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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) ›› 2020, Vol. 14 ›› Issue (01) : 24 -32. doi: 10.3877/cma.j.issn.1674-134X.2020.01.005

所属专题： 文献；

临床论著

保残重建前交叉韧带对膝关节运动学特征的影响
姚望1, 潘剑英1, 曾春1,†()   
  1. 1. 510630　广州，南方医科大学第三附属医院关节外科/运动医学科
  • 收稿日期:2020-01-15 出版日期:2020-02-01
  • 通信作者: 曾春

Kinematic characteristics based on remnant preservation for patients undergoing anterior cruciate ligament reconstruction

Wang Yao1, Jianying Pan1, Chun Zeng1,†()   

  1. 1. Department of Joint Surgery/Sports Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou 510630, China
  • Received:2020-01-15 Published:2020-02-01
  • Corresponding author: Chun Zeng
  • About author:
    Corresponding author: Zeng Chun, Email:
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引用本文：

姚望, 潘剑英, 曾春. 保残重建前交叉韧带对膝关节运动学特征的影响[J]. 中华关节外科杂志(电子版), 2020, 14(01): 24-32.

Wang Yao, Jianying Pan, Chun Zeng. Kinematic characteristics based on remnant preservation for patients undergoing anterior cruciate ligament reconstruction[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2020, 14(01): 24-32.

目的

评估保残与否重建前交叉韧带(ACL)对膝关节术后运动学特征及临床疗效的影响，指导临床治疗及选择更优康复方案。

方法

选取2017年8月至2018年3月南方医科大学第三附属医院关节外科/运动医学科所收治50例行ACL重建患者，根据术中是否保留ACL胫骨残端分为保残组(25例)与非保残组(25例)，以及健康受试者(25例)纳入本研究，纳入标准：年龄≤55岁；身体质量指数(BMI)≤30 kg/m2；术侧或健侧膝关节无活动受限；无神经系统疾病；不伴同侧膝其他韧带损伤，对侧膝关节亦无损伤；留存术后1年完整资料。排除标准：年龄>55岁；BMI>30 kg/m2；术侧或健侧膝关节活动受限；伴有膝关节其他韧带损伤或对侧膝关节存在损伤；存在神经系统疾病；临床资料不完全而无法统计者。采用三维膝关节动态功能分析系统(Opti_Knee)计算膝关节6自由度数据及膝关节运动功能评分，并分析患者Lysholm膝关节功能评分、国际膝关节文献委员会(IKDC)评分及Tegner膝关节运动评分、本体感觉(位置觉和运动觉)数据，以及胫骨隧道内口(术前为ACL足迹)中心至外侧半月板前角韧带足迹前后向及内外向距离偏差，其中，各组6自由度统计学差异采用双因素方差分析及t检验，各组基本数据计量资料采用单因素方差分析检测及t检验、计数资料则采用卡方检验，各组运动功能评分、主观评分、本体感觉数据、中心距偏差均采用t检验分析。

结果

保残组术后3个月内外旋、屈伸范围、术后6个月内外旋范围低于对照组(t＝－2.365，P<0.05；t＝－3.123，P<0.01；t＝－2.419，P<0.05)；非保残组术后3个月内外翻、内外旋、屈伸、上下位移、内外位移范围、术后6个月内外旋、屈伸范围低于对照组(F ＝9.554，P<0.05；t＝－5.067，P<0.01；t＝－5.119，P<0.01；t＝－2.655，P<0.05；t＝－2.863，P<0.01；t＝－3.516，P<0.01；t＝－4.100，P<0.01)，术后6月前后位移范围大于对照组(t＝2.464，P<0.05)，术后12月内外旋范围小于对照组(t＝－3.076，P<0.01)。非保残组术后3月内外旋、屈伸角范围、术后6月屈伸角范围低于保残组(t＝2.512，P<0.05；t＝2.428，P<0.05；t＝2.267，P<0.05)。保残组术后3月术侧膝关节运动功能评分高于非保残组(t＝2.272，P<0.05)。保残组术后3月及6月Lysholm评分高于非保残组(t＝4.706、P<0.01；t＝2.106，P<0.05)，保残组术后3月IKDC评分高于非保残组(t＝2.987，P<0.01)，保残组中心内外向距偏差小于非保残组(t＝－2.600，P<0.05)，保残组术后3月及6月60°位置觉小于非保残组(t＝－2.063，P<0.05；t＝－2.147，P<0.05)。

结论

保残重建ACL患者较非保残者在运动学特征上更接近于正常人，而且在术后前中期恢复更优于非保残者。

关键词: 前交叉韧带重建, 膝关节, 步态分析
Objective

To evaluate the kinematic characteristics and efficacy of knees following anterior cruciate ligament(ACL) restoration with remnant preservation, and to guide clinical treatments and choose better rehabilitation methods.

Methods

The clinical data of 50 patients with ACL deficiency and 25 healthy volunteers from August 2017 to March 2018 were analyzed. Inclusion criteria: age less than 55 years old; body mass index (BMI) less than 30 kg/m2; no limitation of movement of the operated or healthy knee; no nervous system disease; no injury of other ligaments of the ipsilateral knee and no injury of the contralateral knee; complete data were retained one year after operation. Exclusion criteria: age>55 years; BMI>30 kg/m2; knee joint movement limitation; accompanied by other knee ligament injury or contralateral knee joint injury; existence of nervous system disease; clinical data was incomplete and could not be counted. The six degrees of freedom (6-DOF) ranges of knee joints and kinematic function score were calculated by Opti_Knee. Lysholm score, International Knee Documentation Committee (IKDC) score, Tegner score, proprioceptive (position and motion) data and the distance error from the center of the tibial tunnel inner mouth to the center of the footprint of the anterior horn ligament of the lateral meniscus were also analyzed. The statistical differences of 6-DOF in each group were analyzed by two-way ANOVA and t test. The statistical differences of basic data in each group were analysed by one-way ANOVA and t-test, while the counting units were tested by chi-square test. The kinematic function scores, subjective scores, proprioceptive data and center distance errors were detected by t-test.

Results

In remnant preservation group, the ranges of internal-external rotation, flexion-extension rotation at three months and the range of internal-external rotation at six months were lower than those in control group (t=-2.365, P<0.05; t=-3.123, P<0.01; t=-2.419, P<0.05). In non-remnant preservation group, the ranges of adduction-abduction rotation, internal-external rotation, flexion-extension rotation, proximal-distal translation, medial-lateral translation at three months, the ranges of internal-external rotation, flexion-extension rotation at six months and the range of internal-external rotation at 12 months were lower than those in control group (F=9.554, P<0.05; t=-5.067, P<0.01; t=-5.119, P<0.01; t=-2.655, P<0.05; t=-2.863, P<0.01; t=-3.516, P<0.01; t=-4.100, P<0.01; t=-3.076, P<0.01), while the range of anterior-posterior translation at six months was larger than control group (t=2.464, P<0.05). Besides, the range of internal-external rotation, flexion-extension rotation at three months and the range of flexion-extension rotation at six months in non-remnant preservation group were also lower than remnant preservation group at the corresponding time (t=2.512, P<0.05; t=2.428, P<0.05; t=2.267, P<0.05). Kinematic function score of operative knees at three months in the remnant preservation group was higher than that in the non-remnant preservation group(t=2.272, P<0.05). The Lysholm score at three months and six months and the IKDC score at three months in the remnant preservation group were higher than the non-remnant preservation group (t=4.706, P<0.01; t=2.106, P<0.05; t=2.987; P<0.01), and the medial-lateral distance error in remnant preservation group was smaller than non-remnant preservation group (t=-2.600, P<0.05). The position perceptions of 60° in the remnant preservation group were smaller than that in the non-remnant preservation group at three and six months after operation(t=-2.063, P<0.05; t=-2.147, P<0.05).

Conclusion

The kinematic characteristics of the remnant preservation group are closer to those of normal people and the rehabilitation of the remnant preservation group is better than that of non-remnant preservation group in the early and mid-term period.

Key words: Anterior cruciate ligament reconstruction, Knee joint, Gait analysis
图1 三维膝关节动态功能分析系统。图A为接红外线信号收器、摄像头和分析软件等；图B为采集数据前用手持探头识别下肢各骨性体表标志
图2 膝关节6自由度。包括内外翻、内外旋、屈伸、前后位移、上下位移、内外位移
图3 受试者膝关节6自由度范围及运动功能评分数据。膝关节运动功能评分(左、右)为三维膝关节动态功能分析系统以多重相关系数计算将所测得双膝数据与正常人大样本对比分析得出，得分越高视作越接近正常人；一致性为比较双膝数据，评价双膝平衡性；三角形中参数为总分，是平衡性及双膝综合得分
图4 MRI测量胫骨隧道内口(术前为ACL足迹)中心至外侧半月板前角韧带足迹中心前后向(A-P)及内外向(M-L)距离。图A为术前胫骨MRI影像；图B为术后胫骨MRI影像
表1 患者各项临床基本资料
组别 例数 性别(男/女) 年龄[岁，(±s)] BMI[kg/m2，(±s)] 术侧肢体(左/右) 受伤时间[周，(±s)]
保残组 25 21/4 29.2±7.9 23.0±3.0 11/14 12.5±15.1
非保残组 25 19/6 30.5±5.9a 22.6±2.4 15/10 10.6±12.4
对照组 25 18/7 26.6±4.0 21.7±3.0 － －
统计值   χ2＝0.500 F＝2.668 F＝1.483 χ2＝1.282 t＝0.481
P值   >0.05 >0.05 >0.05 >0.05 >0.05
图5 术前各受试者位移自由度范围柱状图
图6 术前各受试者旋转自由度范围柱状图。*1-屈伸－非保残组vs对照组(F＝27.898，P<0.05)；*2-屈伸－保残组vs对照组(F＝18.276，P<0.05)
图7 术后3月各受试者位移自由度范围柱状图。*1-上下位移－非保残组vs对照组(t＝－2.655，P<0.05)；*2-内外位移－非保残组vs对照组(t＝－2.863，P<0.01)
图8 术后3月各受试者旋转自由度范围柱状图。*1-内外翻－非保残组vs对照组(F＝9.554，P<0.05)；*2-内外旋－保残组vs非保残组(t＝2.512，P<0.05)；*3-内外旋－非保残组vs对照组(t＝－5.067，P<0.01)；*4-内外旋-保残组vs对照组(t＝－2.365，P<0.05)；*5-屈伸－保残组vs非保残组(t＝2.428，P<0.05)；*6-屈伸－非保残组vs对照组(t＝－5.119，P<0.01)；*7-屈伸－保残组vs对照组(t＝－3.123，P<0.01)
图9 术后6月各受试者位移自由度范围柱状图。*-前后位移－非保残组vs对照组(t＝2.464，P<0.05)
图10 术后6月各受试者旋转自由度范围柱状图。*1-内外旋－非保残组vs对照组(t＝－3.516，P<0.01)；*2-内外旋－保残组vs对照组(t＝－2.419，P<0.05)；*3-屈伸－非保残组vs对照组(t＝－4.100，P<0.01)；*4-屈伸－非保残组vs保残组(t＝2.267，P<0.05)
图11 术后12月各受试者位移自由度范围柱状图
图12 术后12月各受试者旋转自由度范围柱状图。*-内外旋－非保残组vs对照组(t＝－3.076，P<0.01)
表2 术后各受试者主观评分(±s)
组别 例数 Lysholm评分
术前 术后3月 术后6月 术后12月
非保残组 25 62.4±10.1 72.0±5.0 83.9±4.2 89.9±4.3
保残组 25 59.6±10.1 78.7±5.1 86.2±3.6 91.4±3.7
t值   －0.965 4.706 2.106 1.338
P值   >0.05 <0.01 <0.05 >0.05
组别 例数 IKDC评分
术前 术后3月 术后6月 术后12月
非保残组 25 59.6±9.3 70.0±6.2 83.6±4.4 91.1±4.3
保残组 25 60.1±7.6 74.9±5.4 84.3±3.8 92.7±4.3
t值   0.200 2.987 0.586 1.305
P值   >0.05 <0.01 >0.05 >0.05
组别 例数 Tegner评分
术前 术后3月 术后6月 术后12月
非保残组 25 2.4±1.1 3.4±0.8 6.2±1.0 7.8±0.9
保残组 25 2.3±0.9 3.6±1.0 6.3±0.9 7.7±0.9
t值   －0.279 0.757 0.302 －0.322
P值   >0.05 >0.05 >0.05 >0.05
表3 各受试者中心距[mm，(±s)]
组别 例数 术前M-L 术后M-L 偏差 术前A-P 术后A-P 偏差
保残组 25 7.7±1.8 8.1±1.2 1.6±0.9 0.8±2.5 －1.1±1.5a 3.3±1.5
非保残组 25 7.9±2.2 9.0±1.4 2.4±1.3 0.1±3.0 －1.2±2.2 3.4±1.3
t值   － － －2.600 － － －0.387
P值   － － <0.05 － － >0.05
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