Abstract
目的
评估两种不同的股骨皮质悬吊装置(固定袢和可调节袢)重建前交叉韧带术后12个月患者的股骨骨道增宽情况及膝关节功能。
方法
共纳入60例行前交叉韧带重建术的患者，根据袢在粗骨道中长度(n)[n=袢的总长度-(股骨骨道总长度-粗骨道的总长度)]将患者分为A(可调节袢在粗骨道中长度为0 mm)、B(固定袢在粗骨道中长度为＞0 mm、≤10 mm之间)、C(固定袢在粗骨道中长度＞10 mm)三组，其中A组病例数为11例，B组病例数为27例，C组病例数为22例，比较三组患者在膝CT关节三维重建术后12个月与术后即刻股骨骨道增宽情况，同时比较三组患者的国际膝关节委员会(International Knee Documentation Committee，IKDC)评分、Lysholm评分及Tegner评分。
结果
A、B、C三组的股骨骨道增宽程度存在差异，术后12个月和术后即刻股骨骨道增宽差值中位数：A＜B＜C。A组的股骨骨道增宽差值及差值占比与B、C两组相比，差异有统计学意义(P＜0.05)。根据线性回归关系发现n值与骨道增宽差值存在线性关系，随着n值的增大，骨道增宽的差值逐渐变大。股骨中上骨道的增宽差值中位数出现负数，中下骨道的增宽差值中位数均为正数。随访时发现三组术后12个月的IKDC、Lysholm、Tegner评分差异无统计学意义(P＞0.05)。
结论
A组与B组、C组相比，其术后12个月的骨道增宽程度较小；在A、B、C三组中随着袢在粗骨道中的长度逐渐增大，骨道增宽程度越显著；前交叉韧带重建术后12个月患者，其股骨中下骨道较术后即刻骨道增宽明显，股骨中上骨道已逐渐开始发生重建肌腱和股骨愈合；在术后12个月的随访患者中，A、B、C三组膝关节功能评分差异无统计学意义。
Keywords: 前交叉韧带重建, 固定袢, 可调节袢, 骨道增宽, 膝关节功能
Abstract
Objective
To evaluate the effects of two different femoral cortical suspension devices (fixation loop and adjustable loop) on tunnel widening and knee function in patients following anterior cruciate ligament reconstruction for 12 months.
Methods
A total of 60 patients who had undergone anterior cruciate ligament reconstruction were included in this study. According to the length of the loop(n)[n= total length of loop-(total length of femoral tunnel-total length of coarse tunnel)] in the rough bone tunnel, the patients were divided into A (adjustable loop was 0 mm in the coarse bone tunnel), B (fixation loop was greater than 0 mm and less than or equal to 10 mm in the coarse bone tunnel) and C (fixation loop was greater than 10 mm in the coarse bone tunnel) groups, of which 11 cases were in group A, 27 cases in group B and 22 cases in group C. In the three-dimensional reconstruction of the knee joint with multi-slice spiral CT, the widening of the bone tunnel in the three groups was compared. At the same time, IKDC, Lysholm and Tegner scores of the patients in the three groups were compared.
Results
There were differences in the widening degree of the femoral canal among groups A, B and C, and the median difference of the widening degree of the femoral tunnel 12 months and immediately after the surgery was A < B < C. The difference of femoral canal widening in group A was significantly different from that in groups B and C (P < 0.05).According to the linear regression the relationship between the difference of the width of the femoral canal and the change of the length (n) of the loop in the coarse canal, it was found that there was a linear relationship between the value of n and the difference of the width of the bone canal. With the increase of the value of n, the difference of the width of the bone canal gradually became larger. The median difference of the width of the middle and superior tunnel was negative, while the median difference of the width of the middle and inferior tunnel was positive. During the follow-up, we found that there were no statistical differences in IKDC, Lysholm and Tegner scores among the three groups one year after surgery (P > 0.05).
Conclusion
Twelve months after surgery, compared with group B (fixed loop group) and group C (fixed loop group), group A (adjustable loop group) had less bone tunnel widening.In groups A, B and C, as the length of the loop in coarse bone tunnel gradually increased, the width of bone tunnel became more significant. At the end of 12 months follow-up after anterior cruciate ligament reconstruction, the medial and inferior femoral tunnel was significantly wider than immediately after surgery, and the medial and superior femoral tunnel had gradually begun to undergo tendon-bone healing. There was no significant difference in knee function scores among groups A, B, and C in the follow-up 12 months after surgery.
Keywords: Anterior cruciate ligament reconstruction, Fixation loops, Adjustable loops, Bone tunnel widening, Knee function
随着前交叉韧带损伤患者逐年增长和手术治疗方式的提升，人们对前交叉韧带损伤的治疗效果也就越来越重视。目前，前交叉韧带断裂采取的主要治疗方式是前交叉韧带重建术。骨皮质悬吊装置操作简单、可靠、抗拉强度高，故在前交叉韧带重建中得到广泛应用[1-2]。据文献报道[3]，悬吊装置的缺点之一就是骨道直径的渐进扩大。固定袢(如Endobutton)主要通过将钛板拉出股骨骨道远端外侧，通过翻钛板感来确定其已固定在股骨外侧，即使通过精确的测量仍将会导致移植物与粗细骨道交界处存在一段间隙，这将导致移植物的运动增加，间隙增大，移植物活动范围越大，从而将导致骨道增宽越显著。可调节袢(如Tightrope)可以用类似滑轮系统的原理来缩短环，并将移植物送到粗细骨道交界处，使其紧密接触在一起，因此，从理论上讲可调节袢可以减少“蹦极”效应，减少骨道增宽[4]。对于前交叉韧带重建术后骨道增宽患者，文献报道不会导致膝关节不稳，也不会导致明显的不适症状及体征[5]，但对于前交叉韧带重建术后再次发生前交叉韧带断裂的患者，其骨道的增宽对于翻修而言影响较大，由此可能导致翻修手术分期进行，一期行骨道内固定物取出、骨道的清理、骨道内植骨，待骨道融合后再行二期翻修手术。
本研究以腘绳肌为移植物比较在前交叉韧带重建患者中可调节袢与固定袢分别固定股骨端时，袢在粗骨道中的长度(n)对股骨骨道增宽及膝关节功能的影响。
1. 资料与方法
1.1. 一般资料
2019年8月至2020年1月在北京大学第三医院首都机场院区行前交叉韧带重建手术患者共206例，符合入组要求的患者为103例，失访43例(因新冠疫情影响，很多患者无法按时完成术后复查，故失访)，最终符合纳入和排除标准要求的60例连续行前交叉韧带重建术的患者中男性46例(平均年龄为33.3岁)，女性14例(平均年龄为39.2岁)。根据袢在粗骨道中长度(n)的大小[n=袢的总长度-(股骨骨道总长度-粗骨道的总长度)]将患者分为A(n=0 mm)、B(0 mm＜n≤10 mm)、C(n＞10 mm)三组，手术适应证为患者前交叉韧带断裂诊断明确，不能满足其运动或竞技需求，患膝疼痛明显，严重影响其生活质量，且经保守治疗无效的患者。本研究所有纳入患者均比较术后12个月与术后即刻CT测量结果，从而判断骨道增宽情况。纳入标准: (1)术前MRI和术中检查明确诊断为前交叉韧带断裂；(2)修复后12个月使用术后CT评估固定袢或可调节袢仍处于正常位置，未滑脱或移位；(3)术后12月评估患者膝关节的功能状态；(4)单纯前交叉韧带断裂，不存在其他韧带联合伤；(5)术后即刻及术后12个月的CT影像学资料完整。排除标准：(1)影像学资料不完整及显示不清；(2)既往曾行同侧膝关节手术；(3)多韧带损伤患者；(4)膝关节X线或CT显示钛板与股骨皮质贴合不紧密。本研究为回顾性研究，已经过北京大学第三医院医学科学研究伦理委员会审查批准(2013111)。
1.2. 手术方法
患者在硬膜外麻醉状态下以平卧位进行手术，常规前内、前外入路确认前交叉韧带断裂，取腱器取出半腱肌及股薄肌。前内入路内下附加入路定位股骨止点，用4.5 mm的克氏针在平卧位屈膝状态下打出股骨骨道，并根据重建韧带粗度打出粗骨道，点对点瞄准器定位胫骨止点并制备胫骨骨道，通过胫骨骨道将股骨端固定物拉出，钛板被拉出股骨骨道后再进行翻转固定，确认伸屈时移植物无移动，伸直时前方及外侧无撞击，拉紧移植物，在后推应力下通过螺钉固定重建韧带下止点。
1.3. 袢在粗骨道中的长度及术后骨道宽度的测量方式
所有患者均在CT扫描三维重建下评估患者膝关节的骨道增宽数据。n=袢的总长度-(股骨骨道总长度-粗骨道的总长度)，如股骨端固定物为可调节袢时，可认为n=0 mm。A组患者股骨端固定物全部使用可调节袢，B组患者股骨端固定物全部使用固定袢，但其袢在粗骨道中的长度为0＜n≤10 mm，C组患者股骨端固定物全部使用固定袢，但其袢在粗骨道中的长度为n＞10 mm。袢在粗骨道中的长度及术后骨道宽度的具体测量方法为：进入影像归档和通信系统(Picture Archiving and Communication Systems, PACS)中，选择膝关节CT的重建模块，视野中分别呈现出膝关节的冠状位、矢状位和轴位图像，选择多斜线模式，在膝关节的冠状位、矢状位和轴位图像中均出现垂直相交的两条基准线，其相交的点为基准点，调整膝关节CT基准点的位置，膝关节的冠状位、矢状位和轴位均会发生相应的变化，调整膝关节冠状位的层面直至出现骨道，将基准点放在冠状位骨道的任意一点上，其斜轴位上将出现股骨骨道，并将斜轴位的基准点放置在骨道的中心位置上，同时将一条基准线调至与股骨骨道平行，可在斜矢状位上看到股骨骨道，调整斜矢状位的层面至骨道宽度最大时(图 1)，便为穿过骨道中心轴的层面，并测量此位置上股骨上骨道长度和粗骨道长度，同时可在斜轴位上看到通过骨道中心轴的骨道层面(图 2A)，并测量此位置上股骨上骨道长度和粗骨道长度，我们发现不管是在斜矢状位还是斜轴位上，测得的股骨上骨道长度和粗骨道长度基本相同，调整垂直于骨道的另一条基准线的位置，可以测得骨道各个位置的直径(图 2B)，这样我们便可以测得粗骨道中心轴的4个点的骨道宽度(图 2C、D)，这4个点分别为股骨骨道的内口(切迹处)宽度(M1)、股骨粗骨道下1/3点处骨道宽度(M2)、股骨粗骨道上1/3点处骨道宽度(M3)、粗细骨道交界处宽度(M4)。同时可在斜矢状位或斜轴位的骨道中心轴层面测出整个股骨上骨道的长度(S)和粗骨道的长度(X)，从而便可计算出袢在粗骨道中的长度(n)。通过同样办法可测量术后12个月的骨道宽度，从而进行比较。
图 1.
CT三维重建斜矢状位骨道中心轴切面
Oblique sagittal view of the central axis of the femoral tunnel in a 3D reconstruction CT
1, superior femoral tunnel is 32.2 mm; 2, femoral coarse tunnel is 23.8 mm.
图 2.
CT测量粗骨道各个位置的骨道宽度
CT measurement of the width of the bony tunnel at each position
A, oblique axial central section of the femoral tunnel in a 3D reconstruction, 3 of the superior femoral tunnel is 32.7 mm, 4 of the femoral coarse tunnel is 23.6 mm; B, oblique coronal section perpendicular to the central axial section of the femoral tunnel in a 3D reconstruction CT; C, schematic view of oblique axial central section of the femoral tunnel in a 3D reconstruction CT, S is the length of the superior femoral tunnel, X is the length of the coarse femoral tunnel, M1 is the width of the internal opening (notch) of the femoral tunnel, M2 is the width of the lower 1/3 point of the femoral coarse femoral tunnel, M3 is the width of the 1/3 point of the femoral coarse femoral tunnel, and M4 is the width of the junction of the thick and thin femoral tunnel; D, schematic view of oblique coronal section perpendicular to the central axial section of the femoral tunnel in a 3D reconstruction CT, double arrows show the measured tunnel width.
1.4. 术后康复
三组在修复后均采用相同的康复方案。术后麻醉消退后立即开始踝泵练习、股四头肌收缩、腘绳肌收缩、直抬腿，术后第一天开始伸膝练习，术后第二天可进行屈膝练习。单纯前交叉韧带重建患者术后第二天即可下地负重行走，以满足简单日常生活。合并软骨损伤、半月板切除或缝合的患者的负重行走酌情延后(即患肢不可以踩地)。
1.5. 影像学及临床评估指标
影像学评估：所有患者均计算上骨道长度、粗骨道长度、粗骨道宽度(移植物直径，T)，股骨骨道内口(切迹处)、粗细骨道交界处、股骨骨道内口与粗细骨道交界处这两点的三等分位置的骨道宽度。
临床评估：所有患者均通过年龄、体重指数(body mass index，BMI)、IKDC评分、Lysholm评分、Tegner评分评估患者的膝关节功能。
1.6. 数据分析
所有的统计分析均使用SPSS 22.0软件，根据统计数据对粗骨道各个位置的分布进行了分布总结及线性回归分析，以分组计算中位数, 并进行Wil-coxon秩和检验分析，用t检验来比较三组骨道的增宽情况及膝关节功能评分，并绘制膝关节功能评分的箱线图。
2. 结果
A、B、C三组的术后12个月和术后即刻股骨骨道增宽差值及差值占比中位数：A＜B＜C，股骨中上骨道的增宽差值中位数出现负数，中下骨道的增宽差值中位数均为正数(表 1)。在年龄、BMI、粗骨道直径(移植物直径)、M3方面，A、B、C三组在两组分别相互比较时差异无统计学意义(P＞0.05)。B组与C组、A组与C组在上骨道长度方面相互比较时差异无统计学意义(P＞0.05)，A组与B组之间比较时差异有统计学意义(P＜0.05)。在粗骨道长度方面，A与B、C两组相互比较时差异有统计学意义(P＜0.05)，B组与C组之间相互比较时差异无统计学意义(P＞0.05)。对M1来说，C组与A组、B组之间相互比较时差异有统计学意义(P＜0.05)，A组与B组之间差异无统计学意义(P＞0.05)。对M2、M4来说，B组与A组、C组之间差异无统计学意义(P＞0.05)，A组与C组之间差异有统计学意义(P＜0.05)。根据术后12个月粗骨道各位置的骨道宽度与术后即刻粗骨道宽度(T)的差值及差值所占术后即刻粗骨道直径的百分比进行统计分析，A、B、C三组两两进行比较时发现M1-T、(M1-T)/T差异有统计学意义(P＜0.05)。在M2-T、M3-T、M4-T、(M2-T)/T、(M3-T)/T、(M4-T)/T这些变量方面，A组与B组、A组与C组之间相互比较时差异有统计学意义(P＜0.05)，B组与C组之间差异无统计学意义(P＞0.05，表 2)。根据线性回归关系发现n值与骨道增宽差值存在线性关系，随着n值的增大，骨道增宽的差值逐渐变大(图 3)。根据分析结果我们发现A、B、C三组在术后12月的膝关节功能评分(IKDC评分、Lysholm评分、Tegner评分)差异无统计学意义(P＞0.05)，在箱线图上可以更直观的呈现(表 3、图 4~6)。
表 1.
A、B、C三组变量的结果
Results of variables in group A, B and C
| Items | A | B | C |
| T, width of the coarse femoral tunnel; M1, width of the femoral tunnel at the notch(at 12 months postoperatively); M2, width of the femoral tunnel at the lower 1/3 point(at 12 months postoperatively); M3, width of the femoral tunnel at higher 1/3 point(at 12 months postoperatively); M4, width of the femoral tunnel at the junction of the thick and thin passages(at 12 months postoperatively). A, adjustable loop is 0 mm in the coarse bone tunnel; B, fixation loop is greater than 0 mm and less than or equal to 10 mm in the coarse bone tunnel; C, fixation loop is greater than 10 mm in the coarse bone tunnel. | |||
| Age/year, M (Min, Max) | 33 (25，45) | 31 (18，58) | 36 (24，48) |
| BMI/(kg/m2), M (Min, Max) | 25.7 (20.6，28.7) | 24.0 (18.2，31.4) | 24.1 (18.6，29.7) |
| Lengths of the superior femoral tunnel/mm, M (Min, Max) | 30.0 (29.0，36.9) | 34.2 (29.0，43.0) | 33.6 (25.8，38.6) |
| Lengths of the coarse femoral tunnel/mm, M (Min, Max) | 17.7 (15.5，25.0) | 25.2 (16.7，29.4) | 26.9 (22.0，29.4) |
| T/mm, M (Min, Max) | 8.000 (7.000，9.000) | 8.000 (7.000，9.000) | 8.000 (7.000，9.000) |
| M1/mm, M (Min, Max) | 9.300 (7.600，11.800) | 9.600 (7.900，12.000) | 10.950 (8.800，15.100) |
| M2/mm M (Min, Max) | 9.400 (7.200，11.900) | 9.500 (8.100，13.000) | 10.300 (8.400，12.700) |
| M3/mm M (Min, Max) | 7.600 (4.500，9.900) | 8.200 (6.000，10.700) | 7.700 (6.300，12.200) |
| M4/mm M (Min, Max) | 4.000 (1.600，6.000) | 5.100 (3.500，8.000) | 5.200 (4.200，9.300) |
| M1-T/mm M (Min, Max) | 1.000 (0.300，3.800) | 1.800 (0.700，3.600) | 3.100 (1.500，7.100) |
| M2-T/mm M (Min, Max) | 1.100 (-0.500，3.900) | 1.800 (0.300，5.000) | 2.300 (0.600，5.200) |
| M3-T/mm M (Min, Max) | -0.400 (-4.500，1.900) | 0.250 (-1.700，2.700) | 0.350 (-1.300，3.800) |
| M4-T/mm M (Min, Max) | -3.100 (-7.100，-2.100) | -2.700 (-4.500，-1.000) | -2.600 (-3.700，1.300) |
| (M1-T)/T/% M (Min, Max) | 0.125 (0.038，0.475) | 0.243 (0.088，0.450) | 0.401 (0.188，0.888) |
| (M2-T)/T/% M (Min, Max) | 0.157 (-0.056，0.488) | 0.238 (0.038，0.625) | 0.301 (0.075，0.743) |
| (M3-T)/T/% M (Min, Max) | -0.050 (-0.500，0.238) | 0.016 (-0.213，0.338) | 0.019 (-0.162，0.529) |
| (M4-T)/T/% M (Min, Max) | -0.443 (-0.800，-0.263) | -0.348 (-0.563，-0.111) | -0.346 (-0.463，0.163) |
表 2.
A、B、C三组组间相互比较的Wilcoxon秩和检验分析结果
Analysis results of Wilcoxon rank sum test among groups A, B and C
| Items | A vs.B | B vs.C | A vs.C |
| Abbreviations as in Table 1. | |||
| Age | 0.420 | 0.243 | 0.863 |
| BMI | 0.910 | 0.185 | 0.073 |
| Length of the superior femoral tunnel | 0.022 | 0.278 | 0.089 |
| Length of the coarse femoral tunnel | 0.000 | 0.097 | 0.000 |
| T | 0.177 | 0.729 | 0.148 |
| M1 | 0.375 | 0.003 | 0.003 |
| M2 | 0.326 | 0.091 | 0.024 |
| M3 | 0.097 | 0.960 | 0.187 |
| M4 | 0.085 | 0.725 | 0.026 |
| M1-T | 0.005 | 0.000 | 0.000 |
| M2-T | 0.010 | 0.129 | 0.002 |
| M3-T | 0.031 | 0.936 | 0.037 |
| M4-T | 0.010 | 0.566 | 0.002 |
| (M1-T)/T | 0.004 | 0.000 | 0.000 |
| (M2-T)/T | 0.007 | 0.129 | 0.002 |
| (M3-T)/T | 0.031 | 0.912 | 0.041 |
| (M4-T)/T | 0.014 | 0.636 | 0.012 |
图 3.
股骨骨道各位置增宽差值随着袢在粗骨道中的长度值变化的线性回归示意图
Schematic diagram of linear regression of the widening difference in each position of the femoral tunnel with the change of length of loop in the coarse tunnel value
表 3.
A、B、C三组术后12个月膝关节功能评分的均值方差及P值相互比较
Comparison of mean variance and P value of knee function score in group A, B and C at 12 months after surgery
| Items | A | B | C | P | ||
| A vs. B | A vs. C | B vs. C | ||||
| IKDC, International Knee Documentation Committee. | ||||||
| Tegner score, x±s | 4.18±0.75 | 4.44±0.75 | 4.54±1.01 | 0.341 | 0.394 | 0.973 |
| Lysholm score, x±s | 91.81±9.13 | 92.67±7.66 | 90.91±9.54 | 0.790 | 0.791 | 0.492 |
| IKDC score, x±s | 77.63±8.88 | 78.37±7.33 | 78.58±7.47 | 0.813 | 0.772 | 0.921 |
图 4.
A、B、C三组术后12个月的IKDC评分箱线图
Boxplot of IKDC score in group A, B and C at 12 months after surgery
A, adjustable loop is 0 mm in the coarse bone tunnel; B, fixation loop is greater than 0 mm and less than or equal to 10 mm in the coarse bone tunnel; C, fixation loop is greater than 10 mm in the coarse bone tunnel. IKDC, International Knee Documentation Committee.
图 6.
A、B、C三组术后12个月的Tegner评分箱线图
Boxplot of Tegner score in group A, B and C at 12 months after surgery
A, adjustable loop is 0 mm in the coarse bone tunnel; B, fixation loop is greater than 0 mm and less than or equal to 10 mm in the coarse bone tunnel; C, fixation loop is greater than 10 mm in the coarse bone tunnel.
图 5.
A、B、C三组术后12个月的Lysholm评分箱线图
Boxplot of Lysholm score in group A, B and C at 12 months after surgery
A, adjustable loop is 0 mm in the coarse bone tunnel; B, fixation loop is greater than 0 mm and less than or equal to 10 mm in the coarse bone tunnel; C, fixation loop is greater than 10 mm in the coarse bone tunnel.
3. 讨论
目前以腘绳肌为移植物行前交叉韧带重建术时，股骨端固定方法分为两种，一种为挤压界面螺钉固定，另一种为骨皮质悬吊装置，其中骨皮质悬吊装置又分为固定袢和可调节袢。对同一移植物不同的固定方式，其术后骨道增宽情况可能存在差异。Fauno等[6]对以腘绳肌为移植物的拟行前交叉韧带重建的患者分为两组，一组股骨端采用固定袢固定，另一组股骨端采用界面螺钉固定，结果发现固定袢固定有更明显的股骨骨道增宽，他们认为股骨端固定装置越靠近关节线可降低股骨骨道增宽。虽然，不少学者认为使用可吸收挤压螺钉固定腘绳肌可降低术后股骨骨道的增宽，但也有学者认为使用可吸收挤压界面螺钉固定并不能降低股骨骨道增宽。Buelow等[7]认为直径较大的可吸收挤压螺钉虽然可以使移植物牢固地固定在股骨骨道内，但同时也将因为自身对股骨骨道的挤压造成骨道显著的增宽。因骨皮质悬吊装置操作简单、可靠、抗拉强度高，所以在前交叉韧带重建中得到广泛应用[1-2]。
在前交叉韧带重建术中，股骨端固定物不管使用何种固定方式均会发生不同程度的骨道增宽。根据目前文献报道，前交叉韧带重建术后骨道增宽主要与机械力学因素及生物学因素相关[8]。机械学因素包括移植物在骨道中的运动、固定方法、装置移植物的压力、不恰当的骨道定位、单束和双束技术以及激进的康复计划等[5, 9-15]。生物学因素包括移植物的肿胀、异体组织移植物的排斥反应、骨道内滑膜液的渗透、关节腔内细胞因子水平的增高、移植物的长度及细菌的存在和浓度等[5, 9-11, 13, 16-23]。
一些生物力学研究表明，与固定袢相比，可调节袢回路可能发生延长，但临床结果的数据有限[24-27]。在体内条件下，延长环会导致移植物松动，从而导致术后膝关节松弛、再断裂和骨道加宽。Choi等[4]发现分别行两种固定方法术后的患者，他们的膝关节松弛评估和膝关节功能结果差异无统计学意义(P＞0.05)。同时有研究提到[28]，分别行固定环或可调节环固定股骨端的患者术后移植物的滑膜覆盖率或破裂率无任何差异。
为了进一步明确固定袢和可调节袢导致的股骨骨道增宽是否存在差异，准确的骨道测量方式是必不可少的。以往文献中提到对骨道宽度的测量主要是依据Iorio等[29]提出的CT方案，研究和评估股骨骨道在轴位切迹处及轴位、冠状位、矢状位骨道中点的骨道宽度，并与术后即刻X线所测量的骨道宽度进行比较[30]。我们此次所采用的测量方式主要是比较术后12个月与术后即刻的膝关节CT，同时通过CT三维重建找到整个股骨骨道中心轴，并对股骨切迹处、粗细骨道交界处及这两点的三等分位置的两个点进行骨道宽度的测量，这样测得的数据更加准确。实践证明，A组(可调节袢组)与B组(固定袢组)、C组(固定袢组)相比，其术后12个月的骨道增宽程度较小。
有研究指出[28]，固定袢和可调节袢固定方法为前交叉韧带重建提供了相似的临床结果和稳定性，差异没有统计学意义。同时研究指出前交叉韧带重建后股骨骨道的加宽在两个固定组之间差异没有统计学意义。与这些研究相反，我们发现在前交叉韧带重建术后不仅固定袢组和可调节袢组会导致股骨骨道增宽程度不一，即使股骨端固定物均为固定袢，其袢在粗骨道中的长度不一，术后12个月发生骨道增宽的程度也不一样。从表 1的结果中，我们发现关于股骨粗骨道的四个位点(M1、M2、M3、M4)，A、B、C三组在这四个位点的骨道增宽的差值及差值占比均存在差异，同时从图 3中的线性回归图中看到在股骨粗骨道中的四个位点中，每个位点随着袢在粗骨道的长度增大，其骨道增宽的差值也逐渐增大，这说明A、B、C三组在前交叉韧带重建后股骨隧道的拓宽在股骨粗骨道的各个位置存在差异，在股骨各位置的骨道宽度，随着袢在粗骨道中长度的逐渐增大，其股骨骨道逐渐增宽。表 1的中位数描述显示，在M1、M2点位的骨道增宽差值的中位数均为正值，表明在前交叉重建术后12个月时股骨中下骨道较术后即刻骨道增宽，在M3、M4点位的骨道增宽差值的中位数出现负值，表明在前交叉韧带重建术后12个月时股骨中上骨道已逐渐发生重建肌腱和股骨愈合，从表 2中A、B、C三组组间相互比较的Wilcoxon分析结果中发现，在M1点位上，A、B、C三组的骨道增宽差值及差值占比两两比较时差异有统计学意义(P＜0.05)，根据表 1中的中位数数值，可以看出骨道增宽程度：A＜B＜C。在M2、M3、M4位点的A、B、C三组的骨道增宽差值及差值占比进行两两比较时A组与B组、A组与C组的差异有统计学意义(P＜0.05)，结合表 1中的中位数数值，固定袢较可调节袢骨道增宽显著。虽然B组与C组比较时其P值大于0.05，但并不能说明固定袢为股骨端固定物时，袢在粗骨道中的长度对骨道增宽无影响，因为从线性回归图的趋势上看，随着n值的增大，骨道增宽程度还是在逐步增大的。
在既往的文献中，前交叉韧带重建术后，两种股骨端固定方式的膝关节功能评分并无显著差异[4, 28]。从表 3的数据中同样发现，在前交叉韧带重建术后12个月的患者中，A、B、C三组的膝关节功能评分(Tegner评分、Lysholm评分、IKDC评分)的差异无统计学意义(P＞0.05)。从图 4~6的箱线图中更能直观地发现，三组的膝关节功能评分在前交叉韧带重建术后12个月差异无统计学意义。
本研究存在的不足之处主要是采用可调节袢的病例数相对于固定袢的病例数较少，未考虑胫骨端固定物对骨道产生的影响。
Funding Statement
国家自然科学基金(8140810)
Supported by the National Natural Science Foundation of China (8140810)
References
- 1.Saccomanno MF, Shin JJ, Mascarenhas R, et al. Clinical and functional outcomes after anterior cruciate ligament reconstruction using cortical button fifixation versus transfemoral suspensory fixation: A systematic review of randomized controlled trials. Arthroscopy. 2014;30(11):1491–1498. doi: 10.1016/j.arthro.2014.05.028. [DOI] [PubMed] [Google Scholar]
- 2.Han DL, Nyland J, Kendzior M, et al. Intratunnel versus extratunnel fixation of hamstring autograft for anterior cruciate ligament reconstruction. Arthroscopy. 2012;28(12):1555–1566. doi: 10.1016/j.arthro.2012.02.021. [DOI] [PubMed] [Google Scholar]
- 3.Jansson KA, Harilainen A, Sandelin J, et al. Bone tunnel enlargement after anterior cruciate ligament reconstruction with the hamstring autograft and endobutton fifixation technique A clinical, radiographic and magnetic resonance imaging study with 2 years follow-up. Knee Surg Sports Traumatol Arthroscopy. 1999;7(5):290–295. doi: 10.1007/s001670050166. [DOI] [PubMed] [Google Scholar]
- 4.Choi NH, Yang BS, Victoroff BN. Clinical and radiological outcomes after hamstring anterior cruciate ligament reconstructions: Comparison between fifixed-loop and adjustable-loop cortical suspension devices. Am J Sports Med. 2017;45(4):826–831. doi: 10.1177/0363546516674183. [DOI] [PubMed] [Google Scholar]
- 5.Clatworthy MG, Annear P, Bulow JU, et al. Tunnel widening in anterior cruciate ligament reconstruction: A prospective evaluation of hamstring and patella tendon grafts. Knee Surg Sports Traumatol Arthrosc. 1999;7(3):138–145. doi: 10.1007/s001670050138. [DOI] [PubMed] [Google Scholar]
- 6.Fauno P, Kaalund S. Tunnel widening after hamstring anterior cruciate ligament reconstruction is influenced by the type of graft fixation used: A prospective randomized study. Arthroscopy. 2005;21(11):1337–1341. doi: 10.1016/j.arthro.2005.08.023. [DOI] [PubMed] [Google Scholar]
- 7.Buelow JU, Siebold R, Ellermann A. A prospective evaluation of tunnel enlargement in anterior cruciate ligament reconstruction with hamstrings: Extracortical versus anatomical fixation. Knee Surg Sports Traumatol Arthrosc. 2002;10(2):80–85. doi: 10.1007/s00167-001-0267-6. [DOI] [PubMed] [Google Scholar]
- 8.Wilson TC, Kantaras A, Atay A, et al. Tunnel enlargement after anterior cruciate ligament surgery. Am J Sports Med. 2004;32(2):543–549. doi: 10.1177/0363546504263151. [DOI] [PubMed] [Google Scholar]
- 9.Fahey M, Indelicato PA. Bone tunnel enlargement after anterior cruciate ligament replacement. Am J Sports Med. 1994;22(3):410–414. doi: 10.1177/036354659402200318. [DOI] [PubMed] [Google Scholar]
- 10.Schulte K, Majewski M, Irrgang JJ, et al. Radiographic tunnel changes following arthroscopic ACL reconstruction: Autograft versus allograft. Arthroscopy. 1996;11(6):372–373. [Google Scholar]
- 11.Hoher J, Moller HD, Fu FH. Bone tunnel enlargement after anterior cruciate ligament reconstruction: Fact or fiction? Knee Surg Sports Traumatol Arthrosc. 1998;6(4):231–240. doi: 10.1007/s001670050105. [DOI] [PubMed] [Google Scholar]
- 12.Buelow JU, Siebold R, Ellermann A. A new bicortical tibial fixation technique in anterior cruciate ligament reconstruction with quadruple hamstring graft. Knee Surg Sports Traumatol Arthrosc. 2000;8(4):218–225. doi: 10.1007/s001670000120. [DOI] [PubMed] [Google Scholar]
- 13.Fink C, Zapp M, Benedetto KP, et al. Tibial tunnel enlargement following anterior cruciate ligament reconstruction with patellar tendon autograft. Arthroscopy. 2001;17(2):138–143. doi: 10.1053/jars.2001.21509. [DOI] [PubMed] [Google Scholar]
- 14.Webster KE, Feller JA, Hameister KA. Bone tunnel enlargement following anterior cruciate ligament reconstruction: A randomised comparison of hamstring and patellar tendon grafts with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2001;9(2):86–91. doi: 10.1007/s001670100191. [DOI] [PubMed] [Google Scholar]
- 15.Morgan CD, Stein DA, Leitman EH, et al. Anatomic tibial graft fixation using a retrograde bio-interference screw for endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 2002;18(7):1–8. doi: 10.1053/jars.2002.35144. [DOI] [PubMed] [Google Scholar]
- 16.Jackson DW, Windler GE, Simon TM. Intraarticular reaction associated with the use of freeze-dried, ethylene oxide-sterilized bone-patella tendon-bone allografts in the reconstructuion of the anterior cruciate ligament. Am J Sports Med. 1990;18(1):1–11. doi: 10.1177/036354659001800101. [DOI] [PubMed] [Google Scholar]
- 17.Zijl JA, Kleipool AE, Willems WJ. Comparison of tibial tunnel enlargement after anterior cruciate ligament reconstruction using patellar tendon autograft or allograft. Am J Sports Med. 2000;28(4):547–551. doi: 10.1177/03635465000280041701. [DOI] [PubMed] [Google Scholar]
- 18.Cameron ML, Buchgraber A, Passler HH, et al. The natural hisroty of the anterior cruciate ligament-deficient knee. Changes in synovial fluid cytokine and keratan sulfate concentrations. Am J Sports Med. 1997;25(6):751–754. doi: 10.1177/036354659702500605. [DOI] [PubMed] [Google Scholar]
- 19.Schamalzried TP, Akizuki KH, Fedenko AN, et al. The role of access of joint fluid to bone in periarticular osteolysis: A report of four cases. J Bone Joint Surg. 1997;79(3):447–452. doi: 10.2106/00004623-199703000-00021. [DOI] [PubMed] [Google Scholar]
- 20.Beyaz S, Güler Üö, Demir Ş, et al. Tunnel widening after single versus doublebundle anterior cruciate ligament reconstruction: A randomized 8year followup study. Arch Orthop Trauma Surg. 2017;137(11):1547–1555. doi: 10.1007/s00402-017-2774-z. [DOI] [PubMed] [Google Scholar]
- 21.Flanigan DC, Everhart JS, DiBartola A, et al. Bacterial DNA is associated with tunnel widening in failed ACL reconstructions. Knee Surg Sports Traumatol Arthrosc. 2019;27(11):3490–3497. doi: 10.1007/s00167-019-05405-6. [DOI] [PubMed] [Google Scholar]
- 22.Bjarnsholt T, Tolker-Nielsen T, Givskov M, et al. Detection of bacteria by fluorescence in situ hybridization in culture-negative soft tissue filler lesions. Dermatol Surg. 2009;35(2):1620–1624. doi: 10.1111/j.1524-4725.2009.01313.x. [DOI] [PubMed] [Google Scholar]
- 23.Everhart JS, DiBartola AC, Dusane DH, et al. Bacterial deoxyribonucleic acid is often present in failed revision anterior cruciate ligament reconstructions. Arthroscopy. 2018;34(11):3046–3052. doi: 10.1016/j.arthro.2018.06.033. [DOI] [PubMed] [Google Scholar]
- 24.Wise BT, Patel NN, Wier G, et al. Outcomes of ACL reconstruction with fixed versus variable loop button fixation. Orthopedics. 2017;40(2):e275–e280. doi: 10.3928/01477447-20161116-04. [DOI] [PubMed] [Google Scholar]
- 25.Petre BM, Smith SD, Jansson KS, et al. Femoral cortical suspension devices for soft tissue anterior cruciate ligament reconstruction: A comparative biomechanical study. Am J Sports Med. 2013;41(2):416–422. doi: 10.1177/0363546512469875. [DOI] [PubMed] [Google Scholar]
- 26.Barrow AE, Pilia M, Guda T, et al. Femoral suspension devices for anterior cruciate ligament reconstruction: Do adjustable loops lengthen? Am J Sports Med. 2014;42(2):343–349. doi: 10.1177/0363546513507769. [DOI] [PubMed] [Google Scholar]
- 27.Johnson JS, Smith SD, LaPrade CM, et al. A biomechanical comparison of femoral cortical suspension devices for soft tissue anterior cruciate ligament reconstruction under high loads. Am J Sports Med. 2015;43(1):154–160. doi: 10.1177/0363546514553779. [DOI] [PubMed] [Google Scholar]
- 28.Ahn HW, Seon JK, Song EK, et al. Comparison of clinical and radiologic outcomes and second-look arthroscopic findings after anterior cruciate ligament reconstruction using fixed and adjustable loop cortical suspension devices. Arthroscopy. 2019;35(6):1736–1742. doi: 10.1016/j.arthro.2019.01.051. [DOI] [PubMed] [Google Scholar]
- 29.Iorio R, Di Sanzo V, Vadalà A, et al. ACL reconstruction with hamstrings: How different technique and fifixation devices influence bone tunnel enlargement. Eur Rev Med Pharmacol Sci. 2013;17(21):2956–2961. [PubMed] [Google Scholar]
- 30.Lanzetti RM, Monaco E, de Carli A, et al. Can an adjustable-loop length suspensory fifixation device reduce femoral tunnel enlargement in anterior cruciate ligament reconstruction? A prospective computer tomography study. Knee. 2016;23(5):837–841. doi: 10.1016/j.knee.2016.01.015. [DOI] [PubMed] [Google Scholar]