前交叉韧带重建的移植物选择

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Graft Selection for Anterior Cruciate Ligament Reconstruction：A Level I Systematic Review Comparing Failure Rates and Functional Outcomes

前交叉韧带重建的移植物选择：一篇将失败率与功能性结局指标同时比较的Ⅰ级循证系统综述

KEYWORDS

Anterior cruciate ligament Bone-patellar tendon-bone composites Combined semitendinosus and gracilis hamstring tendons Revision

关键词：

前交叉韧带骨-髌韧带-骨移植物联合应用半腱肌和股四头肌腘绳肌腱翻修

Tear of the anterior cruciate ligament (ACL) is the most common ligamentous injury of the knee. Reconstructing this ligament is often required to restore functional stability of the knee.1,2 Despite the popularity of the procedure, the preferred graft remains controversial. Ideally, the graft should have similar characteristics as the native ACL. Regardless of graft type, the biologic and mechanical properties of the graft material should provide a favorable setting for early biologic incorporation, be amenable to secure fixation, and limit potential morbidity related to donor site.

前交叉韧带（ACL）撕裂是最常见的膝关节韧带损伤。韧带重建的目的就是要恢复膝关节的功能性稳定。尽管（重建）过程各异，但移植物的选择仍有争议。理想的移植物应该与天然ACL具有相似的特性。尽管移植物类型各异，但其生物学及力学特性都应该为（重建后的）早期生物学整合提供有利环境，有利于安全固定，并限制供体部位潜在的发病率。

Many graft options are available for ACL reconstruction, including different autograft and allograft tissues. Autografts include bone-patellar tendon-bone composites (PT), combined semitendinosus and gracilis hamstring tendons (HT), and quadriceps tendon. Allograft options include the same types of tendons

harvested from donors, in addition to Achilles and tibialis tendons. Tissue-engineered anterior cruciate grafts are not yet available for clinical use, but may become a feasible alternative in the future.

ACL重建有多种移植物可供选择，包括自体组织移植物和异体组织移植物。自体移植物包括骨-髌韧带-骨移植物（PT）、联合应用半腱肌骨薄肌腘绳肌腱（HT）和股四头肌腱。除了跟腱和胫骨肌腱之外，还包括取自供者的相同类型的肌腱。组织工程生产的ACL尚未用于临床，但其将来可能成为一种可行的ACL替代物。

For the past few decades, PT autograft has been the gold standard for ACL reconstruction. Reasons for this include the strength of the tissue, relative ease of harvest, and bone-to-bone healing with secure fixation. More recently, HT autografts have joined PT in surgeons‘ popularity.3 The recent trend toward increased use of HT resulted from concerns with use of PT relating to a potential negative effect on the knee extensor mechanism and donor site morbidity, including anterior knee pain and risk for patella fracture.4 Nevertheless, despite their increasing popularity, HT grafts also have potential limitations, including slower soft tissue graft-tunnel healing compared with bone-to-bone healing with PT grafts, potential for tunnel widening and graft laxity, and functional hamstring weakness resulting from graft harvesting.5,6

在过去的几十年中，PT已经成为ACL重建（移植物选择）的金标准。原因包括其组织强度、（移植物）较易获得和安全固定的骨骨愈合（程度）。近来，HT移植物已越来越受到外科医生的欢迎。鉴于PT可能对膝关节伸肌有潜在的消极影响和提高供体部位病变率（包括膝关节前疼痛和髌骨骨折），HT的应用有逐渐升高的趋势。然而，尽管越来越受欢迎，但HT也有其潜在的限制，包括与PT的骨骨愈合相比的减慢的软组织移植物隧道愈合（速度），潜在的骨隧道扩大和移植物松弛，以及由移植物采集引起的功能性股薄肌无力。

There are several randomized controlled trials (RCTs) in the literature comparing the two most popular graft choices, PT and HT, either used as autografts or allografts. Many of the systematic reviews and meta-analyses in the literature that investigate graft choice for ACL reconstruction are biased by their inclusion of inadequately randomized trials that are not true level I studies.7–9 Also, functional outcomes,