关节镜下保留残端重建前交叉韧带的临床前瞻性对照研究

目的 前瞻性评估保留残端对于前交叉韧带重建临床疗效的意义.方法 2008年8月至2009年9月共70例有韧带残端存留的前交叉韧带损伤患者入选本研究组,随机分为保留残端组(n=35)和对照组(n=35).分别采取关节镜下保留残端重建前交叉韧带和切除残端的前交叉韧带重建手术技术,移植物均使用同种异体肌腱.术后随访分别进行膝关节功能评分(IKDC分级和Lysholm评分)、客观稳定性评估(Lachman试验、轴移试验和KT-1000测量)、本体感觉功能测量和二次关节镜手术探查.结果 70例患者中共61例(87%)获得随访,平均随访时间13.1个月.两组的功能评分无显著差异:Lysholm评分:保留残端组96.4分,对照组94.9分(P=0.71);IKDC分级中A和B级:保留残端组30例,对照组29例(P=0.586).两组的客观稳定性评估无显著差异:KT-1000测量的侧-侧差值:保留残端组1.69 mm,对照组1.65 mm(P=0.83);Lachman试验阴性例数:保留残端组29例,对照组28例(P=1.00);轴移试验阴性例数:保留残端组31例,对照组27例(P=0.225).本体感觉的角度重复试验结果无显著差异:保留残端组4.56°,对照组4.28°(P=0.522).二次手术探查时发现的移植物滑膜覆盖率无显著差异:保留残端组85%,对照组84.2%.结论 保留残端同时使用异体肌腱移植重建前交叉韧带,对术后膝关节主观功能评分、稳定性和本体感觉和移植物滑膜覆盖程度并无促进作用.

Abstract：

Objective To evaluate the clinical significance of arthroscopic anterior cruciate ligament (ACL)reconstruction using the remnant-preserved technique.Methods From August 2008 to September 2009,70 cases with the remnant of injured ACL were included in the trials,which were randomized into the remnant preservation(RP)group and the control group,35 cases in each group.All patients in the two groups underwent arthroscopic ACL reconstruction surgeries,with ACL-remnant preserving technique in RP group and ACL-remnant resection in control group,respectively.The injured ACL was reconstructed with allograft in all cases.Postoperative follow-up assessment included the International Knee Documentation Committee(IKDC)grading and Lysholm score,Lachman test,pivot shift test and KT-1000 measurement,proprioception measurements and the arthroscopic second look evaluation.Results Sixty-one(61/70,87%)cases were available for an average of 13.1 months follow-up assessment postoperatively.There were no significant differences between the RP and control group in functional outcome as evaluated with Lysholm score(96.4 vs.94.9,P = 0.71)and IKDC grading(cases with A and B gradings:30 vs.29,P = 0.586).Regarding objective stability,there were no differences between the 2 group in mean side-to-side difference of KT-1000(1.69 mm vs.1.65 mm,P =0.83),Lachman test(negative cases:29 vs.28,P = 1.00)and pivot shift test(negative cases:31 vs.27,P =0.225).There was also no difference between the groups in proprioception evaluation measured with angle repetitive test(4.56°vs.4.28°,P=0.522).During second look arthroscopic examination,the grafts synoveal coverage rates were found to be 85% in the RP group and 84.2% in the control group,without significant difference(P＞0.05).Conclusions Arthroscopic ACL reconstruction with the remnant preserving technique using tendon allograft do not improve the postoperative knee-joint function scores,stability,proprioception and synovial coverage of grafts.     

Biomechanics of the anterior cruciate ligament:Physiology,rupture and reconstruction techniques

The influences and mechanisms of the physiology,rupture and reconstruction of the anterior cruciate ligament(ACL)on kinematics and clinical outcomes have been investigated in many biomechanical and clinical studies over the last several decades.The knee is a complex joint with shifting contact points,pressures and axes that are affected when a ligament is injured.The ACL,as one of the intra-articular ligaments,has a strong influence on the resulting kinematics.Often,other meniscal or ligamentous injuries accompany ACL ruptures and further deteriorate the resulting kinematics and clinical outcomes.Knowing the surgical options,anatomic relations and current evidence to restore ACL function and considering the influence of concomitant injuries on resulting kinematics to restore full function can together help to achieve an optimal outcome.     

膝关节镜手术专用导向器的试制及临床应用

目的：探讨我院自行试制的膝关节镜专用滑臂式导向器用于前交叉韧带(ACL)和后交叉韧带(PCL)重建的临床效果。方法：回顾分析1996年7月--2000年2月应用滑臂式导向器定位，在关节镜下行ACL、PCL重建，随访超过18月患52例，其中ACL重建组33例，PCL重建组19例，重建材料均用深低温冷冻异体跟腱移植，术前及术后18月用Lysholm-Ⅱ评分评定膝关节功能及患运动水平。结果：根据膝关节功能评分(Lysholm-Ⅱ评分)ACL重建组：术前平均48分(36--62分)，术后18月平均86分(58--98分)，优良率90．9％(30／33)。PCL重建组：术前平均56分(42--64分)，术后18月平均84分(56--94分)，优良率89．5％(17／19)。结论：滑臂式导向器定位准确，使用方便，用于关节镜下ACL、PCL重建可获得良好的临床效果。     

Does age, time since injury and meniscal injury affect short term functional outcomes in arthroscopic single bundle anterior cruciate ligament reconstruction?

Purpose

We conducted this study to correlate the short term clinical outcomes after anterior cruciate ligament (ACL) reconstruction with patients' age, time since injury and associated meniscal injury.

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.     

关节镜下应用自体胭绳肌腱重建前交叉韧带的临床分析

目的探讨自体股薄肌及半腱肌重建前交叉韧带（ACL）的临床疗效。方法研究应用自体股薄肌、半腱肌移植重建前交叉韧带损伤病例共30例。术后追踪随访进行为期2年的康复训练,术前和术后随访时行患肢X线检查、功能评分。结果本组病例均获得随访,时间平均32个月（24～40个月）,术后Lachman征及旋转移位试验阴性。Lysholm评分由术前平均（54．80±2．10）分增加至术后2年为（91．00±2．30）分,两者之间的差异有统计学意义（t=61．930,P〈0．01）。而Tegner评分则由术前平均（5．00±1．20）分增加至术后2年（6．23±1．40）分,两者之间的差异有统计学意义（t=3．650,P〈0．01）。手术前后x线复查无退行性改变。结论自体胭绳肌腱重建ACL术后2年随访发现患者膝关节前向不稳消失,膝关节功能评分比术前明显增加。用该方法重建ACL能有效恢复膝关节的功能。     

保留并牵张胫骨残端的前交叉韧带双束重建

目的探讨保留并牵张胫骨残端的前交叉韧带（ACL）双束重建方法的近期临床效果。方法对56例急性股骨附着端撕裂的ACL损伤患者,在外伤后6周之内进行保留残留纤维的ACL双束重建。双束重建方法为采用八股胭绳肌肌腱的反向构型的四隧道重建,术中残留纤维近端用PDS线穿缝,将缝线从深束股骨隧道拉出以维持张力。术后随访1年以上,按照IKDC和Lysholm膝关节评分标准评价疗效。结果所有患者均获得随访。最后随访时,55例患者（98．2％）Lachman试验阴性,1例患者Lachman试验I度阳性。KT－1000检查显示双侧膝关节前向松弛度差值平均为（－0．48mm±1．41mm）（术前8．09mm±1．86mm,t=36．09,P〈0．01）;其中29例（51．8％）〈0mm,即患侧关节稳定度高于健侧;26例（46．4％）为0～2mm;1例（1．8％）〉2mm。所有患者轴移实验检查均为阴性。活动度检查发现49例伸屈活动度均正常,1例有5°屈膝欠缺,1例患者有10°屈膝欠缺,4例有5°过伸欠缺。从膝关节稳定性方面分析,55例（98．2％）IKDC评级为正常,1例（1．8％）评级为接近正常。综合分析,51例（91．1％）IKDC评级正常,5例（8．9％）为接近正常。术后IKDC膝关节主观评分为（94．9±3．7）分,Lysholm评分为（93．71±3．3）分。受伤前Tegner评分平均为7．3,最后随访时为6．9。结论在亚急性期进行保留并牵张胫骨残端的ACL双束重建,能够建立具有高度稳定性的膝关节,使所有患者获得IKDC评级正常或者接近正常的结果。     

Analysis of modified double-bundle anterior cruciate ligament reconstruction with implantless fixation on tibial side

Purpose: To avoid potential problems of double-bundle anterior cruciate ligament reconstruction (ACLR), various modifications have been reported. This study analyzed a novel technique of modified doublebundle (MDB) ACLR without implant on tibial side in comparison to single-bundle (SB) ACLR. Methods: Eighty cases of isolated anterior cruciate ligament tear (40 each in SB group or MDB group) were included. SB ACLR was performed by outside in technique with quadrupled hamstring graft fixed with interference screws. In MDB group, ACLR harvested tendons were looped over each other at the center and free ends whipstitched. Femoral tunnel was created by outside in technique. Anteromedial tibial tunnel was created with tibial guide at 55. The anatomic posterolateral aiming guide (SmithNephew) was used to create posterolateral tunnel. With the help of shuttle sutures, the free end of gracillis was passed through posterolateral tunnel to femoral tunnel followed by semitendinosus graft through anteromedial tunnel to femoral tunnel. On tibial side the graft was looped over bone-bridge between external apertures of anteromedial and posterolateral tunnel. Graft was fixed with interference screw on femoral side in 10 knee flexion. International Knee Documentation Committee (IKDC), Tegner score, Pivot shift and knee laxity test (KLT, Karl-Storz) were recorded pre- and post-surgery. At one year magnetic resonance imaging (MRI) was done. Statistical analysis was done by SPSS software. Results: Mean preoperative KLT reading of (10.00 ± 1.17) mm in MDB group improved to (4.10 ± 0.56) mm and in SB group it improved from (10.00 ± 0.91) mm to (4.80 ± 0.46) mm. The mean preoperative IKDC score in MDB group improved from (49.49 ± 8.00) to (92.5 ± 1.5) at one year and that in SB group improved from (52.5 ± 6.9) to (88.4 ± 2.6). At one-year 92.5% cases in MDB group achieved their preinjury Tegner activity level as compared to 60% in SB group. The improvement in IKDC, KLT and Tegner scale of MDB group was superior to SB group. MRI confirmed graft integrity at one year and clinically at 2 years. Conclusion: MDB ACLR has shown better outcome than SB ACLR. It is a simple technique that does not require fixation on tibial side and resultant graft is close to native ACL.     

A follow-up study of arthroscopic combined reconstruction of anterior and posterior cruciate ligaments with allograft patellar tendon

Objective： To evaluate the therapeutic effect of combined reconstruction of anterior cruciate ligament （ ACL ） and posterior cruciate ligament （ PCL ） simultaneously by using allograft patellar tendon under arthroscopy. Methods： From May 2003 to November 2005, 10 cases of ruptured ACL and PCL were fixated with compressed screws and reconstructed under arthroscopy with allograft patellar tendon simultaneously. The clinical results were evaluated according to IKDC, Lysholm, and Tegner clinical rating scales. Results. All patients were followed up for 12-30 months （mean： 18 months ）. At the last follow-up, there was no knee extension limitation and knee flexion was between 120° and 135°, with an average of 128.38°. The Lysholm score of the 10 cases was 66. 5 ± 5. 6 before operation and 89.8 ± 3.4 at last follow up. The difference was statistically significant （ P 〈 0.01 ）. The average Tegner activity score decreased from 6.9 ± 1.7 （ range ： 4-9 ） before injury to 5.5 ± 1. 6 （rang： 2-9） at the follow-up （P=0.53）. At the end of follow-up, IKDC score was graded as A in 4 cases （40.0 % ）, B in 5 （50.0 % ）, and C in 1 （10.0%）. Of the 10 patients, 8 returned to the same sports level as before injury and 2 were under the level. Conclusion. Arthroscopic combined reconstruction of ACL and PCL with allograft patellar tendon has the advantages of minimal trauma in surgery and reliable satisfactory outcome.     

CT在诊断膝关节交叉韧带断裂中的价值

目的　探讨CT对于确定交叉韧带断裂部位的价值。方法　对有膝关节外伤史、膝关节检查有可疑交叉韧带损伤者 ,分别摄双侧膝关节屈膝 90°前、后抽屉试验位X线侧位片。于X线片上 ,从股骨髁的中心点向胫骨平台前、后缘连线做垂线将后者分为前后两段 ,任何一段比健侧同段长 5mm以上则为阳性。即前段长者为前交叉韧带完全断裂 ,后段长者为后交叉韧带完全断裂。之后作膝关节部位的薄层CT扫描 (层厚、层距均为 1 5mm) ,观察胫骨上端前、后方有无撕脱性小骨块 ,以及股骨髁间窝处股骨外髁内侧或股骨内髁外侧有无撕脱性小骨块。结果　从 1994年 1月～ 1999年 11月按上述方法共诊断交叉韧带完全断裂者 18例。其中 ,前交叉韧带于胫骨止点处撕脱者 1例 ;后交叉韧带于胫骨止点处撕脱者 2例 ;前交叉韧带于股骨外侧髁起点处撕脱者 2例 ;后交叉韧带于股骨内侧髁起点处撕脱同时伴内侧副韧带股骨附着部撕脱性骨折 1例 ;1例膝关节脱位者伴腓骨小头撕脱性骨折及腓总神经损伤。其余病例自韧带实质部断裂。所有病例均经手术修复或重建 ,除 1例术前诊断为单纯前交叉韧带实质部完全断裂 ,而术中发现前交叉韧带实质部断裂约 90 %外 ,其余病例的术前诊断与术中所见均完全吻合。结论　CT对于确定交叉韧带断裂部位具有重要价值     

Mucoid Degeneration of Both ACL and PCL

Unlike meniscal tears and chondral defects, the mucoid degeneration of the anterior cruciate ligament (ACL) is a rare cause of knee pain and there have been no case reports of mucoid degeneration of both the ACL and the posterior cruciate ligament (PCL). A 48-year-old-male patient presented with knee pain and limitation of motion. The patient''s magnetic resonance imaging, arthroscopic findings, and pathologic diagnosis confirmed a clinical diagnosis of mucoid degeneration of both the ACL and the PCL. The symptoms disappeared after arthroscopic partial excision of the ACL and PCL.     

膝关节多韧带损伤的手术治疗体会

目的 :介绍膝关节多韧带损伤的手术治疗方法和结果 ,总结治疗的经验与教训。方法 :随访自2008年至2013年经治的26例膝关节多韧带损伤患者,其中男17例,女9例;年龄29~55岁,平均40.7岁。所有患者在关节镜下采用自体或异体肌腱重建交叉韧带,并同时修补内侧副韧带、外侧副韧带及处理内外侧复合体损伤。9例分期手术,其余均采取Ⅰ期手术处理所有损伤。用Lysholm膝关节评分评价手术前后膝关节功能。结果:26例均获随访,时间为0.8~3.2年,平均1.6年,手术平均等待时间为1.2个月。术前膝关节Lysholm评分42.5±4.5(33~48分),终末随访时78.1±3.9(57~95分),随访时评分提高。术后关节活动度均超过90°,内外翻试验正常或接近正常,所有患者在屈70°时Lachman试验阴性。结论 :膝关节韧带多发损伤应首选关节镜下Ⅰ期重建;如无法Ⅰ期同时重建前后交叉韧带,则Ⅰ期先重建后交叉韧带,Ⅱ期重建前交叉韧带;后交叉韧带因多种原因易漏诊,避免因术前准备不充分而分期手术。     

A Proposal for a New Tibial Guide System for Posterior Cruciate Ligament Reconstruction

Posterior cruciate ligament reconstruction is always a challenge to the orthopaedic surgeon. It is difficult when the anterior cruciate ligament (ACL) is intact. We propose a new guide system through the posteromedial portal, avoiding ACL damage. The arthroscope is inserted anteromedially (30°), and anterolateral portals are used for instruments to confirm the diagnosis and inspect the joint to search for and treat associated lesions that may appear eventually. The posteromedial portal is located posterior to the collateral medial ligament superficially, adjacent to a portion of the posteromedial femoral condyle, which is located 1 cm proximal to the posteromedial tibial plate (where a skin marker must be used before insufflation of the knee). Our system is designed with an articular end in the form of a rasp, which helps prepare the area of the posterior tibia to be stripped before the tibial tunnel is drilled while being protected by the drill guide; this simplifies the preparation and creation of the tibial tunnel via a single device, which can be done with a 30° arthroscope but is easier with a 70° arthroscope. The guide system through the posteromedial portal is used to determine a fixed 40° angle of approach to the tibia in the anteroposterior direction to drill the tibial tunnel; this approach is particularly helpful in the presence of an intact ACL. The graft into the femoral tunnel is fixed with a bioabsorbable interference screw whose size must fit the graft and the tunnel walls. Before tibial graft fixation, it is necessary to reduce the posterior drawer. In the tibia the bundle corresponding to the anterolateral portion is tensioned and fixed under flexion, followed by the posteromedial portion in extension, by means of a Bottom Fix system (Smith & Nephew, Mayfield, MA) placed near the exit of the tibial tunnel.     

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With Anatomic Aimers

Graft positioning is a key issue in anterior cruciate ligament (ACL) reconstruction and even more sensitive in double-bundle reconstruction, where 2 tunnels have to be drilled within the ACL footprints at both the femoral and tibial insertion sites. Specific ancillary instruments have been developed to facilitate the positioning of the 4 sockets necessary when performing anatomic double-bundle ACL reconstruction. This technical note describes the rationale and the step-by-step method of using the specific aimers developed for this purpose. However, a prerequisite for successful double-bundle ACL reconstruction is a good knowledge of ACL footprint anatomy.     

腘绳肌腱结嵌压固定法重建交叉韧带的临床应用与生物力学研究

目的探讨腘绳肌腱结嵌压固定法重建交叉韧带的可行性。方法对52例陈旧性前、后交叉韧带损伤患者在关节镜下行双股腘绳肌腱中间打结,嵌入瓶颈状股骨隧道内固定,胫骨端采用肌腱编织缝合在骨桥上打结固定,重建交叉韧带。其中前交叉韧带25例,前、后十字韧带同时重建15例,后交叉韧带12例。生物力学实验采用猪膝关节。股骨端固定分为肌腱结嵌入组(n=13)和骨髌腱骨(B PT B)介面螺钉固定组(B PT B介面钉组,n=11)。胫骨端固定分为肌腱编织缝合线在骨桥打结组(n=7)、肌腱编织缝合介面螺钉组(n=8)。进行最大拔出强度、最大位移和固定刚度等力学实验。结果术后随访49例,平均14 6个月,Lanchman试验阴性46例,阳性3例。术后Lysholm评分由术前56 7分提高到92 8分。按膝关节疗效评定标准,优46例,良3例。生物力学实验最大拔出强度肌腱结嵌入组高于B PT B介面钉组;固定刚度肌腱结嵌入组小于B PT B介面钉组;最大位移肌腱结嵌入组大于B PT B介面钉组。胫骨端固定抗拉强度和刚度骨桥打结组优于介面螺钉组。结论腘绳肌腱结嵌压固定重建交叉韧带生物力学抗拉强度能满足生理需求,方法可行;可克服位移因素,降低韧带松弛率,提高疗效。     

胫骨平台前外侧撕脱骨折合并前交叉韧带损伤的诊治

胫骨平台前外侧撕脱骨折(Segond骨折)合并前交叉韧带(ACL)损伤在临床中并不少见。对于Segond骨折合并ACL损伤患者如何诊治,越发的被重视起来。本文通过对Segond骨折合并ACL损伤的准确诊断、应急处理、恰当治疗、康复锻炼等方面作一综述,旨在对Segond骨折合并ACL损伤的诊治有所帮助,同时该合并伤应根据个体损伤情况制定个性化的方案。     

Arthroscopic placement of the interference screw for anterior cruciate ligament reconstruction

This article describes a simple technique to check arthroscopically the position of the interference screw in bone patellar tendon bone reconstruction of the anterior cruciate ligament. With this simple and inexpensive method we can be sure that the bone plug in the tunnel has a rigid fixation and that the screw does not damage that graft.