关节镜下“人”字缝线固定治疗后交叉韧带胫骨止点撕脱骨折 A

【摘要】 目的探讨关节镜下“人”字缝线固定治疗后交叉韧带(PCL)胫骨止点撕脱骨折的疗效。 方法 回顾性分析2013年1月至2014年12月期间收治的17例PCL胫骨止点撕脱骨折患者资料。男11例，女6例；年龄为21~57岁，平均38.7岁。骨折按Meyers-McKeever分型：Ⅲ型11例，Ⅳ型6例。术中将缝线在骨折块腱骨结合部打结后呈“人”字形向骨折块远端经胫骨平台后方的2个骨道穿出，通过在胫骨平台前方骨桥上打结来实现骨折块的复位与加压固定。记录患者的疼痛视觉模拟评分(VAS)、膝关节Lysholm评分、胫骨平台后向移位KT-2000值及术后并发症的发生情况。结果17例患者术后获7 ~19个月（平均13.5个月）随访。术后1~2个月（平均1.3个月）X线片示骨痂形成，无骨折 复位丢失现象发生。末次随访时所有患者骨折均获骨性愈合，膝关节平均活动范围：伸直2.00±3.5。，屈曲134.20±12.5。；膝关节Lysholm评分平均为89.3分(83~ 95分)；屈膝90。时胫骨平台大力下后向移位 KT-2000值平均为1.5 mm(0.5~5.3 mm)。1例患者术后发生胫后深静脉血栓形成，2例患者胫骨平台后向移位>5 mm。 结论关节镜下“人”字缝线复位固定技术能有效复位和固定PCL胫骨止点撕脱骨折，恢复PCL的张力，提高胫骨平台的后向稳定性，减少继发性骨性关节炎的发生，疗效良好。

【关键词】后交叉韧带；胫骨骨折；骨折固定术，内；关节镜检查 Arthroscopic treatment of posterior cruciate ligament avulsion fracture with knotted suture Zhang Qingsong,LiTao, Fan,g Yushun, Tan Hongfei, Wang Junwen, Kan Wusheng
Department of Sports Traumatology, Puai Hospital,Tongji Medical College,Huazhong University of Science and Technology, Wu,han, 430033, China
【Abstract】 ob[x]jective To evaluate the outcomes of arthroscopic treatment of posterior cruciate ligament(PCL) avulsion fracture with knotted suture. Methods We arthroscopically treated l7 patients with PCL avulsion fractures from January 2013 through December 2014. They were 11 males and 6 females, from 21 to 57years of age (mean, 38.7 years). By Meyers-McKeever classification, there were type Ⅲ in 11 cases and type Ⅳin 6.The PCL tendon close to the avulsion bone was surrounded with non-absorbable suture;2 arms of the suture were knotted and then retrieved from 2 bone tunnels drilled from the anterior tibia to the lower part of fracture bone bed. Fine reduction and fixation was achieved by tying the sutures at the bone bridge of the anterior tibia. X-tray or CT scan was taken routinely to confirm the bone healing during postoperative follow-up. Visual analogue scale (VAS), Lysholm knee scoring and the posterior migration of the tibial plateau under KT-2000 were also recorded.Results The 17 patients obtained an average follow-up of 13.5 months (from 7 t0 19months). X-ray films at l t0 2 months after surgery (mean, 1.3 months) showed porosis but no loss of fracture reduction. The final follow-ups showed bony union in all. The average ranges of motion were extension of 2. 00±3.50 and flexion of 134. 20±12. 50; the average Lysholm knee score was 89.3 (from 83 t0 95).The average posterior migration of the tibial plateau under KT-2000 with the knee flexed at 900 was l.5 mm (from0.5to 5.3．mm). Deep vein thrombosis occurred in one case, and 2 cases had a posterior migration of the tibial plateau of more than 5 mm. ConclusionTreatment of PCL avulsion fracture with knotted suture under arthroscopy can result in effective reduction and reliable fixation to restore the PCL tension, enhance the posterior stability of tibial plateau, and reduce incidence of secondary traumatic osteoarthritis.
[Key words] Posterior cruciate ligament; Tibial fractures; Fracture fixation, internal,Arthroscopy
后交叉韧带（posterior cruciate ligament, PCL）胫骨止点撕脱骨折是膝关节的一种特殊类型损伤，多见于摩托车伤常见的治疗方法有切开复位内固定、关节镜下螺钉内固定、带线锚钉固定或高强度缝线固定等。但开放手术创伤较大，关节镜下手术操作复杂，胭后神经、血管损伤一直是影响手术疗效的主要问题。骨折不愈合或畸形愈合会导致PCL松弛，并出现髌股关节压力增加、胫股关节不稳，终损害关节内次要稳定结构和关节内软骨，继发骨性关节炎，严重影响患者膝关节功能的恢复[1-2]。我院自2013年1月至2014年12月采用全关节镜下“人”字缝线复位固定17例PCL胫骨止点撕脱骨折患者，疗效满意。本文回顾性分析此17例患者的临床资料，报告如下。

资料与方法

一、病例纳入标准与排除标准病例纳入标准：（11eyers-MCKeever分型为Ⅲ、Ⅳ型的①PCL胫骨止点撕脱骨折患者，②受伤至手术时间≤2周的患者，③骨折块大横径<2.0 cm的患者。病例排除标准：①合并膝关节后外侧结构损伤者；②合并多韧带损伤，累及韧带超过2根者；③磁共振成像显示PCL实质部分或股骨止点撕裂者；④ 骨折累及胫骨平台关节面且有塌陷者；⑤伴有下肢深静脉血栓形成者。

二、一般资料 本研究共纳入17例，男11例，女6例；年龄为21~ 57岁，平均38.7岁。致伤原因：交通伤12例，重物砸伤2例，跌落伤3例。合并伤：半月板损伤7例，内侧副韧带损伤3例。X线片、CT、磁共振成像均提示PCL胫骨止点撕脱骨折并移位，骨折按Meyers-McKeever分型：Ⅲ型11例，I型6例：受伤至手术时间为3~14d．平均8.5d：本研究得到华中科技大学同济医学院附属普爱医院伦理委员会批准，所有患者均签署知情同意书

三、手术方法 采用全身麻醉或者蛛网膜下腔阻滞联合硬膜外麻醉。患者取仰卧位，患膝处于悬垂位,常规前外侧、前内侧入路检查膝关 节内各间室，处理相关软骨、半月板并发损伤二经前交叉韧带与PCL之间打开后纵膈，在关节镜监视下做高位、低位2个后内侧入路，高位后内侧入路为观察人路，经低位后内侧入路置入刨刀进一步清理后纵膈，将骨折块周围组织及下方的关节囊进 行部分清理，显露骨折块及弪骨骨床下方0.5~1.0 cm。