前交叉韧带重建术后再断裂翻修重建联合改良Lemaire术

Arthroscopic revision reconstruction combined with modified Lemaire procedure for retorn anterior cruciate ligament after primary reconstruction

摘要:

[目的]探讨治疗前交叉韧带（anterior cruciate ligament, ACL）重建术后再断裂治疗方法。[方法]采用翻修 ACL 重建联合改良 Lemaire 术治疗 ACL 重建术后再断裂 5 例患者。患者取仰卧位，关节镜确认 ACL 重建术后移植物再断裂，探查隧道内口位置及直径，清理股骨及胫骨骨隧道；取对侧腘绳肌腱或者同侧腓骨长肌腱，编织后套入中空的 LARS 韧带中，移植物直径超过初次移植物直径至少 1~2 mm；将移植物拉入隧道及关节内，分别用金属挤压钉固定；然后行改良 Lemaire 手术：沿着 Gerdy 结节至股骨外上髁连线切 1 条长 6~8 cm 的皮肤切口，切取一条长度 8~10 cm、宽 1 cm 的阔筋膜条，保留阔筋膜 Gerdy 结节远端止点，近端编织，将肌腱从外侧副韧带下方穿过，拉入 ALL 股骨隧道并固定。[结果]5 例患者均顺利完成手术，手术时间（90.2±30.1）min，术中出血量（50.2±30.1）mL，术后伤口均 I 期愈合，无感染、血管神经损伤等严重并发症。术后随访 12 个月以上，术后 3 例重返运动，2 例未再运动。术后 1 例膝关节有轻微弹响。按照改良 HSS 膝关节功能评分标准，术后 12 个月临床结果评定为优 4 例，良 1 例。术后 Kneelax 3 测量前-后位移双侧差值 ≤2 mm。[结论]对于合并危险因素的 ACL 重建术后失败患者采用 ACL 翻修联合改良 Lemaire 手术可以有效恢复膝关节前向稳定性，改善旋转稳定性，减少移植物再撕裂率， 术后功能满意。

Abstract:

[Objective] To investigate the surgical technique for treatment of re-ruptured anterior cruciate ligament (ACL) after primary reconstruction. [Methods] A total of 5 patients underwent revised ACL reconstruction combined with modified Lemaire surgery for reruptured ACL after primary reconstruction. The patient was placed in supine position, underwent arthroscopic examination to confirm the re-rupture of the reconstructed ACL. After the location and diameter of the inner apertures of the tunnels were investigated, the femoral and tibial bone tunnels were debrided. The hamstring tendon harvested contralaterally or peroneal longus tendon ipsilaterally was folded, and inserted into the hollow LARS ligament to prepare the graft with diameter at least 1~2 mm larger than the previous graft. The graft was introduced into the tunnels and the joint cavity and fixed with metal interference screws respectively in proper tension. Subsequently, the modified Lemaire surgery is performed. A 6-8cm skin incision was made along the line between Gerdy's tubercle and the lateral epicondyle of the femur, and the iliotibial band (ITB) was cut to form a bundle 8-10cm in length and 1cm in width with intact attachment on Gerdy tubercle at the distal end, while the free proximal end stitched. The free end of ITB bundle was passed under the lateral collateral ligament, introduced into the bone tunnel on femoral insertion of anterolateral ligament (ALL) and fastened with interference screw in proper tension. [Results] All the 5 patients were operated on successfully with operation time of (90.2±30.1) min, intraoperative bleeding of (50.2±30.1) mL, and got incision healed well, without serious complications, such as infection, vascular and nerve injury. Twelve months after revision surgery, 3 patients returned to sports activity, and 2 patients did not regain the sports capacity, and 1 patient had a slight knee snap. According to the modified HSS score, the clinical results were marked as excellent in 4 and good in 1 patient 12 months after surgery. After operation, Kneelax 3 measured the bilateral difference of anteriorposterior displacement ≤2 mm. [Conclusion] ACL revision reconstruction combined with modified Lemaire surgery does effectively restore knee anteroposterior stability, improve rotational stability, reduce graft re-failure chance, and achieve satisfactory function for failed ACL reconstruction with high risk.