经髁间窝入路保残后交叉韧带重建技术

Remnant-preservation posterior cruciate ligament reconstruction with artificial graft through the intercondylar fossa approach

摘要:

[目的]介绍关节镜下经髁间窝入路韧带增强重建系统（ligament augmentation and reconstruction system, LARS）韧带保残重建后交叉韧带的手术技巧和初步临床疗效。[方法]患者腰硬联合麻醉后取平卧位，建立膝关节镜前内侧入路、前外侧入路以及经正中髌腱入路作为镜下观察及术中操作入路。清理增生滑膜组织、后交叉韧带胫骨止点后方组织，显露后交叉胫骨止点、后板股韧带，同时显露后外关节腔。从前内侧入路将 PCL 胫骨定位器经 ACL 内侧插入膝关节后间隙，其尖端位于胫骨平台下 2 cm 处，即 PCL 附着点，钻取胫骨骨道后，导入钢丝备用；用股骨瞄准套筒在股骨关节软骨面向上 8 mm、距离股骨髁间线 12 mm 处，从外向内钻通股骨骨道，钢丝从前内侧入路穿出备用，将韧带两端用钢丝牵入关节腔，然后分别从股骨和胫骨两端拉出，调整人工韧带的张力和位置后，固定人工韧带。[结果]21 例患者均顺利手术，随访 12~25 个月。与术前相比，术后 12 个月膝关节功能 Lysholm 评分 [(35.2±6.0), (88.7±4.2), P＜0.001] 和 IKDC 评分 [(33.1±7.1), (89.4±4.1), P＜0.001] 均显著改善。 [结论]关节镜下经髁间窝入路 LARS 韧带保残重建后交叉韧带技术可行，临床效果良好。

Abstract:

[Objective] To introduce the surgical technique and preliminary clinical outcome of remnant-preservation posterior cruciate ligament (PCL) reconstruction with Ligament Augmentation and Reconstruction System (LARS) under arthroscopy. [Methods] The patient was placed in a supine position after combined lumbar and epidural anesthesia, and then the anteromedial (AM), anterolateral (AL) and transpatellar (TP) portals were established for arthroscopic observation and instrument operation. The proliferative synovial tissue posterior to the PCL were debrided, whereas the PCL remnant was preserved properly, and the PCL tibial insertion and posterior meniscofemoral ligament in the posterior compartment were exposed. The PCL tibial locator was inserted into the posterior compartment by medial side of the ACL through the anteromedial portal. Its tip was fitted 2cm below the tibial platform, on the anatomic PCL attachment. After the tibial bone tunnel was created, a wire loop was introduced into the tunnel and pulled out through the anteromedial porta for next step use. The femoral bone tunnel was made outside-in at 8 mm above the articular cartilage and 12 mm away from the femoral intercondylar line. Another wire loop was introduced into the femoral tunnel and pulled out through the anteromedial portal. The two ends of the LARS graft were pulled into the joint cavity with both wire loops, and then pulled both ends out external apertures of the femoral and tibial tunnel, respectively. Under proper tension, the graft was fastened on the femoral and tibial sides with interference screws to accomplish PCL reconstruction. [Results] All the 21 patients were operated on successfully and followed up from 12 months to 25 months. The Lysholm score [(35.2±6.0), (88.7±4.2), P＜0.001] and IKDC score [(33.1±7.1), (89.4±4.1), P＜0.001] were significantly improved 12 months after surgery compared with those preoperatively. [Conclusion] Arthroscopic remnant-preservation reconstruction of posterior cruciate ligament with LARS graft via intercondylar fossa is a feasible technique and has good clinical consequence.