改良关节镜下前交叉韧带重建术的安全性研究

目的探讨关节镜下经前内侧入路（anteromedial,AM）建立股骨隧道的膝关节前交叉韧带（anterior cruciateligament,ACL）移植重建手术的改良方法的安全性。方法 2010年1～10月采用改良AM方法完成ACL重建20例（实验组）,2009年1～12月采用传统AM方法完成ACL重建20例（对照组）,比较2组股骨隧道的长度,股骨隧道斜度,股骨外髁后壁爆裂和后外侧管神经损伤的情况。结果实验组术中股骨隧道长度为（41.8±4.1）mm,显著长于对照组（37.2±4.4）mm（t=3.421,P=0.002）。实验组股骨隧道冠状角度为51.9°±7.7°,显著大于对照组39.1°±5.8°（t=5.938,P=0.000）。对照组1例出现股骨隧道后壁爆裂,2组其余患者未发现后壁爆裂和后外侧血管神经损伤。结论改良AM方法可以增加ACL重建手术的安全性。     

经胫骨隧道与前内侧入路建立前交叉韧带股骨隧道的比较研究

目的 比较关节镜下前交叉韧带(ACL)重建术中经胫骨隧道与髌下前内侧入路建立股骨隧道的长度和角度。 方法回顾性分析2000年11月至2009年11月收治的102例ACL重建手术患者资料,其中50例采用经胫骨隧道建立股骨隧道（经胫骨隧道组）：男39例,女11例;年龄15～49岁,平均（27.9±7.6）岁。52例采用经前内侧入路建立股骨隧道（前内侧入路组）：男33例,女19例;年龄15～56岁,平均(30.5±10.7)岁。术中记录股骨隧道长度,术后行膝关节前后位及侧位X线片检查,测量股骨隧道在冠状面与内、外髁连线及矢状面与股骨干轴线的夹角,并进行统计学分析。 结果 经胫骨隧道组股骨隧道的平均长度[（50.9±5.0）mm]长于前内侧入路组[(37.8±4. 7)mm],差异有统计学意义(t=15.083,P=0. 000);经胫骨隧道组冠状面股骨隧道角度(68.6°±7.0°)、矢状面股骨隧道角度(45.1°±8.1°)均大于前内侧入路组(49.8°±7.7°)、33.7°±9.7°),差异均有统计学意义(t=12. 874,P=0. 000;t =5. 877,P=0. 000)。 结论关节镜下ACL重建术中,采用前内侧入路制备的股骨隧道长度短、角度小。     

保留残端半腱肌和股薄肌双股双隧道解剖重建前交叉韧带的临床研究

目的探讨关节镜下半腱肌股薄肌保留残端双股双隧道解剖重建前交叉韧带(ACL)的疗效。方法回顾自2006年1月～2008年1月,本组在关节镜下联合应用半腱肌腱和股薄肌腱双股双隧道重建ACL患者20例其中男18例,女2例,年龄17～46岁(平均31.5岁)。取腱器分别切取半腱肌、股薄肌编织成股,保留前叉韧带在股骨、胫骨的附着点残端,于ACL前内侧束和后外侧束附着部分别钻隧道,用半腱肌腱重建前内侧束,股薄肌腱重建后外侧束,以enderbutton悬吊固定股骨端,挤压螺钉固定胫骨端肌腱。所有患者术前及术后12个月行前抽屉试验、Lachman试验、Lysholm评分方法评定膝关节功能。结果术后随访14～48个月,平均31个月。术前患者前抽屉试验均为阳性,Lachman试验阳性13例,术后前抽屉试验3例屈膝60°位阳性,1例屈膝30°位阳性,其余均转阴性。5例Lachman试验仍阳性,但患者术后无膝关节不稳。2例患者术后胫骨前伤口瘢痕红肿凸起,给予切开引流后良好愈合。用Lysholm膝关节功能评分法评定术后疗效,术前评分为38～49分,平均43.5分,术后14个月为69～92分,平均80.5分,优13例,良5例,可2例,优良率为90.0%。结论应用自体肌腱双股双隧道重建ACL,术后膝关节动态稳定性好,疗效满意。     

由外向内与经前内侧入路法重建前交叉韧带股骨隧道的比较

目的：研究由外向内法（OI）与经前内侧入路法（AM）重建前交叉韧带（ACL）股骨侧隧道相关参数及隧道长度与股骨髁部大小的关系,探寻二者区别。方法取15具新鲜解冻膝关节标本,测量股骨髁部左右径及股骨外侧髁前后径大小,采用自行改进的内钩槽游标卡尺,定位ACL股骨侧止点中心,分别模拟采用OI法与AM法定位股骨外侧壁隧道口点。测量隧道长度、隧道口点与股骨外上髁位置关系。正侧位X线位上股骨隧道与膝关节线、股骨纵轴夹角。结果 OI法股骨隧道长度为（36.9±2.5）mm,AM法为（35.0±2.1）mm,差异有统计学意义（P＜0.05）;OI法与AM法股骨外侧壁隧道口点均位于股骨外上髁近前侧。 OI法较AM法偏近心端分布,但AM法更为集中;股骨髁部越大,隧道长度越长。 OI法较AM法隧道更为垂直。结论采用OI法与AM法均可满足ACL重建术对股骨隧道长度及位置的要求。 OI法相比下更随意,不受屈膝角度的影响。     

前十字韧带在维持膝关节稳定性上的重要性

前十字韧带（anterior cruciate ligament，ACL）是膝关节的四条主要韧带之一，其功能是与膝关节内部及周围的其他解剖结构共同维持膝关节的静态和动态平衡。ACL具有复杂的三维结构，传统上将ACL分为两束，前内侧束和后外侧束…，是以韧带在胫骨上的插入方向命名的（图1）。ACL起始于胫骨髁间隆起的前区，延伸至股骨髁间窝后外侧。[第一段]     

前交叉韧带单束重建股骨隧道定位方式的选择与CT三维模型评估

目的比较前交叉韧带(ACL)单束重建术中股骨钩定位法与钻头直接定位法确定股骨隧道的特点,并对其应用CT三维模型进行分析。方法回顾性分析自2011-02—2013-10关节镜下ACL单束重建术86例,应用股骨定位钩定位股骨隧道34例(股骨钩定位组),应用钻头直接定位股骨隧道52例(钻头直接定位组),术后行膝关节三维CT扫描并结合四分法、坐标轴法比较2组隧道长度以及隧道的位置。结果钻头直接定位组隧道长度34~41(37.0±2.1)mm,股骨钩定位组隧道长度38~48(42.0±3.5)mm。在四分法4×4网格中,股骨钩定位组有31例股骨隧道位置落于1a中,3例落于2a中;钻头直接定位组有49例股骨隧道位置落于2b中,2例落于1b中,1例落于2a中。在t线上,股骨钩定位组股骨隧道位置与前内侧束(AM)位置差异无统计学意义(P=0.295),与后外侧束(PL)位置差异有统计学意义(P0.001);在h线上,股骨钩定位组股骨隧道位置与AM、PL位置差异均有统计学意义(P0.001)。在t线和h线上,钻头直接定位组股骨隧道位置与AM、PL位置差异均无统计学意义(P0.025)。结论股骨钩定位法股骨隧道位置偏高、偏后,但长度较长;钻头直接定位法股骨隧道位置更接近解剖止点,但长度偏短。ACL单束重建术中股骨隧道定位方法可根据情况灵活选择。     

前内侧入路解剖重建单束前交叉韧带的临床评估

目的评估关节镜下经前内侧入路解剖重建单束前交叉韧带(ACL)的位置、形态及临床效果。方法对25例ACL断裂患者在关节镜下经前内侧入路应用解剖重建技术行单束ACL重建术,移植物应用自体腘绳肌腱。术后行X线、MRI检查,了解骨道情况,观察移植物形态及张力,并与11例健侧膝关节的正常ACL进行对比。应用Lysholm评分系统评估膝关节功能。结果术后X线片显示股骨隧道内口位于髁间窝顶与股骨后缘皮质线交叉点前缘,胫骨隧道内口位于髁间窝顶后方。MRI显示所有重建ACL张力良好,ACL上倾角为50.82°±4.57°,胫骨平台止点至前缘距离与平台纵径比值为0.50±0.04,两项与对照组比较差异均无统计学意义(P0.05)。患者均获得随访,时间为13~44个月。Lysholm评分术后为92.20分±4.29分,明显高于术前的64.76分±7.16分(P0.01)。结论关节镜下经前内侧入路解剖重建ACL的位置及形态接近解剖结构,早中期临床效果满意。     

前交叉韧带单束重建中两种股骨隧道制备方法的疗效比较

[目的]比较前交叉韧带单束重建中不同的股骨隧道制备方法对手术效果的影响.[方法]自2005年6月～2010年10月,采用自体半腱肌、股薄肌肌腱单束单隧道重建前交叉韧带140例,其中85例采用经胫骨隧道建立股骨隧道,55例采用经前内侧切口建立股骨隧道.通过Lysholm膝关节功能评分和屈膝30°位KT-1000前向松弛度对手术效果进行比较.[结果]所有患者术后均得到随访,随访时间至少12个月.术后Lysholm膝关节功能评分和KT-1000前向松弛度均较术前有改善.而术后经胫骨隧道组和经前内侧切口组在Lysholm膝关节功能评分和KT-1000前向松弛度方面比较无踢显差异.[结论]前交叉韧带单束重建术中经胫骨隧道建立股骨隧道与经前内侧切口建立股骨隧道两种方法可达到相同的治疗结果.     

经胫骨隧道与前内入路建立股骨骨道早期变化的差异

目的：比较分析经胫骨隧道与前内入路两种方式建立股骨骨道早期变化的差异,探讨相关的影响因素。方法对94例患膝关节在关节镜下单束重建前交叉韧带,A 组（42例）经胫骨隧道建立股骨隧道,B 组（52例）经前内侧入路建立股骨隧道。重建后用相同的方法进行康复锻炼,术后1周和6个月复查 X 线片了解骨道情况。结果A 组38例、B 组42例完成 X 线检查。术后骨道增宽的发生率两组比较差异无统计学意义（P＞0．05）;术后骨道增宽的程度 A 组较 B 组明显,差异有统计学意义（P ＝0．001）。结论两种入路建立的股骨股道术后早期均具有较高的骨道扩大发生率,经前内侧入路行 ACL 重建更有利于减轻股骨骨道的扩大。     

解剖重建前交叉韧带前内侧束或后外侧束的临床观察

目的探讨关节镜下应用可吸收Rigidfix交叉钉与Intrafix膨胀挤压螺钉固定自体或异体肌腱解剖重建膝关节前交叉韧带（ACL）的前内侧束或后外侧束的疗效。方法对18例ACL单束损伤患者,在关节镜下保留未损伤的部分ACL、建立骨隧道、穿过移植肌腱、股骨侧用可吸收Rigidfix交叉钉固定,胫骨侧用Intrafix膨胀挤压螺钉固定。结果 18例均获随访,时间6-27个月。术后患者疼痛均消失,关节稳定,恢复关节活动度,固定物无松动。1例出现关节积液和滑膜炎,经保守治疗后好转。IKDC分级：术前B级5例、C级10例、D级3例,术后A级8例、B级8例、C级2例,差异有统计学意义（P〈0.01）。Lysholm评分：术前（68.34±4.53）分,术后（93.24±3.61）分,差异有统计学意义（P〈0.01）。结论关节镜下应用Rigidfix交叉钉与In-trafix膨胀挤压螺钉固定自体或异体肌腱重建膝关节ACL的前内侧束或后外侧束,方法简便、固定确实,恢复其解剖结构,保留的部分束促进韧带愈合,利于膝关节本体觉建立和早期功能康复。     

Anatomic assessment of femoral tunnel by transtibial drilling technique in double-bundle anterior cruciate liga- ment reconstruction： an in vivo study

Objective： To evaluate the anatomy of femoral tunnels created by simulated transtibial technique in double-bundle anterior cruciate ligament （ACL） reconstruction. Methods： Two tibial tunnels, anteromedial （AM） and posterolateral （PL）, were drilled 45° and 55° to tibial plateau respectively. On the femoral side, the AM and PL tunnels were drilled through anteriomedial portal. After the four tun- nels were established, the shaft of a reamer was introduced into the joint through tibial tunnel and reached against the lateral wall of intercondylar notch. The position that the reamer shaft can reach was marked and recorded. Results： Neither femoral AM nor PL tunnel opening can be fully or partially reached by the reamer shaft through the tibial AM tunnel in all cases. The evaluation through the tibial PL tunnel showed that only in 8 of 50 cases （16%） the femoral AM tunnel opening and in 4 cases （8%） the PL opening can be fully reached. On the other hand, in 12 cases （24%） the femoral AM tunnel opening and in 10 cases （20%） the PL opening can be partially reached by the shafts through the tibial PL tunnel. Conclusion： The result strongly suggests that transtibial technique is not well competent for femoral tun- nel drilling in anatomic double-bundle ACL reconstruction as we have hypothesized.     

双束双隧道6股腘绳肌腱解剖重建前交叉韧带

目的探讨双束双隧道6股腘绳肌腱重建前交叉韧带（ACL）的可行性及近期疗效。方法对28例ACL损伤患者行关节镜下ACL重建术。采用股骨胫骨双隧道建立前内侧束（AMB）及后外侧束（PLB）。分别将股薄肌腱、半腱肌腱编织成3股肌腱,用于重建PLB与AMB。AMB与PLB股骨端均用Endobutton钢板固定,胫骨端AMB用Bio-Intrafix固定,PLB用Milagro可吸收界面螺钉固定。结果 28例均获随访,时间12-24（19.54±3.84）个月。根据Lysholm膝关节功能评分：术前为18-60（34.79±12.53）分,术后1年为90-98（95.54±2.06）分,差异有统计学意议（t=26.51,P〈0.01）。结论双束双隧道6股腘绳肌腱重建ACL,手术操作简便,固定牢固,效果可靠。     

Anterior Cruciate Ligament Double-Bundle Reconstruction With Hamstring Tendon Autografts

The anterior cruciate ligament (ACL) surgical technique via a 5-strand hamstring tendon autograft is designed with a conventional single-bundle reconstruction that has shown favorable results and an additional posterolateral (PL) bundle reconstruction. The conventional single-tunnel technique is performed for the tibial tunnel, and the double-tunnel technique is performed for the femoral tunnel. The anteromedial (AM) femoral tunnel is prepared with 1 mm of the posterior femoral cortex being left over the top at the 11- to 1-o’clock position. The PL femoral tunnel is prepared with the outside-in technique by use of a 4.5-mm cannulated reamer. The AM bundle is fixed with a rigid fixation system on the femoral side, and the PL bundle is fixed to tie with the miniplate from the outside femur. A double-bundle reconstruction with 5-strand hamstring autografts, in conjunction with a conventional AM bundle and an additional PL bundle, seems to be a very effective method for the treatment of ACL instabilities. Although the long-term clinical outcome of the procedure is yet to be determined, complications including graft impingement, limitation in range of motion, and residual instability have not been observed to date in the first 38 patients who have undergone our technique.     

Hybrid Anterior Cruciate Ligament Reconstruction: Introduction of a New Technique for Anatomic Anterior Cruciate Ligament Reconstruction

Recently, anatomic or double-bundle reconstruction of the anterior cruciate ligament (ACL) has been presented in an effort to more accurately restore the native anatomy. These techniques create 2 tunnels in both the femur and tibia to reproduce the bundles of the ACL. However, the increased number of tunnels, particularly on the femoral side, has raised some concerns among authors and surgeons. We describe a technique to reconstruct the 2 distinct bundles of the ACL by using a single femoral tunnel and 2 tibial tunnels, the “hybrid” ACL reconstruction. The femoral tunnel is drilled through an anteromedial arthroscopy portal, which allows placement in a more anatomic position. Fixation in the femur is achieved with a novel device that separates a soft-tissue graft into 2 independently functioning bundles. Once fixed in the femur, the anteromedial and posterolateral bundles of the graft are passed through respective tunnels at the anatomic footprint on the tibia. These bundles are independently tensioned, which creates a reconconstruction that is similar to the native ACL. The technique presented provides surgeons with an alternative to other double-bundle techniques involving 4 tunnels.     

Aperture Fixation in Arthroscopic Anterior Cruciate Ligament Double-Bundle Reconstruction

The native anterior cruciate ligament (ACL) consists of 2 bundles, which have distinct biomechanical yet synergistic functions with respect to anterior tibial translation and combined rotatory loads. Traditionally, most ACL reconstruction techniques have primarily addressed the restoration of the anteromedial bundle, and less consideration was given to the posterolateral bundle. Recently, various ACL double-bundle reconstruction techniques have been described. With most of these techniques, however, an indirect extra-anatomic fixation far from the articular surface was performed. Because extra-anatomic fixation techniques, rather than aperture fixation techniques, are associated with graft tunnel motion, windshield wiper action, and suture stretch-out, concerns may arise regarding delayed biological incorporation, tunnel enlargement, and secondary rotational and anterior instability. We, therefore, present a novel arthroscopic technique that reapproximates the footprints of native ACL with the use of double-strand semitendinosus and gracilis autografts for reconstruction of the anteromedial and posterolateral bundles, respectively. A separate femoral and tibial tunnel is drilled for each double-strand autograft. The femoral tunnel for the anteromedial bundle is drilled primarily through a transtibial technique, and the femoral tunnel for the posterolateral bundle is drilled via an accessory anteromedial portal with the use of a 4-mm offset drill guide in the anteroinferior aspect of the femoral tunnel for the anteromedial bundle. Bioabsorbable interference screws are used in aperture fixation for anatomic fixation of each bundle. This technique attempts to reproduce closely the native ligament and its biomechanical function.     

3D CT evaluation of femoral and tibial tunnels in anatomic double bundle anterior cruciate ligament reconstruction

BackgroundAn anatomical double bundle ACL reconstruction replicates the anatomy of native ACL as the tunnels are made to simulate the anatomy of ACL with AM and PL bundle foot prints. The goal of anatomic ACL reconstruction is to tailor the procedure to each patient’s anatomic, biomechanical and functional demands to provide the best possible outcome. The shift from single bundle to double bundle technique and also from transtibial to transportal method has been to provide near anatomic tunnel positions.PurposeTo determine the position of femoral and tibial tunnels prepared by double bundle ACL reconstruction using three dimensional Computed tomography.Study designA prospective case series involving forty patients with ACL tear who underwent transportal double bundle ACL reconstruction.MethodComputed tomography scans were performed on forty knees that had undergone double bundle anterior cruciate ligament reconstruction. Three-dimensional computed tomography reconstruction models of the knee joint were prepared and aligned into an anatomical coordinate axis system for femur and tibia respectively. Tibial tunnel centres were measured in the anterior-to-posterior and medial-to-lateral directions on the top view of tibial plateau and femoral tunnel centres were measured in posterior to anterior and proximal-to-distal directions with anatomic coordinate axis method. These measurements were compared with published reference data.ResultsAnalysing the Femoral tunnel, the mean posterior-to-anterior distances for anteromedial and posterolateral tunnel centre position were 46.8% ± 7.4% and 34.5% ± 5.0% of the posterior-to-anterior height of the medial wall and the mean proximal-to-distal distances for the anteromedial and posterolateral tunnel centre position were 24.1% ± 7.1% and 61.6% ± 4.8%. On the tibial side, the mean anterior-to-posterior distances for the anteromedial and posterolateral tunnel centre position were 28.8% ± 4.3% and 46.2% ± 3.6% of the anterior-to posterior depth of the tibia measured from the anterior border and the mean medial-to-lateral distances for the anteromedial and posterolateral tunnel centre position were 46.5% ± 2.9% and 50.6% ± 2.8% of the medial-to-lateral width of the tibia measured from the medial border. There is high Inter-observer and Intra-observer reliability (Intra-class correlation coefficient).Discussion and conclusionFemoral AM tunnel was positioned significantly anterior and nearly proximal whereas the femoral PL tunnel was positioned significantly anterior and nearly distal with respect to the anatomic site. Location of tibial AM tunnel was nearly posterior and nearly medial whereas the location of tibial PL tunnel was very similar to the anatomic site Evaluation of location of tunnels through the anatomic co-ordinate axes method on 3D CT models is a reliable and reproducible method. This method would help the surgeons to aim for anatomic placement of the tunnels. It also shows that there is scope for improvement of femoral tunnel in double bundle ACL reconstruction through transportal technique.     

Anatomic Double Bundle: A New Concept in Anterior Cruciate Ligament Reconstruction Using the Quadriceps Tendon

Surgical procedures for double-bundle anterior cruciate ligament reconstruction, which currently use hamstring graft, have been described, but some concerns remain regarding graft fixation and the ability to obtain adequate bundle size. We report an original double-bundle anterior cruciate ligament reconstruction technique using a quadriceps tendon graft and a simplified outside-in femoral tunnel–drilling process. The graft consists of a patellar bone block with its attached tendon split into superior and inferior portions, which yields 2 bundles. The anteromedial tunnel is drilled from the outside through a small lateral incision by use of a guide. The posterolateral tunnel is made through the same incision with a specific guide engaged in the anteromedial tunnel. A single tibial tunnel is created. The graft is routed from the tibia to the femur with the bone block in the tibial tunnel and the 2 bundles in their respective femoral tunnels. After fixation of the bone block in the tibia, the 2 bundles are tensioned and secured separately in their femoral tunnels.     

Anteromedial Portal Technique for the Anterior Cruciate Ligament Femoral Socket: Pitfalls and Solutions

Creating the anterior cruciate ligament (ACL) femoral socket using the anteromedial (AM) portal technique has advantages. Furthermore, the technique is ideal for anatomic double-bundle (particularly posterolateral bundle) and all-inside ACL techniques. However, although the AM portal technique has advantages, the learning curve is steep when making the transition from familiar, transtibial reaming to the AM portal technique for ACL femoral tunnel creation. Complications and challenges are many when learning the AM portal technique. The purpose of this technical note is to describe tips and pearls for surgeons contemplating the transition to the AM portal technique for the ACL femoral socket.     

Anteromedial Portal Technique for Creating the Anterior Cruciate Ligament Femoral Tunnel

There has been a renewed focus on anterior cruciate ligament (ACL) insertional anatomy and its biomechanics. It has been postulated that traditional single-bundle transtibial reconstructions have placed grafts in a less anatomic location relative to the true ACL insertion site. In traditional transtibial techniques, the femoral tunnel is predetermined by the position of the tibial tunnel. It is our belief that achieving the most anatomic position for the graft requires the femoral and tibial tunnels to be drilled independently. Use of the anteromedial portal technique provides us with more flexibility in accurately placing the femoral tunnel in the true ACL insertion site as compared with the transtibial technique. Advantages include anatomic tunnel placement, easy preservation of any remaining ACL fibers when performing ACL augmentation procedures, and flexibility in performing either single- or double-bundle reconstructions in primary or revision settings. This technique is not limited by the choice of graft or fixation and offers the advantage of true parallel screw placement through the same portal as that used for tunnel drilling in the case of interference fixation.     

The acorn Beath couple: articular salvation for double-bundle femoral tunnels in cruciate ligament reconstruction

With the recent increase in interest in arthroscopic double-bundle cruciate reconstructions, efficient, safe, and reproducible techniques are needed. This technical trick is applicable to both arthroscopic anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction when double-bundle femoral tunnels are performed through an accessory far lateral or far medial incision as with the all-inside femoral tunnel drilling approach. A standard double-bundle cruciate reconstruction technique is applied until placement of the femoral footprint Beath pins in anticipation of tunnel drilling. Femoral footprint targeting with a Beath pin requires use of a far accessory portal. Before the long Beath pin is introduced into the joint, an acorn reamer is placed over the Beath pin to within 5 mm of the pin tip, thus creating an acorn Beath couple. The eyelet pin end is loaded onto a quick-release pin collet driver, leaving the acorn reamer free to turn. The acorn Beath couple is then introduced into the appropriate accessory portal and positioned in the center of the desired femoral footprint. An assistant holds the acorn reamer shaft while the Beath pin is advanced. The collet driver is then disengaged from the pin and replaced with an adjustable chuck and secured to the acorn reamer shaft of the acorn Beath couple. The femoral tunnel is drilled to the appropriate depth, and the Beath pin is pulled out the anterior thigh. Doing so disengages the acorn reamer and allows for safe removal of the reamer from the notch. The technique is then repeated with the coupling of a 4.5 Endobutton reamer and the Beath pin.