膝关节镜在下肢骨折合并膝不稳定的作用.doc

膝关节镜在下肢骨折合并膝不稳定的作用膝关节镜在下肢骨折合并膝不稳定的作用更新日期：2010-07-03 叶文凌杜元坤施俊雄 【摘要】目的探讨关节镜在下肢骨折中的应用价值。方法自1994年7月1996年6月,共收治1062例、1119个股骨或胫骨骨折。其中股骨骨折495个,胫骨骨折624个。176例膝关节有症状且具有不稳定现象者予以关节镜手术。结果平均随访(25.310.7)个月。136例(12.8%)有十字韧带损伤。其中前十字韧带损伤101例(74.3%),后十字韧带损伤35例(25.7%)。自附着处撕裂及部分撕裂多于间质撕裂及完全撕裂,半月状软骨在前十字韧带损伤者为42.6%,在后十字韧带损伤者为60%。但半月状软骨关节囊韧带破裂多于半月状软骨本体损伤,旋转性不稳定多于单纯不稳定。骨软骨骨折亦常见。十字韧带损伤需手术治疗者占33.8%。行手术治疗者Lysholm评分为84,非手术治疗者为79。膝活动度:弯曲(129.110.4),伸直(2.11)。结论在股骨或胫骨骨折且膝关节有症状或具有不稳定现象者行关节镜手术,疗效显著。 【关键词】股骨骨折胫骨骨折膝韧带损伤关节镜 Effect of Arthroscope on Lower-limb Fractures Combined with Knee InstabilityYE Wen-ling, DU Yuan-kun, SHI Jun-xiong. Dept. of Emergency and Traumatic Orthopedics, Changgeng Memorial Hospital, Linkou 【Abstract】Aim To explore the effect of arthroscope on lower-limb fractures. MethodsFrom July 1994 to June 1996, 1062 patients with femoral or tibial fractures (495 femoral fractures, 642 tibial fractures) in the same hospital were reviewed. Among them, 176 patients who have shown injury symptoms of the knee and shown instability in physical examination were included in the arthroscopic evaluation. ResultsFollowed up for (25.310.7) months, 136 knees (12.8%) were found to have cruciate ligament lesions. In which, anterior cruciate ligament (ACL) lesions were in 101 knees (74.3%) and posterior cruciate ligament (PCL) lesions in 35 knees (25.7%). Avulsion from ligament attachment and partial tear were more than interstitial tear and complete tear. Meniscus lesions occurred in 42.6% of ACL group and 60% of PCL group. But meniscocapsular lesions were more than meniscus rupture itself. Rotatory instabilities (89.1% in ACL group and 77.1% in PCL group) were more than single plane instabilities, which reflect the nature of high energy trauma. Osteochondral fractures and pathologic medical plica were common (8.9% and 16.8 in ACL group, 20% and 25.7% in PCL group). Operative treatments were needed in 33.8% of knees (35.6% of ACL group and 28.6% of PCL group). Lysholm score was 84 in the operative group and 79 in the nonoperative group. The range of motion was (129.110.4) in flexion, and (2.11) in extension. ConclusionArthroscopic evaluation is valuable in symptomatic knee after femoral or tibial diaphyseal fracture. 【Key words】Femoral fractureTibial fractureKnee ligament injuryArthroscope 在运动损伤中,膝损伤占第1或第2位。其中包括前后十字韧带损伤、内侧及外侧副韧带损伤、其他相关支持构造损伤、半月状软骨损伤、软骨损伤、关节内骨折等。膝关节镜手术应用于运动损伤已被广为接受且效果良好。其优点在于手术相关的损伤少,视野清楚,住院日数短,术后并发症少,病人可尽早运动及工作。随着机动车辆性能的大幅提高,摩托车辆的不断增加,行人对交通规则的漠视,道路质量低下及设计缺陷等因素,台湾车祸受伤人数远比运动受伤的人数多得多。而下肢骨折(股骨及胫腓骨骨折)更是其中之最。值得注意的是,不论是股骨或胫腓骨骨折,其受伤机制多由于高能量损伤所致。Kyle1报告,如欲使股骨骨折,至少要250N方可。在北美地区1年约有185 000个胫腓骨骨折,股骨骨折则约为此数的1/92。在这么大的外力损伤及这么多的种类中,自然会有许多膝损伤病例,但文献报道却极为有限。Pedersen等3、Dunbar等4、Walling等5、Lakshman等6均报告股骨合并或不合并胫腓骨骨折时,膝韧带损伤的机率约为33%70%7。但是,绝大多数文献只是用主观的理学检查来诊断膝韧带损伤。至于韧带损伤的型态、相关构造是否损伤则往往不得而知。既然关节镜在运动医学已倍受肯定,笔者便尝试用关节镜来得到这方面的答案。 临床资料与方法 为使研究单纯化,笔者将范围限定于股骨干及胫骨干骨折的病人,重新研究病史,X线片,并做问卷调查。以下的病人则予以排除:(1)髋臼骨折;(2)转子附近骨折及转子下骨折;(3)膝部关节内骨折;(4)髌骨骨折;(5)前后十字韧带撕裂性骨折;(6)膝脱臼;(7)膝外伤病史;(8)浮动膝(floating knee),即同时合并同侧股骨和胫骨骨折。 自1994年7月1996年6月,林口长庚医院急诊室共收治20 537例车祸病人。其中病历、X线片、问卷完全者,共计1062例病人、1119个股骨或胫骨骨折。男性834例(78.5%),女性228例(21.5%);平均年龄30.5岁(1772岁)。股骨骨折495例(44.2%),胫骨骨折624例(55.8%)。闭合性骨折695例(65.4%),开放性骨折367例(34.6%)。受伤原因:摩托车车祸447例(42.1%),汽车车祸451列(42.5%),高处坠落103例(9.7%),其他损伤61例(5.7%)。骨折的相关治疗见表1。 表1骨折治疗方式及例数 骨折部位及治疗方式 例数 百分比(%) 股骨 Kuntscher骨髓内钉 100 20.2 镶钳式骨髓内钉 332 67.1 外固定器 42 8.5 骨板 18 3.6 其他 3 0.6 胫骨 Kuntscher骨髓内钉 98 15.7 镶钳式骨髓内钉 356 57.1 外固定器 67 10.7 骨板 67 10.7 其他 3