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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2018, Vol. 12 ›› Issue (03) : 317 -323. doi: 10.3877/cma.j.issn.1674-134X.2018.03.004

所属专题： 文献；

临床论著

经胫骨隧道入路与前内入路重建前交叉韧带比较
耿云航1, 刘晓阳2, 徐强2, 李桂石2, 隋来健2, 陈焕杰1, 石吉华1, 盖鹏宙2,†()   
  1. 1. 266000　青岛大学医学部研究生院；264000　烟台，青岛大学附属烟台毓璜顶医院
    2. 264000　烟台，青岛大学附属烟台毓璜顶医院
  • 收稿日期:2017-04-15 出版日期:2018-06-01
  • 通信作者: 盖鹏宙

Transtibial approach vs. anteromedial portal for anterior cruciate ligament reconstruction

Yunhang Geng1, Xiaoyang Liu2, Qiang Xu2, Guishi Li2, Laijian Sui2, Huanjie Chen1, Jihua Shi1, Pengzhou Gai2,†()   

  1. 1. Postgraduate Institute, Qingdao University, Qingdao 266000, China; Affiliated QingDao medical school YanTai YuHuangDing Hospital, Yantai 264000, China
    2. Affiliated QingDao medical school YanTai YuHuangDing Hospital, Yantai 264000, China
  • Received:2017-04-15 Published:2018-06-01
  • Corresponding author: Pengzhou Gai
  • About author:
    Corresponding author: Gai Pengzhou, Email:
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引用本文：

耿云航, 刘晓阳, 徐强, 李桂石, 隋来健, 陈焕杰, 石吉华, 盖鹏宙. 经胫骨隧道入路与前内入路重建前交叉韧带比较[J]. 中华关节外科杂志(电子版), 2018, 12(03): 317-323.

Yunhang Geng, Xiaoyang Liu, Qiang Xu, Guishi Li, Laijian Sui, Huanjie Chen, Jihua Shi, Pengzhou Gai. Transtibial approach vs. anteromedial portal for anterior cruciate ligament reconstruction[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2018, 12(03): 317-323.

目的

创新性地以临床功能和膝关节稳定性结合股骨隧道位置和长度作为评估标准，以此评价前内入路和经胫骨隧道入路，哪一种手术方法更具优越性。

方法

从2010年8月至2013年7月，烟台毓璜顶医院连续104位重建前交叉韧带的病人被纳入研究。纳入标准：随访至少1年，正常的对侧膝关节，无严重的术后并发症，获得术后CT三维重建影像资料的病人。排除标准：伴有后交叉韧带损伤、伴有侧副韧带损伤、伴有骨关节炎的病人、翻修手术。病人随机分为两组，其中经前内入路组为56人，包括男性46人，女性10人，平均年龄(30±12)岁；经胫骨隧道入路组是48人，包括男性40人，女性8人，平均年龄(32±11)岁。所有病人均前瞻性地于术前和最后1次随访时行Lysholm膝关节评分、国际膝关节文献委员会评分(IKDC评分)、Tegner膝关节运动水平评分。于最后1次随访时行屈膝30°前抽屉试验(Lachman试验)、轴移试验(Pivot-shift试验)、KT-1000评估。于术后1周行基于CT的三维重建，以此评估股骨隧道位置，并于术中测量股骨隧道长度。对于Lysholm评分，IKDC评分，Tegner评分，隧道长度，KT-1000和隧道位置均行两独立样本的t检验。Lachman试验和Pivot-shift试验结果行Mann-Whitney秩和检验(两独立样本的非参数检验)。

结果

前内入路组平均随访时间(26±7)月，经胫骨隧道入路组平均随访时间(25±6)月。术前和最后1次随访时，两组间Lysholm评分(术前t＝0.347，P >0.05；末次随访t＝1.557，P>0.05)，IKDC评分(术前t＝－0.383，P>0.05；末次随访t＝1.102，P>0.05)和Tegner评分(术前t＝0.283，P>0.05；末次随访t＝1.763，P>0.05)相比，差异均无统计学意义。最后1次随访时，两组间Lachman试验(Z＝－0.482，P>0.05)、Pivot-shift试验(Z＝－1.455，P>0.05)和KT-1000(t＝－0.750，P >0.05)相比，差异均无统计学意义。然而，前内入路组平均股骨隧道长度明显短于经胫骨隧道组，差异有统计学意义(t＝－5.554，P<0.01)；前内入路组隧道位置明显比经胫骨隧道组更深(t＝－4.508，P<0.01)、更低(t＝8.865，P<0.01)，差异有统计学意义。

结论

前内入路与经胫骨隧道入路的临床功能和膝关节稳定性没差别，但是前内入路股骨隧道长度明显短于经胫骨隧道，且位置更深、更低，更容易定位于前交叉韧带股骨端解剖足印区。

关键词: 前交叉韧带, 胫骨, 股骨
Objective

To determine if the anteromedial portal (AMP) is better than transtibial approach (TT) in terms of clinical function, knee joint stability, femoral tunnel length and location.

Methods

From August 2010 to July 2013 , 104 patients who underwent anterior cruciate ligament reconstruction in Yantai Yuhuangding Hospital were enrolled. Inclusion criteria: at least one year post-operative follow-up, normal contralateral knee joint, no serious postoperative complications, and postoperative three-dimensional reconstruction CT imaging data can be obtained. Exclusion criteria: combining anterior and posterior cruciate ligaments injury, accompanying collateral ligament injury, osteoarthritis and revision surgery. The patients were randomly divided into two groups: 56 patients in the AMP group including 46 males and 10 females, mean age was (30±12) years; 48 patients in the TT group including 40 males and eight females, mean age was (32±11) years. All the patients were assessed by Lysholm score, International Knee Documentation Committee (IKDC) score, Tegner score pre-operatively and at last follow-up. All the patients underwent Lachman test, Pivot-shift test and KT-1000 evaluation at the last follow-up. The length of femoral tunnel was measured intraoperatively; one week after the operation, 3D-CT anatomical reconstruction was performed to assess the location of the femoral tunnel. Unpaired ttest and Mann-Whitney rank test (non-parametric test of two independent samples) were used statistical comparisons.

Results

The mean follow-up time of the AMP group was (26±7) months, and the average follow-up time of the TT group was (25±6) months. There was no statistically significant difference in Lysholm score(pre-operation t=0.347, P>0.05; last follow-up t=1.557, P >0.05), IKDC score(pre-operation t=-0.383, P >0.05; last follow-up t=1.102, P >0.05) or Tegner score(pre-operation t=0.283, P >0.05; last follow-up t=1.763, P >0.05) between the two groups before the operation or at the last follow-up. In Lachman test(Z=-0.482, P>0.05), Pivot-shift test (Z=-1.455, P >0.05)and KT-1000(t=-0.750, P>0.05), there was no statistically significant difference between the two groups at the last follow-up. The mean femoral tunnel length in the AMP group was significantly shorter than that in the TT group (t=-5.554, P<0.01). Tunnel location was significantly lower (t=8.865, P<0.01) and deeper (t=-4.508, P<0.01)with the AMP technique than with the transtibial method.

Conclusion

Clinical function and knee joint stability are similar in AMP and TT; however, AMP has a shorter femoral tunnel than TT of which the location is deeper, lower, and closer to the femoral footprint.

Key words: Anterior cruciate ligament, Tibia, Femur
图2 左膝关节镜图像。男，37岁，扭伤致左膝关节疼痛、活动受限3 d，镜下示前交叉韧带撕裂
图4 术后1周基于CT的膝关节三维重建图像。d为Blumensat线，b垂直于Blumensat线，a为股骨隧道中心至Blumensat线的距离，c为股骨隧道中心至b的距离；a/b表示为高度比，即股骨隧道中心至髁间窝顶部的距离与髁间窝总高度的比例，c/d表示为深度比，即股骨隧道中心至股骨外侧髁后关节面的距离与髁间窝总深度的比例
表1 入组患者一般资料
分组 例数 男/女(例) 年龄[岁，(±s)] 随访时间[月，(±s)] 受伤到手术时间[周，(±s)] 受伤膝关节(左/右，例) BMI[kg/m2，(±s)]
AMP组 56 46/10 30±12 26±7 10±6 26/30 24±3
TT组 48 40/8 32±11 25±6 11±7 22/26 24±3
统计值 ? χ2＝0.026 t＝－0.946 t＝0.632 t＝－0.589 χ2＝0.004 t＝0.474
P值 ? >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
表2 两组临床功能评分比较(±s)
分组 例数 术前Lyshom评分 术前IKDC评分 术前Tegner评分 术后Lysholm评分 术后IKDC评分 术后Tegner评分
AMP组 56 45.9±6.6 35.7±6.3 5.0±1.0 93.3±5.0 89.5±8.8 6.8±1.4
TT组 48 45.4±6.2 36.1±6.6 5.0±1.1 91.6±6.5 87.4±10.0 6.3±1.4
t值 ? 0.347 －0.383 0.283 1.557 1.102 1.763
P值 ? >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
表3 膝关节稳定性评估(±s)
分组 例数 Lachman试验 Pivot-shift试验
0 1＋ 2＋ 3＋ 0 1＋ 2＋ 3＋
AMP组 56 44 12 0 0 44 12 0 0
TT组 48 36 11 1 0 32 14 2 0
Z值 ? －0.482 －1.455
P值 ? >0.05 >0.05
表4 骨隧道参数
分组 例数 隧道长度[mm，(±s)] 隧道位置
深度比[%，(±s)] 高度比[%，(±s)]
AMP组 56 37.3±3.9 20.3±2.0 33.3±1.8
TT组 48 42.0±4.8 22.1±2.1 30.2±1.7
t值 ? －5.554 －4.508 8.865
P值 ? <0.01 <0.01 <0.01
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