经三后内侧入路关节镜治疗后交叉韧带胫骨止点撕脱骨折

doi:10.3877/ cma.j.issn.1674-134X.2025.02.006

目的

分析关节镜下经三后内侧入路治疗后交叉韧带（PCL）胫骨止点撕脱骨折的疗效。

方法

回顾性分析2019年12月至2021年12月期间在西安交通大学第一附属医院榆林医院采用膝关节镜下经三后内侧入路治疗PCL胫骨止点撕脱骨折的患者资料，排除合并膝关节韧带撕裂的患者，进行回顾性分析。随访观察骨折愈合率，比较患者术前及术后2年Lysholm评分、国际膝关节文献委员会主观膝关节评分（IKDC评分）、美国特种外科医院膝关节评分（HSS评分）采用t检验；视觉模拟评分（VAS）采用秩和检验。

结果

本研究共纳入8例患者，所有PCL胫骨止点撕脱骨折均愈合，愈合率为100%，后抽屉试验均为阴性，1例患者残留膝关节疼痛，患者满意率为87.5%，术后2年随访各评分较术前均有显著改善，Lysholm评分（45±13）vs（.89±8）（t=8.232，P<0.001）、IKDC评分（37±5） vs.（ 71±7） (t=10.03，P<0.001）、HSS评分（34±8） vs.（ 92±4）(t=17.87，P<0.001）及VAS评分6（6，7） vs. 0（0，0）（t=2.536，P=0.011），Lysholm评分优良率达75.0%（6/8），IKDC评分优良率达62.5%（5/8），HSS评分优良率达100%（8/8）。

结论

关节镜下经三后内侧入路治疗PCL胫骨止点撕脱骨折实现了临床疗效好，手术微创，骨折固定可靠，膝关节功能恢复快的临床需求，是PCL胫骨止点撕脱骨折的良好手术方式。

关键词: 关节镜, 后交叉韧带, 骨折，撕脱性

Objective

To evaluate the clinical outcomes of arthroscopic fixation for avulsion fractures of posterior cruciate ligament (PCL) tibial insertion through three posteromedial approaches.

Methods

A retrospective analysis was conducted on patients treated for PCL tibial avulsion fractures via arthroscopic tripleportal posteromedial approach in Yulin Hospital of the First Affiliated Hospital of Xi’an Jiaotong University between December 2019 and December 2021. Patients with concomitant ligament injuries of the knee were excluded. Fracture healing rate was recorded, and clinical outcomes were assessed using Lysholm score,International Knee Documentation Committee (IKDC) subjective knee form, Hospital for Special Surgery(HSS) knee score, and visual analog scale (VAS) for pain. Scores before operation and two years after operation were compared using paired t test and rank sum test.

Results

A total of eight patients were included. All the fractures achieved union, yielding a 100% healing rate. The posterior drawer test was negative in all cases.One patient reported residual knee pain. The overall satisfaction rate was 87.5%. At two-year follow-up,all clinical scores showed significant improvement compared to baseline: Lysholm score (45±13) vs. (89±8)(t=8.232, P<0.001), IKDC score (37±5) vs. (71±7) (t=10.03, P<0.001), HSS score (34±8 ) vs. (92±4) (t=17.87,P<0.001), and VAS score 6(6, 7) vs. 0(0, 0) (t=2.536, P=0.011). The excellent-to-good rates were 75.0%(6/8) in Lysholm score, 62.5% (5/8) in IKDC score, and 100% (8/8) in HSS score.

Conclusions

Arthroscopic fixation of PCL tibial avulsion fractures via three posteromedial approaches is a minimally invasive, reliable, and effective surgical technique. It ensures solid fixation, promotes early functional recovery, and meets the clinical demands for optimal outcomes in the treatment of PCL tibial avulsion fractures.

Key words: Arthroscope, Posterior cruciate ligament, Avulsion fracture

图1 关节镜下经三后内侧入路治疗PCL（后交叉韧带）胫骨止点撕脱骨折手术步骤图。图A～B为建立双后内侧入路；图C为显露腓肠肌内侧头肌腱；图D为显露PCL胫骨止点撕脱骨折块；图E～F为建立极高位后内侧入路；图G～H为骨折块复位后置入空心钉

Figure 1 Surgical steps of arthroscopic treatment for avulsion fracture of PCL（posterior cruciate ligament） tibial insertion via three posteromedial portals. A to B demostrate the establish two posteromedial portals; C shows the medial head of the gastrocnemius tendon; D shows the avulsion fracture fragment of the PCL tibial insertion; E to F demonstrate establishment of the ultra-high posteromedial portal; G to H demonstrate that after repositioning the fracture fragment, a hollow nail is inserted

表1 治疗前后各评分对比（n=8）

Table 1 Comparisons of evaluation scores before and after surgery

时间点Time points	Lysholm评分（ $\overset{ˉ}{x}$ ± s ）	IKDC评分（ $\overset{ˉ}{x}$ ± s ）	HSS（ $\overset{ˉ}{x}$ ± s ）	VAS评分 M（P₂₅，P₇₅）
术前Before surgery	45±13	37±5	34±8	6（6，7）
术后2年Two years after surgery	89±8	71±7	92±4	0（0，0）
W值	0. 9247	0. 9138	0. 9440	0. 8107
P值	>0. 05	>0. 05	>0. 05	0. 0038^*
t值	8. 232	10. 03	17. 87	2. 536
P值	＜0. 001	＜0. 001	＜0. 001	0. 011

表1 治疗前后各评分对比（n=8）

Table 1 Comparisons of evaluation scores before and after surgery

时间点Time points	Lysholm评分（ $\overset{ˉ}{x}$ ± s ）	IKDC评分（ $\overset{ˉ}{x}$ ± s ）	HSS（ $\overset{ˉ}{x}$ ± s ）	VAS评分 M（P₂₅，P₇₅）
术前Before surgery	45±13	37±5	34±8	6（6，7）
术后2年Two years after surgery	89±8	71±7	92±4	0（0，0）
W值	0. 9247	0. 9138	0. 9440	0. 8107
P值	>0. 05	>0. 05	>0. 05	0. 0038^*
t值	8. 232	10. 03	17. 87	2. 536
P值	＜0. 001	＜0. 001	＜0. 001	0. 011

图2 典型病例手术前后右膝关节影像学图片。图A为术前右膝侧位X线片，示右膝PCL（后交叉韧带）胫骨止点撕脱骨折；图B为术前MRI，示右膝PCL撕脱骨折块移位明显；图C为关节镜下用2枚空心螺钉固定右膝PCL撕脱骨折；图D为术后右膝关节侧位X线示骨折复位良好，内固定位置佳

Figure 2 Images of right knee of typical case before and after surgery. A is the lateral X-ray image of right knee before surgery，demonstrating avulsion fracture of PCL（posterior cruciate ligament） tibial insertion site; B is MRI image of right knee before surgery,showing obvious displacement of the avulsion fracture fragment of the PCL; C demonstrates fixation of the PCL avulsion fracture fragment with two hollow screws under arthroscope; D is the lateral X-ray image of the right knee after surgery, showing good fracture reduction and optimal position of the internal fixation

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Arthroscopic surgery via three posteromedial approaches for posterior cruciate ligament tibial avulsion fractures

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Arthroscopic surgery via three posteromedial approaches for posterior cruciate ligament tibial avulsion fractures