Department of Orthopaedics, André Mignot Hospital Center, 177, rue de Versailles, 78157 Le Chesnay cedex, France.
Orthop Traumatol Surg Res. 2009 Feb;95(1):28-35. doi: 10.1016/j.otsr.2008.09.006. Epub 2009 Feb 18.
Arthroscopically-assisted ACL-reconstructions are currently reliable, reproducible and thoroughly used methods. Residual anterior knee symptoms however, especially after patellar-BTB graft use, are not uncommon occurrences following ACL-reconstructions, and can downgrade patient's satisfaction. Anterior knee pain contributing factors are numerous and include injury to the saphenous nerve infrapatellar branches (SNIB) and/or histologic changes at the harvest site. We thus preferably suggest a double-incision minimal approach for the patellar transplant harvesting stage in order to prevent injury to the SNIB.
This technical variation decreases the risk of injury to the saphenous nerve infrapatellar branches while preserving the peritenon.
Prospective controlled trial.
Two groups were alternatively constituted in 2004: ligament reconstructions were either performed via a two-incisions approach during the first 2004 semester or via a single-incision approach during the second 2004 semester. Pain, even at a mild level, was evaluated. Patients were assessed using objective pain provocative tests and sensory assessment, a Lille University femoropattelar score, the IKDC Knee evaluation, the SF36 quality of life score in combination with radiographic and ultrasonographic investigations.
Forty patients were reviewed at a mean 33 months follow-up delay: 21 of these had a double-incision approach and 19 had a single-incision approach. Four patients from the double-incision sub-group and 11 from the single-incision sub-group reported anterior knee pain (p<0.01). The knee-walking test came out normal in 11 patients from the double-incision sub-group and in three from the single-incision sub-group (p<0.02). The Lille University patello-femoral score was 91/100, demonstrating no significant difference. At follow-up, sensory disorders were observed in 17 patients from the single-incision sub-group and in nine from the double-incision sub-group (p<0.002). However, no statistical correlation could be established between anterior knee pains and sensorial disturbances. SF36 and IKDC objective and subjective scores were similar in both groups. Ultrasonographic findings revealed a lesser degree of patellar tendon thickening in the double-incision sub-group. However, no statistically significant differences definitely emerged between the two groups (p=0.50).
The results of this study strongly support our main hypothesis: The double-incision approach significantly reduces the mid-term incidence of anterior knee pains after ACL-reconstructions. Additionally, this technical variation markedly decreased the occurrence of sensory disorders and the extent of hypoesthesia. We thus advocate the use of a double-incision graft harvesting technique in ACL-reconstructions using a patellar-bone-tendon-bone transplant.
关节镜辅助 ACL 重建术目前是一种可靠、可重复且经过充分验证的方法。然而，ACL 重建术后，尤其是使用髌腱-骨-腱（BTB）移植物后，患者常出现膝关节前侧疼痛，这降低了患者的满意度。膝关节前侧疼痛的原因很多，包括隐神经髌下支（SNIB）损伤和/或采集部位的组织学变化。因此，我们建议在髌腱移植采集阶段采用双切口微创入路，以防止 SNIB 损伤。
这种技术变化可降低 SNIB 损伤的风险，同时保留髌腱周围组织。
前瞻性对照试验。
2004 年，两组患者交替分组：2004 年上半年采用双切口入路进行韧带重建，下半年采用单切口入路进行韧带重建。评估疼痛，即使是轻度疼痛。采用客观疼痛激发试验和感觉评估、里尔大学髌股评分、IKDC 膝关节评估、SF36 生活质量评分以及影像学和超声检查对患者进行评估。
40 例患者在平均 33 个月的随访后进行了回顾性分析：其中 21 例采用双切口入路，19 例采用单切口入路。双切口组有 4 例患者和单切口组有 11 例患者报告膝关节前侧疼痛（p<0.01）。双切口组 11 例患者和单切口组 3 例患者的膝关节行走试验正常（p<0.02）。里尔大学髌股评分均为 91/100，无显著差异。随访时，单切口组 17 例患者和双切口组 9 例患者出现感觉障碍（p<0.002）。然而，膝关节前侧疼痛和感觉障碍之间没有统计学相关性。两组的 SF36 和 IKDC 客观和主观评分相似。超声检查发现，双切口组髌腱增厚程度较轻，但两组间无统计学差异（p=0.50）。
本研究结果强烈支持我们的主要假设：双切口入路可显著降低 ACL 重建术后中期膝关节前侧疼痛的发生率。此外，这种技术变化显著降低了感觉障碍的发生率和感觉减退的程度。因此，我们提倡在使用髌腱-骨-腱（BTB）移植物进行 ACL 重建时使用双切口供体采集技术。
