评分 t=4.127、5.872，均为P＜0.05；ROM t=4.875、4.500，均为P＜0.05），术后6个月关节镜组和切开组VAS评分、Lysholm评分、IKDC评分、膝关节ROM的差异不具有统计学意义（t=0.438、1.792、1.999、1.433，均为P＞0.05）。时间上，关节镜组和切开组从手术前到术后6个月VAS评分呈降低趋势，关节镜组和切开组从手术前到术后6个月IKDC评分、Lysholm评分、ROM评分呈升高趋势。

结论

关节镜下单隧道缝线套捆固定治疗成人后交叉韧带胫骨止点骨折，早期效果满意，疗效优于切开固定手术，具有创伤小，康复快，功能恢复满意，值得临床推广。

关键词: 后交叉韧带, 胫骨骨折, 骨折固定术, 内, 关节镜

Objective

To explore the arthroscopic binding fixation through single bone tunnel using wire versus open fixation for tibial insertion of the posterior cruciate ligament in adults.

Methods

From June 2018 to June 2023， 40 patients with acute adult posterior cruciate ligament tibial insertion fractures admitted to Jianhu Clinical Medical College of Yangzhou University were randomly divided into two groups： arthroscopic group （n=20） and incision group （n=20）. Follow-up assessment included visual analogue scale （VAS）， Lysholm knee score， International Knee Documentation Committee （IKDC）， range of motion（ROM） for knee， posterior drawer test， Lachman test and radiological evaluation before surgery and three days， one month and six months after surgery. Overall differences in VAS， Lysholm score， IKDC， ROM were analyzed by variance for repeated measurement data， differences at each time point were analyzed by independent samples t test. The categorical data were analyzed by rank sum test.

Results

All the patients were followed up for eight to 12 months， with an average of （9.91.0） months. All the incisions achieved healing by first intention after operation. There was no incision infection， popliteal neurovascular injury or thrombosis in deep veins of lower limbs. X-ray films at six months after operation showed the fractures obtained bone union. The back drawer test and Lachman test were both negative. The total differences of VAS （F=18.364）， Lysholm score （F=49.371）， IKDC score （F=14.094）， and ROM （F=174.708） between the two groups were statistically significant （all P＜0.001）， which showed that the arthroscopic group were better than the incision group. In terms of grouping， the differences of VAS （t=-3.048、2.1250）， Lysholm （t=6.725、6.280， both）， IKDC （t=4.127、5.872）， ROM （t=4.875、4.500） between the two groups were statistically significant on three days and one month after surgery （all P＜0.05）. The differences of VAS， Lysholm， IKDC， ROM between the two groups were not statistically significant at six months after surgery（t=0.438、1.792、1.999、1.433， all P＞0.05）. In terms of time，the VAS of the two groups decreased from preoperation to six months after operation，and Lysholm， IKDC， ROM of the two groups increased from pre-operation to six months after operation.

Conclusions

Arthroscopic binding fixation of avulsion fractures of the tibial insertion of the posterior cruciate ligament through single bone tunnel using wire in adults has satisfactory early results and better efficacy than open fixation surgery， which is minimally invasive， benefit for rehabilitation. It can achieve satisfactory recovery and is worthy of clinical application.

Key words: Posterior cruciate ligament, Ttibial fractures, Fracture fixation， internal, Arthroscopes

图1 关节镜修复后交叉韧带操作图。图A为用硬膜外穿刺针建立低位后内侧入路；图B～C为用4.5mm的空心钻头从高位前内侧入路经股骨内侧髁和PCL之间进入膝关节后室间隙，用PDSⅡ线经该空心钻头把1根5号爱惜邦缝线对折端引入膝关节后室间隙；图D为直视下在膝关节后室从爱惜邦缝线对折端之间伸入抓线钳，抓住缝线的两游离端；图E为缝线套捆在PCL胫骨止点骨折块上；图F为从胫骨结节内侧向PCL胫骨止点骨床后下方正中间钻一个骨隧道；图G为用抓线钳自隧道入口进入膝关节后室将缝线两游离端自隧道引出；图H为缝线套捆固定示意图

Figure 1 Images of posterior cruciate ligament repair under arthroscope. A shows the establishment of a low posterior medial approach using an epidural puncture needle； B and C show the use of a 4.5mm hollow drill bit to enter the posterior compartment space of the knee joint from the anterior medial side of the femur through the medial condyle of the femur and PCL， PDS II suture is then inserted into the posterior compartment space of the knee joint through the hollow drill bit， with the folded end of one No. 5 Ethibond suture thread； D shows the process of inserting the grasping forceps into the posterior compartment of the knee joint from between the folded ends of the suture，and grasping the two free ends of the suture； E shows the suture wrapped around the PCL tibial insertion fracture fragment； F shows a bone tunnel drilled from the inner side of the tibial tuberosity towards the posterior lower middle of the PCL tibial insertion point bone bed； G shows the use of a wire gripper to enter the posterior chamber of the knee joint from the tunnel entrance and extract the two free ends of the suture from the tunnel； H is a schematic diagram of suture bundling fixation

表1 两组患者术前临床资料比较

Table 1 Comparison of preoperative clinical data between the two groups

组别 Groups	例数 Number of cases	性别（男/女） Gender（male/female）	年龄［岁，（ $\bar{x}$ ±s）］ Age（year）	膝关节侧别（左/右） Side of knee （left/right）	骨折分型Ⅱ/Ⅲ/Ⅳ Fracture classification	受伤时间（d） Time of injury
关节镜组Arthroscopic group	20	13/7	41.9±8.1	9/11	6/10/4	5.9±2.2
切开组Incision group	20	12/8	41.1±7.1	7/13	5/12/3	5.8±1.9
统计值Statistical value		χ ²=0.107	t=0.312	χ ²=0.417	χ ²=0.416	t=0.076
P值		＞0.05	＞0.05	＞0.05	＞0.05	＞0.05
组别 Groups	例数 Number of cases	VAS评分（分） VAS scores	Lysholm评分（分） Lysholm scores	IKDC评分（分） IKDC scores	ROM（°） ROM	-
关节镜组Arthroscopic group	20	5.9±1.2	14.9±3.1	40.4±5.1	41.2±5.6	-
切开组Incision group	20	6.4±1.2	14.1±2.8	38.6±5.9	42.5±4.3	-
统计值Statistical value		t=-1.313	t=0.812	t=1.035	t=-0.794	-
P值		＞0.05	＞0.05	＞0.05	＞0.05	-

表1 两组患者术前临床资料比较

Table 1 Comparison of preoperative clinical data between the two groups

组别 Groups	例数 Number of cases	性别（男/女） Gender（male/female）	年龄［岁，（ $\bar{x}$ ±s）］ Age（year）	膝关节侧别（左/右） Side of knee （left/right）	骨折分型Ⅱ/Ⅲ/Ⅳ Fracture classification	受伤时间（d） Time of injury
关节镜组Arthroscopic group	20	13/7	41.9±8.1	9/11	6/10/4	5.9±2.2
切开组Incision group	20	12/8	41.1±7.1	7/13	5/12/3	5.8±1.9
统计值Statistical value		χ ²=0.107	t=0.312	χ ²=0.417	χ ²=0.416	t=0.076
P值		＞0.05	＞0.05	＞0.05	＞0.05	＞0.05
组别 Groups	例数 Number of cases	VAS评分（分） VAS scores	Lysholm评分（分） Lysholm scores	IKDC评分（分） IKDC scores	ROM（°） ROM	-
关节镜组Arthroscopic group	20	5.9±1.2	14.9±3.1	40.4±5.1	41.2±5.6	-
切开组Incision group	20	6.4±1.2	14.1±2.8	38.6±5.9	42.5±4.3	-
统计值Statistical value		t=-1.313	t=0.812	t=1.035	t=-0.794	-
P值		＞0.05	＞0.05	＞0.05	＞0.05	-

表2 两组患者术前及术后VAS 评分［分，（±s）］

Table 2 VAS scores before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	5.9±1.2	3.5±0.9	2.3±0.9	1.0±0.8	82.21	＜0.001	222.82	208.29	18.36
切开组Incision group	20	6.3±1.2	4.3±0.9	1.7±0.6	0.9±0.6	166.01	＜0.001
t值		-1.313	-3.048	2.125	0.438			-	-	-
P值		＞0.05	0.004	0.042	0.664			＜0.001	＜0.001	＜0.001

表2 两组患者术前及术后VAS 评分［分，（±s）］

Table 2 VAS scores before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	5.9±1.2	3.5±0.9	2.3±0.9	1.0±0.8	82.21	＜0.001	222.82	208.29	18.36
切开组Incision group	20	6.3±1.2	4.3±0.9	1.7±0.6	0.9±0.6	166.01	＜0.001
t值		-1.313	-3.048	2.125	0.438			-	-	-
P值		＞0.05	0.004	0.042	0.664			＜0.001	＜0.001	＜0.001

表3 两组患者术前及术后Lysholm 评分［分，（±s）］

Table 3 Lysholm scores before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	14.9±3.1	44.3±4.5	73.9±7.0	88.1±6.6	694.61	＜0.001	1946.49	1565.82	49.37
切开组Incision group	20	14.1±2.8	35.0±4.3	62.1±4.7	84.5±5.9	915.71	＜0.001
t值		0.812	6.725	6.280	1.792			-	-	-
P值		＞0.05	＜0.001	＜0.001	＞0.05			＜0.001	＜0.001	＜0.001

表3 两组患者术前及术后Lysholm 评分［分，（±s）］

Table 3 Lysholm scores before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	14.9±3.1	44.3±4.5	73.9±7.0	88.1±6.6	694.61	＜0.001	1946.49	1565.82	49.37
切开组Incision group	20	14.1±2.8	35.0±4.3	62.1±4.7	84.5±5.9	915.71	＜0.001
t值		0.812	6.725	6.280	1.792			-	-	-
P值		＞0.05	＜0.001	＜0.001	＞0.05			＜0.001	＜0.001	＜0.001

表4 两组患者术前及术后IKDC 评分［分，（±s）］

Table 4 IKDC scores before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	40±5	57±5	75±4	90±4	456.94	＜0.001	780.04	657.21	14.09
切开组Incision group	20	39±6	51±4	67±5	88±4	406.84	＜0.001
t值		1.035	4.127	5.872	1.999			-	-	-
P值		＞0.05	＜0.001	＜0.001	＞0.05			＜0.001	＜0.001	＜0.001

表4 两组患者术前及术后IKDC 评分［分，（±s）］

Table 4 IKDC scores before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	40±5	57±5	75±4	90±4	456.94	＜0.001	780.04	657.21	14.09
切开组Incision group	20	39±6	51±4	67±5	88±4	406.84	＜0.001
t值		1.035	4.127	5.872	1.999			-	-	-
P值		＞0.05	＜0.001	＜0.001	＞0.05			＜0.001	＜0.001	＜0.001

表5 两组患者术前及术后 ROM比较［°，（±s）］

Table 5 ROM before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	41±6	87±4	102±6	118±6	750.32	＜0.001	1489.98	1023.34	174.71
切开组Incision group	20	42±4	80±5	94±6	115±6	667.269	＜0.001
t值		-0.794	4.875	4.500	1.433			-	-	-
P值		＞0.05	＜0.001	＜0.001	＞0.05			＜0.001	＜0.001	＜0.001

表5 两组患者术前及术后 ROM比较［°，（±s）］

Table 5 ROM before and after operation of the two groups

组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	F值
组别 Groups	例数 Number of cases	手术前 Before operation	术后第3天 Three days after operation	术后1个月 One month after operation	术后6个月 Six months after operation	F值	P值	分组Group	时间Time	交互Interaction
关节镜组Arthroscopic group	20	41±6	87±4	102±6	118±6	750.32	＜0.001	1489.98	1023.34	174.71
切开组Incision group	20	42±4	80±5	94±6	115±6	667.269	＜0.001
t值		-0.794	4.875	4.500	1.433			-	-	-
P值		＞0.05	＜0.001	＜0.001	＞0.05			＜0.001	＜0.001	＜0.001

图2 左膝关节PCL胫骨止点骨折（ Meyers-Mckeever Ⅲ型）关节镜手术前后影像图。图A为术前左膝X线正侧位片，示PCL胫骨止点骨折；图B为术前左膝CT冠状位、矢状位影像，图C为术前左膝CT三维重建图，示骨折分离移位；图D为术前左膝MRI矢状位影像，示骨折分离移位；图E为术后左膝X线正侧位片，示骨折复位固定满意；图F为术后6个月左膝X线正侧位片，示骨折愈合

Figure 2 Images of tibial insertion avulsion fracture of left knee joint （Meyers-McKeever type Ⅲ） before and after arthroscopic surgery.A is X ray image of left knee at anteroposterior and lateral positions before surgery，showing PCL tibial insertion fracture； B is coronal and sagittal CT image of left knee before surgery， C is three-dimensional reconstruction of CT image before surgery， both showing fracture separation and displacement； D is MRI sagittal view of left knee before surgery， showing fracture separation and displacement； E is X ray image of left knee at anteroposterior and lateral positions after surgery， showing satisfactory reduction and fixation of the fracture； F is X ray image of left knee at anteroposterior and lateral positions six months after surgery， showing fracture healing

图3 左膝关节PCL胫骨止点骨折（ Zaricznyi IV型）切开手术前后影像。图A为术前左膝X线正侧位片，示PCL胫骨止点骨折；图B为术前左膝CT冠状位、矢状位影像，图C为左膝CT三维重建图，示骨折分离、旋转移位；图D为术前左膝MRI矢状位影像，示骨折分离移位；图E为术后左膝X线正侧位片，示骨折复位固定满意；图F为术后6个月左膝X线正侧位片，示骨折愈合

Figure 3 Images of tibial insertion avulsion fracture of left knee joint （Zaricznyi IV type） before and after open surgery. A is X ray image of left knee at anteroposterior and lateral positions before surgery，showing PCL tibial insertion fracture； B is coronal and sagittal CT image of left knee before surgery， C is three-dimensional reconstruction of CT image before surgery， both showing fracture separation and displacement； D is MRI sagittal view of left knee before surgery， showing fracture separation and displacement； E is X ray image of left knee at anteroposterior and lateral positions after surgery， showing satisfactory reduction and fixation of the fracture； F is X ray image of left knee at anteroposterior and lateral positions six months after surgery， showing fracture healing

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Comparison of therapeutic effects of two surgical methods for tibial insertion fracture of posterior cruciate ligament

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Comparison of therapeutic effects of two surgical methods for tibial insertion fracture of posterior cruciate ligament