股四头肌腱的临床应用解剖

目的　为临床应用股四头肌腱重建膝关节交叉韧带提供临床解剖学资料。 方法　在10具成人尸体标本上（20只膝关节）解剖观察股四头肌腱的形态和走行关系以及在髌骨附着点的解剖学特点,测量股直肌腱起止点宽度、长度以及髌骨上极的厚度。 结果　股直肌止点的宽度为（3.20±0.33）cm。起点的宽度为（1.28±0.25）cm。完全为腱性组织的长度为（6.96±0.80）cm。股直肌腱近侧端约4/5完全游离,远侧端约1/5与股外侧肌和股中间肌融合,共同构成股四头肌腱,附着于髌骨上极前方约3/4部分。髌上极的平均厚度为(2.22±0.14)cm。 结论　股四头肌腱的的解剖学特点,完全使其可以作为临床上行膝关节交叉韧带重建的供区之一。     

自体肌腱移植双束解剖重建内侧髌股韧带治疗髌骨脱位

背景：对于髌骨不稳的治疗,临床上一般分为保守和手术治疗,其中手术治疗方法众多,每种方法各有侧重,对于使用何种方法治疗髌骨不稳,目前仍没有形成统一的共识。 目的：探讨应用自体移植肌腱双束解剖重建内侧髌股韧带治疗髌骨脱位。 方法：选择安徽医科大学第一附属医院骨科行膝关节镜辅助下内侧髌股韧带重建髌骨脱位患者46例,所有患者均采用自体移植肌腱双束解剖重建。 结果与结论：重建后随访2~16个月,观察患者关节稳定性及灵活度。46例患者随访期间未见严重并发症,患膝轻度伸直受限1例,重建后均未见髌骨复发脱位。重建后随访Lysholm膝关节评分和Kujala评分均高于重建前(P < 0.01)。结果证实,采用膝关节镜辅助下自体移植肌腱双束解剖重建内侧髌股韧带治疗髌骨脱位效果较好。      

髌腱末端病运动员膝关节屈伸峰力矩和表面肌电图的特征☆

背景：髌腱末端病是腱止点部位的微细损伤,股四头肌群中的股内侧肌与股外侧肌之间的力量平衡发生变化,可直接导致髌骨产生异常运动从而对腱止点部位产生影响。 目的：分析髌腱末端病发生机制和髌腱末端病对膝关节及其周围肌肉活动产生的影响。 方法：选择10名患有髌骨肌腱病的男运动员及10名运动项目、身高和年龄匹配的正常男运动员,采用瑞士CON-TREX等速肌力测试与训练系统,分别进行膝关节力量和表面肌电图的测试,比较与分析膝关节屈肌力矩、伸肌力矩和股四头肌表面肌电图的变化。 结果与结论：发现在等长运动时,末端病组的伸肌伸肌峰力矩明显小于对照组、峰值转矩比比值明显大于对照组;在等速运动时,末端病组的伸肌伸肌峰力矩明显小于对照组,并随着运动角速度增加而变化显著,而峰值转矩比比值均不同程高于对照组;末端病组的股内侧肌/股外侧肌的整合肌电图比值在等长运动和等速运动时,均明显低于对照组。提示髌腱末端病运动员膝关节屈肌与伸肌的力量差距较为突出,存在股内侧肌活动低下和股内侧肌与股外侧肌之间不平衡的现象。     

非接触性前交叉韧带损伤特点及机制的研究进展

前交叉韧带断裂是膝关节最常见运动损伤之一,大部分是非接触性原因造成的。理解前交叉韧带受力和损伤机制对预防和治疗损伤有重要意义。本文综述了国内外对前交叉韧带损伤特点及其受力和损伤机制的研究结果。研究表明,下肢矢状面的生物力学是前交叉韧带受力的主要影响因素,如较小的膝关节屈角,较大的地面反作用力,较大的股四头肌力。其中较大的地面反作用力引发较大的股四头肌力和胫骨近端向前的拉力从而增加前交叉韧带负荷。较小的膝关节角合并较大的髌韧带与胫骨夹角和前交叉韧带倾斜角会增大韧带负荷。交叉韧带并不是承受膝关节内、外翻和内旋     

髌股关节排列异常的生物力学特性变化的实验研究

目的：采用电测实验应力分析和压敏片测量技术相结合的方法,对髌股关节的运动肌群应力的变化特点、髌股关节接触面积和应力分布进行了一系列实验测试。材料与方法：采用8具人膝关节标本,保留关节囊及股四头肌机腱,髌股关节间隙内安放压敏片,肌腱上安放应力传感器,进行不同条件下的加载试验。结果：（1）股四头肌肌力对髌骨的稳定起重要作用。股内、外侧肌力不平衡（即股内侧肌肌力较弱）可使骸股关节接触压力和分布状态发生变化,使外侧髌股关节面接触压力升高。（2）在模拟髌股关节排列异常（髌骨外侧倾斜）的标本上,外侧髌股关节面接触压力及范围均明显增高,但髌骨固定在相对较小范围,使局部应力集中。（3）模拟外侧支持带松解的标本上,外侧关节接触压力和面积均有所下降,髌骨活动度增大,缓解了局部高接触压状态,但股四头肌肌力的不平衡仍影响髌骨的稳定。结论：股四头肌肌力不平衡对髌股关节接触应力和分布状态以及髌骨的位移范围均有较大影响,提示临床治疗中不应忽视对股四头肌肌力的恢复。     

自体富白细胞-血小板纤维蛋白凝胶与腘绳肌腱修复创伤性髌骨脱位

背景：临床上创伤性髌骨脱位合并内侧髌股韧带股骨止点或体部撕裂多采用内侧髌股韧带重建手术，为促进内侧髌股韧带重建术后的腱骨愈合，研究者采用了包括生长因子、干细胞、富血小板血浆在内的多种生物治疗技术。目的：探讨自体富白细胞-血小板纤维蛋白凝胶联合腘绳肌腱重建内侧髌股韧带修复创伤性髌骨脱位的临床疗效。方法：选择2019年2月至2021年2月秦皇岛市第一医院诊治的创伤性髌骨脱位患者37例，采用随机数字表法分为试验组(n=18)与对照组(n=19)，试验组接受自体富白细胞-血小板纤维蛋白凝胶联合自体腘绳肌腱重建内侧髌股韧带手术，对照组接受单纯自体绳肌腱重建内侧髌股韧带手术。两组患者术后随访12个月，通过目测类比评分、Lysholm评分、Kujala髌股关节评分及膝关节活动度评估患者膝关节疼痛及功能状态，通过MRI及CT片测量髌股关节髌骨倾斜角、髌骨适合角及髌骨外移率，评估髌股关节的稳定性及改善情况。结果与结论：(1)两组术后6,12个月的目测类比评分均低于术前(P <0.05)，术后6,12个月的Lysholm评分、Kujala髌股关节评分均高于术前(P <0.05)；试验组术后6个...     

骑行时不同屈曲角度膝关节软骨受力分析

在对骑行人车系统动力学研究的基础上,分析在骑行周期内膝关节软骨的受力状态,以期获得关节软骨受力的规律,增加对骑行时膝关节生物力学特性的理解。基于有限元分析法,建立包括股骨、胫骨、腓骨、髌骨、关节软骨、半月板及韧带组织的人体全膝关节有限元模型。将骨组织刚体化,并对其施加屈曲位移边界条件,包括胫骨相对股骨的内旋、内收、前移和外移以及髌骨相对股骨的屈曲、内旋、内倾以及外移。通过显式动力学分析计算,获得膝关节屈曲60°、80°和100°相位,同时得到骑行状态上述屈曲位处膝关节软骨的应力分布。结果 通过有限元分析,获得骑行姿态下膝关节相关相位的力学分布规律。结果表明,相同载荷下,最大von-Mises应力出现在屈曲100°位置,股骨软骨应力增幅达71.25%,髌骨软骨增大29.36%;随着骑行屈曲角度的增加,胫股关节高应力区逐渐向膝关节后部转移,髌股关节软骨受力逐渐上移。骑行时高应力发生在膝关节屈曲角度较大位置,胫骨平台软骨后侧、髌骨软骨上侧承受更大应力。     

自体腘绳肌腱重建内侧髌股韧带治疗复发性髌骨脱位:中期随访评价

背景:以自体腘绳肌腱重建内侧髌股韧带是现在较流行的修复方式。目的:观察重建内侧髌股韧带治疗复发性髌骨脱位的中期临床疗效。方法:回顾性研究2006年9月至2009年9月因复发性髌骨脱位而接受内侧髌股韧带重建的患者24例(25膝)资料,随访时间2-5年,平均3.1年,观察临床疗效、膝关节功能恢复及CT评估髌骨位置。结果与结论:随访结果显示,IKDC评分优良率为92%,2例(8%)患者再次发生髌骨脱位,需要再次手术治疗,随访时IKDC评分、Tenger评分、Lycholm评分明显高于术前(P0.01)。结果证实,自体腘绳肌腱重建内侧髌股韧带治疗髌骨脱位中期临床疗效较好。     

股外侧肌腱与股骨外侧髁接触的解剖学观察及其临床意义

目的：探讨髌骨半脱位致髌骨外侧软骨面压力过高的形态学因素。方法：对５０侧膝关节标本股外侧肌腱内面及其与股骨外侧髁的接触进行了解剖学观察。结果：股外侧肌腱内面呈椭圆形或圆形光滑面。其周围有滑膜皱襞附着，其长２．１±０．９（１．０～５．４）ｃｍ，宽１．３±０．４（０．７～２．４）ｃｍ，与髌上囊以皱襞相隔。在屈曲９０°时与股骨外侧髁边缘相接触，接触处为光滑的骨软骨结构约１．０ｃｍ×０．８ｃｍ大小。摸拟髌骨半脱位时，整个股四头肌腱外移，股外侧肌腱内面与股骨外侧髁不能接触。结论：①在正常情况下股外侧肌腱内面与股骨外侧髁存在着接触，这可能是缓解髌骨外侧关节软骨面压力的正常接触；②当髌骨半脱位时，该接触减小或消失，可能是髌骨半脱位时外侧面压力增高的原因之一     

股四头肌腱旁血管与肌腱内乏血管区的关系及其临床意义

目的:探讨股四头肌腱旁血管与肌腱内乏血管区的内在联系及其临床意义。方法:10具新鲜成人标本一次性经股动脉灌注明胶—氧化铅混悬液,分离出股四头肌及其肌腱,连同髌骨、髌韧带与周围结蒂组织及皮肤完整取下拍摄X线片并层次解剖。将血管造影图像引入电脑,应用数字图像处理软件“Scion image for windows”进行分析。结果:股四头肌腱旁可见3个明显的血管弓,由这些血管弓自外周向肌腱内供血。因此,肌腱周边的血液供应远较中心区丰富。股四头肌腱的Ⅱ区为乏血管区,此区动脉分布密度的平均灰度像素值仅为(90.0±19.3)pixels。结论:股四头肌腱的血供主要来源于周边的3个血管弓,肌腱内乏血管区恰与临床上股四头肌腱撕裂的常见部位一致;对股四头肌腱旁及肌腱内血管规律的了解,有助于避免手术时损伤过多的肌腱中心血供来源,以促使肌腱尽快恢复及减少并发症。     

全膝关节置换后关节线变化对髌股关节生物力学的影响

BACKGROUND: In addition to infection, the reasons for total knee arthroplasty revision are polyethylene liner wear and prosthesis loosening. The impact of joint line height on patellofemoral biomechanics was inconclusive. OBJECTIVE: To study the impact of joint line changes after total knee arthroplasty on patellofemoral joint biomechanics. METHODS: Three-dimensional finite element models were established after total knee arthroplasty. The impact of different joint line height on quadriceps tensile force, patella tendon tension, and patellofemoral joint forces was calculated at range of flexion of 0°, 30°, 60° and 90°.  RESULTS AND CONCLUSION: (1) At knee flexion of 0°, the height of the joint line in -3 mm-4.5 mm did not have great impacts on quadriceps tensile force, patella tendon tension and patellofemoral joint forces. (2) At knee flexion of 30°-90°, the height of the joint line below 3 mm did not have great impacts on quadriceps tensile force, patella tendon tension and patellofemoral joint forces. The height of the joint line more than 3 mm had obvious impacts on quadriceps tensile force, patella tendon tension and patellofemoral joint forces. (3) It was recommended that the height of joint line in total knee arthroplasty was preferably controlled within 3 mm.      

Biomechanics of the knee joint in flexion under various quadriceps forces

Bioemchanics of the entire knee joint including tibiofemoral and patellofemoral joints were investigated at different flexion angles (0° to 90°) and quadriceps forces (3, 137, and 411 N). In particular, the effect of changes in location and magnitude of restraining force that counterbalances the isometric extensor moment on predictions was investigated. The model consisted of three bony structures and their articular cartilage layers, menisci, principal ligaments, patellar tendon, and quadriceps muscle. Quadriceps forces significantly increased the anterior cruciate ligament, patellar tendon, and contact forces/areas as well as the joint resistant moment. Joint flexion, however, substantially diminished them all with the exception of the patellofemoral contact force/area that markedly increased in flexion. When resisting extensor moment by a force applied on the tibia, the force in cruciate ligaments and tibial translation significantly altered as a function of magnitude and location of the restraining force. Quadriceps activation generated large ACL forces at full extension suggesting that post ACL reconstruction exercises should avoid large quadriceps exertions at near full extension angles. In isometric extension exercises against a force on the tibia, larger restraining force and its more proximal location to the joint substantially decreased forces in the anterior cruciate ligament at small flexion angles whereas they significantly increased forces in the posterior cruciate ligament at larger flexion angles.     

Patellofemoral forces after total knee arthroplasty: effect of extensor moment arm

Total knee arthroplasty implant designs with larger extensor moment arms theoretically should generate lower extensor forces for the same externally applied loads. This study measured knee kinematics, quadriceps forces, and patellofemoral forces under conditions of dynamic knee extension under load in two knee designs with differing quadriceps moment arms. Six human cadaver knees were tested both before implantation and after sequential implantation with two posterior cruciate retaining designs. The extensor moment arm of the LMA (long extensor moment arm design, Scorpio, Howmedica Osteonics, Rutherford, NJ) was approximately 1 cm longer than that of the Control design (7000, Howmedica Osteonics). Quadriceps tension was measured during dynamic closed kinetic chain knee extension. Patellar compressive and shear forces were also recorded using a patellar component instrumented with a custom triaxial load transducer. Knee kinematics were monitored using a three-dimensional electromagnetic tracking device. Both designs produced similar patterns of femoral rollback and tibial rotation. Quadriceps tension was lower in the LMA design compared with the Control design. Patellofemoral compressive forces were also significantly reduced in the LMA design when compared with Control (8-18% lower at angles greater than 50 degrees flexion). The design with the longer extensor moment arm required less quadriceps force to extend the knee under load and reduced patellofemoral compressive forces. Reduced quadriceps forces may facilitate postoperative rehabilitation and activities such as stair climbing. Reduction in patellofemoral forces could reduce patellar complications such as anterior knee pain, component wear, and loosening.     

Reliability of a technique for determining sagittal knee geometry from lateral knee radiographs

The purposes of this study were to describe an analytical technique for determining selected 2-dimensional geometric characteristics of a knee joint using lateral knee radiographs and to examine the inter- and intra-analyst reliability of this technique. Five lateral knee radiographs of different knee flexion angles (25-85 degrees at intervals of 15 degrees ) were obtained from five subjects. Two graduate and five undergraduate students with knowledge of knee anatomy served as the analysts and were asked to identify certain landmarks from the radiographs. The coordinates of these landmarks were used to determine the effective moment arm of the quadriceps force, patellar tendon length, patella height, patellar mechanism and patellar tendon angles, and tibiofemoral and patellofemoral joint spaces. For each radiograph, intraclass correlation coefficients (ICCs) were computed for combinations of 2-7 analysts. Using all seven analysts, the ICCs ranged from 0.9967 to 0.9985 for different radiographs. When fewer analysts were used, the average ICCs were 0.9975 (6 analysts), 0.9974 (5 analysts), 0.9974 (4 analysts), 0.9974 (3 analysts), and 0.9973 (2 analysts). Four of the analysts re-analyzed the radiographs 2-3months after the initial analyses. Intra-analyst ICCs ranged from 0.9842 to 0.9999. Overall, the high ICC values indicate excellent inter- and intra-analyst reliability. The proposed technique is reliable and may be used for both clinical and research purposes. The relatively small reductions in ICCs when fewer analysts were used suggest that a single experienced analyst is sufficient for clinical assessment. However, 2-3 analysts are recommended for research purposes.     

保留止点自体肌腱移植治疗陈旧性髌韧带断裂

背景：髌韧带在膝关节的运动中起着非常重要的的作用,因其断裂比较少见,临床上误诊率较高。目前重建髌韧带的方法较多,疗效报道不一,治疗不当容易出现髌骨位置不良,会严重影响膝关节的功能。 目的：探讨保留止点自体肌腱移植治疗陈旧性髌韧带断裂的临床疗效。 方法：对8例单侧陈旧性髌韧带断裂的患者行保留止点的半肌腱、股薄肌重建髌韧带,髌韧带重建后行半环形石膏后托固定屈膝15°1周,髌韧带重建后2周拆除切口缝线,3周去除石膏行股四头肌等长等张练习,6周时佩戴可调节膝关节护具进行膝关节活动度锻炼,3次/d,每周增加10°。髌韧带重建3个月后允许完全负重行走。 结果与结论：所有患者髌韧带重建后无并发症,X射线示髌骨恢复正常高度。膝关节功能恢复良好。所有患者髌韧带重建后24个月行走2 km以上膝关节无不适。与髌韧带重建前相比,髌韧带重建后24个月患者的Lysholm评分明显增加(P < 0.05),说明保留止点的半腱肌、股薄肌重建髌韧带可重建治疗陈旧性髌韧带断裂。     

胫骨结节前移的生物力学分析

本研究的目的是评估胫骨结节前移术（Ｍａｑｕｅｔ手术）降低髌股关节接触力的效果。采用膝关节活体几何学数据结合生物力学模型模拟Ｍａｑｕｅｔ手术。６例健康青年人在膝关节负重屈伸时（上一级楼梯）以视屏系统连续记录膝关节的动态Ｘ线影像，采用计算机系统分析数字化Ｘ线影像得到膝关节的几何学数据。根据上述数据对６例右膝进行计算机手术模拟，将髌腱止点前移３、５、１０、１５和２０°，随后，对模拟结果作生物力学分析。结果显示，膝屈曲角度达９０°时，Ｍａｑｕｅｔ手术仅能使髌股关节接触力减少２０％，只有在膝关节屈角度小于２０°及髌腔前移１５°或２０°时，髌股关节接触力才有明显下降，达５０％。髌腱前移１５°或２０°意味着胫骨结节前移几乎达１英寸。结果还显示，Ｍａｑｕｅｔ手术可使髌股装置的力传导效率下降２０％，因而在膝关节屈曲角度大于２０°时，手术效果变得很小。上述发现提示Ｍａｑｕｅｔ手术仅适用于屈膝角度较小的老年人或活动较少的病人。     

膝关节矢状面机构模型

建立矢状面上膝关节二维机构模型，求解矢状面髌股关节求解屈膝过程中髌骨与股骨的接触点移动，髌骨倾角、髌韧带倾角变化，髌股关节功能角变化以及髌股接触力和髌韧带作用力的变化等髌股关节运动及动力学参数．依据膝关节主要组成部分的功能及相互间连接关系，以股胫关节交叉四连杆模型为基础，通过对髌股关节的几何描述及力平衡限定，并运用ADAMS软件进行分析计算，计算结果与文献实验结果吻合良好。     

A mathematical modelling study investigating the influence of knee joint flexion angle and extension moment on patellofemoral joint reaction force and stress

BackgroundPatellofemoral pain (PFP) is the most common orthopaedic condition among runners. Individuals with PFP exhibit greater patellofemoral joint (PFJ) reaction force and stress when compared with pain-free controls. However, it is not clear whether PFJ reaction force and stress are the highest (or lowest) when knee joint flexion angle and extension moment are in which combinations. We aimed to investigate the influence of knee joint flexion angle and extension moment on PFJ reaction force and stress.MethodsA PFJ sagittal model was used to quantify PFJ reaction force and stress. Based on the public dataset of the previous study, peak knee joint flexion angle and extension moment at various running speeds was calculated. Based on the calculated peak value, simulation ranges were set to knee joint flexion angle of 10–45° and extension moment of 0–240 Nm. The quadriceps force, effective lever arm length at quadriceps muscle, and PFJ contact area were determined as a function of the knee joint flexion angle and extension moment, and finally PFJ forces and stress were estimated.ResultsPFJ reaction force increased as the knee flexion angle and extension moment increased. Although PFJ stress also increased as the knee extension moment increased, it was at the highest and lowest at 10° and about 30° knee joint flexion angles, respectively.ConclusionsIncorporating knee flexion posture (approximately 30°) during running may help in reducing PFJ stress, which would be useful in the prevention of pain and act as an optimal treatment program for PFP.     

The influence of asymmetric quadriceps loading on patellar tracking — An in vitro study

BackgroundIn patients with anterior knee pain and patellar instability, a specific training of the quadriceps muscle – especially the vastus medialis – is often recommended, although the practicability is discussed controversially and the proof of a measurable clinical effect is difficult. Therefore, this in vitro study investigates the influence of asymmetric muscle loading on the motion of the human patella.MethodsSeven human knee specimens were tested in a specially developed knee simulator. During simulated weight-bearing knee flexion, the kinematics of tibia, femur and patella were measured using an ultrasound motion capture system. The quadriceps forces were controlled to achieve a constant ankle force over the whole flexion range which is assumed to represent almost physiological loading. Three different force distributions of the quadriceps were tested — a central, equally distributed load as well as mainly lateral and medial loads.ResultsA significant influence of different quadriceps force distributions was found for patellar tilt around a proximodistal axis (up to 1.7°) and patellar rotation around an anteroposterior axis (up to 3.8°) with respect to the femur. Interestingly, the patellar mediolateral shift was influenced only marginally (< 1.5 mm).ConclusionsSpecific muscle training might help patients with patellofemoral pain and cartilage damage by a slight modification of the kinematics, but we could show that even highly asymmetric quadriceps loads only led to a small alteration of the mediolateral shift in case of a physiologic anatomy of the trochlear groove.