切换至 "中华医学电子期刊资源库"

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:
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/OL]. 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/OL]. 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。

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.

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
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)
表3 各受试者中心距[mm,(±s)]
[1]
Zantop T, Herbort M, Raschke MJ, et al. The role of the anteromedial and posterolateral bundles of the anterior cruciate ligament in anterior tibial translation and internal rotation[J]. Am J Sports Med, 2007, 35(2): 223-227.
[2]
Ahn JH, Bae TS, Kang KS, et al. Longitudinal tear of the medial meniscus posterior horn in the anterior cruciate ligament-deficient knee significantly influences anterior stability[J]. Am J Sports Med, 2011, 39(10): 2187-2193.
[3]
Gianotti SM, Marshall SW, Hume PA, et al. Incidence of anterior cruciate ligament injury and other knee ligament injuries: a National population-based study[J]. J Sci Med Sport, 2009, 12(6): 622-627.
[4]
蔡道章.膝关节前交叉韧带损伤治疗的历史变革与发展[J/CD].中华关节外科杂志(电子版),2013,7(1):1-2.
[5]
Erhart-Hledik JC, Chu CR, Asay JL, et al. Longitudinal changes in knee gait mechanics between 2 and 8 years after anterior cruciate ligament reconstruction[J]. J Orthop Res, 2018, 36(5): 1478-1486.
[6]
Asaeda M, Deie M, Fujita N, et al. Gender differences in the restoration of knee joint biomechanics during gait after anterior cruciate ligament Reconstruction[J]. Knee, 2017, 24(2): 280-288.
[7]
Guskiewicz KM, Perrin DH, Martin DE, et al. Effect of ACL reconstruction and tibial rotation on anterior knee laxity[J]. J Athl Train, 1995, 30(3): 243-246.
[8]
Magnussen RA, Reinke EK, Huston LJ, et al. Effect of high-grade preoperative knee laxity on 6-year anterior cruciate ligament reconstruction outcomes[J]. Am J Sports Med, 2018, 46(12): 2865-2872.
[9]
Teng HL, Wu D, Su F, et al. Gait characteristics associated with a greater increase in medial knee cartilage T1ρ and T2 relaxation times in patients undergoing anterior cruciate ligament Reconstruction[J]. Am J Sports Med, 2017, 45(14): 3262-3271.
[10]
Hong L, Li X, Zhang H, et al. Anterior cruciate ligament reconstruction with remnant preservation[J]. Am J Sports Med, 2012, 40(12): 2747-2755.
[11]
Zhang Q, Zhang S, Cao X, et al. The effect of remnant preservation on tibial tunnel enlargement in ACL reconstruction with hamstring autograft: a prospective randomized controlled trial[J]. Knee Surg Sports Traumatol Arthrosc, 2014, 22(1): 166-173.
[12]
周敬滨,钱驿,席蕊,等.保残重建与非保残解剖重建对"后交叉韧带愈合"型前交叉韧带损伤的短期临床疗效对比研究[J].中国运动医学杂志,2018,37(11):899-904.
[13]
Wang HD, Wang FS, Gao SJ, et al. Remnant preservation technique versus standard technique for anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials[J/OL]. J Orthop Surg Res, 2018, 13(1): 231. doi: 10.1186/s13018-018-0937-4.
[14]
Ahn JH, Wang JH, Lee YS, et al. Anterior cruciate ligament reconstruction using remnant preservation and a femoral tensioning technique: clinical and magnetic resonance imaging results[J]. Arthroscopy, 2011, 27(8): 1079-1089.
[15]
李涛,敖英芳,周谋望.前交叉韧带重建术后膝关节位置觉和运动觉的早期观察研究[J].中国骨科临床与基础研究杂志,2009,1(1):44-48.
[16]
吴彦生,李永胜,陈百成.后交叉韧带保留与否对膝关节本体感觉的影响[J]. 中国修复重建外科杂志,2013,27(7):851-854.
[17]
代辰飞,白伦浩,高琳,等.前交叉韧带重建术后本体感觉恢复评价:股骨牵张保残法与标准方法比较[J].中国运动医学杂志,2014,33(1):5-9.
[18]
Pedneault C, Laverdière C, Hart A, et al. Evaluating the accuracy of tibial tunnel placement after anatomic single-bundle anterior cruciate ligament reconstruction[J]. Am J Sports Med, 2019, 47(13): 3187-3194.
[19]
Crain EH, Fithian DC, Paxton EW, et al. Variation in anterior cruciate ligament scar pattern: does the scar pattern affect anterior laxity in anterior cruciate ligament-deficient knees?[J]. Arthroscopy, 2005, 21(1): 19-24.
[20]
Muneta T, Koga H, Ju YJ, et al. Remnant volume of anterior cruciate ligament correlates preoperative patients' status and postoperative outcome[J]. Knee Surg Sports Traumatol Arthrosc, 2013, 21(4): 906-913.
[21]
Lee BI, Kwon SW, Kim JB, et al. Comparison of clinical results according to amount of preserved remnant in arthroscopic anterior cruciate ligament reconstruction using quadrupled hamstring graft[J]. Arthroscopy, 2008, 24(5): 560-568.
[22]
区永亮,黄华扬,郑小飞,等.单隧道双束前交叉韧带重建不同移植物固定角度的生物力学研究[J/CD].中华关节外科杂志(电子版),2013,7(1):70-76.
[23]
孙磊,吴波,田敏,等.兔保留与切除残迹前交叉韧带重建生物力学的比较[J/CD].中华关节外科杂志(电子版),2013,7(1):81-88.
[24]
Lin Z, Huang W, Ma L, et al. Kinematic features in patients with lateral discoid meniscus injury during walking[J/OL]. Sci Rep, 2018, 8(1): 5053. doi: 10.1038/s41598-018-22935-0.
[25]
Zhang Y, Huang WH, Yao ZL, et al. Anterior cruciate ligament injuries alter the kinematics of knees with or without meniscal deficiency [J]. Am J Sports Med, 2016, 44(12): 3132-3139.
[26]
Akpinar B, Thorhauer E, Irrgang JJ, et al. Alteration of knee kinematics after anatomic anterior cruciate ligament reconstruction is dependent on associated meniscal injury[J]. Am J Sports Med, 2018, 46(5): 1158-1165.
[27]
翟永喜,叶劲,陈艺,等.单髁与全膝关节置换术治疗膝内侧骨关节炎术后步态对比研究[J/CD].中华关节外科杂志(电子版),2017,11(1):9-16.
[28]
Lee BI, Min KD, Choi HS, et al. Immunohistochemical study of mechanoreceptors in the tibial remnant of the ruptured anterior cruciate ligament in human knees[J]. Knee Surg Sports Traumatol Arthrosc, 2009, 17(9): 1095-1101.
[29]
张磊,岳娜,张太良,等.保留残端与不保留残端重建前交叉韧带腱骨愈合情况比较[J].中国组织工程研究,2016,20(51):7634-7641.
[30]
Berchuck M, Andriacchi TP, Bach BR, et al. Gait adaptations by patients who have a deficient anterior cruciate ligament[J]. J Bone Joint Surg Am, 1990, 72(6): 871-877.
[31]
Konrath JM, Vertullo CJ, Kennedy BA, et al. Morphologic characteristics and strength of the hamstring muscles remain altered at 2 years after use of a hamstring tendon graft in anterior cruciate ligament Reconstruction[J]. Am J Sports Med, 2016, 44(10): 2589-2598.
[32]
Czamara A, Markowska I, Królikowska AA, et al. Kinematics of rotation in joints of the lower limbs and pelvis during gait: early results-SB ACLR approach versus DB ACLR approach [J/OL]. Biomed Res Int, 2015, 2015: 707168. doi: 10.1155/2015/707168.
[33]
Liu SH, Panossian V, Al-Shaikh R, et al. Morphology and matrix composition during early tendon to bone healing[J]. Clin Orthop Relat Res, 1997, 339(339): 253-260.
[34]
Rodeo SA, Arnoczky SP, Torzilli PA, et al. Tendon-healing in a bone tunnel: a biomechanical and histological study in the dog[J]. J Bone Joint Surg Am, 1993, 75(12): 1795-1803.
[35]
Rodeo SA, Suzuki K, Deng XH, et al. Use of recombinant human bone morphogenetic protein-2 to enhance tendon healing in a bone tunnel[J]. Am J Sports Med, 1999, 27(4): 476-488.
[1] 刘鹏, 罗天, 许珂媛, 邓红美, 李瑄, 唐翠萍. 八段锦对膝关节炎疗效的初步步态分析[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 590-595.
[2] 苏介茂, 齐岩松, 王永祥, 魏宝刚, 马秉贤, 张鹏飞, 魏兴华, 徐永胜. 关节镜手术在早中期膝骨关节炎治疗的应用进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(05): 646-652.
[3] 杨滢甄, 黄子荣, 梁家敏, 黄晓芳, 胡艳, 朱伟民. 膝关节前交叉韧带重建术前康复治疗的研究进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(04): 538-544.
[4] 赵飞鸿, 陈颖杰, 林静芳, 郑晓春, 廖燕凌. 超声引导下周围神经阻滞对髋膝关节置换术后恢复的影响[J/OL]. 中华关节外科杂志(电子版), 2024, 18(04): 457-468.
[5] 高小康, 张净宇, 刘金伟, 田东牧, 胡永成, 徐卫国. 连接型人工膝关节假体运动和负重模式的演变和进展[J/OL]. 中华关节外科杂志(电子版), 2024, 18(04): 505-516.
[6] 罗烨, 胡梦铃, 黄小凡, 林金鹏, 李竺蔓, 王少白. 支持向量机用于膝骨关节炎和韧带损伤的分类研究[J/OL]. 中华关节外科杂志(电子版), 2024, 18(02): 201-208.
[7] 蔡雨琦, 史尉利, 陶立元, 曹建夫, 崔国庆, 杨渝平. 支持带松解联合外侧成形治疗髌骨外侧过度挤压综合征[J/OL]. 中华关节外科杂志(电子版), 2024, 18(02): 186-192.
[8] 陆帅, 徐亮, 张尧, 方超, 赵其纯. 前交叉韧带重建术半月板成形对膝骨关节炎的远期影响[J/OL]. 中华关节外科杂志(电子版), 2024, 18(02): 167-174.
[9] 韩伟峰, 王典, 陈艺丹, 曾峥. 关节镜下半月板成形术与康复训练治疗中年退行性内侧半月板撕裂的疗效比较[J/OL]. 中华损伤与修复杂志(电子版), 2024, 19(02): 134-140.
[10] 高瑞, 康迪斯, 秦蘅, 胡月明, 初同伟, 代丽. 加速康复管理改善膝关节置换术后肺部感染并发症和疗效的Meta分析[J/OL]. 中华肺部疾病杂志(电子版), 2024, 17(02): 234-237.
[11] 宋庆成, 郑占乐, 王天瑞, 王宇钏, 张凯旋, 纳静, 蔚佳昊, 杨思繁, 宋九宏, 张英泽. “人老膝不老”:膝关节健康管理的全方位探索与实践[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(06): 321-324.
[12] 郑占乐, 王宇钏, 蔚佳昊, 宋庆成, 张凯旋, 纳静, 王天瑞, 宋九宏, 张英泽, 王娟. 保膝须“开膝”——“开膝”在膝骨关节炎中的临床应用价值[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(06): 325-330.
[13] 王浩汀, 尚运涛, 曹光, 张延祠, 李军勇. 胫骨高位截骨联合关节镜与单髁置换治疗单间室膝关节骨性关节炎的临床疗效比较[J/OL]. 中华老年骨科与康复电子杂志, 2024, 10(04): 229-236.
[14] 曾倩, 徐朝阳, 张丽芳. 帕金森病步态分析的研究进展[J/OL]. 中华脑科疾病与康复杂志(电子版), 2024, 14(04): 235-238.
[15] 于晓光, 秦永辉, 李佳, 贾国兴, 李军, 赵振栓, 刘国彬. 人工单髁置换术治疗膝关节内侧间室骨关节炎合并前交叉韧带功能不良的近期疗效[J/OL]. 中华临床医师杂志(电子版), 2024, 18(04): 337-342.
阅读次数
全文


摘要