Cooper Daniel E, Stewart Donna
W.B. Carrell Memorial Clinic, Dallas, Texas, USA.
Am J Sports Med. 2004 Mar;32(2):346-60. doi: 10.1177/0363546503261511.
Reconstruction of the posterior cruciate ligament (PCL) using the tibial inlay fixation has been reported as an alternative to the transtibial tunnel technique. Previous failures in PCL reconstruction and early reports raising potential biomechanical and clinical advantages have spurred interest in this technique. The purpose of this study was to evaluate the minimum 2-year results of PCL reconstruction using a single-bundle bone-patellar tendon-bone graft and tibial inlay fixation.
The authors prospectively studied 44 patients having isolated or combined PCL reconstruction using the direct tibial inlay fixation technique. The study period was from 1991 to 2001. Two-year minimum follow-up was 93% (41/44) and averaged 39.4 months. These 41 patients comprised the study group. Thirty-one patients were male and 10 patients were female; average age was 28 years. There were 35 primary and 6 revision reconstructions. Surgery was performed in the acute or subacute setting (<8 weeks) in 34% (14/41) and chronic setting in 66% (27/41). Combined reconstructions involving the posterolateral corner, anterior cruciate ligament (ACL), or medial collateral ligament (MCL) were done in 85% (35/41). In all patients, preoperative posterior drawer (PD) examination demonstrated greater than 12 mm posterior translation. All PCL reconstructions were performed with bone-patellar tendon-bone graft, which was 12 to 18 mm in width (16 autograft; 25 allograft). Wider tendon grafts were prepared from the allografts and tubularized to fit through an 11-mm tunnel. All patients were evaluated with preoperative and postoperative examination and x-rays. Final follow-up International Knee Documentation Committee (IKDC) subjective evaluation, final follow-up IKDC objective evaluation, and final follow-up Telos stress radiography were performed in all patients.
Postoperative PD examination demonstrated the following: 0 (normal) in 9 patients, 1+ in 25 patients, 2+ in 7 patients, and none >2+, as compared to preoperative PD 3+ or greater in all patients in this report. No patient had <12 mm PD preoperatively. Mean improvement in PD was >2 grades of translation as compared to preoperative exam. Forty of forty-one demonstrated a solid endpoint on clinical PD testing. Final follow-up Telos stress radiography with 25 kg posterior load applied at 80 degrees to 90 degrees of flexion demonstrated average side-to-side difference of 4.11 mm (-2 to 10 mm). Average flexion loss was 4 degrees (0-15 degrees ). None lost extension. Preoperative IKDC objective evaluation rated all knees as severely abnormal based on instability. Final follow-up objective IKDC evaluation distribution was as follows: A, 4 knees; B, 24 knees; C, 11 knees; and D, 2 knees, as compared to all 41 D preoperatively. Average final follow-up IKDC subjective score was 75.1 (20-100). When assessing final follow-up stability with Telos stress radiography, primary cases were significantly more stable than revision cases (P <.05). There was no difference in stability when comparing allograft versus autograft, but improved IKDC scores were seen with allograft (P <.05). There was a trend for combined reconstructions to be more stable than isolated reconstructions. All patients evaluated their knee as improved or greatly improved and would repeat the procedure.
Reconstruction of the PCL-deficient knee with severe posterior laxity is a challenging surgical problem, as combined instability patterns frequently coexist (85% in this study). When appropriate combined reconstructions or primary repair is used, PCL reconstruction with autologous or allograft bone-patellar tendon-bone graft using tibial inlay fixation was shown to be a successful technique at 2- to 10-year follow-up. Based on their initial experience with this technique and previous experience with open and arthroscopic techniques using a transtibial tunnel, the authors continue to use the tibial inlay technique as their preferred technique for isolated or combined reconstruction of the PCL.
据报道，使用胫骨嵌体固定重建后交叉韧带（PCL）是经胫骨隧道技术的一种替代方法。此前PCL重建的失败案例以及早期报道中提及的潜在生物力学和临床优势激发了人们对该技术的兴趣。本研究的目的是评估使用单束骨 - 髌腱 - 骨移植物和胫骨嵌体固定进行PCL重建至少2年的结果。
作者前瞻性地研究了44例采用直接胫骨嵌体固定技术进行孤立或联合PCL重建的患者。研究时间段为1991年至2001年。至少2年的随访率为93%（41/44），平均随访时间为39.4个月。这41例患者组成研究组。其中男性31例，女性10例；平均年龄28岁。初次重建35例，翻修重建6例。34%（14/41）的手术在急性或亚急性阶段（<8周）进行，66%（27/41）在慢性阶段进行。85%（35/41）的患者进行了涉及后外侧角、前交叉韧带（ACL）或内侧副韧带（MCL）的联合重建。所有患者术前的后抽屉试验（PD）显示后移大于12 mm。所有PCL重建均采用骨 - 髌腱 - 骨移植物，其宽度为12至18 mm（16例自体移植物；25例同种异体移植物）。从同种异体移植物制备更宽的肌腱移植物并制成管状以适合通过11 mm的隧道。所有患者均接受术前和术后检查及X线检查。所有患者均进行了末次随访国际膝关节文献委员会（IKDC）主观评估、末次随访IKDC客观评估以及末次随访Telos应力X线检查。
术后PD检查结果如下：9例为0（正常），25例为1+，7例为2+，无大于2+的情况，而本报告中所有患者术前PD为3+或更大。术前无患者的PD小于12 mm。与术前检查相比，PD平均改善超过2级的移位。41例中的40例在临床PD测试中显示有坚实的终点。在80度至90度屈曲位施加25 kg后负荷的末次随访Telos应力X线检查显示，平均两侧差异为4.11 mm（-2至10 mm）。平均屈曲丧失为4度（0 - 15度）。无患者伸直丧失。术前IKDC客观评估根据不稳定情况将所有膝关节评为严重异常。末次随访IKDC客观评估分布如下：A，4例膝关节；B，24例膝关节；C，1例膝关节；D，2例膝关节，而术前所有41例均为D级。末次随访IKDC主观评分平均为75.1（20 - 100）。当用Telos应力X线检查评估末次随访稳定性时，初次病例比翻修病例明显更稳定（P <.05）。同种异体移植物与自体移植物相比稳定性无差异，但同种异体移植物的IKDC评分有所改善（P <.05）。联合重建有比孤立重建更稳定的趋势。所有患者均评价其膝关节有所改善或明显改善，并愿意再次接受该手术。
重建严重后松弛的PCL缺失膝关节是一个具有挑战性的外科问题，因为联合不稳定模式经常并存（本研究中为85%）。当采用适当的联合重建或初次修复时，使用胫骨嵌体固定的自体或同种异体骨 - 髌腱 - 骨移植物进行PCL重建在2至10年的随访中显示是一种成功的技术。基于他们对该技术的初步经验以及先前使用经胫骨隧道的开放和关节镜技术的经验，作者继续将胫骨嵌体技术作为他们孤立或联合重建PCL的首选技术。
