Arthroscopic treatment with canulated screw fixation through very high-posteromedial portal approach versus double bundle suture fixation for avulsion fracture of tibial attachment of posterior cruciate ligament

doi:10.3969/j.issn.2095-4344.2017.35.013

Abstract

Abstract:

BACKGROUND: This team modified the arthroscopic reduction and internal fixation with canulated screw through very high-posteromedial portal approach to perform direct compression. Thus, the pressure of the fracture block is evenly distributed on the healing line, and the operation is convenient and fixed firmly, but its clinical effect remains to be further confirmed.

OBJECTIVE: To compare the clinical outcome of arthroscopic reduction and internal fixation with canulated screw through very high-posteromedial portal approach and double bundle suture fixation for avulsion fracture of the tibial attachment of posterior cruciate ligament.

METHODS: From January 2011 to May 2017, 60 cases of the avulsion fracture of posterior cruciate ligament (transverse diameter of fracture block > 10 mm) were treated operatively at the Orthopedics and Arthroscopic Ward Two, First Hospital of Qinhuangdao, China. According to different modes of operation in different periods, patients were assigned to two groups. In the canulated screw group (n=31), patients were treated with canulated screw through very high- posteromedial portal approach. In the suture group (n=29), patients were treated with double bundle suture fixation through posteromedial portal approach. General conditions were compared between the two groups. Knee function was assessed with the Intemational Knee Documentation Committee and Lysholm scores. Knee stability was evaluated with KT-2000 and posterior drawer test.

RESULTS AND CONCLUSION: (1) All the patients were followed up (range 6-12 months). (2) The average operation time was (63.49±3.97) minutes in the canulated screw group and (87.28±3.46) minutes in the suture group (P < 0.05). At 3 months after surgery, all the patients were healed. (3) At the final follow-up, in the canulated screw group, the negative rate of posterior drawer test was 90%. Lysholm scores were 94.89±4.75. IKDC scores were 94.01±3.25. In the suture group, the negative rate of posterior drawer test was 90%. Lysholm scores were 95.56±3.63. IKDC scores were 95.52±4.72. No significant difference was determined between the two groups (P > 0.05). (4) KT-2000 measurement results revealed that there were no significant differences between the surgical knee and the normal knee in both groups (canulated screw group: (2.53±1.02) mm versus (2.12±0.83) mm; suture group: (2.65±0.82) mm versus (2.19±0.63) mm (P > 0.05). Moreover, no significant difference was detected in the affected knee of KT-2000 results between the two groups. (5) Both arthroscopic reduction with canulated screw through very high-posteromedial portal approach and double bundle suture fixation can achieve satisfactory clinical outcomes, but arthroscopic reduction with canulated screw through very high-posteromedial portal approach in patients with fracture block diameter > 10 mm can result in shorter operation time, more reliable fixation, and thus permit an early postoperative functional exercise.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Tibial Fractures, Posterior Cruciate Ligament, Arthroscopes, Tissue Engineering

CLC Number:

R318

Wang Xin-min, Liu Fei, Zhao Hai-xia, Wang Wei, Wang Jian-quan. Arthroscopic treatment with canulated screw fixation through very high-posteromedial portal approach versus double bundle suture fixation for avulsion fracture of tibial attachment of posterior cruciate ligament[J]. Chinese Journal of Tissue Engineering Research, 2017, 21(35): 5655-5660.

Figures/Tables 2

2.1 参与者数量分析按意向性处理，共有60例后交叉韧带胫骨止点撕脱骨折患者参与试验，其中31例患者进行关节镜下极后高位入路空心螺钉固定，29例患者行标准入路缝线固定，全部进入结果分析，无脱落。试验流程图见图4。 2.2 一般情况的比较所有患者顺利完成手术并获得随访，随访时间为6-12个月。两组患者的年龄、性别、损伤原因及侧别、骨折类型和受伤至手术时间比较差异均无显著性意义(表1)。空心钉组手术时间为(63.49±3.97) min，缝线组手术时间为(87.28±3.46) min，两组比较差异有显著性意义(P < 0.05)(表2)。空心钉组2例患者复位欠佳，缝线组3例复位欠佳。术后3个月X射线片显示所有患者骨折处均为一期愈合，无移位。 2.3 客观指标的比较末次随访时(术后6个月)后抽屉试验结果显示，空心钉组Ⅰ度阳性2例，Ⅱ度阳性1例，阴性率90%，缝线组Ⅰ度阳性2例，Ⅱ度阳性1例，阴性率90%次随访时两组患者后抽屉试验结果比较无明显差异(P > 0.05)。空心钉组膝关节活动度正常者29例；末次随访时(术后6个月)，KT-2000结果显示，空心钉组患膝为(2.53± 1.02) mm，健膝为(2.12±0.83) mm，患膝与健膝胫骨后向松弛度无显著差异；缝线组患膝为(2.65±0.82) mm，健膝为(2.19±0.63) mm，患膝与健膝胫骨后向松弛度差异无显著意义；KT-2000结果显示两组患者末次随访时患膝之间比较差异无显著意义(表3)。 2.4 主观指标的比较末次随访时(术后6个月)缝线组及空心钉组Lysholm评分、国际膝关节文献委员会膝关节评分及分级结果比较差异无显著意义(P > 0.05)(表2)。 2.5 并发症膝关节活动度受限者2例：1例合并外侧半月板损伤，术中给予半月板缝合，伸膝正常，屈膝较健侧差15°；1例合并内侧副韧带损伤，术后给予伸直位支具固定8周，屈膝较健侧差10°。双股缝线组膝关节活动度正常者26例，伸膝活动受限2例，伸直差5°-10°，屈膝活动受限1例，均<5°。两组患者术后均未出现切口感染、皮肤坏死、深静脉血栓及螺钉松动等并发症。"

References

[1] 刘平,敖英芳.膝关节后交叉韧带及板股韧带临床解剖学研究[J].中国运动医学杂志,2008, 27(2):189-193..

[2] Kim YM, Lee CA, Matava MJ. Clinical results of arthroscopic single-bundle transtibial posterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2011;39(2):425-434.

[3] Lu XW, Hu XP, Jin C, et al. Reduction and fixation of the avulsion fracture of the tibial eminence using mini-open technique. Knee Surg Sports Traumatol Arthrosc. 2010; 18(11): 1476-1480.

[4] Cosgarea AJ, Jay PR. Posterior cruciate ligament injuries: evaluation and management. J Am Acad Orthop Surg. 2001;9(5):297-307.

[5] Logan M, Williams A, Lavelle J, et al. The effect of posterior cruciate ligament deficiency on knee kinematics. Am J Sports Med.2004; 32(8):1915-1922.

[6] Sasaki SU, da Mota e Albuquerque RF, Amatuzzi MM, et al. Open screw fixation versus arthroscopic suture fixation of tibial posterior cruciate ligament avulsion injuries: a mechanical comparison. Arthroscopy. 2007; 23(11):1226-1230.

[7] Littlejohn SG, Geissler WB. Arthroscopic repair of a posterior cruciate ligament avulsion. Arthroscopy. 1995;11(2): 235-238.

[8] Choi NH, Kim SJ. Arthroscopic reduction and fixation of bony avulsion of the posterior cruciate ligament of the tibia. Arthroscopy.1997;13(6): 759-762.

[9] Wajsfisz A, Makridis KG, Van Den Steene JY, et al. Fixation of posterior cruciate ligament avulsion fracture with the use of a suspensory fixation. Knee Surg Sports Traumatol Arthrosc. 2012; 20(5): 996-999.

[10] 吴术红,刘毅.关节镜下韧带末端缝扎固定治疗后十字韧带胫骨止点骨折[J].中华骨科杂志, 2011,31(7):779-183.

[11] 林瑞新,董伊隆,杨国敬.关节镜下双套环技术治疗后十字韧带胫骨止点撕脱性骨折[J].中华骨科杂志,2010,30(12):1187-1191.

[12] Kim SJ, Shin SJ, ChoiNH, et al. Arthroscopically assisted treatment of avulsion fractures of the posterior cruciate ligament from the tibia. J Bone Joint Surg Am. 2001; 83(5): 698-708.

[13] Zhao JY, He B, Wang J. Arthroscopic treatment of acute tibial avulsion fracture of the posterior cruciate ligament with suture fixation technique through Y-shaped bone tunnels. Arthroscopy.2006;22(2):172-181.

[14] Gui JC, Wang LM, Jiang YQ, et al. Single-tunnel suture fixation of posterior cruciate ligament avulsion fracture. Arthroscopy.2009;25(1): 78-85.

[15] Chen SY, Cheng CY, Chang SS, et al. Arthroscopic suture fixation for avulsion fractures in the tibial attachment of the posterior cruciate ligament. Arthroscopy. 2012; 28(10):1454-1463.

[16] Mao YQ, Dong P, Wang Y. Ganglion cysts of the cruciate ligaments: a series of 31 cases and review of the literature. BMC Musculoskelet Disord.2012;13:137.

[17] Sabat DA, Jain P, Kumar V. Displaced posterior cruciate ligament avulsion fractures: a retrospective comparative study between open posterior approach and arthroscopic single-tunnel suture fixation. Arthroscopy.2016;32(1): 44-53.

[18] Joshi S, Bhatia C, Gondane A, et al. Open reduction and internal fixation of isolated posterior cruciate ligament avulsion fractures: clinical and functional outcome.Knee Surg Relat Res.2017; 29(3):210-216.

[19] 李建赤,黄必留,梁江声,等.锚钉内固定治疗后交叉韧带胫骨止点撕脱性骨折[J].中华关节外科杂志(电子版),2013,7(1):44-47.

[20] Nicandri GT, Klineberg EO, Wahl CJ, et al. Treatment of posterior cruciate ligament tibial avulsion fractures through a modified open posterior approach: operative technique and 12- to 48-month outcomes. J Orthop Trauma. 2008;22(5):317-324.

[21] 徐国浩,桂鉴超,周金明.关节镜下缝线固定手术治疗后交叉韧带胫骨止点撕脱骨折[J].中国骨与关节损伤杂志, 2017,32(2):208-209.

[22] Meyers MH, McKeever FM. Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am.1970; 52(8):1677-1684.

[23] 赵金忠,蒋垚.关节镜下缝线固定治疗后交叉韧带胫骨止点撕脱骨折[J].中华创伤杂志,2003. 19(9):569-570.

[24] Paine R, Lowe W. Comparison of Kneelax and KT-1000 knee ligament arthrometers. J Knee Surg. 2012;25(2):151-154.

[25] 黄乐春,胡惠民,梁宇翔.膝关节功能评分量表评述.中国医药科学, 2016, 6(13):50-53.

[26] Fanelli GC, Fanelli MG, Fanelli DG. Revision posterior cruciate ligament surgery. Sports Med Arthrosc. 2017;25(1):30-35.

[27] Berg E.E. Comminuted tibial eminence anterior cruciate ligament avulsion fractures: failure of arthroscopic treatment. Arthroscopy.1993; 9(4):446-450.

[28] 张青松,李涛,方禹舜,等.关节镜下“人”字缝线固定治疗后交叉韧带胫骨止点撕脱骨折[J].中华创伤骨科杂志, 2016,18(11):998-1000.

[29] 张中兴,许峰,金伟.带线锚钉治疗后交叉韧带胫骨止点撕脱骨折21例报告[J].中国骨与关节杂志, 2016(2):120-12.

[30] Jazayeri SM, Esmaili JA, Karami M. A safe postero-medial approach to posterior cruciate ligament avulsion fracture. Knee Surg Sports Traumatol Arthrosc. 2009; 17(3): 244-247.