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中华关节外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (06) : 690 -696. doi: 10.3877/cma.j.issn.1674-134X.2022.06.007

临床论著

前交叉韧带重建术后膝前疼痛的危险因素分析
崔毅鹏1, 李若尘1, 刘蔚1, 陈曦2, 杨佩1, 王坤正1, 李苗3,†()   
  1. 1. 710004　西安交通大学第二附属医院骨关节外科
    2. 710004　西安交通大学第二附属医院肿瘤科
    3. 710004　西安交通大学第二附属医院超声科
  • 收稿日期:2022-04-14 出版日期:2022-12-01
  • 通信作者: 李苗
  • 基金资助:
    国家自然科学基金(81772346)

Risk factors of anterior knee pain after anterior cruciate ligament reconstruction

Yipeng Cui1, Ruochen Li1, Wei Liu1, Xi Chen2, Pei Yang1, Kunzheng Wang1, Miao Li3,†()   

  1. 1. Department of Bone and Joint Surgery, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, China
    2. Department of Oncology, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, China
    3. Department of Ultrasound, the Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710004, China
  • Received:2022-04-14 Published:2022-12-01
  • Corresponding author: Miao Li
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引用本文：

崔毅鹏, 李若尘, 刘蔚, 陈曦, 杨佩, 王坤正, 李苗. 前交叉韧带重建术后膝前疼痛的危险因素分析[J]. 中华关节外科杂志(电子版), 2022, 16(06): 690-696.

Yipeng Cui, Ruochen Li, Wei Liu, Xi Chen, Pei Yang, Kunzheng Wang, Miao Li. Risk factors of anterior knee pain after anterior cruciate ligament reconstruction[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2022, 16(06): 690-696.

目的

通过基于肌骨超声和多变量logistic回归分析的回顾性研究探索前交叉韧带重建术(ACLR)后膝前疼痛(AKP)的危险因素。

方法

采用回顾性病例对照研究随访于西安交通大学第二附属医院行ACLR的患者，排除有同侧膝关节周围手术史及同侧膝关节慢性疾病患者，纳入18~50岁、由同一医师行自体腘绳肌腱ACLR的患者35人。根据术后症状及视觉模拟评分法(VAS)分为AKP组与无AKP组，记录两组患者的年龄、性别等资料。完善国际膝关节文献委员会膝关节评估表(IKDC)、部分费勒量表；测量胫骨前位移量、伸膝受限角度等；利用二维超声检测髌腱及髌下脂肪垫(IFP)的形态学、厚度，利用多普勒超声检测IFP血流信号，利用弹性超声检测IFP及髌腱横波传导速度。对部分变量进行相关分析后，确定回归模型，进行多变量logistic回归分析，寻找相关危险因素。

结果

单变量分析结果显示，AKP组中女性患者占比更高(P＝0.018)，AKP组患者的股四头肌肌力下降高于非AKP组(Z＝2.40，P<0.05)，超声检查发现AKP组IFP血流增加的患者比例更高(P＝0.018)，横波传导速度更快(t＝7.64，P<0.05)，其余指标差异无统计学意义(均P>0.05)。多变量logistic回归分析结果显示，女性[比值比(OR)＝12.13，95%置信区间(CI) (1.55，94.99)]、股四头肌肌力下降[OR＝7.94，95%CI(1.14，55.43)]及IFP血流增加[OR＝8.90，95%CI(1.25，63.56)]是ACLR术后膝前疼痛的危险因素(均为P<0.05)。

结论

前交叉韧带重建术后女性发生膝前疼痛的风险高于男性，股四头肌肌力下降及IFP充血水肿是膝前疼痛发生的危险因素。

关键词: 前交叉韧带重建, 髌股疼痛综合征, 脂肪组织, 超声检查, 回归分析
Objective

To investigate the possible risk factors for anterior knee pain syndrome (AKP) after the anterior cruciate ligament reconstruction (ACLR) based on multivariate logistic regression analysis and musculoskeletal ultrasound (MSKUS).

Methods

A retrospective case-control study was conducted to analysis patients who underwent anterior cruciate ligament reconstruction (ACLR) in the Second Affiliated Hospital of Xi’an Jiaotong University. Patients with a history of surgery or chronic disease around the ipsilateral knee were excluded. A total of 35 patients aged from 18 to 50 years who underwent ACLR with autologous hamstring tendon by the same doctor were enrolled and divided into two groups: the anterior knee pain group (the AKP group) and the non-AKP group, according to the postoperative symptoms and visual analogue scale (VAS) score. The patient baseline characteristics, such as age, gender, were recorded. The patients filled out a questionnaire about the International Knee Documentation Committee (IKDC) scale and sectional Feller scale. Anterior knee laxity and flexion contracture were measured. The morphological features and thickness of the patellar tendon and infrapatellar fat pad (IFP) were measured by two-dimensional ultrasound. The IFP blood flow signal were measured by Doppler ultrasound. The shear wave velocity of the patellar tendon and IFP were measured by ultrasonic elastography. After correlation analysis of some variates with statistical differences, the multivariate logistic regression analysis was conducted to find relevant risk factors.

Results

Univariate analysis showed that the proportion of female patients in the AKP group was higher (P=0.018), the reduction of quadriceps muscle strength in the AKP group was higher than that in the non-AKP group (Z=2.40, P<0.05), ultrasonography showed that the proportion of patients with increased IFP blood flow was higher in the AKP group (P=0.018), and the shear wave velocity of IFP was faster in the AKP group(t=7.64, P<0.05). There was no significant difference in other variates (all P>0.05). Multivariate logistic regression analysis showed that female [odds ratio(OR)=12.13, 95% confidence interval(CI) (1.55, 94.99)], the reduction of quadriceps muscle strength [OR=7.94, 95%CI (1.14, 55.43)] and the increase of IFP blood flow[OR=8.90, 95%CI (1.25, 63.56)] were risk factors for anterior knee pain after ACLR (all P<0.05).

Conclusion

The risk of AKP is higher in female than in men after ACLR. Moreover, the reduction of quadriceps muscle strength, the hyperemia and edema of IFP are risk factors for AKP after ACLR.

Key words: Anterior cruciate ligament reconstruction, Patellofemoral pain syndrome, Adipose tissue, Ultrasonography, Regression analysis
表1 随访ACLR术后患者基线资料比较
分组 例数 性别(例) 年龄[岁，(±s)] 受伤侧别(例) 术前Tegner评分(±s) 术后门诊就诊时间[周，(±s)] 合并半月板缝合(例)
男 女 右 左 是 否
AKP组 19 6 13 33.1±9.5 13 6 4.0(3.0，5.0) 5.7±2.7 15 4
无AKP组 16 12 4 34.4±3.0 10 6 5(3.3，7.8) 5.9±3.4 11 5
统计值 － t＝0.55 － Z＝1.62 t＝0.18 －
P值 0.018* >0.05 0.736* >0.05 >0.05 0.700*
表2 ACLR术后患者体格检查结果比较
分组 例数 IKDC评分(±s) 双腿部分费勒得分差异M(P25，P75) 胫骨前移量[mm，(±s)] 患膝伸直受限角度(例)
>10° ≤10°
AKP组 19 52.4±9.7 6.0(6.0，6.0) 1.1±0.4 7 12
无AKP组 16 50.9±11.6 4.0(2.0，6.0) 0.9±0.3 3 13
统计值 t＝0.40 Z＝2.40 t＝1.07 －
P值 >0.05 <0.05 >0.05 0.285
图1 患者膝关节超声检查结果(男性，24岁)。图A二维超声提示髌腱及髌下脂肪垫形态正常，未见异常回声；图B多普勒超声提示髌下脂肪垫血流信号增强；图C弹性成像模式下髌下脂肪垫、髌腱弹性图像以红色为主，横波传导速度：髌下脂肪垫4.3 m/s，髌腱7.7 m/s
表3 ACLR术后患者的超声评估指标
分组 例数 二维超声[mm，(±s)] 多普勒超声(例) 弹性成像[m/s，(±s)]
髌腱厚度 IFP厚度 IFP血流不增加 IFP血流增加 髌腱横波传导速度 IFP横波传导速度
AKP组 19 2.72±0.34 8.06±0.57 6 13 7.70±0.14 4.17±0.75
无AKP组 16 2.72±0.34 8.16±0.77 12 4 7.60±0.16 2.72±0.32
统计值 t＝0.03 t＝0.44 － t＝1.88 t＝7.64
P值 >0.05 >0.05 0.018* >0.05 <0.05
表4 AKP的多变量logistic回归分析(Forward，LR，α＝0.05)
回归系数 标准误 Vald的χ2值 OR(95%CI) P值
性别 男 2.50 1.05 5.65 1.00 <0.05
女 12.13(1.55，94.99)
双腿部分Feller评分差异 <6 2.07 0.99 4.37 1.00 <0.05
≥6 7.94(1.14，55.43)
IFP血流增加 否 2.19 1.00 4.76 1.00 <0.05
是 8.90(1.25，63.56)
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