膝关节内侧副韧带浅层(sMCL)止点的解剖学及有限元分析

目的:探究膝关节内侧副韧带浅层止点的位置、形态及大小,同时利用有限元软件分析内侧副韧带浅层的力学止点分布,从而为临床手术治疗内侧副韧带损伤提供解剖依据。方法:新鲜成人膝关节标本10例,沿膝关节内侧逐层切开,暴露内侧副韧带浅层,沿纤维走形确定内侧副韧带浅层的股骨及胫骨止点,标记止点并切断,测量止点与周围解剖标志的距离以及止点的长度和面积。利用三维薄层核磁共振及三维重建软件MIMICS建立膝关节三维模型,通过有限元分析软件ANSYS模拟侧翻应力试验,观察内侧副韧带浅层的应力分布情况。结果:内侧副韧带浅层的股骨止点近似一椭圆形,位于股骨内上髁后上方,距离内上髁距离为6.82±0.64 mm,平均止点面积为61.64±7.02 mm^2。内侧副韧带浅层的胫骨止点近似一矩形,其中心点距离关节线距离为60.02±0.55 mm,长28.69±4.13 mm,宽8.99±0.62 mm,长宽比为3.19︰1,止点面积为217.78±50.32 mm^2。有限元分析显示,sMCL股骨端应力较高区域靠近内上髁,胫骨端应力较高区域位于胫骨嵴上,与其解剖止点位置基本相符。其中胫骨端应力最大处位于sMCL胫骨止点的最近端。结论:解剖学结果定性及定量描述了sMCL股骨止点与胫骨止点的形状、位置、大小及与周围解剖标志的距离。有限元结果显示sMCL止点的应力与其止点形状及位置基本相符。在临床进行内侧副韧带浅层重建时,应依据其解剖特性及生物力学止点进行解剖重建,以期达到最好的临床效果。     

膝部骨挫伤的MRI评估

目的：进一步认识膝部骨挫伤的ＭＲＩ表现以及与其他结构损伤的关系。材料和方法：回顾性分析膝部外伤后６周内行ＭＲＩ检查的５８例连续性资料，骨挫伤与其他结构损伤诊断由两位骨关节放射专家一致认可，采用相关分析法确定二者有无关系。根据损伤机理，就其挫伤部位推断其他哪些结构可能出现损伤。并将２１例骨挫伤ＭＲＩ表现与退变对照比较。结果：骨挫伤与其他结构损伤有关系（ＯＲ＝５．１５），扭伤为骨挫伤最常见的原因，胫骨平台后外侧与股骨外髁中部骨挫伤多见，常伴有前交叉韧带及内侧副韧带撕裂，软骨、内侧半月板损伤及创伤性滑膜炎。其次为胫骨平台内侧与股骨内髁挫伤，多伴有外侧副韧带撕裂、软骨、内侧半月板损伤及创伤性滑膜炎。根据病变部位、形态及Ｔ２Ｗ信号特点等，结合临床可与膝关节退变鉴别。结论：根据骨挫伤的ＭＲＩ表现可引导发现相关隐匿性损伤，避免误诊与漏诊     

Segond骨折的影像征象分析

目的 :探讨Segond骨折时膝关节韧带、骨骼损伤的影像征象。方法:回顾性分析30例Segond骨折患者的影像学及临床资料,对Segond骨折中相关的十字韧带、内外侧副韧带损伤、半月板损伤、胫骨平台、股骨内外侧髁、腓骨小头骨折的影像学表现进行总结。结果:影像诊断前交叉韧带完全断裂19例,前交叉韧带部分断裂1例,前交叉韧带胫骨止点处骨折10例,内侧副韧带损伤18例,后交叉韧带断裂1例,半月板损伤21例,股骨内髁损伤20例,股骨外髁损伤26例,胫骨平台后份骨折26例,腓骨近端骨折14例,关节积液30例。结论:Segond骨折与膝关节韧带及骨损伤密切相关,认识Segond骨折各种相关损伤的影像表现,可减少漏诊。     

膝关节内侧副韧带及其损伤的MRI诊断

目的　研究正常和损伤的膝关节内侧副韧带的MRI表现。材料与方法　对 6 1例正常膝关节内侧副韧带的MRI表现进行回顾性分析 ,在冠状位上测量内侧副韧带的宽度 ,评价 2 1例内侧副韧带损伤的MRI表现。结果　正常膝关节冠状位MRI上 ,内侧副韧带股骨段平均宽度 3mm ,胫骨段平均宽度 2mm。内侧副韧带损伤的MRI表现为连续性中断 ,局部或弥漫性肿胀 ,信号增高。结论　MRI是一种准确诊断内侧副韧带损伤的方法     

骨挫伤的MRI表现及意义

目的:探讨骨挫伤的MRI表现及意义。方法:回顾性分析两年内1 050名患者中的86例骨挫伤病例的MRI表现。结果:骨挫伤常伴有其他结构损伤,以股骨及胫骨外侧髁骨挫伤最多见,其次为股骨及胫骨内侧髁骨挫伤;常伴有前后交叉韧带、内外侧副韧带、内外侧半月板损伤及创伤性滑膜炎。结论:MRI对骨挫伤及其他结构损伤的发现有重要的临床意义。     

膝关节损伤核磁共振成像诊断分析

目的探讨G-SCAN检查对膝关节损伤的诊断价值。方法 120例膝关节损伤,采用G-SCAN（0.25T可旋转式核磁共振成像仪）膝关节表面线圈检查,分别采用自旋回波序列、梯度回波序列、脂肪抑制序列,做矢状位、冠状位及横断位扫描。结果 G-SCAN可以清楚显示膝关节半月板、韧带及骨挫伤。本组120例病例中,半月板损伤95例,其中单纯外侧半月板损伤63例,单纯内侧半月板损伤8例,内、外侧半月板同时损伤24例;韧带损伤85例,其中前交叉韧带损伤68例,后交叉韧带损伤19例,胫侧副韧带损伤65例,腓侧副韧带损伤5例;骨挫伤35例,其中单纯胫骨挫伤22例,单纯股骨挫伤5例,胫骨及股骨同时挫伤8例。结论 G-SCAN是诊断膝关节结构损伤的最佳检查方法之一,可为临床医生选择合适的治疗方法提供依据,具有重要的临床价值。     

胫骨远端外侧缘骨折

在解剖学上,胫骨骨间崤伸向远侧时,约在踝关节上方5～6厘米就分为两条崤,形成一个浅凹三角区。此区面向外侧与远侧腓骨干相邻。胫骨前结节位于此凹陷区下缘的一侧,而胫骨后结节则位于另侧。于此沟处骨间韧带连接着胫骨和腓骨的相应部位而形成韧带联合。前下胫腓韧带附着于胫骨前结节及外踝的前面,后下胫腓韧带附着于胫骨后结节及外踝的后面。前距腓韧带、后距腓韧带及跟腓韧带于腓骨的附着处位于腓侧副韧带的远侧。大多数踝部损伤系因强烈外旋、外展或外旋加外展     

膝关节内侧副韧带损伤的X线诊断

膝关节内侧副韧带损伤的Ｘ线诊断匡楚龙胡爱东膝内侧副韧带损伤在膝韧带损伤中最为常见。当没有股骨内髁或胫骨内髁撕脱骨折时，易漏诊。双膝０°加压外展正位Ｘ线平片检查对本病有重要的诊断与鉴别诊断价值。我们通过６例膝内侧副韧带完全性断裂的病例得出以下经验，现介...     

关节镜下膝关节腘肌腱重建的实验研究

目的:进一步研究膝关节后外复合体(posterolateral complex,PLC)与腘肌复合体的解剖特点,设计关节镜下重建腘肌腱的手术方法.方法:通过10例成人膝关节尸体标本进行两部分研究,每部分各取5例标本:第一部分进行大体解剖研究,对腘肌复合体(包括腘肌腱、肌腹、股骨附着点、肌腱-肌腹交界区)的解剖特点以及周围相邻解剖结构(包括胫骨平台、外侧半月板后角、后交叉韧带、胭腓韧带、血管)进行观察和测量.第二部分进行关节镜下手术重建技术的流程设计.设计显露腘肌腱的股骨附着点和肌腱-肌腹交界点的关节镜入路以及股骨和胫骨隧道的定位与制备方法,引入移植物并固定,完成腘肌腱的重建.结果:第一部分:腘肌腱的股骨附着点位于滑膜反折区,属滑膜外结构;止于股骨的腘肌腱沟的最近端,与关节软骨边缘紧邻,与外侧副韧带股骨附着点中心相距1.5～1.6cm.腘肌腱走行于腘肌腱浅沟内、肌腱-肌腹交界点位于胫骨后外侧平台的内、外中线与关节软骨面远侧1.0cm线的交点上,内侧距离后交叉韧带外侧边缘1.2～2.0cm、外侧与上胫腓关节的内侧缘紧邻.第二部分:进行膝关节镜下手术操作.采用前外入路及外侧辅助关节镜入路切除腘肌腱近端附着点周围滑膜反折,显露整个附着区,并利用克氏针确定中心点,自外向内制备股骨隧道.通过后外、后内及穿后间隔关节镜入路,沿腘肌腱走行局部切开与后关节囊的结合部,显露肌腱-肌腹交界点,并利用前交叉韧带重建胫骨导向器定位,自Gerdy结节向该交界点制备前后方向胫骨骨隧道.将移植物引入两隧道,并用挤压螺钉固定.5例标本手术均获成功,移植物可有效控制外旋稳定性.结论:根据解剖研究确定腘肌腱远近端的定位标志,通过关节镜技术进行显露及定位,在关节镜下完成腘肌腱的重建手术具有可行性.     

膝关节骨挫伤的MR诊断与临床分析

 目的探讨膝关节骨挫伤的MR诊断价值.方法回顾分析32例骨挫伤的MR表现,并与临床资料相对照.结果本组32例膝关节骨挫伤MR均表现信号异常,为骨骺或于骺端松质骨内斑片状、地图状或网状信号,自旋回波SE序列及快速自旋回波FSE序列T1W呈低或等信号,T2W呈混杂高信号,境界不清,梯度回波脂肪抑制GE序列及短时反转恢复STIR序列病变T2W呈显著高信号,境界清晰.膝关节骨挫伤扭伤多见,常位于胫骨平台后外侧、股骨外髁和胫骨平台内侧,可合并半月板、前交叉韧带和侧副韧带损伤,14例临床症状消失后复查MR示骨挫伤信号恢复正常.结论MR能揭示膝关节骨挫伤的病理改变,准确判断有无其他结构的损伤,是膝关节骨挫伤的最佳检查手段.     

Anatomic and biomechanical study of the lateral collateral and popliteofibular ligaments

The position of the fibula around the proximal tibia varies in different people; it was therefore hypothesized that this variation would affect the orientation of the lateral collateral ligament and the popliteofibular ligament complex. This hypothesis was studied in 10 cadaveric knees by measuring the orientation and length changes in these structures as the knee was flexed. The data were correlated with tibiofibular joint position. The strength of the ligaments was also tested. There were significant correlations between fibular head position and ligament orientation with the knee extended. The lateral collateral ligament slackened significantly with knee flexion, whereas the popliteofibular ligament complex did not. The structures became significantly steeper in the sagittal plane as the knee was flexed. The lateral collateral ligament passed through vertical at 70 degrees of knee flexion and was thus poorly oriented to withstand tibial external rotation. The lateral collateral and popliteofibular ligaments had tensile strengths of 309 and 186 N, respectively. The popliteofibular ligament is dominant when the knee is flexed, because of the slackening of the lateral collateral ligament, and so it should always be reconstructed. The anatomic variation causes some knees to have better ligament orientations to withstand posterolateral tibial displacements and, conversely, other knees may be inherently more difficult to stabilize by reconstruction.     

Force displacement characteristics of the posterior cruciate ligament.

The percent force changes in the posterior cruciate ligament were calculated using a previously validated computerized knee model after the femoral insertion sites were varied 2.5 and 5.0 mm in an anterior, posterior distal, anterior distal, and posterior distal direction. The tibial insertion sites were also varied 2.5 and 5.0 mm in the medial, lateral, proximal, and distal directions. Percent force changes were measured over a range of 0 degree to 90 degrees. These insertion sites simulated potential surgical placement errors. Results of this study demonstrated that the greatest percent force changes in the posterior cruciate ligament were at full extension. The greatest absolute percent force change between 0 degree and 90 degrees of flexion was with a femoral insertion of the posterior cruciate ligament placed 5 mm anterior to its normal attachment site, which resulted in a 39% change in the posterior cruciate ligament force. Distal femoral site attachment had the least effect (10% at 5.0 mm). Alterations at the tibial attachment site were less sensitive than on the femur; the greatest absolute percent force changes occurred with medial and lateral attachment sites (14% and 15%, respectively, at 5.0 mm). A minimal amount of percent force changes were seen between 45 degrees and 75 degrees of knee flexion in all positions tested for both tibial and femoral attachment sites. This model suggests that, like the anterior cruciate ligament, the force in the posterior cruciate ligament is also sensitive to attachment site position. As in anterior cruciate ligament studies, the femoral attachment site was found to be more sensitive.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effect of enforced exercise on the healing of ligament injuries

Previous studies have documented that mobilization ad libitum has a beneficial effect on the healing of ligaments as compared to immobilization. This study was undertaken to determine whether enforced exercise (over and above motion ad libitum) would have a further beneficial effect or, instead, an adverse effect on the healing of ligaments. Large male Sprague-Dawley rats with unrepaired transections of the medial collateral ligament were separated into five groups of similar mean weights. Two of these groups had the anterior cruciate ligament and the medial capsule transected in addition to the medial collateral ligament, rendering the knee unstable. The groups were then subjected to varying regimens of enforced exercise (swimming). After 12 days, the mechanical characteristics of the femur, medial collateral ligament, and tibia complex were evaluated. Rats with intact secondary valgus stabilizers (medial capsule and anterior cruciate ligament) that swam daily for either 5 (moderate) or 15 (near exhaustion) minutes were found to have increases in the tensile strength of the femur, medial collateral ligament, tibia complex as compared to rats that did not swim. Unstable knees (with transected secondary valgus stabilizers) did not show an increase in the tensile strength of the femur, medial collateral ligament, tibia complex when subjected to moderate increase in enforced exercise (swimming 5 minutes). The unstable groups were, however, significantly more lax than the groups that underwent identical exercise regimens but had intact secondary valgus stabilizers. Significant differences in the stiffness of the ligaments in the different groups were not detected.(ABSTRACT TRUNCATED AT 250 WORDS)     

Immunolocalization of types I, II, and X collagen in the tibial insertion sites of the medial meniscus

The medial meniscus of the rabbit knee joint attaches to the tibial plateau via anterior and posterior insertions. Intact meniscal tibial insertions are essential for meniscal function. In the present study the distributions of types I, II, and X collagen in meniscal tibial insertions were investigated by indirect immunohistochemistry in a rabbit model. Four tissue zones were histologically identified in the anterior insertion site, including the ligamentous zone, uncalcified and calcified fibrocartilaginous zones and bone; the ligamentous zone was not observed in the posterior insertion site. Labeling for type I collagen was found to be strong in the ligament tissue and bone, and weak in the fibrocartilages which were also labeled for type II collagen. Tissues positive for different types of collagen overlapped and formed an irregular interface with various angles and depths, especially at the interface between the calcified fibrocartilage and bone. Positive labeling for type X collagen was identified only in the calcified fibrocartilage zone. The coexistence of types I and II collagen in the meniscal tibial insertions may indicate that this structural unit is subjected to both compressive and tensile loads. Type X collagen may play a role in maintaining the calcifying status of this tissue zone, so that its mechanical stiffness is kept between that of uncalcified fibrocartilage and hard bone. Restoration of the insertional structure including the distinct collagen distribution should be considered for a functional meniscal substitution. Received: 22 June 1999/Accepted: 27 September 1999     

Biomechanical evaluation of a new ulnar collateral ligament reconstruction technique with interference screw fixation

BACKGROUND: Techniques for ulnar collateral ligament reconstruction have evolved. HYPOTHESIS: Ulnar collateral ligament reconstruction with interference screw fixation restores elbow kinematics and failure strength to that of the native ligament. STUDY DESIGN: Controlled laboratory study. METHODS: Of 10 matched pairs of cadaveric elbows, one underwent kinematic testing under conditions of an intact, released, and reconstructed ligament. Single 5-mm diameter bone tunnels were created at the isometric anatomic insertion sites on the medial epicondyle and sublime tubercle. Graft fixation was achieved with 5 x 15 mm soft tissue interference screws. The reconstructed and contralateral intact elbows were then tested to failure. RESULTS: Average stiffness for intact elbows (42.81 +/- 11.6 N/mm) was significantly greater than for reconstructed elbows (20.28 +/- 12.5 N/mm). Ultimate moment for intact elbows (34.0 +/- 6.9 N.m) was not significantly different from reconstructed elbows (30.6 +/- 19.2 N.m). Release of the ulnar collateral ligament caused a significant increase in valgus instability. Reconstruction restored valgus stability to near that of the intact elbow. CONCLUSIONS: With this reconstruction method, failure strength was comparable with that of the native ligament and physiologic elbow kinematics were reliably restored. Clinical Relevance: This technique returns elbow kinematics to near normal, with less soft tissue dissection and risk of ulnar nerve injury and ease of graft insertion, tensioning, and fixation.     

Tibial inlay reconstruction of the medial collateral ligament using Achilles tendon allograft for the treatment of medial instability of the knee

Although various surgical procedures have been described for the medical collateral ligament (MCL) reconstruction, none can accurately reestablish its original anatomy and orientation. The purpose of this study was to present a technique restoring the anatomy and stability of the medial knee with an Achilles tendon allograft using a tibial inlay technique. The bone block was fixed into a cancellous trough created on the medial surface of the tibia with a cancellous screw and washer, while the tendinous portion was fixed into the femoral insertion site of the superficial MCL with a bioabsorbable interference screw. This technique can successfully reproduce the native anatomy and orientation of the MCL. Level of evidence IV.     

Post traumatic osteoma of tibial insertion of medial collateral ligament of knee joint

Two cases are presented of post traumatic para-articular osteoma developing at the site of tibial attachment of the medial collateral ligament of knee joint. These occurred after injuries sustained while playing football and in one case the ossified mass was treated with surgical excision for unresolved symptoms after conservative measures. A comparison is made with Pellegrini Stieda disease, which is a similar affection of the femoral insertion of the medial ligament of the knee joint.




     

Spectrum of MR imaging findings in spinal tuberculosis

OBJECTIVE: We describe three patients who presented with radiographic findings of a fragment on the medial side of the tibial plateau of the knee that represented an avulsion of the deep portion of the medial collateral ligament. These findings were all associated with disruption of the posterior cruciate ligament and a peripheral medial meniscal tear-the so-called reverse Segond fracture. CONCLUSION: Avulsion fracture at the tibial insertion of the deep component of the medial collateral ligament is a rare finding. When this type of injury is diagnosed, the radiologist should consider posterior cruciate ligament injury and peripheral medial meniscal tears as possible associated findings.     

The effect of nonphysiologically high initial tension on the mechanical properties of in situ frozen anterior cruciate ligament in a canine model

An experimental study was performed in 32 adult beagle dogs to clarify the effect of nonphysiologically high initial tension on the mechanical and histologic properties of in situ frozen anterior cruciate ligaments. Both anterior cruciate ligaments in each dog underwent the in situ freeze-thaw treatment. The tibial insertion of the ligament was then made free from the tibia along with a cylindrical bone block. In the right knee, an initial tension of 20 N was applied on the anterior cruciate ligament by translocating the bone block in the distal direction. In the left knee, this bone block was anatomically reduced. Each bone block was firmly fixed with an interference screw. Ten animals were sacrificed at 6 weeks and 10 at 12 weeks. The tensile strength and the tangent modulus in the highly tensioned knee were significantly less than those in the physiologically tensioned knee at 12 weeks. Histologically, cell nuclei appeared to be spindle-shaped in the physiologically tensioned knee, while oval nuclei and focal degenerative changes with a number of vacuoles were occasionally found in the matrix in the highly tensioned knee. This study demonstrated that a nonphysiologically high tension significantly deteriorates the mechanical properties of the in situ frozen anterior cruciate ligament compared with physiologic tension.