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首页> 外文期刊>Orthopaedic Journal of Sports Medicine >Extraaarticular Reconstruction In ACL Deficient Knee: 25 Years Later
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Extraaarticular Reconstruction In ACL Deficient Knee: 25 Years Later

机译：25年后的ACL膝关节置换术

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Objectives: Extraarticular Reconstructions (ERs), isolated or in association with Intraarticular ACL Reconstructions (IRs) were popular in the eighties. However they were almost completely given up as a result of a consensus conference organized by AOSSM in 1989 in Snowmass (Co) where the experts concluded that ERs, even if biomechanically justified, were unable to provide any improvement in clinical results with greater morbidity, higher risk of complications and increased rate of degenerative osteoarthritis (DOA). However, as since then the surgical techniques and postoperative rehabilitation have radically changed, it could be helpful to reconsider ERs and their long term effect on knee stability and on DOA. Methods: One hundred consecutive patients who underwent an anatomic single bundle ACL reconstruction with hamstrings were re-evaluated at a minimum follow up of eleven years. In 23 cases (group B), due to the presence of a Pivot Shift test graded as +++ or in cases of athletes involved in high risk sports, a lateral tenodesis (Coker/Arnold) was associated. The other 77 patients, where an isolated IR was performed with the same technique (group A), served as control. All patients followed the same, standard postoperative rehabilitation program. At follow up Lysholm, IKDC and Tegner activity scores were used. A side to side maximum manual (S/S MM) KT1000 measurement was done. Comparative weight bearing antero-posterior and lateral radiograms were performed and analyzed according to Fairbank, Kellgren and IKDC classification. Tibio-femoral and patella-femoral joints were analyzed separately. Statistical analysis was performed using Student t-test, Pearson chi-square test with SPPS 9.0 software. Results: Group A and B were homogeneous for sex and age. At final follow up seven patients were lost. Subjectively Lysholm score, IKDC and Tegner Activity score improved significantly in both groups with no significant difference. Objectively the number of patient categorized as A and B according to the IKDC was significantly higher in group B than in group A ( P=0.05). Considering as a failure a S/S M/M difference > 5mm or a Pivot Shift test graded as ++ or +++ or a recurrence of any giving way episode, we found 7 cases in group A and no cases in group B (P=0.006). Radiogical evaluation showed no statistically significant difference between the two groups in all scales in both femoro-tibial and patello-femoral joints. Conclusion: The main limitation of the study is that the two groups were not homogeneous in term of preoperative conditions. However as highest grades of activity level and Pivot Shift correlate with an increased risk of DOA, this limitation appears to strengthen the value of the study. Adding a lateral tenodesis to an ACL IR with hamstrings, followed by a standard rehabilitative protocol, seems not to increase the risk of development of DOA, improving rotatory knee stability and reducing risk of recurrence. The meeting in Snowmass has been a milestone event in the evaluation of role of ERs in ACL deficent knee, giving an outstanding contribution to their definition, their biomechanical effect and their role in rotatory instability. However, on the basis of the results of this study, we could speculate that the conclusions of the meeting were somewhat misleading or at least misinterpreted, as they were based on surgical techniques and rehabilitation procedures no more in use in the modern ACL surgery.
机译：目的：八十年代，孤立的或与关节内ACL重建（IR）相关的关节外重建（ER）很流行。但是，由于AOSSM于1989年在斯诺马斯（Co）组织的共识会议的结果，它们几乎被完全放弃了，专家得出的结论是，即使生物力学上合理，急诊室也无法以更高的发病率，更高的发病率改善临床结果。发生并发症的风险和变性骨关节炎（DOA）的发生率增加。但是，由于从那时起，手术技术和术后康复发生了根本性的变化，因此重新考虑ER及其对膝关节稳定性和DOA的长期影响可能会有所帮助。方法：至少连续随访11年，对连续100例接受绳肌解剖性ACL重建的患者进行重新评估。在23例（B组）中，由于存在等级为+++的数据透视转换测试，或者在从事高风险运动的运动员中，发生了外侧肌腱固定术（Coker / Arnold）。其余77例患者，采用相同的技术进行了孤立的IR检查（A组），作为对照。所有患者均遵循相同的标准术后康复计划。随访Lysholm，IKDC和Tegner活动评分。进行了左右最大手动（S / S MM）KT1000测量。根据Fairbank，Kellgren和IKDC分类，进行了比较的负重前后和X线摄片，并进行了分析。胫股关节和bio骨股关节分别进行分析。使用Student t检验，SPPS 9.0软件的Pearson卡方检验进行统计分析。结果：A组和B组在性别和年龄方面均相同。在最后的随访中，有7名患者丢失。两组的主观Lysholm评分，IKDC和Tegner活动评分均显着改善，差异无统计学意义。客观上，根据IKDC分类为A和B的患者人数在B组中明显高于A组（P = 0.05）。将S / SM / M差异> 5mm或等级为++或+++的Pivot Shift测试或任何让步事件的复发视为失败，我们在A组中发现7例，在B组中没有发现任何病例（P = 0.006）。影像学评估显示，两组在股胫关节和骨股关节的所有尺度上均无统计学差异。结论：该研究的主要局限性在于两组术前状况不均。然而，由于最高水平的活动水平和枢轴移位与DOA风险增加相关，因此这种局限性似乎增强了这项研究的价值。向带有CL绳肌的ACL IR中添加外侧腱固定术，然后采用标准的康复方案，似乎并不会增加DOA发生的风险，改善旋转膝关节的稳定性并降低复发的风险。在斯诺马斯会议上，这是评估ER在ACL清醒性膝关节中的作用的里程碑事件，为ER的定义，其生物力学作用以及它们在旋转不稳定性中的作用做出了杰出贡献。但是，根据这项研究的结果，我们可以推测出会议的结论有些误导或至少被误解了，因为它们基于的是在现代ACL手术中不再使用的手术技术和康复程序。

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