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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) ›› 2021, Vol. 15 ›› Issue (01) : 23 -32. doi: 10.3877/cma.j.issn.1674-134X.2021.01.005

所属专题： 文献；

临床论著

前交叉韧带重建术后膝关节功能及三维运动步态分析
赵立连1, 卢明峰1,†(), 邢基斯1, 何利雷1, 许挺1, 王昌兵1   
  1. 1. 528000　佛山市中医院运动医学科
  • 收稿日期:2020-01-20 出版日期:2021-02-01
  • 通信作者: 卢明峰

Function and three-dimensional gait analysis of knee after anterior cruciate ligament reconstruction

Lilian Zhao1, Mingfeng Lu1,†(), Jisi Xing1, Lilei He1, Ting Xu1, Changbing Wang1   

  1. 1. Department of Sports Medicine, Foshan Hospital of Traditional Chinese Medicine, Foshan 528000, China
  • Received:2020-01-20 Published:2021-02-01
  • Corresponding author: Mingfeng Lu
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引用本文：

赵立连, 卢明峰, 邢基斯, 何利雷, 许挺, 王昌兵. 前交叉韧带重建术后膝关节功能及三维运动步态分析[J]. 中华关节外科杂志(电子版), 2021, 15(01): 23-32.

Lilian Zhao, Mingfeng Lu, Jisi Xing, Lilei He, Ting Xu, Changbing Wang. Function and three-dimensional gait analysis of knee after anterior cruciate ligament reconstruction[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2021, 15(01): 23-32.

目的

探讨前交叉韧带(ACL)重建术后膝关节稳定性、功能及三维步态运动学情况。

方法

回顾性分析2015年7月到2017年7月在佛山市中医院运动学科采用自体腘绳肌腱行ACL重建并进行了二次关节镜探查的270例病例，其中男164例，女106例。采用Lysholm评分、国际膝关节评分委员会(IKDC)评分、Tenger评分、膝关节损伤和骨关节炎(KOOS)评分、Lachman试验、轴移试验及KT-1000侧-侧差值评价膝关节功能及稳定性；比较膝关节6-自由度运动学参数，以客观评估术后膝关节功能；二次关节镜观察移植物连续性、移植物滑膜覆盖情况，分析移植物形态与膝关节功能、运动步态的相关性；分析患者术后重返运动情况及其影响因素。计数资料比较采用卡方检验，计量资料采用t检验。

结果

270例患者平均随访时间为(26 ± 11)个月，1例出现术后感染，经关节镜清理、置管引流后痊愈，其余病例均未发生感染、移植物吸收等并发症。所有患者末次随访平均Lysholm评分、IKDC主观评分、Tegner评分、KOOS的功能、生活质量、疼痛、日常生活及症状评分、IKDC客观评分、轴移试验、Lachman试验、和KT-1000侧-侧差值均较术前明显改善(t＝71.13、15.08、45.94、15.73、21.72、15.25、23.69、36.30、532.19、432.00、444.30、214.65，均为P<0.05)；二次关节镜探查191例前交叉韧带完整，79例重建韧带部分撕裂，230例韧带紧张，40例韧带松弛，220例移植物滑膜覆盖为优，50例为差。末次随访时所有患者的膝关节6自由度运动学参数(内外翻、内外旋、屈伸、上下位移、内外位移和前后位移范围)明显优于术前(t＝2.54、-8.67、11.06、-17.44、2.80、2.94，均为P<0.05)；滑膜覆盖优组其Lysholm评分、IKDC评分、Tegner评分及KT-1000侧-侧差值及膝关节6自由度运动学参数(内外旋角度和前后位移的范围)均优于滑膜覆盖差组(t＝13.50、7.69、20.05、12.69，均为P<0.01；t＝3.97、8.23，均为P<0.05)。屈伸角度、内外翻角度、内外和上下位移的范围滑膜覆盖优组与覆盖差组相当(P>0.05)。270例患者中有98例患者重返运动，重返运动率为36.3%。

结论

采用自体腘绳肌腱重建ACL能够获得较好的膝关节稳定性及功能，然而术后患者重返运动率较低，这是今后需要努力解决的关键问题。

关键词: 前交叉韧带重建, 膝, 运动
Objective

To investigate the knee joint stability, function and three-dimensional gait kinematics after anterior cruciate ligament reconstruction.

Methods

A retrospective analysis of 270 cases of ACL reconstruction and secondary arthroscopy was performed in the sports department of Foshan Traditional Chinese Medicine from July 2015 to July 2017.There were 164 males and 106 females. Lysholm score, International Knee Documentation Committee(IKDC) score, Tenger scale, knee injury and osteoarthritis outcome (KOOS) score, Lachman test, axle shift test and KT-1000 were used to evaluate function and stability of the knee. Six free domofmotion(6-DOF)was compared to evaluate the postoperative knee joint function objectively. Graft continuity, graft synovial coverage, and abnormal structure were observed in the joint during second look. The relationship between the morphology of the graft and the function and kinematics feature of the knee was analysed. The rate of return-to-sport (RTS) was caculated and the influencing factors were compared with those failed to RTS. Enumeration data were compared using the chi-square test, the quantity data were compared by t test.

Results

The average follow-up time of 270 patients was (26±11) months. One patient developed postoperative infection, which was cured by arthroscopy, catheterization and drainage. The other patients had no complication such as infection or graft absorption. At the last follow-up, Lysholm score, IKDC subjective score, Tegner score, KOOS (function score, quality of life, pain score, daily life, symptom score), IKDC objective evaluation, axial shift test, Lachman test and KT-1000 side to side difference in the last follow-up of all the patients were significantly improved compared with those before operation (t=71.13, 15.08, 45.94, 15.73, 21.72, 15.25, 23.69, 36.30, 532.19, 432.00, 444.30, 214.65, all P<0.05). During the second look, 191 patients had intact anterior cruciate ligament while other 79 patients had reconstructed ligament with partial tear. ACL of 230 patients demonstrated good tension while the others showed a loose ligament. ACL of 220 patients had good synovial coverage and the others showed poor synovial coverage. At the last follow-up, the 6-DOF kinematic parameters (ranges of adduction-abduction angles, internal-external angles, flexion and extension, proximal-distal translation, lateral-medial translation, anterior-posterior translation) of all the patients were significant superior than those before the operation(t=2.54, -8.67, 11.06, -17.44, 2.80, 2.94, all P<0.05). The Lysholm score, IKDC score, Tegner score, KT -1000 side-to-side difference, the ranges of internal-external angles, anterior-posterior translation of 6-DOF kinematic parameters of knee joint of superior synovium coverage group were better than those of poor synovium coverage group(t=13.50, 7.69, 20.05, 12.69, all P<0.01; t=3.97, 8.23, both P<0.05). The range of flexion and extension angles, adduction-abduction angles, lateral-medial translation, proximal-distal translation in the optimal synovium coverage group were similar to those in the poor synovium coverage group (P> 0.05). Among 270 patients, 98 patients returned to exercise, the rate of return to exercise was 36.3%.

Conclusions

ACL reconstruction with autogenous hamstring tendon can obtain better stability and function of knee joint. However, the rate of patients returning to exercise is low, which is the key problem to be solved in the future.

Key words: Anterior cruciate ligament reconstruction, Knee, Movement
图1 关节镜下二次探查包膜包裹情况。图A为韧带滑膜覆盖为优；图B为韧带滑膜覆盖为差
图2 关节镜下二次探查ACL(前交叉韧带)张力情况。图A为韧带紧张；图B为韧带松弛
图3 ACL(前交叉韧带)损伤后，术前步态分析提示胫骨前位移及内旋较对侧膝关节增大
表2 前交叉韧带重建术前与末次随访时膝关节功能及稳定性比较(例)
时间点 IKDC客观评级 Lachman试验
A级 B级 C级 D级 - ＋ ＋＋ ＋＋＋
例数 194 74 83 189 234 144 135 27
术前 0 0 81 189 0 108 135 27
末次随访 194 74 2 0 234 36 0 0
χ2值 532.19 432.00
P值 <0.05 <0.05
时间点 轴移试验 KT-1000侧-侧差值
- ＋ ＋＋ ＋＋＋ <3 mm 3～5 mm >5 mm
例数 237 120 134 49 223 143 174
术前 0 87 134 49 43 65 162
末次随访 237 33 0 0 180 78 12
χ2值 444.30 214.65
P值 <0.05 <0.05
表1 前交叉韧带重建术患者术前及末次随访功能评分(±s)
  Lysholm评分 Tegner评分 IKDC主观评分 KOOS评分
功能 生活质量 疼痛 日常生活 症状
术前 43.7±9.9 4.3±0.8 48.3±7.8 68.3±10.2 60.3±12.6 80.6±7.5 88.4±4.6 72.3±4.8
末次随访 92.2±6.1 6.6±2.2 86.7±10.4 85.0±12.1 70.6±12.0 88.9±8.7 97.1±3.8 85.2±3.1
t值 71.13 15.08 45.94 15.73 21.72 15.25 23.69 36.30
P值 <0.05 <0.05 <0.05 <0.05 <0.05 <0.05 <0.05 <0.05
表3 不同移植物滑膜覆盖分级的膝关节功能比较(±s)
滑膜覆盖分级 Lysholm评分 Tegner评分 IKDC主观评分 KT-1000侧-侧差值
优(220例) 94.1±4.2 7.2±1.1 93.2±2.9 1.2±0.6
差(50例) 85.3±4.0 5.7±1.7 80.2±5.3 2.9±1.6
t值 13.50 7.69 20.05 12.69
P值 <0.001 <0.001 <0.001 <0.001
表4 不同移植物滑膜覆盖分级膝关节的6-DOF变化(±s)
滑膜覆盖情况 内-外翻(°) 内-外旋(°) 屈曲-伸直(°) 前-后位移(cm) 内-外位移(cm) 上-下位移(cm)
优(220例) -9.1±5.6 13.5±4.9 57.8±6.2 1.0±0.5 -1.2±0.7 1.7±0.9
差(50例) -10.2±5.9 16.5±4.4 58.9±7.6 1.7±0.7 -1.3±0.6 1.8±0.6
t值 1.30 3.97 1.10 8.23 0.89 0.93
P值 >0.05 <0.05 >0.05 <0.05 >0.05 >0.05
表5 前交叉韧带重建术前与末次随访膝关节的6-DOF变化(±s)
时间点 内-外翻(°) 内-外旋(°) 屈曲-伸直(°) 前-后位移(cm) 内-外位移(cm) 上-下位移(cm)
术前 -10.8±5.8 19.2±4.4 50.6±9.0 2.7±0.7 -1.3±0.5 1.8±0.7
末次随访 -9.9±6.2 15.6±5.3 58.2±9.0 1.6±0.9 -1.2±0.9 1.7±0.7
t值 2.54 -8.67 11.06 -17.44 2.80 2.94
P值 <0.05 <0.05 <0.05 <0.05 <0.05 <0.05
表6 前交叉韧带重建术患者重返运动与未重返运动的比较
分组 例数 年龄[岁，(±s)] 女性(例) 有合并伤(例) 手术时间[min，(±s)] BMI[kg/m2，(±s)] 术前Tegner评分(±s)
重返运动组 98 28.3±7.4 34 8 40.6±17.5 23.6±2.2 4.5±1.2
未重返运动组 172 36.4±7.6 72 13 41.7±15.8 25.5±2.3 4.1±1.0
统计值   t＝8.49 χ2＝1.35 χ2＝0.03 t＝0.52 t＝6.77 t＝3.40
P值   <0.05 >0.05 >0.05 >0.05 <0.05 <0.05
分组 例数 术后KOOS评分(±s)
功能 生活质量 疼痛 日常生活 症状
重返运动组 98 88.2±11.5 72.5±13.3 84.7±9.7 97.6±3.5 77.6±2.1
未重返运动组 172 81.8±12.6 69.7±11.2 93.2±6.4 96.6±4.6 86.8±1.9
统计值   t＝4.16 t＝1.88 t＝8.60 t＝1.92 t＝36.46
P值   <0.05 >0.05 <0.05 >0.05 <0.05
图4 关节镜下内支架情况。图A为移植物包膜完整，内支架松弛；图B为术中探查显示内支架高强线松弛
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