关节镜下双钢丝牵引固定钢丝法修复膝前交叉韧带撕脱骨折临床操作要点

1、关节镜下双钢丝牵引固定钢丝法修复膝前交叉韧带撕脱骨折临床操作要点                  作者：徐又佳，周海斌，周正明，俞晨，王向利，姜雪峰，董启榕，郑祖根【摘要】  目的探讨在关节镜下运用双钢丝牵引固定钢丝法修复膝前交叉韧带胫骨髁间嵴撕脱骨折的手术方法和要点。方法2006年2月2006年8月运用该方法治疗14例患者，男9例，女5例，年龄540岁（平均32.6岁）；致伤原因：车祸伤7例、运动中摔倒致伤5例，

2、坠落伤2例。所有患者术前X线片、Artoscan均提示前交叉韧带胫骨髁间嵴撕脱骨折。在关节镜下用“固定钢丝”横行穿过撕脱骨折腱骨联合区；在胫骨平台撕脱骨折两侧建立骨隧道；用2根“牵引钢丝”牵引“固定钢丝”从骨隧道中穿出并固定；术后屈膝20°位石膏托固定34周，4周去除石膏托固定功能锻炼，8周扶拐行走。结果经平均10.5个月随访，门诊X线片提示骨性愈合时间平均在术后5.5个月，随访末次的改良Lysholm评分：优8例、良4例、可2例、差0例，近期优良率85.1。结论运用“双钢丝牵引固定钢丝”法治疗无需传统切口，拥有创伤小、恢复快、并发症少等优点；在临床操作中了解该手术的要点，对顺利运用

3、该方法十分有益。 【关键词】  关节镜； 前交叉韧带； 髁间嵴撕脱骨折； 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     膝前交叉韧带损伤的部位有多种，较常见的是膝前交叉韧带胫骨髁间嵴撕脱骨折。关于这类损伤的临床治疗基本是用“固定钢丝”横行穿过撕脱骨折部位的腱骨联合

10、区，然后钢丝两端从胫骨平台下的骨隧道中穿出并固定1。在关节镜下进行这一固定，无需传统切口，创伤小，恢复快，膝关节避免切开关节囊的术后并发症。关于关节镜下“固定钢丝”的穿进、穿出、固定的方法有很多，临床操作的方便程度、难易程度各不尽相同24。作者自2006年2月2006年8月运用双钢丝牵引固定钢丝穿入骨隧道方法简便实用，共治疗14例，术后效果满意，现将临床操作要点报告如下。    1  资料与方法    1.1  一般资料    本组14例，男9例，女5例。年龄540岁（平均32.6岁）

11、。致伤原因：车祸伤7例、运动中摔倒致伤5例，坠落伤2例。    临床表现：患膝肿胀，膝关节屈、伸活动受限，浮髌征（+），前抽屉试验阳性5例（术中麻醉后与对侧比较均为阳性），Lachman征阳性7例；X线片均可见胫骨髁间嵴前缘有移位的骨块影，X线片按Meyers-Mckeever分型：型6例、型8例；Artoscan提示本组均有前交叉韧带胫骨髁间嵴止点撕脱骨折，骨块移位最大点间距离>3 mm。受伤至手术时间：616 d，平均8.5 d。    1.2  手术方法    患者均为硬膜外麻醉，平位在屈膝手术床，患肢行气囊止血带止血；关节镜按常规步骤操作。    图1  关节镜下前交叉韧带胫骨止点撕脱表现  图2  第1根牵引钢丝关节镜下所见及操作示意图    图3  第2根牵引钢丝关节镜下所见操作示意图  图4  固定钢丝关节镜下所见操作示意图  图5  镜下胫骨髁间嵴骨块复位固定前、后表现    1.3