關(guān)節(jié)鏡下雙鋼絲牽引固定鋼絲法修復(fù)膝前交叉韌帶撕脫骨折臨床操作要點(diǎn)

1、關(guān)節(jié)鏡下雙鋼絲牽引固定鋼絲法修復(fù)膝前交叉韌帶撕脫骨折臨床操作要點(diǎn)                  作者：徐又佳，周海斌，周正明，俞晨，王向利，姜雪峰，董啟榕，鄭祖根【摘要】  目的探討在關(guān)節(jié)鏡下運(yùn)用雙鋼絲牽引固定鋼絲法修復(fù)膝前交叉韌帶脛骨髁間嵴撕脫骨折的手術(shù)方法和要點(diǎn)。方法2006年2月2006年8月運(yùn)用該方法治療14例患者，男9例，女5例，年齡540歲（平均32.6歲）；致傷原因：車(chē)禍傷7例、運(yùn)動(dòng)中摔倒致傷5例，

2、墜落傷2例。所有患者術(shù)前X線片、Artoscan均提示前交叉韌帶脛骨髁間嵴撕脫骨折。在關(guān)節(jié)鏡下用“固定鋼絲”橫行穿過(guò)撕脫骨折腱骨聯(lián)合區(qū)；在脛骨平臺(tái)撕脫骨折兩側(cè)建立骨隧道；用2根“牽引鋼絲”牽引“固定鋼絲”從骨隧道中穿出并固定；術(shù)后屈膝20°位石膏托固定34周，4周去除石膏托固定功能鍛煉，8周扶拐行走。結(jié)果經(jīng)平均10.5個(gè)月隨訪，門(mén)診X線片提示骨性愈合時(shí)間平均在術(shù)后5.5個(gè)月，隨訪末次的改良Lysholm評(píng)分：優(yōu)8例、良4例、可2例、差0例，近期優(yōu)良率85.1。結(jié)論運(yùn)用“雙鋼絲牽引固定鋼絲”法治療無(wú)需傳統(tǒng)切口，擁有創(chuàng)傷小、恢復(fù)快、并發(fā)癥少等優(yōu)點(diǎn)；在臨床操作中了解該手術(shù)的要點(diǎn)，對(duì)順利運(yùn)用

3、該方法十分有益。 【關(guān)鍵詞】  關(guān)節(jié)鏡； 前交叉韌帶； 髁間嵴撕脫骨折； 固定    Abstract：ObjectiveTo explore the operating methods and key points of bysteel-wire guiding fixative steel-wire repearing tibial intercondylar eminence avulsion fractures under arthroscope.MethodFrom February 2006 to August  2006,14 p

4、atients with tibial intercondylar eminence avulsion fractures were treated in bysteel-wire guiding fixative steel-wire method. Among them,there are  9 males and 5 females  with an average age of  32.6 years,aged from 5 to 40 years.Injury cause:7 of road accident,5 of falling down whil

5、e moving and 2 of falling from height.The results of preoperative x-Ray and  Artoscan of all patients suggested the avulsion fracture of anterior cruciate ligament from the tibial spine.In the operation, firstly,fixative steel-wire cross the avulsion fracture tendon-bone joint zone.Then,make ea

6、ch side of avulsion fracture a bone tunnel on the tibial plateau .Finally,guide fixative steel-wire out of these two bone tunnels and then fix this steel -wire with the help of guiding steel-wires. After operation,fix the knee joint with plaster slab bended at  20° in three or four weeks.R

7、emove the plaster slab  and do functional exercise after 4 weeks.And move with walking stick 8 weeks later.ResultAll 14 patients were available at follow up with mean duration of 10.5 months.The X-Ray suggested bone healed at about 5.5 months after operation. We got the excellent in 8 cases,goo

8、d in 4 and fair in 2 according to the advanced Lyshdm's classification at the last follow up.The excellent and good rate was 85.1%.ConclusionThe technique needn't traditional cut,and has many advantages,such as micro injury,rapid recovery  and  few complications.And it is good to m

9、aster the main points of this technique for applying it.    Key words：arthroscopy;  anterior cruciate ligament (ACL);  avulsion fracture of intercondylar eminence;  fixation     膝前交叉韌帶損傷的部位有多種，較常見(jiàn)的是膝前交叉韌帶脛骨髁間嵴撕脫骨折。關(guān)于這類(lèi)損傷的臨床治療基本是用“固定鋼絲”橫行穿過(guò)撕脫骨折部位的腱骨聯(lián)合

10、區(qū)，然后鋼絲兩端從脛骨平臺(tái)下的骨隧道中穿出并固定1。在關(guān)節(jié)鏡下進(jìn)行這一固定，無(wú)需傳統(tǒng)切口，創(chuàng)傷小，恢復(fù)快，膝關(guān)節(jié)避免切開(kāi)關(guān)節(jié)囊的術(shù)后并發(fā)癥。關(guān)于關(guān)節(jié)鏡下“固定鋼絲”的穿進(jìn)、穿出、固定的方法有很多，臨床操作的方便程度、難易程度各不盡相同24。作者自2006年2月2006年8月運(yùn)用雙鋼絲牽引固定鋼絲穿入骨隧道方法簡(jiǎn)便實(shí)用，共治療14例，術(shù)后效果滿(mǎn)意，現(xiàn)將臨床操作要點(diǎn)報(bào)告如下。    1  資料與方法    1.1  一般資料    本組14例，男9例，女5例。年齡540歲（平均32.6歲）

11、。致傷原因：車(chē)禍傷7例、運(yùn)動(dòng)中摔倒致傷5例，墜落傷2例。    臨床表現(xiàn)：患膝腫脹，膝關(guān)節(jié)屈、伸活動(dòng)受限，浮髕征（+），前抽屜試驗(yàn)陽(yáng)性5例（術(shù)中麻醉后與對(duì)側(cè)比較均為陽(yáng)性），Lachman征陽(yáng)性7例；X線片均可見(jiàn)脛骨髁間嵴前緣有移位的骨塊影，X線片按Meyers-Mckeever分型：型6例、型8例；Artoscan提示本組均有前交叉韌帶脛骨髁間嵴止點(diǎn)撕脫骨折，骨塊移位最大點(diǎn)間距離>3 mm。受傷至手術(shù)時(shí)間：616 d，平均8.5 d。    1.2  手術(shù)方法    患者均為硬膜外麻醉，平位在屈膝手術(shù)床，患肢行氣囊止血帶止血；關(guān)節(jié)鏡按常規(guī)步驟操作。    圖1  關(guān)節(jié)鏡下前交叉韌帶脛骨止點(diǎn)撕脫表現(xiàn)  圖2  第1根牽引鋼絲關(guān)節(jié)鏡下所見(jiàn)及操作示意圖    圖3  第2根牽引鋼絲關(guān)節(jié)鏡下所見(jiàn)操作示意圖  圖4  固定鋼絲關(guān)節(jié)鏡下所見(jiàn)操作示意圖  圖5  鏡下脛骨髁間嵴骨塊復(fù)位固定前、后表現(xiàn)    1.3