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北京大学学报（医学版） ›› 2021, Vol. 53 ›› Issue (5): 857-863. doi: 10.19723/j.issn.1671-167X.2021.05.008

• 论著 • 上一篇    下一篇

前交叉韧带翻修重建术后中长期临床疗效及影响因素

蒋艳芳,王健,王永健,刘佳,裴殷,刘晓鹏,敖英芳,马勇()   

  1. 北京大学第三医院运动医学科,北京大学运动医学研究所,运动医学关节伤病北京市重点实验室,北京 100191
  • 收稿日期:2021-06-24 出版日期:2021-10-18 发布日期:2021-10-11
  • 通讯作者: 马勇 E-mail:huidong01@sina.com
  • 基金资助:
    国家重点研发计划(2019YFF0301705-1);国家重点研发计划(2019YFF0301700)

Mid-to-long term clinical outcomes and predictors after anterior cruciate ligament revision

JIANG Yan-fang,WANG Jian,Yong-WANG Jian,LIU Jia,PEI Yin,LIU Xiao-peng,AO Ying-fang,MA Yong()   

  1. Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing 100191, China
  • Received:2021-06-24 Online:2021-10-18 Published:2021-10-11
  • Contact: Yong MA E-mail:huidong01@sina.com

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摘要：

目的: 分析前交叉韧带翻修重建术后中长期临床疗效及预后影响因素。方法: 收集2001年1月至2015年12月间在北京大学第三医院运动医学科行膝关节前交叉韧带(anterior cruciate ligament,ACL)重建术首次翻修手术的235例患者,采集患者人口学信息、ACL首次翻修重建信息(移植物断裂时间、失效原因、翻修重建时间、手术技术、合并损伤及处理方式)和初次ACL重建手术时的信息(初次断裂时间、受伤原因、受伤机制、初次重建时间、手术技术、合并损伤及处理方式)。同时对患者进行术后2年以上的随访,随访内容包括疼痛视觉模拟评分(visual analogue scale,VAS)、Tegner活动水平评分、Lysholm评分、国际膝关节文献委员会(International Knee Documentation Committee,IKDC)膝关节主观评分、翻修术后同侧膝关节和对侧膝关节损伤和手术情况。通过多因素分析确定临床疗效的独立影响因素。结果: 按排除标准实际随访纳入166例(70.63%),平均随访时间(4.44±2.40)年(2.03~14.63年)。患者末次随访时Lysholm评分、Tegner活动水平评分、IKDC主观评分均较术前明显提高,分别从70.51±21.25、3.39±1.77、63.78±15.04提高至术后88.64±14.36、4.67±1.739和 80.23±13.31(P<0.05)。3例患者(1.81%)翻修术后出现感染,39例(23.49%)患者在随访期内同侧和对侧膝关节再次接受手术(41例次)。与运动损伤导致的移植物失效相比,因生活意外或初次重建手术技术原因导致翻修的患者术后评分显著偏低(P<0.05):Lysholm评分分别低9.90(95%CI:1.49~18.31)、8.53(95%CI:1.31~15.75), IKDC分别低10.35(95%CI:0.17~20.54)和9.39(95%CI:1.03~17.74),Tegner活动水平评分分别低1.41(95%CI:0.10~2.72)和1.28(95%CI:0.14~2.43)。经胫骨骨道钻取股骨骨道的患者术后Lysholm评分较经前内入路患者低11.18(95%CI:4.73~17.63, P=0.001)。术中同期进行内侧半月板缝合的患者术后IKDC评分较无半月板合并损伤患者高11.06(95%CI:1.21~20.92, P=0.029)。其他预后因素差异无统计学意义。结论: ACL翻修术可提高患者膝关节稳定性,明显改善膝关节功能。与生活意外或初次重建手术技术原因导致的翻修相比,运动损伤导致移植物失效的患者术后疗效恢复更好。内侧半月板缝合和经前内入路钻取股骨骨道对ACL翻修术后的临床功能在统计学上体现出保护作用。

关键词: 前交叉韧带损伤, 前交叉韧带重建, 再手术, 临床疗效, 预后

Abstract:

Objective: To assess the mid-to-long term clinical outcomes after anterior cruciate ligament (ACL) revision surgery and to analyze their predictors. Methods: The medical records of 235 patients undergoing ACL revision surgery between Jan. 2001 and Dec. 2015 at Department of Sports Medicine, Peking University Third Hospital were reviewed. Data were collected including demographic information, information related to revision surgery (time and cause of graft failure, date of revision surgery, surgical technique, combined injuries and management, etc.), as well as information related to primary ACL reconstruction (time, cause and mechanism of first-time ACL rupture, date of primary ACL reconstruction, surgical technique, combined injuries and management, etc.). Patients were followed up at least 2 years after revision surgery for clinical outcomes [Tegner score, Lysholm score, and International Knee Documentation Committee (IKDC) subjective knee score]. Post-revision surgeries on the involved knee and the contralateral knee joint were also documented. Multivariate regression model was used to analyze the predictors of clinical outcomes after ACL revision surgery. Results: A total of 166 (70.63%) patients were followed up at a mean of (4.44±2.40) years (2.03-14.63 years). Clinical outcomes improved significantly at the last follow-up from pre-operative level, with the Lysholm, Tegner, and IKDC scores improving from 70.51±21.25, 3.39±1.77, 63.78±15.04 to 88.64±14.36, 4.67±1.739, 80.23±13.31 (P<0.05), respectively. Three (1.81%) patients experienced infection while 39 (23.49%) patients underwent surgery after revision surgery during the follow-up. Compared with that those occurred during sports, graft failure that occurred during daily activities or due to surgical technical errors that led to poorer clinical outcomes, with the Lysholm, Tegner, and IKDC scores of 9.90 (95%CI: 1.49-18.31), 1.41 (95%CI: 0.10-2.72), 10.35 (95%CI: 0.17-20.54), and 8.53 (95%CI: 1.31-15.75), 1.28 (95%CI: 0.14-2.43), 9.39 (95%CI: 1.03-17.74) lower, respectively. Compared with antero-medial portal, transtibial technique for placement of the femoral bone tunnel showed poorer Lysholm scores of 11.18 (95%CI: 4.73-17.63, P=0.001). Concurrent repair of medial meniscus yielded higher IKDC scores of 11.06 (95%CI: 1.21-20.92, P=0.029) than those with intact medical meniscus. Other factors showed no significant effect. Conclusion: ACL revision surgery is able to restore knee stability and improve knee function. Graft failure caused by sports, concurrent repair of medical meniscus and antero-medial portal technique predicts better outcomes after revision surgery.

Key words: Anterior cruciate ligament injuries, Anterior cruciate ligament reconstruction, Reoperation, Treatment outcome, Prognosis

中图分类号: 

  • R686.5

图1

患者筛选流程图"

表1

纳入研究患者和失访患者的一般情况对比"

Baseline characteristics Included (n=166) Excluded (n=69) P value
Gender, n(%) 0.324
Male 128 (77.11) 49 (71.01)
Female 38 (22.89) 20 (28.99)
Professional athletes, n(%) 15 (9.04) 10 (14.49) 0.217
Age at revision/years, x ?±s 27.55±7.60 27.04±7.55 0.639
BMI/(kg/m2), x ?±s 25.19±3.73 24.31±3.21 0.090
Interval between primary ACLR and revision/years, M (range) 2.78 (0.40-18.40) 3.17 (0.40-16.99) 0.895
Side, n(%) 0.919
Left knee 82 (49.40) 34 (49.28)
Right knee 84 (50.60) 35 (50.72)
Hospital of primary ACLR, n(%) 0.761
Peking University Third Hospital 81 (48.80) 36 (52.17)
Other hospitals 85 (51.20) 33 (47.83)
Technique at primary ACLR, n(%) 0.209
Single-bundle 70 (42.17) 35 (50.72)
Double-bundle 10 (6.02) 1 (1.45)
Unknown 86 (51.81) 33 (47.83)
Graft at primary ACLR, n(%) 0.122
Autografts 79 (47.59) 44 (63.77)
Hamstring 76 (45.78) 37 (53.62)
BPTB 2 (1.20) 5 (7.25)
Hybrid graft 1 (0.60) 2 (2.90)
Allograft 17 (10.24) 6 (8.70)
Artificial ligament 7 (4.22) 2 (2.90)
Hybrid autograft and allograft 2 (1.20) 0
Unknown 61 (36.74) 17 (24.64)
Cause of graft failure, n(%) 0.025
Sports 73 (43.98) 30 (43.48)
Daily activities 29 (17.47) 22 (31.88)
Traffic accident 4 (2.40) 0
Technical 60 (36.14) 17 (24.64)
Technique at revision, n(%) 0.521
Single-bundle 165 (99.40) 68 (98.55)
Double-bundle 1 (0.60) 1 (1.45)
Graft at revision, n(%) 0.078
Autograft 164 (98.80) 66 (95.65)
Hamstring 109 (65.66) 37 (53.62)
BPTB 52 (31.33) 24 (34.78)
Quadriceps 3 (1.81) 3 (4.35)
Others 0 2 (2.90)
Allograft 2 (1.20) 3 (4.35)

表2

ACL首次翻修手术前后临床主观评分比较(n=160)"

Patient-reported outcomes Pre-operation Last follow-up P value
Tegner 3.39±1.77 4.67±1.73 <0.001
IKDC 63.78±15.04 80.23±13.31 <0.001
Lysholm 70.51±21.25 88.64±14.36 <0.001

表3

ACL首次翻修术后临床疗效的影响因素"

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