Fithian Donald C, Paxton Elizabeth W, Stone Mary Lou, Luetzow William F, Csintalan Rick P, Phelan Daniel, Daniel Dale M
Department of Orthopedic Surgery, Southern California Permanente Medical Group, 250 Travelodge Drive, El Cajon, CA 92020, USA.
Am J Sports Med. 2005 Mar;33(3):335-46. doi: 10.1177/0363546504269590.
Specific guidelines for operative versus nonoperative management of anterior cruciate ligament injuries do not yet exist.
Surgical risk factors can be used to indicate whether reconstruction or conservative management is best for an individual patient.
Prospective nonrandomized controlled clinical trial; Level of evidence, 2.
Patients were classified as high, moderate, or low risk using preinjury sports participation and knee laxity measurements. Early anterior cruciate ligament reconstruction (within 3 months of injury) was recommended to high-risk patients and conservative care to low-risk patients. It was recommended that moderate-risk patients have either early reconstruction or conservative care, according to the day of presentation. Assessment of subjective outcomes, activity, physical measurements, and radiographs was performed at mean follow-up of 6.6 years.
Early phase conservative management resulted in more late phase meniscus surgery than did early phase reconstruction at all risk levels (high risk, 25% vs 6.5%; moderate risk, 37% vs 7.7%, P = .01; low risk, 16% vs 0%). Early- and late-reconstruction patients' Tegner scores increased from presurgery to follow-up (P < .001) but did not return to preinjury levels. Early-reconstruction patients had higher rates of degenerative change on radiographs than did nonreconstruction patients (P < .05).
Early phase reconstruction reduced late phase knee laxity, risk of symptomatic instability, and the risk of late meniscus tear and surgery. Moderate- and high-risk patients had similar rates of late phase injury and surgery. Reconstruction did not prevent the appearance of late degenerative changes on radiographs. Relationship between bone contusion on initial magnetic resonance images and the finding of degenerative changes on follow-up radiographs were not detected. The treatment algorithm used in this study was effective in predicting risk of late phase knee surgery.
目前尚无关于前交叉韧带损伤手术治疗与非手术治疗的具体指南。
手术风险因素可用于指示重建或保守治疗对个体患者而言哪种更佳。
前瞻性非随机对照临床试验；证据等级为2级。
根据伤前运动参与情况和膝关节松弛度测量结果，将患者分为高风险、中风险或低风险。建议高风险患者早期进行前交叉韧带重建（伤后3个月内），低风险患者接受保守治疗。建议中风险患者根据就诊日期选择早期重建或保守治疗。在平均6.6年的随访中进行主观结果、活动情况、体格测量和X光片评估。
在所有风险水平上，早期保守治疗导致的晚期半月板手术比早期重建更多（高风险，25%对6.5%；中风险，37%对7.7%，P = 0.01；低风险，16%对0%）。早期和晚期重建患者的特格纳评分从术前到随访有所提高（P < 0.001），但未恢复到伤前水平。早期重建患者X光片上的退变改变发生率高于未重建患者（P < 0.05）。
早期重建可降低晚期膝关节松弛度、症状性不稳定风险以及晚期半月板撕裂和手术风险。中风险和高风险患者的晚期损伤和手术发生率相似。重建并不能防止X光片上出现晚期退变改变。未检测到初始磁共振成像上的骨挫伤与随访X光片上退变改变之间的关系。本研究中使用的治疗算法可有效预测晚期膝关节手术风险。
