经前交叉韧带腋下胫骨定位的后交叉韧带重建术

[目的]介绍关节镜下经前交叉韧带(anterior cruciate ligament, ACL)腋下胫骨定位的后交叉韧带(posterior cruciate ligament, PCL)重建术的技术及初步疗效。[方法] 2016年3月～2018年11月,对20例后交叉韧带断裂患者采用关节镜下经ACL腋下定位胫骨骨道,保残重建后交叉韧带。术中保留PCL残束,经前入路由内向外建立PCL股骨隧道,经ACL腋下置入胫骨隧道定位器,在后内入口观察下,于PCL止点平台下建立胫骨隧道。将移植腱由胫骨前侧经胫骨隧道拉入、再引入股骨隧道,股骨侧悬吊固定,拉紧移植物,胫骨侧挤压螺钉和"n"形钉固定。[结果]所有患者均顺利手术,无严重并发症。随访1年以上,Lysholm评分从术前(38.75±14.52)分显著增加至术后1年(93.70±4.23)分(P0.05)。影像测量后向应力胫骨后移由术前(10.81±3.07) mm减少至术后1年(3.86±1.10) mm (P0.05)。[结论]经ACL腋下定位胫骨骨道重建PCL,能精确的偏下偏外定位胫骨骨道;并可以最大程度的保留PCL残端,有利于重建术后韧带的愈合。     

膝关节创伤性多发韧带损伤中后外复合体重建的临床疗效

目的 探讨膝关节创伤性多发韧带损伤中后外复合体(PLC)重建的治疗方案和临床疗效.方法 2003年7月至2008年11月共收治85例陈旧性膝关节多发韧带损伤且同时累及PLC损伤的患者,男63例,女22例;平均年龄34.6岁(15～52岁).损伤类型:前交叉韧带合并PLC损伤2例,前后交叉韧带合并PLC损伤21例,后交叉韧带合并PLC损伤51例,后交叉韧带、内侧副韧带合并PLC损伤11例.PLC损伤根据Fanelli对膝关节后外不稳定的分型:A型48例,使用异体胫前肌腱重建腘腓韧带或腘肌腱;C型37例,其手术方式包括劈裂跟腱的手术技术、外侧副韧带+腘肌腱或腘腓韧带联合重建术.患者术前和末次随访时采用国际膝关节文献委员会(IKDC)综合评分评估,麻醉下膝关节应力像检查评估膝关节后向和内翻稳定性,胫骨外旋试验评估膝关节后外旋转稳定性.结果 58例患者(A型35例,C型23例)术后获1～5年(平均38.5个月)随访,27例失访.35例A型损伤患者胫骨后移程度由术前平均(16.7±5.3)mm减少为末次随访时的(5.1±3.8)mm,胫骨外旋由16.7°±4.7°减小为-1.8°±6.60°23例C型损伤患者胫骨后移由术前平均(14.9±4.4)mm减少为末次随访时的(5.4±4.2)mm,胫骨外旋由16.2°±9.9°减小为-3.0°±8.6°,外侧关节间隙张开由(13.8±2.6)mm减小为(8.6±2.7)mm,以上术前与末次随访时数据比较差异均有统计学意义(P<0.05).58例患者术前IKDC综合评分分级:C级2例,D级56例;末次随访时:A级31例,B级15例,C级12例.结论 对膝关节创伤性多发韧带损伤中的PLC损伤进行系统分类,根据不同的损伤类型进行相应的解剖重建,近中期临床随访结果显示:能明显改善膝关节后向和后外稳定性.     

全关节镜下膝关节后外复合体重建

目的 介绍全关节镜下腘肌腱重建、腘肌腱联合腘腓韧带重建或膝关节后外复合体(posterolateral corner,PLC)解剖重建的手术技术,探讨全关节镜下PLC重建治疗膝关节后外不稳定的效果.方法 2008年8月至2010年4月,共完成全关节镜下后十字韧带(posterior cruciate ligament,PCL)+PLC重建手术34例.患者在接受手术时平均年龄34.1岁(15～52岁);男32例,女2例;从受伤到手术平均10.7个月.所有病例均为陈旧性损伤,且均为复合韧带损伤.所有PCL损伤的病例都存在PLC损伤.合并前十字韧带损伤6例(17.6%),合并前十字韧带、内侧副韧带损伤2例(5.9%),合并内侧副韧带损伤5例(14.7%).对膝关节PLC损伤进行分型,采用不同的重建技术进行治疗.对于A型旋转不稳定,采用全关节镜下腘肌腱重建、腘肌腱联合腘腓韧带重建;对于C型后外不稳定,采用全关节镜下PLC解剖重建.结果 14例患者获得随访并进行二次关节镜检查,平均随访18.5个月(13～25个月).终末随访包括:膝关节查体、KT-1000测量、膝关节应力像和胫骨外旋稳定性.使用膝关节应力像测量胫骨后移程度,胫骨后移由术前平均15.56mm减少为术后5.16mm,手术前后差异有统计学意义.使用屈膝30°位胫骨外旋试验评估膝关节后外旋转不稳定.对比患侧与健侧胫骨外旋的差值,由术前平均14.92°减小为术后-0.22°,手术前后差异有统计学意义.术后患者平均屈曲受限4.23°,无伸膝受限.结论 对于膝关节PLC损伤导致的不稳定,采用全关节镜下PLC重建的手术技术,能够有效恢复膝关节后外旋转不稳定.这种手术技术能够与PCL重建联合应用.

Abstract：

Objectiye To introduce the surgical technique of arthroscopy assisted anatomical posterolateral corner (PLC) reconstruction,including popliteal ligament,popliteofibular ligament and lateral collateral ligament,and evaluate the results of this technique.Methods From August 2008 to April 2010,34arthroscopic posterior cruciate ligament (PCL) and PLC reconstruction surgeries were performed.The average age of the patients was 34.1 (15-52) years.There were 32 males and 2 females.The average time period from injury to surgery was 10.7 months.All patients were chronic injuries and combined ligament injuries,including PCL and PLC injuries.Some cases had other ligament injury,including 6 patients of anterior cruciate ligament (ACL) injury (17.6%),2 of ACL combined medial cruciate ligament (MCL) injuries (5.9%),and 5 of MCL injuries (14.7%).According to Fanellis classification,for type A posterolateral rotation instability,we performed arthroscopic popliteal ligament reconstruction or popliteal ligament combined popliteofibular ligament reconstruction.For type C posterolateral instability,we performed arthroscopic PLC anatomical reconstruction.Results During the follow-up period,14 patients had undergone a second look arthroscopic examination and removal of hardware.The average follow-up time was 18.5 months (13-25 months).At the final follow-up,physical examination,stability evaluation with KT-1000 and Telos stress view,and dial test were performed.The posterior displacement of the knee had decreased from 15.56 mm preoperatively to 5.16mm postoperatively.The external rotation instability had decreased from 14.92° preoperatively to -0.22°postoperatively.The average limitation of knee flexion was 4.23° and no knee extension was limited.Conclusion With the surgical technique of arthroscopy assisted anatomical PLC reconstruction,we can restore the external rotation stability of knee.This technique can be performed combine with PCL reconstruction.     

股骨单隧道内分叉双束纤维重建后交叉韧带的实验研究

目的在人膝关节标本上行股骨单隧道分叉双束纤维重建后交叉韧带(posterior cruciate ligament,PCL),探讨其术式的优缺点。方法应用力学试验机对14侧捐赠新鲜冷冻人膝关节标本进行生物力学测试,男12侧,女2侧;年龄20～31岁。标本股骨段长20cm,胫骨段长20cm。首先测量PCL完整时胫骨后移距离和交叉韧带的应变(完整组,n=14);然后切断PCL(切断组,n=14),测量胫骨受力时的后移距离后,再将标本随机分为两组:单束重建组(n=7)和分叉双束重建组(n=7),分别测量屈膝0、30、60、90和120°5个角度时胫骨后移距离和移植韧带的应变。结果胫骨受到100N后向力量,完整组在不同屈膝角度下,胫骨向后移位1.97±0.29～2.60±0.23mm,前外束和后内束纤维交替紧张松弛。切断组膝关节明显松弛,胫骨向后移位达11.27±1.06～14.94±0.67mm,与完整组比较差异有统计学意义(P<0.05);单束纤维重建组,在不同屈膝角度下胫骨向后移位1.99±0.19～2.72±0.38mm,移植韧带持续紧张。双束纤维重建组在不同屈膝角度下胫骨向后移位2.27±0.32～3.05±0.44mm,移植的双束纤维交替紧张,协同作用。组内比较:双束重建组在不同屈膝角度时胫骨向后位移差异无统计学意义(P>0.05),而单束重建组在屈膝90°时与屈膝30、60和120°时相比,胫骨后移增大,差异有统计学意义(P<0.05)。结论股骨单隧道内分叉双束纤维重建PCL术在各屈膝角度均能有效防止胫骨后移,股骨单隧道单束重建术屈膝90°时后移较其他角度时增大。分叉双束重建PCL的两束纤维束交替紧张,生物力学特征更接近于正常PCL。     

关节镜下可吸收螺钉固定腘绳肌重建膝后交叉韧带的疗效评价

目的 探讨关节镜下可吸收螺钉固定腘绳肌腱单束重建膝后交叉韧带(posterior cruciate ligament,PCL)的效果.方法 2004年4月～2005年4月,我院25例(25膝)经关节镜检查证实为PCL断裂,在关节镜下行自体腘绳肌腱单束PCL 重建术,生物可吸收挤压螺钉解剖位固定重建韧带. 结果 手术时间平均90min(80～100min).25例膝术毕PCL重建后后抽屉试验均为阴性.术后住院时间7～14 d,平均10.4 d.25例术后随访12～24个月,平均18个月,23例膝后抽屉试验阴性,2例后抽屉试验1级.术后12个月Lysholm膝关节功能评分由术前(44.8±8.1)分提高至(77.8±6.4)分(t=-15.999,P=0.000).按国际膝关节文件编制委员会膝关节标准评价膝关节功能分级,术前异常(C级)10例、显著异常(D级)15例,随访时正常(A级)8例、接近正常(B级)15例、异常(C级)2例(Z=-4.394,P=0.000). 结论 关节镜下可吸收螺钉固定自体腘绳肌腱单束重建膝PCL创伤小,固定可靠,手术操作简单,术后膝关节功能恢复效果好.     

关节镜下自体双束半腱肌股薄肌腱重建后交叉韧带

目的关节镜下应用自体半腱肌腱、股薄肌腱双束股骨双隧道重建膝后交叉韧带(PCL),并探讨其近期临床效果。方法采用自体半腱肌腱、股薄肌腱双束股骨双隧道重建膝后交叉韧带29例。结果随访时间12～26个月,平均16个月。本组29例术后PDT试验(-)9例,( )19例,( )1例;IKDC评分正常9例,接近正常17例,不正常3例;Lysholm评分:优20例,良6例,中3例。膝关节伸直受限2例,均小于10°。膝关节屈曲活动正常者20例,5例屈曲受限小于10°,3例小于20°,1例30°。术前屈膝30°和90°时KT-2000测定胫骨后移分别为(13.2±2.8)mm和(13.9±3.2)mm,术后分别为(4.0±0.4)mm和(4.4±0.5)mm,术前、术后二者比较有显著性差异(P<0.01)。结论关节镜下应用自体半腱股薄肌腱双束重建后交叉韧带更加符合PCL的解剖重建和生理学功能,稳定性好,疗效肯定。     

关节镜下LARS人工韧带重建后交叉韧带

目的探讨关节镜下LARS人工韧带重建后交叉韧带（PCL）可行性及近期疗效。方法用LARS人工韧带对6例PCL损伤患者行关节镜下PCL重建术。采用PCL重建技术钻胫骨、股骨骨道,将LARS韧带拉入骨道,韧带游离部分位于关节腔内,拉紧后2枚界面螺钉固定韧带。结果手术时间50-80（65±9.92）min。术后无滑膜炎、韧带断裂、活动明显受限等并发症。6例随访6-12（8±2.28）个月。根据Lysholm膝关节功能评分,术前评分：20-37（23.67±10.84）分;术后评分：84-93（88.00±3.46）分（t=16.69,P〈0.01）。结论关节镜下LARS人工韧带重建PCL术中操作简便,效果可靠。     

基于后十字韧带的膝关节多发韧带损伤两种重建技术的对比研究

目的 比较采用关节镜下经胫骨隧道技术和切开胫骨镶嵌骨块技术重建基于后十字韧带的多发韧带损伤患者术后的后向稳定性和临床疗效.方法 自2005年4月至2009年12月,共连续完成基于后十字韧带的多发韧带损伤重建修复手术135例,2年以上随访者88例.后十字韧带采用关节镜下经胫骨隧道技术重建57例(64.8％),切开镶嵌骨块技术重建31例(35.2％),合并损伤予同期重建或修复.随访时间平均(45.9±17.0)个月(24～77个月).采用KT-1000和Telos应力装置测量手术前后膝关节后向稳定性.采用Tegner、Lysholm、AAOS评分评价临床疗效.结果 两组患者的性别、年龄、受伤至手术时间、合并损伤和主观评分比较,差异均无统计学意义.经胫骨隧道组术前KT-1000两侧差值为(13.5±4.8) mm,术后为(2.4±3.4)mm;术前Telos两侧差值为(14.9±7.1) mm,术后为(4.6±4.0) mm.切开胫骨镶嵌骨块组术前KT-1000两侧差值为(13.7±5.2) mm,术后为(2.2±3.6)mm;术前Telos两侧差值为(14.9±5.9) mm,术后为(4.3±3.9) mm.两组患者KT-1000和Telos两侧差值手术前后组内比较差异均有统计学意义,而组间比较差异均无统计学意义.两组患者术后Tegner、Lysholm、AAOS评分的差异均无统计学意义.结论 采用两种技术重建基于后十字韧带的多发韧带损伤,两组患者术后的后向稳定性及功能评分差异均无统计学意义,且均可明显恢复膝关节后向稳定性.     

关节镜下保留残端单束重建后交叉韧带疗效观察

目的：观察关节镜下保留残端单束重建后交叉韧带（posterior cruciate ligament, PCL）的临床疗效。方法回顾性分析自2010年1月至2013年1月对18例PCL损伤患者在我院行关节镜下保留残端PCL单束重建术。记录并比较患者的Lysholm和国际膝关节文献委员会膝关节评估表（International Knee Documentation Committee, IKDC）评分。结果本组患者随访时间24~42个月,平均31.2个月。患者均未发生严重并发症。患者膝关节Lysholm评分由术前的（58.4±4.5）分提高到术后的（91.6±3.1）分,差异有统计学意义（P＜0.05）。IKDC评分由术前的（52.1±7.6）分提高到术后的（88.3±6.2）分,差异有统计学意义（P＜0.05）。结论关节镜下保留残端单束重建PCL术后临床疗效良好,功能满意。     

一期前、后交叉韧带及后外侧复合体重建联合内侧副韧带修复治疗KD-Ⅳ型膝关节脱位的近期疗效北大核心CSCD

目的探讨一期前交叉韧带(anterior cruciate ligament,ACL)、后交叉韧带(posterior cruciate ligament,PCL)及后外侧复合体(posterolateral complex,PLC)重建联合内侧副韧带(medial collateral ligament,MCL)修复治疗KD-Ⅳ型膝关节脱位的近期疗效。方法2018年1月—2020年6月,收治9例KD-Ⅳ型膝关节脱位患者。其中,男7例,女2例;年龄23~43岁,平均32.3岁。致伤原因:高处坠落伤6例,交通事故伤3例。损伤侧别:左膝2例,右膝7例。受伤至手术时间为14~24 d,平均19 d。术前国际膝关节文献委员会(IKDC)评分为(45.6±4.2)分、Lysholm评分为(42.4±7.0)分,膝关节主动屈曲活动度为(75.2±12.3)°;后抽屉试验、轴移试验、胫骨外旋试验、0°外翻应力试验均为阳性。关节镜下以自体肌腱重建PCL、同种异体跟腱重建ACL、同种异体胫前肌腱Larson后外侧加强重建PLC,带线锚钉或单纯缝线缝合修复MCL。结果手术时间2~3 h,平均2.5 h。术后切口均Ⅰ期愈合。所有患者均获随访,随访时间12~25个月,平均16.1个月。术后出现2例屈膝障碍及疼痛,1例膝关节僵硬。末次随访时,IKDC评分为(76.9±7.4)分、Lysholm评分为(81.6±6.4)分、膝关节主动屈曲活动度为(122.9±7.2)°,均较术前明显改善(P<0.05)。随访期间移植物均无失效,末次随访时后抽屉试验、轴移试验、胫骨外旋试验以及0°外翻应力试验均较术前改善,差异有统计学意义(P<0.05)。影像学复查显示骨隧道位置均满意,1年后可见韧带移植物成活,MCL连续性良好。结论一期ACL、PCL及PLC重建联合MCL修复治疗KD-Ⅳ型膝关节脱位,能有效恢复膝关节稳定性、改善关节松弛程度,并提高关节运动能力。     

膝关节前交叉韧带胫骨止点的软组织解剖标记

背景：膝关节前交叉韧带（ACL）重建时,胫骨骨道定位不准会产生重建韧带与髁间窝的撞击或起不到维持膝关节稳定性的作用。因此,确定ACL胫骨止点的位置非常重要。目的：研究膝关节ACL胫骨止点前内束（AMB）和后外束（PLB）与软组织标记后交叉韧带（PCL）和外侧半月板前角的距离,从而明确ACL胫骨止点在胫骨平台的位置,为ACL损伤双束重建提供理论支持。方法：解剖18个膝关节尸体标本（左膝10个,右膝8个）,测量ACL中点、AMB中点、PLB中点与PCL和外侧半月板前角的距离,并分析左、右膝关节是否存在差异。结果：AMB中点与PCL和外侧半月板前角的距离分别为（15.00±3.97）mm和（19.78±4.10）mm;PLB中点与两者的距离分别为（10.17±5.56）mm和（19.50±4.40）mm;ACL中点与两者的距离分别为（12.67±4.52）mm和（19.61±3.87）mm。左右膝关节ACL中点、AMB中点、PLB中点与软组织解剖标记的距离无明显统计学差异。结论：膝关节ACL损伤行手术重建时,可采用PCL和外侧半月板前角作为定位标记。     

后十字韧带合并后外侧韧带结构损伤的关节镜下重建

目的 介绍后十字韧带合并后外侧韧带结构损伤的关节镜下重建及加强方式,总结其初期临床结果.方法 2006年11月至2007年10月,20例陈旧性后十字韧带合并后外侧韧带结构损伤患者采用八股自体胭绳肌肌腱双束重建后十字韧带、自体半腱肌肌腱加强后外侧韧带结构的手术方法.移植物采用微型钢板纽扣进行悬吊式固定.根据IKDC、Lyshohn和Tegner评分标准进行膝关节功能评估.结果 术后随访1～2年,平均(15.5±3.3)个月.末次随访时,患者伸膝活动均正常,1例屈膝受限15°,5例屈膝受限5°.后抽屉试验阴性17例,Ⅰ度阳性2例,Ⅱ度阳性1例.KT-1000检查(屈膝90°,30 kg)双侧松弛度差异平均为(2.35±1.35)mm.18例(90%)屈膝30°位外侧膝关节间隙增宽小于5 mm,2例(10%)分别为5 mm和6 nun.屈膝30°位小腿外旋角度较健侧增加均小于5°,平均为2.10°±2.67°.IKDC、Lysholm和Tegner评分分别为(90.00±3.49)分、(91.90±2.57)分和(6.50±0.69)分,与术前差异均有统计学意义.IKDC膝关节韧带评级15例(75%)正常,4例(20%)接近正常,1例(5%)异常.结论 采用八股自体胴绳肌肌腱双束重建后十字韧带,同时用自体半腱肌肌腱加强后外侧韧带结构能够恢复后十字韧带和后外侧韧带结构损伤后的膝关节稳定性.     

Arthroscopic posterior cruciate ligament reconstruction using the posterior trans-septal portal

We describe an arthroscopic technique for the reconstruction of the posterior cruciate ligament (PCL), while preserving the remnant bundle of the original PCL and meniscofemoral ligament, using the posterior trans-septal portal. The posterior trans-septal portal provides an excellent visualization of the PCL tibial attachment and an easy access to the tibial tunnel without injuring any neurovascular structure. The remnant bundle of the original PCL and meniscofemoral ligament, which significantly contributes to the posterior stability of the knee joint, are preserved to be healed with a graft and subsequently form an integrated structure. We report a new arthroscopic technique for an effective reconstruction of the PCL, using the posterior trans-septal portal.     

后交叉韧带胫骨止点与双束重建胫骨骨道定位的临床解剖学研究

目的 解剖研究后交叉韧带(PCL)胫骨止点情况,确定PCL前外侧束(ALB)与后内侧束(PMB)胫骨止点的位置、形状与面积,探讨PCL双束四骨道重建中胫骨骨道定位标志与定位方法.方法 30例成人膝关节标本,根据屈伸膝关节过程中纤维束紧张与松弛情况,将PCL分为ALB与PMB,并确定各束中的功能束,用多种指标测量ALB、PMB与功能束的胫骨止点,解剖寻找双束四骨道重建PCL中胫骨骨道定位标志与定位方法.结果 PCL胫骨止点位于后髁间窝内,其纵轴由近内斜向远外,与胫骨干夹角平均为(16.5±1.4)°.ALB与PMB胫骨止点基本呈远近排列,ALB胫骨止点接近于菱形,平均面积为(90±20)mm2,PMB胫骨止点近似长方形,平均面积(96±32)mm2,二者无显著差异(P>0.05).ALB与PMB中均存在功能束,分别止于ALB胫骨止点的远外侧部及PMB胫骨止点的远内侧部,均接近椭圆形,面积分别为(35±12)mm2与(36±6)mm2,二者无显著差异(P>0.05).ALB功能束胫骨止点中心与PMB功能束胫骨止点中心距离为(12.7 ±1.9)mm.胫骨内、外侧髁间棘及胫骨上端后方骨嵴为重要的解剖标志.结论 PCL胫骨止点可以容纳两个胫骨骨道,PCL的ALB与PMB中均存在功能束,提示临床双束四骨道重建PCL时,胫骨骨道应分别定位于ALB与PMB功能束胫骨止点处.     

Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up

Purpose: This study presents the 2- to 10-year results of 35 arthroscopically assisted combined anterior cruciate ligament and posterior cruciate ligament (ACL/PCL) reconstructions evaluated preoperative and postoperatively using Lysholm, Tegner, and Hospital for Special Surgery knee ligament rating scales, KT-1000 arthrometer testing, stress radiography, and physical examination. Type of Study: Case series. Methods: This study population included 26 men and 9 women with 19 acute and 16 chronic knee injuries. Ligament injuries included 19 ACL/PCL/posterolateral instabilities, 9 ACL/PCL/medial cruciate ligament (MCL) instabilities, 6 ACL/PCL/posterolateral/MCL instabilities, and 1 ACL/PCL instability. All knees had grade III preoperative ACL/PCL laxity and were assessed preoperatively and postoperatively with arthrometer testing, 3 different knee ligament rating scales, stress radiography, and physical examination. Arthroscopically assisted combined ACL/PCL reconstructions were performed using the single-incision endoscopic ACL technique and the single femoral tunnel–single bundle transtibial tunnel PCL technique. PCLs were reconstructed with allograft Achilles tendon (in 26 cases), autograft bone–patellar tendon–bone (BPTB) (in 7 cases), and autograft semitendinosus/gracilis (in 2 cases). ACLs were reconstructed with autograft BPTB (16 cases), allograft BPTB (12 cases), Achilles tendon allograft (6 cases), and autograft semitendinosus/gracilis (1 case). MCL injuries were treated with bracing or open reconstruction. Posterolateral instability was treated with biceps femoris tendon transfer, with or without primary repair, and posterolateral capsular shift procedures as indicated. Results: Postoperative physical examination revealed normal posterior drawer/tibial step-off in 16 of 35 (46%) knees. Normal Lackman and pivot-shift test results were found in 33 of 35 (94%) knees. Posterolateral stability was restored to normal in 6 of 25 (24%) knees, and tighter than normal knee results were found in 19 of 25 (76%) knees evaluated with the external rotation thigh foot angle test. In this group, 30° varus stress testing was normal in 22 of 25 (88%) knees, and grade 1 laxity was found in 3 of 25 (12%) knees. 30° valgus stress testing was normal in 7 of 7 (100%) surgically treated MCL tears, and in 7 of 8 (87.5%) brace-treated knees. Postoperative KT-1000 arthrometer testing mean side-to-side difference measurements were 2.7 mm (PCL screen), 2.6 mm (corrected posterior), and 1.0 mm (corrected anterior) measurements, a statistically significant improvement from preoperative status (P = .001). Postoperative stress radiographic side-to-side difference measurements measured at 90° of knee flexion and 32 lb posteriorly directed proximal force were 0 to 3 mm in 11 of 21 (52.3%) knees, 4 to 5 mm in 5 of 21 (23.8%), and 6 to 10 mm in 4 of 21 (19%) knees. Postoperative Lysholm, Tegner, and HSS knee ligament rating scale mean values were 91.2, 5.3, and 86.8, respectively, showing a statistically significant improvement from preoperative status (P = .001). Conclusions: Combined ACL/PCL instabilities can be successfully treated with arthroscopic reconstruction and the appropriate collateral ligament surgery. Statistically significant improvement is noted from the preoperative condition at 2- to 10-year follow-up using objective parameters of knee ligament rating scales, arthrometer testing, stress radiography, and physical examination. Postoperatively, these knees are not normal, but they are functionally stable. Continuing technical improvements will probably improve future results.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 7 (September), 2002: pp 703–714     

关节镜下缝线加强治疗后交叉韧带损伤

目的 介绍关节镜下缝线加强固定治疗后交叉韧带(PCL)损伤的方法 ,研究其临床效果.方法 2005年10月至2006年6月,对13例单纯PCL损伤患者,在关节镜下采用缝线固定维持胫骨中立位,增加PCL的紧张度.采用IKDC和Lysholm膝关节功能评分表对患膝功能进行评估,通过KT-1000检查比较膝关节的后向松弛度. 结果 术后无伸膝受限,屈膝活动度120°～140°,平均128°.术后随访12～18个月(平均14.5个月),最后随访时IKDC评分:A 6例,B 7例;IKDC膝关节主观评分从术前的(67.4±3.3)分提高到随访结束时的(92.5±4.5)分,差异有统计学意义(t=9.837,P<0.01).屈膝90°位KT-1000检查,双侧胫骨结节后坠差异从术前的(8.1±1.7)mm减少到最后随访时的(2.0±1.3)mm,差异有统计学意义(t=12.230,P<0.01).陈旧性损伤患者术前Lysholm膝关节功能评分为(87.5±3.1)分,最后随访时为(95.8±3.5)分,差异有统计学意义(t=5.376,P<0.01).12例患者恢复了原来的运动水平,1例较损伤前稍有降低. 结论 在关节镜下采用缝线加强固定治疗急性PCL中远部损伤,能取得良好效果;治疗陈旧性PCL部分损伤,能够获得满意的结果.     

关节镜下Ethibond缝线复位固定治疗后交叉韧带胫骨止点撕脱骨折的临床疗效

目的探讨关节镜下Ethibond缝线复位固定治疗后交叉韧带(posterior cruciate ligament,PCL)胫骨止点撕脱骨折的临床效果。方法对2015年2月至2017年12月我院收治的22例PCL胫骨止点撕脱骨折病人,在关节镜下常规前内、前外侧入路结合双后内侧入路显露骨折,将PCL重建定位器置入并在其引导下由前内向后于撕脱骨折床3点和9点处钻出导针,制造两骨隧道。术中使用双根5号Ethibond缝线在韧带后方骨块近侧打结,经胫骨双骨隧道将缝线拉出于胫骨前侧,充分复位骨折块,缝线收紧打结固定。术后定期随访,了解骨折复位、愈合情况及活动度,采用KT 1000测量及后抽屉试验评估膝关节稳定性,比较手术前后的Lysholm评分、Tegner评分、国际膝关节评分委员会(International Knee Documentation Committee,IKDC)评分。结果随访时间为19~28个月,平均24.5个月。术后6周骨折均愈合,复位良好。术后6个月,所有病人后抽屉试验均为阴性,无伸膝、屈膝受限,平均屈膝活动度为138.5°±3.5°。手术前后的KT 1000测量值分别为(10.9±0.7)mm、(1.5±0.6)mm,Lysholm评分分别为(36.5±4.9)分、(94.2±3.3)分,Tegner评分分别为(2.6±0.8)分、(6.7±0.4)分;IKDC评分:术前C级7例(31.82%)、D级15例(68.18%),术后A级21例(95.45%)、B级1例(4.55%)。上述指标手术前后的数值比较,差异均有统计学意义(P均<0.05)。结论关节镜下经胫骨双骨隧道应用5号Ethibond缝线复位固定治疗PCL胫骨止点撕脱骨折,固定方法简便可靠,临床疗效满意。     

Combined reconstruction of chronic posterior cruciate ligament and posterolateral corner deficiency. A two- to nine-year follow-up study

We report a retrospective analysis of the results of combined arthroscopically-assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in 19 patients with chronic (three or more months) symptomatic instability and pain in the knee. All the operations were performed between 1996 and 2003 and all the patients were assessed pre- and post-operatively by physical examination and by applying three different ligament rating scores. All also had weight-bearing radiographs, MR scans and an examination under anaesthesia and arthroscopy pre-operatively. The posterior cruciate ligament reconstruction was performed using an arthroscopically-assisted single anterolateral bundle technique and the posterolateral corner structures were reconstructed using an open Larson type of tenodesis. The mean follow up was 66.8 months (24 to 110). Pre-operatively, all the patients had a grade III posterior sag according to Clancy and demonstrated more than 20 degrees of external rotation compared with the opposite normal knee on the Dial test. Post-operatively, seven patients (37%) had no residual posterior sag, 11 (58%) had a grade I posterior sag and one (5%) had a grade II posterior sag. In five patients (26%) there was persistent minimal posterolateral laxity. The Lysholm score improved from a mean of 41.2 (28 to 53) to 76.5 (57 to 100) (p = 0.0001) and the Tegner score from a mean of 2.6 (1 to 4) to 6.4 (4 to 9) (p = 0.0001). We conclude that while a combined reconstruction of chronic posterior cruciate ligament and posterolateral corner instability improves the function of the knee, it does not restore complete stability.