Nghiên cứu ứng dụng phẫu thuật tạo hình dây chằng chéo sau khớp gối qua nội soi bằng mảnh ghép gân đồng loại tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH HANOI MEDICAL UNIVERSITY LE THANH TUNG STUDYING THE APPLICATION OF ARTHROSCOPIC RECONSTRUCTION OF THE POSTERIOR CRUCIATE LIGAMENT OF KNEE JOINT VIA LAPAROSCOPIC SURGERY WITH USE OF TENDON ALLOGRAFT Specialty : Orthopaedics and Trauma Surgery Code : 62 72 01 29 SUMMARY OF A PhD DISSERTATION ON MEDICINE HA NOI – 2020 The research work has been accomplished at: HA NOI MEDICAL UNIVERSITY Supervisors: Assoc.Prof Nguyen Van Thach Opponent 1: Opponent 2: Opponent 3: The dissertation will be defended in front of designated examining committee at University Time: hour 14 date 26 month 09 year 2020 The dissertation is available at the following libraries: - Viet Nam National Library - Library of Hanoi Medical University INTRODUCTION Posterior cruciate ligament is an important ligament that helps to ensure a strong knee joint Early diagnosis and treatment of posterior cruciate ligament lesions to prevent torn semilunar cartilage, which is necessary for osteoarthritis The posterior cruciate ligament alternative surgical materials are tendon autograft, tendon allograft, composite graft Tendon allograft used to regenerate ligaments is still the most common due to many advantages However, the biggest drawback is the tendon size restriction, but tendon allograft overcomes this limitation Studies of knee anatomy show that the cross-sectional size of posterior cruciate ligament is 1.5 to times larger than cruciate ligament, which requires a graft large enough to reconstruct posterior cruciate ligament that is similar to equivalent to the original ligament size, so the current trend is that many surgeons choose Achilles tendon allograft to use as a graft The current studies in Vietnam are mainly used by authors to tendon autograft for posterior cruciate ligament reconstruction For the use of tendon allograft is less But until now there have been no research reports using Achilles tendon allograft in particular to reconstruct posterior cruciate ligament From that practice, we conducted the project titled: “Studying the application of arthroscopic reconstruction of the posterior cruciate ligament of knee joint via laparoscopic surgery with use of tendon allograft ” with the two goals: Describing clinical features, magnetic resonance imaging and x-ray imaging of knee joints with posterior cruciate ligament lesions of patients under arthroscopic posterior cruciate ligament reconstruction with Achilles tendon allograft Evaluating the results of arthroscopic posterior cruciate ligament reconstruction with tendon allograft The urgency of the Project The use of tendon graft kinetics to regenerate ligaments has been described in the literature since the 1980s and is mainly used to regenerate anterior cruciate ligament Since then this material has been used more and more due to its advantages Many authors study and draw conclusions that using the same type of ribbed material is similar to the use of autograft tendon In the world, there have been many research works on tendon allograft in general and Achilles tendon used as graft to regenerate posterior cruciate ligament for very good results In general, studies on the use of Achilles tendon allograft in deep cryopreservation have a small number of patients and follow-up time is not much In Vietnam posterior cruciate ligament reconstruction surgery has been carried out in several large hospitals in Vietnam in recent years using autograft tendon The use of allograft tendon to date has very few reported works and all have been used to reconstruct anterior cruciate ligament without any studies using Achilles tendon allograft to reconstruct posterior cruciate ligament In view of the aforementioned situations, we carry out this project to contribute to affirm the advantages of using Achilles tendon allograft to reconstruct posterior cruciate ligament to help surgeons have more choices of materials and methods of surgery, which are suitable for each patient New contributions of the thesis - The thesis has outlined the experience of using clinical and subclinical examination in diagnosis of posterior cruciate ligament lesions, applied in clear diagnosis and surgical indications for each specific patient group - Assessing the Achilles tendon size of Vietnamese people in accordance with posterior cruciate ligament shaping with knee diameter of 9.14 ± 0.45mm and a length of 15.3 ± 1.49mm State the treatment method for Achilles tendon allograft, orienting the selection of graft diameter suitable for each specific patient group - Completing the steps in posterior cruciate ligament reconstructive laparoscopic surgery with a piercing technique Experience in selecting bone tunnel drilling site, graft technique and graft fixation in bone tunnel - Arthroscopic posterior cruciate ligament reconstruction with tendon allograft has good results when evaluated clinically and subclinically, can be compared with other tendon autograft Using allograft offers advantages such as shortened surgery time, small surgical scars, less pain and ease of rehabilitation after surgery During the time of monitoring and evaluation, there were no signs of infection, infection or discharge of tissue transplant The thesis structure The thesis has 134 pages, including the following parts: Introduction (3 pages), Literature overview (33 pages), Research subjects and methods (28 pages), Research results (30 pages), Discussion (37 pages), Conclusion (2 pages), Recommendations (1 page) The thesis has 28 tables, 55 figures, 11 charts, 158 references (138 references by foreign authors and 20 references by domestic authors) Chapter LITERATURE OVERVIEW 1.1 Posterior cruciate ligament surgery Posterior cruciate ligament goes from the front half humerus the femur runs down to the back and out, clinging to the back of the tibia posterior cruciate ligament consists of bundles: first bundle after outside Humerus Posterior and interior muscle Anterior and posterior muscles Figure 1.3 Photo of bundles of posterior cruciate ligament in profile * Source: according to Wolfgang Johannes (2010) Posterior cruciate ligament 13mm thick, thick front and outside bundles, 34.5 ± 1.95 mm long and back bundles in pieces, 32.8 ± 1.95 mm long, stretched when folded 90º and almost sagging when the knee was extended The average length of posterior cruciate ligament is 38 mm The posterior cruciate ligament is the narrowest in the middle, with an average width of 11 mm and a tapering taper from the grip point of 32 mm to the grip point of 13.4 mm The posterior cruciate ligament grip at the thigh stretches from 12 o'clock to o'clock clockwise for the right knee and at o'clock counterclockwise for the left knee The point of the muscular tendon on the thigh of the anterior bundle extends from 12h00 to 2h30 in a clockwise direction for the right knee joint and to the position of 9.30 anticlockwise for the left knee joint In tibia: Tibial attachment site area of the first and the last bundle is respectively 84.5 ± 12.52 mm2, 47.8 ± 6.20 mm2 The distance from the edge of the articular cartilage plane to the tibial attachment site posterior cruciate ligament and the posterior margin below the tibial attachment site of posterior cruciate ligament is 9.7 ± 1.73 mm and 13.6 ± 0.96 mm 1.2 Causes, mechanism of posterior cruciate ligament fractures The causes of posterior cruciate ligament injury are listed by many authors as the main causes are sports accidents, traffic accidents, labor accidents, and domestic accidents There are three main mechanisms of posterior cruciate ligament damage: trauma to the front of tibia, over-folding, stretching 1.3 Lesion classification of posterior cruciate ligament - Classification by time: Based on the time of trauma, posterior cruciate ligament lesions are divided into acute, subacute and chronic forms - Classification according to position of injury: Based on the position of injury of posterior cruciate ligament is divided into types: Middle central cut, top cut, lower cut - Classified by level of injury: Based on the degree of damage to many authors have identified the posterior cruciate ligament damage in two types: Orphan totally, not completely off 1.4 Examination and diagnostic tests Clinical test: Based on the following drawer signs, Godfrey’s test, Quadriceps active test Sub-clinical test: This includes conventional X-ray in the acute phase usually detecting lesions in the attachment site of posterior cruciate ligament Reverse Segond fracture X-ray of drawer after quantification using Telos frame to assess the degree of displacement of tibial plateau Nuclear magnetic resonance imaging: This is a very significant method in diagnosis Manifestations of posterior cruciate ligament lesions on Nuclear magnetic resonance imaging include: Unknown ligament shape, only one ligament, fracture images, edema images and bone attachment points Figure 1.21 Image of posterior cruciate signal loss ligament (white arrow position) * Source: according to Ali Naraghi (2014) 1.5 Treatment of posterior cruciate ligament lesions Surgical treatment for patients with posterior cruciate ligament lesions in the acute phase is indicated for patients with coordinated lesions such as bone damage, cartilage damage causing joint jam priority surgery Treat possible causes of complications As for the posterior cruciate ligament lesions alone or in combination, there is no risk of acute phase complications usually requiring conservative treatment Indications for surgery: For posterior cruciate ligament adhesion lesions, the authors recommend early treatment and surgical fixation Patients with posterior cruciate ligament fractures of grade III or II have rehabilitated but still show signs of loose knee No serious complications of osteoarthritis (grade III, IV), no restriction of knee stretching, no infection arthritis Classification of posterior cruciate ligament regeneration techniques Classification of posterior cruciate ligament regeneration techniques Advantages and disadvantages of Achilles tendon graft in ligament regeneration The use of Achilles tendon allograft as a graft to regenerate ligaments has the following advantages: Because it does not take time to remove the tendons, the surgery time is reduced Active graft size No local injury to the tendon, and better aesthetic factor because it does not have to take tendons, so the incision is smaller and can regenerate many ligaments at the same time Not taking tendons, so it does not affect the muscles, does not cause pain and numbness in the tendon area There is a piece of heel bone, so the ability to connect bones and bones in the tunnel is good, and the ability to fix the graft in the tunnel better allows the application of early and positive rehabilitation programs after surgery The disadvantages of using Achilles tendon allograft are increased surgical expenses, risk of disease transmission and the risk of graft elimination Chapter RESEARCH SUBJECTS AND METHODS 2.1 Research subjects The subjects of the study were posterior cruciate fracture ligament fractured patients who came for examination and received reconstructive surgery with Achilles tendon allograft at Vietnam Sports Hospital 2.2 Criteria for choosing studied patients Selection criteria - Patients over 16 years old and under 55 years of age regardless of gender or occupation - Undergoing a posterior cruciate ligament reconstruction surgery using Achilles tendon allograft (provided by Department of Tissue Preservation, Department of Embryology, Hanoi Medical University) Exclusion criteria for studied patients - Patient has posterior cruciate ligament fracture with anterior cruciate ligament rupture, same lateral ligament - Patients who are not qualified for surgery: suffer from muscular atrophy, limiting the amplitude of knee movement after injury - Patients with posterior cruciate ligament reconstruction surgery not use Achilles tendon allograft 2.3 Time and place for conducting the research The study was conducted at the Vietnam Sports Hospital between May 2011 and May 2019 2.4 Research Methods The study was designed using a prospective research method and a retrospective study of clinical intervention without control Convenient sample size: Select all eligible patients according to patient selection criteria during the study Patient visits with pain, loosed/limited mobility of the knee joint - Clinical examination - X-ray, magnetic resonance imaging of knee joint Diagnosis to identify posterior cruciate ligament fractures - Following T0; T1 - Following re-examination T3, T6, T12,Tn Goal Goal Collection of clinical and subclinical characteristics (all patients included in the prospective and retrospective patient group) Perform plastic surgery posterior cruciate ligament by endoscopy using tendon allograft; Evaluate the results of treatment for prospective patients Invited to participate in the research Agreed Disagreed Sign a voluntary commitment Removed Indications for laparoscopic surgery by Achilles tendon allograft Diagram 2.1 Research process 2.5 Posterior cruciate reconstruction surgery of knee ligament with Achilles tendon allograft Preparing the tools and means: Endoscopic arthroscopy apparatus: light source, camera Tendon tension instruments, electric drills, drill bits of sizes, Staple guide nails, bio-size screws Preparing materials for making graft Material used to make graft is Achilles tendon allograft piece with piece of heel bone provided by Department of Tissue Storage, Department of Embryology, Hanoi Medical University 11 Figure 2.8 Drilling to position the tibial tunnel *Source: photos of studied patients (code BA2615NCT07/2018) Insert a thread waiting from outside to match through the front entrance to the rear compartment, use Cloward to thread into the tibial tunnel from the peripheral end to pull the waiting thread end out Making femoral tunnel: The position of the femoral tunnel center is determined in correspondence with the position of the center of the posterior cruciate ligament, at 11 o'clock for the left knee and hour for the right knee, 7-8mm from the edge of the articular cartilage Insert the positioning frame into the joint drive through the front inlet into the position to be determined as the center of the femoral tunnel, drill with mm diameter diameter according to the position and direction of the positioning device, drilling from outside to inside Figure 2.9 Drilling the femoral tunnel *Source: photos of studied patients (code BA2615NCT07/2018) Using hollow bore bore with a diameter equal to the size of the femoral tunnel drilling piece, put through the front entrance outside, drill from the inside out under the direction of the guide drill, drill from the inside to the bone outside Thread the graft and fix the graft in the tunnel: Put the knee in a 900 fold position, Push the graft into the joint through the front entrance 12 outside until the graft is completely in the joint, then stretch the ends of the ribs to suture the outside of the two tunnels Screw into the tunnel to fix the graft using Staple to fix the suture part just outside the tunnel Figure 2.13 Reconstruted posterior cruciate ligament graft *Source: photos of studied patients (code BA2615NCT07/2018 ) 2.6 Data processing methods The following data were collected by using biomedical statistical algorithm with the support of IBM SPSS 20.0 software and R software version 3.4.1 runs on Microsoft Windows 10 operating system platform Chapter RESEARCH RESULTS 3.1 General characteristics of studied patients Table 3.1 General characteristics of studied patients Quantity Characteristics Rate % p (n=36) 16 – 30 22 61,1 Age group 31 – 45 13 36,1 45 2,8 The average age 29,69 ± 6,2 ̅ ± SD (years old) (Max = 54, Min =17) Male 31 86,1 Gender 0,05 Hurt side Right 16 44,4 15 41,7 Sports accident Traffic accidents 19,4 >0,05 Causes Labor accident 25,0 Living accident 13,9 19 52,8 Force exerted from the front Mechanism Too fast 11,1 >0,05 of injury Stretching 13,9 Unknown mechanism 22,2 Comments: There were 55.6% of posterior cruciate ligament lesions on the left leg, the proportion of posterior cruciate ligament lesions on the right leg was 44.4% The cause of posterior cruciate ligament injury from sports accidents was seen in 15 patients (accounting for 41.7%) Traffic accidents and occupational accidents were patients and patients respectively accounting for 19.4% and 25% 3.2.2 Symptoms of mechanical energy Loose joints + arthralgia + thigh muscle atrophy + limited amplitude of motion Loose joints + arthralgia + thigh muscle atrophy 8,3 25 36,1 Loose joints + leg muscle atrophy 16,7 Loose joints + joint pains 13,9 Loose joints Rate % 20 Chart 3.1 Major functional symptoms (n = 36) 40 14 Comments: The proportion of patients who had functional symptoms: pain, loose joints, muscle atrophy and limited mobility were 8.3% of studied patients The proportion of patients with loose joints and thigh muscle atrophy accounted for the highest proportion with 36.1%; the lowest in the group appeared only loose joints merely with 13.9% 3.2.3 Clinical symptoms assessed knee joint instability among studied patients Table 3.3 Physical symptoms Test Posterior drawer (+) Quadriceps muscle (+) Godfrey (+) Quantity (n=36) 36 36 36 Rate % 100 100 100 Comments: At the time of admission, the posterior cruciate ligamentrelated knee instability tests were found in 100% of studied patients 3.3 X-ray imaging and magnetic resonance characteristics of knee joint 3.3.1 X-ray imaging characteristics In the studied patients group, there were of 36 patients accounting for 5.6% of posterior cruciate ligament lesions, no patients with segon lesions 01 patient with bone cartilage defects under femoral cartilage manifested on conventional X-ray film accounted for 8.4% 3.3.2 Tibial plateau deviation prior to surgery on X-ray film using Telos traction frame Table 3.4 The lateral tibial plateau deviation compared to the thigh bridge convex on XQ film using Telos truss (n = 36) Deviation (mm) 0-5 6-10 > 10 Total Number of patients 31 36 Rate % 13,9 86,1 100 15 3.3.3 Result of magnetic resonance imaging of knee joint Table 3.5 Image characteristics of magnetic resonance film (n=36) Magnetic resonance image of posterior cruciate Quantity Rate % ligament of knee joint The shape of the ligament is unknown 11 30,6 Signs of 11 30,6 injury in Photos of loose cuts posterior Pictures of edema 16,7 cruciate Posterior cruciate ligament slack 16,7 ligament Bubbles stick to tibia 5,6 Posterior cruciate ligament completely 28 77,8 broken Degree of Posterior cruciate ligament partly injury 16,7 fractured Bubbles stick to tibia 5,6 Bone marrow edema Indirect 11 30,6 sign Tibial plateau lags behind the thigh bone 13 36,1 Normal posterior cruciate ligament 25 69,4 fracture Posterior ligament posterior fracture + 11,1 medial meniscus tear Normal posterior cruciate ligament Combined 5,6 fracture + lateral meniscus tear injury Normal posterior cruciate ligament fracture + medial and lateral meniscus 2,8 tear Posterior cruciate ligament sprain 5,6 Degeneration of joint cartilage damage 5,6 3.4 Technical characteristics of posterior cruciate ligament reconstruction surgery by Achilles tendon allograft 3.4.1 Characteristics of tendon allograft 16 Table 3.6 Characteristics of tendon allograft (n=36) ̅ ± SD Index Min 9,14 ± 0,45 8,5 The size of the tendon Diameter (mm) draft obtained Length (cm) 15,3± 1,49 11,5 Diameter (mm) 8,94 ± 0,27 8,5 Size of tendon ligament draft Length (cm) 13,55 ± 0,82 11 Time of taking graft → be grafted < hours (n, %) 36 (100) ≥ hours (n, %) (0) Max 11 24,1 9,5 15,2 3.4.2 Survey results of femoral tunnel and tibial tunnel Table 3.7 Characteristics of femoral tunnel and tibial tunnel (n=36) Diameter (mm) Index Femoral tunnel Tibial tunnel ̅ ± SD 8,94 ± 0,27 8,94 ± 0,27 Min 8,5 8,5 Max 9,5 9,5 3.5 Accident during surgery: In the study, there were no complications in surgery such as: screw fracture, tunnel rupture, vascular - nerve damage 3.6 Surgical results 3.6.1 Assessing the patient's condition at the time of discharge Table 3.8 Results of evaluating the patient's condition at the time T1 (n=36) Number Rate Assessment of patients % 2,36 ± 0,72 Pain site VAS ̅ ± SD (site) (Min = 1; Max= 3) The incision is dry, from the beginning 36 100 Incision condition Swelling, redness, drainage 0 Average Hematocrit (l/liter) 0,36 (0,35 – 0,46) Total Average hemoglobin (g/liter) 129 (126 - 1430 blood test Quantity of average white blood cells index 9,1 (7,4 - 9,4) (x109/liter) 17 Average red blood cells (x1012/liter) Ultrasound No spillage (n, %) Little level (60ml) (n, %) 4,2 (4,0 – 5,7) (25) 16 (44,4) 11 (30,6) (0) Comments: The percentage of patients who had the first surgical incision during the postoperative period at the Hospital reached 100% VAS pain points at the time of discharge ranges from 1-3 points 100% of patients at the time of discharge had no fever, blood count tests were within normal limits 3.6.2 Evaluate the results of treatment at the time T3 and T6 and T12 Table 3.9 The change of examination tests at the time of T3 and T6 Test n % Decrease * (n; %) Time T3 Posterior drawer (+) 11 35,5 20 (64,5) Quadriceps muscle (+) 0 31 (100) Godfrey (+) 0 31 (100) Time T6 Posterior drawer (+) 25,8 23 (74,2) Quadriceps muscle (+) 0 31 (100) Godfrey (+) 0 31 (100) (*)Compared to the time before surgery Comments: Clinical examinations have significant changes over time Changes in knee joint function Lyshom score scale: Evaluation of knee joint function after months of surgery shows that most functions are very good and good accounting for 80.7% Knee joint function after surgery was on average 16.1%, which was bad grade, accounting for 3.2% The average Lysholm score is 89.7 ± 6.4 Objective IKDC scale: Assessing the strength of knee joint according to IKDC after months of surgery showed that 77.5% of type A ranked B 18 accounted for 19% of type B, type C accounted for 3.2% Compared to the time of admission, knee joint function has clearly improved There were differences between groups and the difference was statistically significant with p