University of Delaware, Newark, Delaware.
J Bone Joint Surg Am. 2018 Jul 18;100(14):1209-1216. doi: 10.2106/JBJS.17.01014.
Knee osteoarthritis risk is high after anterior cruciate ligament reconstruction (ACLR) and arthroscopic meniscal surgery, and higher among individuals who undergo both. Although osteoarthritis development is multifactorial, altered walking mechanics may influence osteoarthritis progression. The purpose of this study was to compare gait mechanics after ACLR among participants who had undergone no medial meniscal surgery, partial medial meniscectomy, or medial meniscal repair.
This was a secondary analysis of data collected prospectively as part of a clinical trial. Sixty-one athletes (mean age of 21.4 ± 8.2 years) who had undergone primary ACLR participated in the study when they achieved impairment resolution (5.3 ± 1.7 months postoperatively), including minimal to no effusion, full knee range of motion, and ≥80% quadriceps-strength symmetry. Participants were classified by concomitant medial meniscal treatment: no involvement or nonsurgical management of a small, stable tear; partial meniscectomy; or meniscal repair. Participants underwent comprehensive walking analyses. Joint contact forces were estimated using a previously validated, electromyography-driven musculoskeletal model. Variables were analyzed using a mixed-model analysis of variance with group and limb comparisons (α = 0.05); group comparisons of interlimb differences in measurements (surgical minus contralateral limb) were performed to determine significant interactions.
The participants in the partial meniscectomy group walked with a higher peak knee adduction moment (pKAM) in the surgical versus the contralateral limb as compared with those in the meniscal repair group and those with no medial meniscal surgery (group difference for partial versus repair: 0.10 N-m/kg-m, p = 0.020; and for partial versus none: 0.06 N-m/kg-m, p = 0.037). Participants in the repair group walked with a smaller percentage of medial to total tibiofemoral loading in the surgical limb compared with both of the other groups (group difference for repair versus partial: -12%, p = 0.001; and for repair versus none: -7%, p = 0.011). The participants in the repair group loaded the medial compartment of the surgical versus the contralateral limb 0.5 times body weight less than did the participants in the partial meniscectomy group.
Participants in the partial meniscectomy group walked with higher pKAM and shifted loading toward the medial compartment of the surgical limb, while participants in the repair group did the opposite, walking with lower pKAM and unloading the surgical limb relative to the contralateral limb. These findings may partially explain the conflicting evidence regarding pKAM after ACLR and the elevated risk for osteoarthritis (whether from overloading or underloading) after ACLR with concomitant medial meniscectomy or repair.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
前交叉韧带重建（ACLR）和关节镜半月板手术后，膝关节骨关节炎的风险很高，同时进行这两种手术的风险更高。尽管骨关节炎的发生是多因素的，但改变的步行力学可能会影响骨关节炎的进展。本研究的目的是比较 ACLR 后参与者中没有内侧半月板手术、部分内侧半月板切除术或内侧半月板修复的步态力学。
这是一项前瞻性数据的二次分析，作为临床试验的一部分进行。61 名运动员（平均年龄 21.4±8.2 岁）在术后达到损伤缓解（术后 5.3±1.7 个月）时参与了研究，包括最小至无积液、完全膝关节活动范围和≥80%股四头肌力量对称性。参与者根据内侧半月板的治疗方式进行分类：无内侧半月板参与或小、稳定撕裂的非手术治疗；部分半月板切除术；或半月板修复。参与者接受了全面的步行分析。使用先前验证的、肌电图驱动的肌肉骨骼模型估计关节接触力。使用混合模型方差分析对变量进行分析，包括组间和肢体间比较（α=0.05）；进行手术侧与对侧肢体之间的肢体间差异测量的组间比较，以确定显著的相互作用。
与半月板修复组和无内侧半月板手术组相比，部分半月板切除术组的参与者在手术侧的峰值膝关节内收力矩（pKAM）较高（组间差异，部分与修复：0.10 N-m/kg-m，p=0.020；部分与无：0.06 N-m/kg-m，p=0.037）。与其他两组相比，半月板修复组的参与者在手术侧的胫股内侧负荷百分比较小（组间差异，修复与部分：-12%，p=0.001；修复与无：-7%，p=0.011）。与部分半月板切除术组相比，半月板修复组的参与者在手术侧的内侧负荷为体重的 0.5 倍。
部分半月板切除术组的参与者行走时 pKAM 较高，将负荷向手术侧的内侧间隙转移，而半月板修复组则相反，行走时 pKAM 较低，相对于对侧肢体，手术侧的负荷减少。这些发现可能部分解释了 ACLR 后 pKAM 以及 ACLR 后内侧半月板切除术或修复伴发骨关节炎风险（无论是过度负重还是负重不足）的相互矛盾的证据。
治疗性 3 级。有关证据水平的完整描述，请参见作者说明。
