LARS 人工韧带重建治疗陈旧性髌韧带断裂的疗效研究

Effectiveness of patellar tendon reconstruction with LARS artificial ligament for old patellar tendon rupture

岩杨 , ¹ 岩峰王 , ^1, ^* 新贤王 , ² 世忠顾 , ¹ 汉宁王 , ¹ and 立莹吴 ¹

岩杨

中国医科大学附属第一医院骨科（沈阳 110001）, Department of Orthopaedics, the First Affiliated Hospital of China Medical University, Shenyang Liaoning, 110001, P.R.China

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岩峰王

中国医科大学附属第一医院骨科（沈阳 110001）, Department of Orthopaedics, the First Affiliated Hospital of China Medical University, Shenyang Liaoning, 110001, P.R.China

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新贤王

中国医科大学附属第一医院骨科（沈阳 110001）, Department of Orthopaedics, the First Affiliated Hospital of China Medical University, Shenyang Liaoning, 110001, P.R.China

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世忠顾

中国医科大学附属第一医院骨科（沈阳 110001）, Department of Orthopaedics, the First Affiliated Hospital of China Medical University, Shenyang Liaoning, 110001, P.R.China

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汉宁王

中国医科大学附属第一医院骨科（沈阳 110001）, Department of Orthopaedics, the First Affiliated Hospital of China Medical University, Shenyang Liaoning, 110001, P.R.China

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立莹吴

中国医科大学附属第一医院骨科（沈阳 110001）, Department of Orthopaedics, the First Affiliated Hospital of China Medical University, Shenyang Liaoning, 110001, P.R.China 中国医科大学附属第一医院骨科（沈阳 110001）, Department of Orthopaedics, the First Affiliated Hospital of China Medical University, Shenyang Liaoning, 110001, P.R.China 辽宁省金秋医院超声科（沈阳 110015）, Department of Ultrasound, Jinqiu Hospital of Liaoning Province, Shenyang Liaoning, 110015, P.R.China

岩峰王: moc.361@rotcod_fyw

王岩峰，Email：

结论

LARS 人工韧带重建治疗陈旧性髌韧带断裂疗效确切，能够有效修复伸膝装置及恢复膝关节功能。

Keywords: 陈旧性髌韧带断裂, LARS 人工韧带, 韧带重建

Abstract

Objective

To explore the effectiveness of patellar tendon reconstruction by using LARS artificial ligament in treatment of old patellar tendon rupture.

Methods

A clinical data of 12 patients with old patellar ligament ruptures, who met the inclusive criteria and reconstructed with LARS artificial ligament between December 2011 and December 2017, was retrospectively analyzed. There were 8 males and 4 females with an average age of 33.5 years (range, 18-55 years). The cause of injury included traffic accident injury in 4 cases, sport injury in 5 cases, and violent injury in 3 cases. There were 5 cases in the left knee and 7 cases in the right knee. The disease duration was 2-12 weeks (mean, 2.5 weeks). The preoperative Lysholm score and Kujala score were 43.2±3.2 and 43.9±2.6, respectively. The knee range of motion was (106.5±14.7)°. The thigh circumference which was measured at 10 cm above the upper end of the patella was (40.92±1.93) cm. There were 4 cases of patellar ligament body rupture, 1 case of patella distal pola rupture, and 7 cases of tibial tuberosity attachment rupture. Preoperative Caton-Deschamps index was 1.47±0.13.

Results

All patients were followed up 12-30 months (mean, 20.5 months). All incisions healed by first intention. And no complication such as infection, recurrent rupture, and neurovascular injury occurred. At 1 year after operation, the knee range of motion was (131.0±10.2)°, Lysholm score was 87.4±2.4, Kujala score was 88.3±4.8, the thigh circumference which was measured at 10 cm above the upper end of the patella was (42.58±1.93) cm; all showing significant differences when compared with preoperative values ( P <0.05). The effectiveness results were excellent in 9 cases and good in 3 cases according to the Insall evaluation criteria. The Caton-Deschamps index was 1.09±0.11, which was significantly lower than preoperative one ( t =8.155, P =0.000).

Conclusion

Patellar tendon reconstruction with LARS artificial ligament is an effective method for the old patellar ligament rupture, which can effectively repair the knee extension device and restore knee function.

Keywords: Old patellar tendon rupture, LARS artificial ligament, ligament reconstruction

髌韧带断裂是较为罕见的运动系统损伤类型，多为高能量运动损伤或直接暴力引起。髌韧带损伤早期由于功能残留容易误诊，误诊率高达 38% ^{[

1

-

2

]} 。损伤超过 2 周的髌韧带断裂称为陈旧性断裂 ^{[

3

]} ，常伴有断端挛缩、髌韧带纤维缺损及周围组织瘢痕形成 ^{[

4

-

5

]} ，直接缝合很难达到治疗目的，往往需要对髌韧带行重建或加强手术。目前临床可供选择的重建材料较多，包括非生物材料（钢丝、人工绷带、人工韧带、纽扣钢板 ^{[

6

]} 、不可吸收线缝合 ^{[

7

]} 、缝合锚钉）和生物材料（自体或同种异体胫前肌腱、跟腱、骨-腱-骨） ^{[

8

-

10

]} ；手术也可一期或分期（髌骨向下牵引后二期手术）进行 ^{[

11

]} ；术后并发症包括膝关节屈曲功能丢失，股四头肌伸直延迟、无力，功能欠佳，高位髌骨，移植物排斥反应以及切口感染等 ^{[

12

-

13

]} 。但目前临床对于陈旧性髌韧带断裂的最佳治疗方法仍存在较大争议 ^{[

9

,

14

]} 。2011 年 12 月—2017 年 12 月，我们共收治 20 例陈旧性髌韧带断裂患者，其中 12 例采用 LARS 人工韧带重建治疗，获得较好疗效。报告如下。

1. 临床资料

1.1. 患者选择标准

纳入标准：① 年龄 18～60 岁；② 存在明确外伤病史且病程>2 周，单侧损伤；③ 体格检查表现为髌韧带空虚，主动伸膝迟滞无力或无法完全伸膝；④ 标准侧位（屈膝 30°）X 线片示高位髌骨，Caton-Deschamps 指数>1.2；⑤ MRI 检查示髌韧带断裂；⑥ 应用 LARS 人工韧带进行髌韧带重建。排除标准：① 严重骨质疏松；② 严重全身系统性疾病，如糖尿病肾病、类风湿性关节炎、系统性红斑狼疮；③ 手术区域皮肤条件差，皮肤感染过敏等；④ 合并前、后交叉韧带损伤或同侧肢体骨折；⑤ 双侧髌韧带断裂。2011 年 12 月—2017 年 12 月共 12 例患者符合选择标准纳入研究。本研究通过中国医科大学附属第一医院医学伦理委员会批准。

1.2. 一般资料

本组男 8 例，女 4 例；年龄 18～55 岁，平均 33.5 岁。致伤原因：交通事故伤 4 例，运动伤 5 例，暴力伤 3 例。左膝 5 例，右膝 7 例。病程 2～12 周，平均 2.5 周。入院检查：患者均存在髌韧带空虚，与健侧相比，患侧髌骨为高位，伸膝迟滞无力或无法伸膝，股四头肌不同程度萎缩；8 例患者存在膝关节肿胀疼痛，5 例伴有被动屈伸活动受限。术前膝关节 Lysholm 评分为（43.2±3.2）分，Kujala 评分为（43.9±2.6）分，膝关节活动度为（106.5±14.7）°，髌上 10 cm 处大腿周径为（40.92±1.93）cm。所有患者行膝关节侧位（屈膝 30°）X 线片以及膝关节 MRI 检查，提示髌韧带体部断裂 4 例，髌骨下极处断裂 1 例，胫骨结节止点处断裂 7 例；Caton-Deschamps 指数为 1.47±0.13。

1.3. 手术方法

手术由同一位外科医师完成。全麻下，患者取仰卧位，于膝前自髌骨上极至胫骨结节下缘作长约 9 cm 切口。逐层切开皮肤及皮下，切除填充的瘢痕组织，暴露断裂的髌韧带两端，充分松解髌周及股四头肌肌腱周围腱膜，去除导致近端挛缩因素，测试髌韧带近端张力直至松解满意；本组 5 例韧带断端张力良好且足够建立连续性，予以缝合锚钉先行减张缝合修复。

LARS 人工韧带双股重建：以 LARS 人工韧带配套钻头于胫骨结节及髌骨制作骨隧道，胫骨结节为单横行骨道，髌骨为两平行纵行骨道，选择适当骨道位置以免造成医源性髌骨或胫骨结节骨折。将 LARS 人工韧带 U 形穿过髌骨隧道，再将韧带两端相向穿过胫骨结节隧道，拉紧维持适当张力并摄标准侧位 X 线片，计算 Caton-Deschamps 指数，明确 Caton-Deschamps 指数在正常范围内（与健侧对比基本相同）时维持该张力状态，屈膝 90° 以配套界面螺钉固定胫骨隧道内的 LARS 人工韧带。

术中镇痛：所有患者切口缝合前均对创口区进行注射麻醉（鸡尾酒配方：吗啡 0.5 mL，罗哌卡因 10 mL，1% 肾上腺素 2 mL，生理盐水 47.5 mL；共计 60 mL），注射范围包括前方关节囊、内外侧副韧带、髌上囊及皮下。

1.4. 术后处理及疗效评价指标

术后采用可调铰链式支具固定膝关节 ^{[

6

]} ，2 周内设定膝关节活动范围为 0～30°，部分负重 30%；3～6 周逐渐达 90°，部分负重 50%；7～12 周活动范围至 120°，12 周复查确认肌力恢复良好后去除支具，恢复完全负重。康复期间嘱患者行踝泵训练，预防血栓形成；练习直腿抬高及股四头肌等长收缩，防止患肢肌肉萎缩；被动横向推动髌骨，防止髌股关节粘连；6 个月后恢复慢跑等非竞技性运动。

术后 24 h 采用疼痛视觉模拟评分（VAS）评价患者术区疼痛情况。术后 1、2、3、6、12 个月及之后每年随访 1 次，测量膝关节活动度、髌上 10 cm 处大腿周径、Lysholm 评分、Kujala 评分，以及按照 Insall 评定标准评价疗效；复查膝关节侧位 X 线片和 MRI，计算 Caton-Deschamps 指数评估髌骨高度。

1.5. 统计学方法

采用 SPSS20.0 统计软件进行分析。数据以均数±标准差表示，手术前后比较采用配对 t 检验；检验水准 α =0.05。

2. 结果

所有患者术后均获随访，随访时间 12～30 个月，平均 20.5 个月。术后 24 h VAS 评分为 1～3 分，平均 1.5 分。患者切口均Ⅰ期愈合，无感染、韧带再断裂以及神经血管损伤等并发症发生。术后 3 例患者出现膝关节轻度活动受限，经康复训练功能恢复正常。术后 1 年，患者膝关节活动度为（131.0±10.2）°，Lysholm 评分为（87.4±2.4）分，Kujala 评分为（88.3±4.8）分，髌上 10 cm 处大腿周径为（42.58±1.93）cm，与术前比较差异均有统计学意义（ t =6.320， P =0.000； t =34.290， P =0.000； t =36.830， P =0.000； t =–2.117， P =0.000）。按 Insall 评定标准评价疗效，获优 9 例、良 3 例。影像学检查显示术后 1 年 Caton-Deschamps 指数为 1.09±0.11，较术前明显降低，差异有统计学意义（ t =8.155， P =0.000）。见图 1 。

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图 1

A 33-year-old female patient with old patellar tendon rupture of left knee

患者，女，33 岁，左膝关节陈旧性髌韧带断裂

a. 术前侧位 X 线片；b. 术前 MRI；c. 术中见陈旧性髌韧带断裂，髌周瘢痕形成，髌骨回缩（箭头）；d. 术中 LARS 人工韧带重建后侧位 X 线片示髌骨高度及螺钉位置（箭头）；e. 术后 1 周正侧位 X 线片；f. 术后 1 年 MRI 示重建髌韧带（箭头）走行良好

a. Preoperative lateral X-ray film; b. Preoperative MRI; c. Old patellar tendon rupture, scar tissues formed around patella, and patella retract proximally (arrow); d. Intraoperative lateral X-ray film, showing the patella height and the position of screw (arrow) after ligament reconstruction of LARS; e. Anteroposterior and lateral X-ray films at 1 week after operation; f. MRI at 1 year after operation, showing the good morphology of the reconstructed patellar tendon (arrow)

3. 讨论

3.1. 髌韧带断裂的影像学评估

术前髌韧带断裂患者应完善影像学检查，根据检查结果选择恰当的治疗方法，以期达到最理想治疗效果。影像学检查主要包括膝关节标准侧位 X 线片以及 MRI，同时测量 Caton-Deschamps 指数。在标准侧位 X 线片（通常为屈膝 30°）测量髌骨关节面最低点至胫骨前上角距离，以及髌骨关节面长度，计算两者比值即为 Caton-Deschamps 指数，正常膝关节该指数为 1.02±0.19，>1.2 为髌骨上移，提示高位髌骨、髌韧带延长或断裂 ^{[

15

]} 。Caton-Deschamps 指数简单实用，既不受膝关节屈曲角度的影响，也不受髌骨或胫骨结节畸形的影响。本组患者术前测量 Caton-Deschamps 指数显示均>1.2。

3.2. 陈旧性髌韧带断裂的手术治疗

髌韧带断裂超过 2 周后，由于髌韧带及髌周筋膜挛缩，髌骨将向近端回缩，成为陈旧性髌韧带断裂。此时由于髌骨上移，髌韧带断端缺损张力高，很难直接缝合，勉强缝合后也难以达到有效强度，因此往往需要重建髌韧带。常用髌韧带重建方法包括自体/同种异体腘绳肌肌腱修复重建 ^{[

16

]} 、同种异体跟腱修复重建以及 LARS 人工韧带修复重建等。采用自体肌腱会损伤自身解剖结构，理论上增加了膝关节不稳定性，且取材强度无法保证；同种异体肌腱理论上存在排斥反应；LARS 人工韧带来源充足，目前已有用于髌韧带断裂重建并取得良好疗效的报道，其能有效避免自体肌腱供区并发症及移植物排斥反应，且人工韧带高强度更有利于术后患者早期功能锻炼 ^{[

17

-

19

]} 。本组均采用 LARS 人工韧带移植重建治疗陈旧性髌韧带断裂，术后随访各项指标均较术前明显改善。

但是 LARS 人工韧带重建术也存在一些问题，如胫骨结节及髌骨骨折、髌股关节僵硬、膝前疼痛以及切口问题等。为避免术后膝关节僵硬，术中应将髌上囊内外侧沟、髌骨内外侧支持带和股四头肌肌腱在股骨前方作骨膜下剥离，将髌周组织充分松解，必要时行股四头肌 Z 形延长，以确保移植物具备合理的张力来支持膝关节屈伸，同时保证髌骨正常轨迹和高度，避免髌骨下移或回缩，最大程度避免术后屈膝功能障碍 ^{[

20

]} 。

但由于本研究为回顾性分析，样本例数有限，且造成髌韧带断裂的原因及损伤部位不同，因此术后结果存在一定偏倚，需要加大样本量、延长随访时间以及多中心临床随机对照研究进一步探讨该术式的远期疗效。

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Articles from Chinese Journal of Reparative and Reconstructive Surgery are provided here courtesy of Sichuan University

LARS 人工韧带重建治疗陈旧性髌韧带断裂的疗效研究

Effectiveness of patellar tendon reconstruction with LARS artificial ligament for old patellar tendon rupture

岩 杨

岩峰 王

新贤 王

世忠 顾

汉宁 王

立莹 吴

结论

Abstract

Objective

Methods

Results

Conclusion

1. 临床资料

1.1. 患者选择标准

1.2. 一般资料

1.3. 手术方法

1.4. 术后处理及疗效评价指标

1.5. 统计学方法

2. 结果

3. 讨论

3.1. 髌韧带断裂的影像学评估

3.2. 陈旧性髌韧带断裂的手术治疗

References

岩杨

岩峰王

新贤王

世忠顾

汉宁王

立莹吴