Vališ P, Sklenský J, Repko M, Rouchal M, Novák J, Otaševič T
Ortopedická klinika Fakultní nemocnice Brno.
Acta Chir Orthop Traumatol Cech. 2014;81(6):371-9.
The aim of this retrospective study was to present a comprehensive overview of the causes of bone-tendon-bone (BTB) autograft failure after primary anterior cruciate ligament (ACL) reconstruction. MATERIAL AnD METHODS: Between 2003 and 2013, we performed revision ACL replacement in 47 patients who had undergone primary BTB autograft ACL reconstruction in other hospitals. The group consisted of 16 women (aged 25 to 48 years) and 31 men (25 to 46 years). Surgery was performed on the right knee in 26 and on the left knee in 21 patients. In each of the 47 patients, two different assessments were made: 1. Analysis of causes of failure based on surgical protocols and/or intra-operative video records taken during most of the procedures. 2. Evaluation of bone tunnel location on lateral knee radiograms, using the method described by Harner for femoral tunnels and that reported by Stäubli and Rauschning for tibial tunnels.
The most frequent cause of knee instability, occurring in 51.1% of the patients, was new trauma to the knee. nontraumatic instability in the remaining 48.9% was due to insuffiiency of the graft, and resulted from an incorrect surgical technique (42.5%) or biological causes (6.4%). The most common surgical mistake found was incorrect bone tunnel placement in the tibia or femur, with a malpositioned femoral tunnel being most frequent. This was diagnosed in 32 patients (68.1% of all patients) and, in 17, was the main or major cause of BTB graft failure.
Based on relevant literature data and our experience, principles for prevention of graft failure after ACL reconstruction can be summarised as follows: 1. harvest of a suffiiently strong BTB autograft 2. accurate anatomical bone tunnel placement 3. appropriate tension of the BTB autograft 4. preventing graft impingement 5. secure graft fiation 6. early functional rehabilitation with an accent on delaying full weight-bearing on the knee (6 to 9 months post-operatively)
New trauma to the knee is the most frequent cause of BTB autograft failure after ACL reconstruction. This can be avoided by participating in a professionally guided rehabilitation programme and not returning to sports activities earlier than 9 months after ACL reconstruction. The most common technical error in ACL reconstruction is non-anatomical tunnel placement in the tibia and femur. Femoral tunnel malposition is most frequent while incorrect tibial tunnel placement, which does not inflence graft failure so much, is less common.
本回顾性研究旨在全面概述初次前交叉韧带（ACL）重建术后骨-肌腱-骨（BTB）自体移植物失败的原因。
2003年至2013年期间，我们对47例在其他医院接受初次BTB自体移植物ACL重建的患者进行了ACL翻修置换手术。该组包括16名女性（年龄25至48岁）和31名男性（25至46岁）。26例患者在右膝进行手术，21例在左膝进行手术。对47例患者中的每一例都进行了两种不同的评估：1. 根据手术记录和/或大多数手术过程中拍摄的术中视频记录分析失败原因。2. 使用Harner描述的股骨隧道方法和Stäubli及Rauschning报告的胫骨隧道方法，在膝关节外侧X线片上评估骨隧道位置。
膝关节不稳定的最常见原因是膝关节新创伤，发生在51.1%的患者中。其余48.9%的非创伤性不稳定是由于移植物不足，这是由不正确的手术技术（42.5%）或生物学原因（6.4%）导致的。发现的最常见手术失误是胫骨或股骨骨隧道放置不正确，股骨隧道位置不当最为常见。32例患者（占所有患者的68.1%）被诊断为此种情况，其中17例是BTB移植物失败的主要或主要原因。
根据相关文献数据和我们的经验，ACL重建术后预防移植物失败的原则可总结如下：1. 采集足够强壮的BTB自体移植物；2. 准确的解剖学骨隧道放置；3. BTB自体移植物适当的张力；4. 防止移植物撞击；5. 牢固的移植物固定；6. 早期功能康复，重点是延迟膝关节完全负重（术后6至9个月）。
膝关节新创伤是ACL重建术后BTB自体移植物失败的最常见原因。通过参加专业指导的康复计划并在ACL重建术后9个月内不提前恢复体育活动，可以避免这种情况。ACL重建中最常见的技术错误是胫骨和股骨隧道放置不解剖。股骨隧道位置不当最为常见，而不正确的胫骨隧道放置不太常见，其对移植物失败的影响较小。
