原位缝合联合单束重建治疗前交叉韧带损伤

doi:10.3877/cma.j.issn.1674-134X.2022.02.004

目的

应用原位缝合及原位缝合联合单束重建技术治疗前交叉韧带(ACL)损伤，并研究短期随访的临床结果。

方法

选择2016年1月至2018年6月福建医科大学附属第一医院ACL损伤患者作为观察组。纳入标准：确诊为前交叉韧带股骨端损伤的男性患者；排除标准：多发韧带损伤或受伤时间大于3月的患者。根据Sherman分型分为两个亚组并选择不同手术方式，Sherman-Ⅰ型亚组选择原位缝合(原位缝合组)，Sherman-Ⅱ/Ⅲ型选择原位缝合联合单束重建(联合重建组)。选择2015年1月至12月在同单位行ACL重建手术(单束重建)的患者数据作为对照组，同样根据Sherman分型分为Sherman-Ⅰ型亚组和Sherman-Ⅱ/Ⅲ型亚组。原位缝合及原位缝合联合单束重建患者进行1年临床随访。观测指标包括：膝关节评分(IKDC)；信噪比(SNQ)；Opti Knee三维膝关节运动测试；Lachman试验，前抽屉试验及轴移试验，GNRB膝关节稳定度测量仪检测关节稳定度。结果进行亚组间比较。连续性变量使用t检验，计数变量使用卡方检验。

结果

原位缝合及原位缝合联合单束重建17例患者获得随访，韧带重建对照组回顾性资料共获得28例完整数据。其中Sherman-Ⅰ型共19例，8例行原位缝合，11例为ACL重建(对照); Sherman-Ⅱ/Ⅲ型共26例，9例为联合重建组，17例为ACL重建(对照)。在IKDC评分，GNRB膝关节稳定度测试，Lachman试验，前抽屉试验及轴移试验等方面，各组间差异均无统计学意义(均为P>0.05)。术后MRI提示原位缝合组的SNQ值(9.8±3.2)高于联合重建组(6.4±1.9)(t＝2.6，P<0.05)。Opti Knee三维运动测试显示原位缝合组无论步行还是慢跑状态下，外旋角度均较健侧减小[步行状态健侧(22.3±1.2)°，患侧(15.0°±2.0)°，(t＝3.2，P<0.05)；慢跑状态健侧(23.0±1.3)°，患侧(14.1±1.8)°，(t＝4.0，P<0.05)]。股骨近端位移均较健侧减少[步行状态健侧(1.2±0.2) mm，患侧(0.5±0.1)mm，(t＝2.9，P<0.05)；慢跑状态健侧(1.1±0.3)mm，患侧(0.5±0.2)mm，(t＝3.1，P<0.05)]。而联合重建组无论是步行还是慢跑状态下健侧与术侧在各个方向的位移无明显差异。

结论

Sherman-Ⅰ型急性ACL损伤进行单纯原位缝合可以获得相当于韧带重建的临床疗效，针对Sherman-Ⅱ、Ⅲ型损伤，原位缝合联合单束重建术后1年的运动学评估可以完全恢复到健侧相同水平。

关键词: 缝合锚, 前交叉韧带损伤, 关节镜

Objective

Application of primary repair and primary repair combined with single bundle reconstruction technique to treat anterior cruciate ligament(ACL) injury, and study the clinical results of short-term follow-up.

Method

The patients with anterior cruciate ligament injury in the First Affiliated Hospital of Fujian Medical University from January 2016 to June 2018 were selected as the observation group. Inclusion criteria: male patients diagnosed with femoral side injury of ACL. Exclusion criteria: multiple ligament injury or injury time longer than three months. According to Sherman′s classification, they were divided into two subgroups and received different surgical methods. Sherman-type I subgroup chosed in-situ suture(the primary repair subgroup), Sherman-type Ⅱ/Ⅲ subgroup chosed in-situ suture combined with single bundle reconstruction(the combined repair subgroup). The patients who underwent ACL reconstruction(single bundle reconstruction) in the same institute from January to December, 2015 were selected as the control group, and they were also divided into the Sherman- type I subgroup and the Sherman- type Ⅱ/Ⅲ subgroup. The primary repair subgroup and the combined repair subgroup were followed up for one year. Outcome evaluation included: International Knee Documentation Committee (IKDC) knee score, signal / noise ratio (SNQ), Opti Knee three dimentional(3D) knee motion test, Lachman test, anterior drawer test and pivot shift test; the joint stability was examined by GNRB knee stability arthrometer. The results were compared among the subgroups. The t test was used for continuity variables and chi square test was used for counting variables.

Results

Seventeen patients in the primary repair group and the combined repair group were followed up. Complete data of 28 patients with ACL reconstruction were included in the control group. Among theses patients, there were 19 cases of Sherman-type I (eight cases chosed primary repair, and 11 cases were ACL reconstruction). There were 26 cases of Sherman -type Ⅱ/Ⅲ(nine cases chosed combined reconstruction, 17 cases were ACL reconstruction). There was no statistically significant difference among these subgroups in terms of IKDC score, GNRB, Lachman test, anterior drawer test, or pivot-shift test(all P>0.05). The postoperative MRI showed that the SNQ value of the primary repair subgroup (9.8± 3.2) was higher than the combined repair subgroup (6.4±1.9)(t=2.6, P <0.05). Opti Knee 3D motion test showed that in the primary repair group, the external rotation angle reduced on the involved side compared with the healthy side when walking or jogging [walking state: the healthy side was (22.3± 1.2)°, the involved side was(15.0±2.0)° , (t=3.2, P <0.05); jogging state: the healthy side was (23.0±1.3)°, the involved side was (14.1±1.8)°, (t=4.0, P<0.05)]. The proximal femoral displacement was reduced on the involved side compared to the healthy side[walking state: the healthy side was (1.2±0.2)mm, the involved side was (0.5±0.1)mm, (t=2.9, P<0.05); jogging state: the healthy side was (1.1±0.3)mm, the involved side was (0.5±0.2)mm, (t=3.1, P<0.05)]. In the combined repair subgroup, there was no statistically significant difference between the healthy and involved sides during walking or jogging state.

Conclusions

For Sherman-type I acute ACL injury, independent in-situ suture can obtain a clinical effect equivalent to single bundle reconstruction. For Sherman-type Ⅱ/Ⅲ injuries, the kinematic evaluation may indicate that the affected side can be restored to the same status as the healthy side after in-situ suture combined with single bundle reconstruction one year later.

Key words: Suture anchors, Anteiror cruciate ligament injuries, Arthroscope

图1 ACL(前交叉韧带)原位缝合技术。图A前交叉韧带股骨止点置入铆钉；图B应用缝合钩进行缝合；图C缝合后情况

图2 膝关节MRI影像SNQ(信噪比)的测量方法。图A为选取3个点平均作为移植物的信号值；图B为选取股四头肌肌腱前方2 cm作为背景信号

表1 Sherman-Ⅰ型亚组组间基线对比

分组	例数	年龄[岁，(±s)]	受伤时间[周，(±s)]	随访时间[月，(±s)]	ADT(例)		GNRB测量[mm，(±s)]
分组	例数	年龄[岁，(±s)]	受伤时间[周，(±s)]	随访时间[月，(±s)]	阴性	Ⅰ度	GNRB测量[mm，(±s)]
观察组	8	26.9±3.1	2.8±0.9	12.3±3.2	7	1	1.7±1.5
对照组	11	26.2±5.4	3.6±1.8	14.7±4.2	8	3	2.0±1.3
统计值		t＝0.32	t＝-2.64	t＝-1.40	χ²＝0.61		t＝-0.56
P值		>0.05	>0.05	>0.05	>0.05		>0.05
分组	例数	Lachman试验(例)		-	轴移试验(例)		IKDC(±s)
分组	例数	阴性	Ⅰ度	-	阴性	Ⅰ度	IKDC(±s)
观察组	8	6	2	-	6	2	80.9±9.4
对照组	11	9	2	-	9	2	82.6±7.3
统计值		χ²＝0.13		-	χ²＝0.13		t＝-0.07
P值		>0.05		-	>0.05		>0.05

表1 Sherman-Ⅰ型亚组组间基线对比

分组	例数	年龄[岁，(±s)]	受伤时间[周，(±s)]	随访时间[月，(±s)]	ADT(例)		GNRB测量[mm，(±s)]
分组	例数	年龄[岁，(±s)]	受伤时间[周，(±s)]	随访时间[月，(±s)]	阴性	Ⅰ度	GNRB测量[mm，(±s)]
观察组	8	26.9±3.1	2.8±0.9	12.3±3.2	7	1	1.7±1.5
对照组	11	26.2±5.4	3.6±1.8	14.7±4.2	8	3	2.0±1.3
统计值		t＝0.32	t＝-2.64	t＝-1.40	χ²＝0.61		t＝-0.56
P值		>0.05	>0.05	>0.05	>0.05		>0.05
分组	例数	Lachman试验(例)		-	轴移试验(例)		IKDC(±s)
分组	例数	阴性	Ⅰ度	-	阴性	Ⅰ度	IKDC(±s)
观察组	8	6	2	-	6	2	80.9±9.4
对照组	11	9	2	-	9	2	82.6±7.3
统计值		χ²＝0.13		-	χ²＝0.13		t＝-0.07
P值		>0.05		-	>0.05		>0.05

表2 Sherman-Ⅱ/Ⅲ型亚组组间基线对比

分组	例数	年龄[岁，(±s)]	受伤时间[周，(±s)]	随访时间[月，(±s)]	ADT(例)		GNRB测量[mm，(±s)]
分组	例数	年龄[岁，(±s)]	受伤时间[周，(±s)]	随访时间[月，(±s)]	阴性	Ⅰ度	GNRB测量[mm，(±s)]
观察组	9	32.0±3.8	4.9±3.0	12.1±2.6	7	2	1.3±1.3
对照组	17	29.9±7.2	5.6±3.2	14.0±2.4	15	2	1.7±1.0
统计值		t＝1.05	t＝-0.59	t＝-1.88	χ²＝0.49		t＝-0.72
P值		>0.05	>0.05	>0.05	>0.05		>0.05
分组	例数	Lachman试验(例)		轴移试验(例)		IKDC(±s)
分组	例数	阴性	Ⅰ度	阴性	Ⅰ度	IKDC(±s)
观察组	9	8	1	7	2	77.4±11.2
对照组	17	14	3	14	3	80.2±7.0
统计值		χ²＝0.79		χ²＝0.19		t＝-0.80
P值		>0.05		>0.05		>0.05

表2 Sherman-Ⅱ/Ⅲ型亚组组间基线对比

分组	例数	年龄[岁，(±s)]	受伤时间[周，(±s)]	随访时间[月，(±s)]	ADT(例)		GNRB测量[mm，(±s)]
分组	例数	年龄[岁，(±s)]	受伤时间[周，(±s)]	随访时间[月，(±s)]	阴性	Ⅰ度	GNRB测量[mm，(±s)]
观察组	9	32.0±3.8	4.9±3.0	12.1±2.6	7	2	1.3±1.3
对照组	17	29.9±7.2	5.6±3.2	14.0±2.4	15	2	1.7±1.0
统计值		t＝1.05	t＝-0.59	t＝-1.88	χ²＝0.49		t＝-0.72
P值		>0.05	>0.05	>0.05	>0.05		>0.05
分组	例数	Lachman试验(例)		轴移试验(例)		IKDC(±s)
分组	例数	阴性	Ⅰ度	阴性	Ⅰ度	IKDC(±s)
观察组	9	8	1	7	2	77.4±11.2
对照组	17	14	3	14	3	80.2±7.0
统计值		χ²＝0.79		χ²＝0.19		t＝-0.80
P值		>0.05		>0.05		>0.05

图3 ACL(前交叉韧带)单纯原位缝合步行状态下患侧与健侧Opti Knee数据对比。图A为屈曲角度差异(t＝3.0，P<0.05)；图B为外旋角度差异(t＝3.2，P<0.05)；图C为最大近端位移差异(t＝2.9，P<0.05)

图4 ACL(前交叉韧带)单纯原位缝合慢跑状态下患侧与健侧Opti Knee数据对比。图A为外旋角度差异(t＝4.0，P<0.05)；图B为最大近端位移(t＝3.1，P<0.05)

图5 右膝ACL(前交叉韧带)原位缝合后1年内随访膝关节MRI。图A为术前影像；图B术后3个月影像，示缝合处低信号；图C术后6个月影像，示缝合处高信号；图D术后9个月影像，示缝合处高信号；图E术后1年影像，示缝合处变回低信号注：术后1年内信号从低信号变为高信号、术后1年随访时变回低信号，提示移植物成熟过程

图6 右膝ACL(前交叉韧带)原位缝合联合韧带重建后1年内随访的MRI影像，示在韧带成熟过程中没有出现明显的高信号过程。图A为术前影像；图B为术后3个月影像；图C为术后6个月影像；图D为术后1年影像

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Primary repair combined with single-bundle reconstruction for anterior cruciate ligament injury

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Primary repair combined with single-bundle reconstruction for anterior cruciate ligament injury