自体Hamstring腱重建前交叉韧带术后关节镜下再视观察

目的关节镜再视观察游离Hamstring腱重建前交叉韧带后在体内重塑与转归过程.方法关节镜下再视手术,观察关节镜下自体同侧游离Hamstring腱重建前交叉韧带33例.重建术至再视手术时间为2～36个月,平均11.9月.依据重建术至再视术的时间,替代腱按时段分组:1月～,4月～,7月～,10月～,13月～,18月～和25月～组.再视术重点观察评估了移植的Hamstring腱形状、色泽、张力、覆盖的滑漠组织和血管状况.结果再视关节镜下重建前交叉韧带的Hamstring腱随植入时间延长,其形态逐步向正常前交叉韧带重塑与转归;7月～组和此后各组的替代腱在关节镜视下表现为.一种几乎无滑膜和血管的灰白色粗壮的圆柱体,类似于正常的前交叉韧带组织,达到了在体内成熟的程度.结论自体游离多股Hamstring腱重建前交叉韧带术后具有良好早期存活,快速再血管化和重塑过程,其术后的重塑与成熟过程与自体髌腱的过程相似,但其在体内重塑与转归进程相对较快.     

前十字韧带重建术后自体Hamstring腱的超微结构研究

目的 观察自体Hamstring腱重建前十字韧带(anterior cruciate ligament,ACL)后在人体内超微结构的变化过程.方法 单侧关节镜下自体Hamstring腱重建ACL后再行关节镜手术患者18例,男10例,女8例;年龄21～43岁,平均27.3岁;其中16例因取内镶钉,2例因术后疼痛而行关节镜手术.取重建ACL术后Hamstring腱的部分组织块,以正常半腱肌腱和ACL作为对照组.取下的组织块依据重建术后时间分组:1～4个月组2例,4～7个月组4例,7～10个月组3例,10～13个月组3例,13～18个月组2例,18～25个月组2例和>25个月组2例.常规电镜技术制备组织块样品,透射电子显微镜下观察细胞和纤维;按纤维的直径分为细、中、粗三种,计算各纤维的平均数目(频率)和所占的相对面积.结果 显微镜下超微结构显示:植入体内早期(<7个月)细胞数多,主要为成纤维细胞,胶原纤维大小差异很大,以粗纤维为多;中期(7～13个月)细胞数目减少,类成纤维细胞居多,胶原纤维呈平行排列,纤维直径已趋均匀,中、细纤维占多数,且与正常ACL的中、细纤维接近,粗纤维罕见;后期(>13个月)细胞数少,主要为类纤维细胞,胶原纤维密集,聚集呈束状,纤维排列呈平行状,纤维直径不均匀,粗纤维增多,中纤维减少,细纤维占多数.结论 自体Hamstring腱组织重建ACL后在体内早期呈快速变化过程,中期组织以细、中纤维为主,已趋成熟,晚期以细纤维为主,且改建过程仍缓慢进行.     

膝关节多韧带损伤的临床研究

目的探讨膝关节多韧带损伤的诊断与治疗方法并评价其治疗效果。方法治疗51例单侧膝关节多韧带损伤,其损伤类型：21例前交叉韧带（ACL）＋内侧副韧带（MCL）,1例ACL＋后外侧复合体（PLC）,4例后交叉韧带（PCL）＋MCL,6例PCL＋PLC,6例ACL＋PCL＋MCL,3例ACL＋PCL＋PLC,8例ACL＋PCL,2例PCL＋髌腱。14例急性Ⅲ度MCL和3例急性Ⅲ度PLC损伤行切开手术,原位缝合,外固定制动3周,再行关节镜下其他韧带手术。2例Ⅲ度慢性MCL和3例Ⅲ度慢性PLC损伤行切开韧带重建术,并同期行关节镜下ACL或PCL重建术。在总共39条ACL损伤中,20条行关节镜下自体Hamstring腱ACL重建术,17条行关节镜下自体骨-髌腱-骨（BPB）重建ACL术,2条行同种异体肌腱重建ACL;在总共29条PCL损伤中,19条行关节镜下自体Hamstring腱PCL重建术,2条行同种异体肌腱重建PCL,另8条急性损伤经固定后由Ⅲ度变为〈Ⅱ度损伤,故未特别治疗。其中,17例ACL＋PCL损伤处理方法为：4例先行PCL重建,二期再行ACL的重建,7例同期自体Hamstring腱重建PCL、自体BPB重建ACL,2例为同种异体肌腱同期重建ACL和PCL,4例仅做ACL重建术。1例髌腱完全性断裂原位修复,另1例部分性髌腱损伤者未治疗。4例合并腓总神经损伤均未做特别治疗。结果平均随访2.4年（9个月～5年）。术后Lysholm评分平均为86.3（51～100）,Tegner活 动评分为5.2（2～8）,均较术前显著增加（P〈0.001）。1例外翻试验为2＋,2例Lachman试验或轴移试验≥2＋,6例应力后沉征或后抽屉试验2＋,4例内翻试验或反轴移试验2＋。其余的对应各种体格检查均为≤1＋。4例合并腓总神经损伤者,术后3例自行恢复,1例未恢复。结论在多韧带损伤中,≤Ⅱ度的MCL或者PLC损伤应采用保守治疗,Ⅲ度损伤者应尽早手术原位修复内侧副韧带及其关节囊或PLC,以利于后期进行其他重要韧带的治疗。交叉韧带或关节内重要组织可二期在?     

半腱肌腱/股薄肌腱在前交叉韧带重建术中应用

前交叉韧带 (ACL)损伤是较常见的膝部损伤之一。在美国每年新增ACL损伤病例近 10万例 ,且其发生率有逐年增长趋势[1 ] 。ACL损伤后 ,会引起一系列并发损伤 ,关节镜下ACL重建术已被临床广泛采用。该术式虽在临床上取得很好的疗效 ,但仍有高达 10 %～ 2 5 %的失败率[1 ] 。决定手术成功的因素很多 ,但替代物的选择仍是关节镜下ACL重建术的最重要环节之一。目前 ,临床上应用的替代材料有自体替代物、同种异体替代物和人工合成材料三大类。自体材料移植重建ACL仍为首选。现临床常用的自体重建材料有中1 3髌腱 -骨、半腱肌腱 股薄肌腱 (H…     

关节镜下自体Hamstring腱重建前交叉韧带的应用

目的探讨关节镜下自体Hamstring腱重建前交叉韧带(Anterior Cruciate Ligament, ACL)的临床方法和疗效. 方法 22例ACL损伤,年龄17岁～50岁, 平均30.7岁,进行关节镜下自体Hamstring腱ACL重建术. 结果本组22例术后膝关节均获正常活动范围.术后Lachmen试验19例≤1+,2例2+,1例3+.轴移试验20例阴性或可疑,2例阳性.术后Lysholm评分为(87.7±9.6)分,较术前(54.4±12.1)分显著提高(t=2.33,p<0.05).术后Tegner活动评分为(5.1±1.3)分,较术前(2.8±0.8)分显著提高(t=4.36,p<0.01).19例X线内固定物的位置良好,3例内固定物的位置欠佳.3例胫部伤口早期感染,经伤口处理愈合.22例随访7月～25月,平均15.7月. 结论关节镜下自体Hamstring腱重建ACL是一种治疗急慢性ACL损伤的有前景的术式.     

前交叉韧带重建术替代腱固定技术新进展

前交叉韧带（anterior cruciate ligament，ACL）重建常用自体替代腱为骨-肌腱-骨（bone—patellar tendon—bone，BPTB）、股四头肌腱-髌骨（quadriceps tendon—patellar bone．QTPB）、Hamstring腱。替代腱的固定有各式各样的方法，BPTB和QTPB通常采用内镶螺钉和挤压钉固定，Hamstring腱的固定方法有：缝合、内扣器、垫环器、固定锚、U形钉、钉板器、腱内固定器、横钉和内镶钉。     

关节镜下自体腘绳肌腱重建前交叉韧带进展

长期以来，关节镜下重建前交叉韧带(anterior cruciate ligament ACL)以自体骨-髌腱-骨移植应用较多。但由于自体骨-髌腱-骨供区并发症的影响，近年许多学者主张应用自体腘绳肌腱移植重建ACL，本文就自体腘绳肌腱重建ACL的有关问题予以综述。     

前交叉韧带重建自体肌腱移植物愈合研究现状

前交叉韧带（anterior cruciate ligament，ACL）是膝关节重要的前向稳定结构，损伤后可以产生膝关节不稳，导致膝关节退变的早期发生。随着关节镜技术的成熟与完善，关节镜下ACL重建技术得到广泛应用，而移植物良好的生物愈合是ACL重建术获得成功的关键。本文就ACL重建后自体肌腱移植物愈合的研究现状予以综述。     

前交叉韧带损伤外科治疗的10年回顾与反思

目的分析不同手术方法治疗ACL损伤的疗效.方法采用Lysholm与Tegner膝关节综合功能评分及美国运动医学协会膝关节前方稳定性的诊断标准,对1990 1～2000.1手术治疗的243例Ⅱ°～Ⅲ°ACL损伤病人进行了平均3.9年的回顾调查.结果ACL修补+半腱肌加强,半腱肌与股薄肌重建及关节镜下B-PT-B重建术后膝关节功能综合评分及前方稳定性明显优于断端缝合和钢丝拉出缝合(P＜0.05).结论推荐ACL修补+半腱肌加强;半腱肌一股薄肌重建和关节镜下B-PT-B重建作为ACLⅢ°损伤的首选手术.强调对膝关节复合韧带损伤的认识及术后系统康复锻炼的重要性.     

关节镜下同种异体肌腱重建膝前交叉韧带的临床疗效观察

目的 观察关节镜下同种异体肌腱重建膝前交叉韧带(ACL)临床疗效,并和自体肌腱重建ACL的疗效进行比较.方法 关节镜下采用同种异体肌腱重建ACL 20例,并和同期自体肌腱重建ACL进行对比,对手术时间、关节稳定度、lysholm评分进行比较.结果 随访时间6～18个月.术后同种异体肌腱和自体肌腱lysholm评分无统计学差异,同种异体肌腱手术时间明显短于自体肌腱.结论 同种异体肌腱可以作为ACL重建的良好移植物供临床使用.     

Ligament-muscle reflex arc after anterior cruciate ligament reconstruction: electromyographic evaluation

The purpose of this study was to determine if a ligament-muscle reflex arc exists between the bone-patellar tendon-bone autograft after anterior cruciate ligament (ACL) reconstruction and the hamstring muscle group. We studied four patients, average age 34.2 years (range 32–36 years). The mean time between the ACL reconstruction and the study examination was 56.2 months (range 5–108 months). All patients underwent a second-look arthroscopy for meniscal injuries, cyclops lesions, or adhesions. Five patients with a normal ACL served as a control group before we performed an arthroscopic meniscectomy. Electromyographic (EMG) activity was measured using fine wire electrodes under two different testing conditions. No unequivocal EMG activity could be detected in the ACL-reconstructed knees when we pulled on the graft or in the controls. Three of four patients and all controls felt pain when we touched the graft or normal ACL or applied strain on it with the hook. In conclusion, the ACL autograft presents a noxious sensory innervation, the Lachman test maneuver stimulates a reflex arc with hamstrings activation, and an unequivocal ligament-muscle reflex arc from the graft to the hamstring muscle group could not be demonstrated.     

Histologic analysis of the tibial bone tunnel after anterior cruciate ligament reconstruction using solvent-dried and gamma-irradiated fascia lata allograft

Anterior cruciate ligament (ACL) reconstruction using free tendon graft requires biologic fixation in the bone tunnel. This report describes the intratunnel histology retrieved from a 47-year-old woman who underwent high tibial osteotomy 17 months after ACL reconstruction using a hybrid graft (a solvent-dried and gamma-irradiated fascia lata allograft as a core wrapped with iliotibial autograft). The patient underwent revision because of pain resulting from osteoarthrotic change, and the graft appeared to be taut and healthy on second-look arthroscopy. The sample was taken from the site of the metaphyseal osteotomy site. Histologic examination of the samples was performed with a light microscope (H&E and Masson trichrome stain). Biologic fixation of the graft to the bone was evident from observation of collagen fiber continuities, resembling Sharpey fibers. Integration of the autograft and allograft seemed to have occurred; the junction between the allograft and the autograft could not be determined. However, there was a difference in ligamentization depending on location. In the peripheral region of the graft (the autograft region), the collagen fibers showed a distinct crimped pattern; the fibroblasts were arranged regularly along the major axis of the collagen fiber bundle. In the central part of the graft (the allograft region), remodeling seemed to be delayed. There were acellular, bubbly or myxoid degeneration areas in which the fiber bundles were less oriented and there was increased vascularity.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 8 (October), 2001: E32     

Histological comparison of after reconstruction of fate of ligamentous insertion anterior cruciate ligament： autograft vs allograft

Objective ：To analyze the histological results and the biological remodeling of ligamentous insertion after the reconstruction of anterior cruciate ligament （ ACL ） with autograft or allograft tendon. Methods： Extensor digitorum tendon was harvested from hind limb as graft material and transplanted to reconstruct the resected ACL in 12 mongrel dogs. Each free tendon end was secured by holding sutures and then the sutures were tied to the post screw at the femoral and tibial bony tunnel outlet after transplantation respectively. Autograft was randomly performed on one side of knee while allograft on the other side of knee. After transplantation, the histological analysis was undertaken at the 6th, 12th weeks and the 6th month using hematoxylineosin （HE） stain under light microscope. Results： The insertion structure of normal ACL typically consisted of four layers, i. e. , dense connective tissue, fibrocartilage, mineralized fibrocartilage and bone. There was a distinct regular tidemark line between fibrocartilage and mineralized fibrocartilage. At the 6th week postoperatively, loose connective tissue presented in the interspace between graft and bony tunnel wall in both autograft and allograft groups. At the 12th week postoperatively, the collagenons fibers between autograft and tunnel wall became well organized and the four layers of insertion with discontinuous tidemark line were demonstrated indistinctly in autograft group but not in allograft group. At the 6th month postoperatively, both of a clear and continuous tidemark line and distinct four layers could be seen in autograft group. In allograft group, only a waved discontinuous tidemark line was shown and either the anatomic morphology or the maturity of insertion was inferior to that of autograft group. Conclusions： At the 6th month postoperatively, although the ligament-eartilage insertion is primarily formed after ACL reconstruction with autograft or allograft tendon, the histological morphology and the maturation of insertion of autograft tendon are better than those of allograft group, which suggests that postoperative rehabilitation should be paid more attention and could be safer if little delayed during ACL reconstruction with allograft tendon.     

Semitendinosus muscle fatty infiltration following tendon harvest in rabbits

The hamstring tendon autograft is one of the most commonly used graft choices in Anterior cruciate ligament (ACL) reconstruction. There are conflicting results regarding postoperative hamstring strength deficits in patients who have had a hamstring graft. The semitendinosus tendon has been shown to regenerate after harvesting for ACL autograft, suggesting that the muscle has the potential to regain normal function. However, no studies have been performed to define the microstructural changes that occur in the semitendinosus muscle after tendon resection. In this study, we hypothesized that fatty infiltration of the semitendinosus muscle after tendon harvest in New Zealand White rabbits increases postoperatively and remains constant or increases during the first year of repair. The semitendinosus tendon was unilaterally detached and harvested from 15 rabbits. Five rabbits were sacrificed at 3‐, 6‐, and 12‐month intervals, and the semitendinosus muscle‐tendon units were analyzed. The contralateral unoperated limb served as the control. The gross tendon and muscle dimensions and histologic percentage of fatty infiltration were measured. We found no significant difference in fatty infiltration at any time point between the control muscle and test specimens and that there was no progression of fatty infiltration over time. If these results hold true in humans, natural repair of the hamstring muscle following tendon harvest during ACL autograft reconstruction is not inhibited by fatty infiltration. © 2013 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 31:1234–1239, 2013     

Histological comparison of fate of ligamentous insertion after reconstruction of anterior cruciate ligament: autograft vs allograft

Objective: To analyze the histological results and the biological remodeling of ligamentous insertion after the reconstruction of anterior cruciate ligament ( ACL) with autograft or allograft tendon. Methods: Extensor digitorum tendon was harvested from hind limb as graft material and transplanted to reconstruct the resected ACL in 12 mongrel dogs. Each free tendon end was secured by holding sutures and then the sutures were tied to the post screw at the femoral and tibial bony tunnel outlet after transplantation respectively. Autograft was randomly performed on one side of knee while allograft on the other side of knee. After transplantation, the histological analysis was undertaken at the 6th, 12th weeks and the 6th month using hematoxylin-eosin (HE) stain under light microscope. Results: The insertion structure of normal ACL typically consisted of four layers, i. e. , dense connective tissue, fibrocartilage, mineralized fibrocartilage and bone. There was a distinct regular tidemark line between fibrocartilage and mineralized fibrocartilage. At the 6th week postoperativcly, loose connective tissue presented in the interspace between graft and bony tunnel wall in both autograft and allograft groups. At the 12th week postoperatively, the collagenous fibers between autograft and tunnel wall became well organized and the four layers of insertion with discontinuous tidemark line were demonstrated indistinctly in autograft group but not in allograft group. At the 6th month postoperatively, both of a clear and continuous tidemark line and distinct four layers could be seen in autograft group. In allograft group, only a waved discontinuous tidemark line was shown and either the anatomic morphology or the maturity of insertion was inferior to that of autograft group. Conclusions: At the 6th month postoperatively, although the ligament-cartilage insertion is primarily formed after ACL reconstruction with autograft or allograft tendon, the histological morphology and the maturation of insertion of autograft tendon are better than those of allograft group, which suggests that postoperative rehabilitation should be paid more attention and could be safer if little delayed during ACL reconstruction with allograft tendon.     

Electron microscopic evaluation of two-bundle anatomically reconstructed anterior cruciate ligament graft

We investigated the difference in collagen fibrils in the two-bundle anatomically reconstructed anterior cruciate ligament (ACL) and the one-bundle reconstructed ACL. Ten patients with a two-bundle anatomically reconstructed ACL using semitendinosus tendons (Two-ST) were followed for an average of 16 months (7–27 months) and were compared with 15 patients with a one-bundle ACL (One-ST) reconstruction using hamstring tendons followed for an average of 20 months (9–39 months). Biopsy was performed during second-look arthroscopy. The diameter of the collagen fibrils, their density, and the percentage of collagen fibrils were measured using electron micrography. We also investigated biopsy specimens of normal semitendinosus and gracilis tendons from 10 patients. The diameter of the collagen fibrils from hamstring tendons in the Two-ST (45.1 ± 7.6nm) was significantly larger than that in the One-ST (40.1 ± 7.8nm) (P 0.05). The diameter of the collagen fibrils in the normal hamstring tendons was significantly larger than that in the reconstructed ACL with hamstring tendons of the Two-ST and One-ST groups (P 0.01). The results of the study revealed that the diameter of collagen fibrils in the Two-ST was significantly greater than that in the One-ST. Hence, the tensile strength of the two-bundle graft may be greater than that of the one-bundle graft.     

Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis

Background Current debate on treatment options for anterior cruciate ligament (ACL) reconstruction complicate the choice between hamstring and bone patellartendon bone autografts. We hypothesized a priori that cumulative meta-analysis (a form of sensitivity analysis) might show that the evidence for reduction of morbidity by hamstring grafts could have been reached at an earlier time. Furthermore, we hypothesized a priori that modern state-of-the-art hamstring graft fixation technique would give similar results regarding stability as bone-patellar tendon-bone autografts.

Methods We performed a cumulative meta-analysis and sensitivity analysis based on femoral graft fixation techniques to compare hamstring autograft and bonepatellar tendon-bone autografts in ACL reconstruction derived from a previously published meta-analysis.

Results Cumulatively, that hamstring autograft reduces anterior knee pain had already reached statistical significance in 2001 (relative risk 0.49 (95%CI: 0.32-0.76; p = 0.001, I2 = 0%)). The modern endobutton hamstring graft fixation technique (2 studies) yielded similar stability in the Lachman test as bone-patellar tendon-bone grafts, with a relative risk of 1.1 (95%CI: 0.82-1.5; p = 0.6, I2 = 0%). Exclusion of the endobutton group explains the increased laxity in the hamstring graft group.

Interpretation Cumulative meta-analysis strengthens the evidence for reduced morbidity using hamstring tendon autograft for anterior cruciate ligament reconstruction. Sensitivity analysis focusing on state-of-the-art hamstring graft fixation techniques further weakens the evidence that bone-patellar tendon-bone autografts provide better stability.     

Editorial Commentary: Reduce the Failure Risk: A Challenge to Reduce the Risk of Using Hybrid Graft in Anterior Cruciate Ligament Reconstruction

Hybrid grafting (augmentation of small hamstring autografts with allograft tissue) is preferred by many surgeons for anterior cruciate ligament (ACL) reconstruction. Although a recent, well-conducted, systematic review reported no significant differences in failure risk between hybrid graft and autograft ACL reconstruction, a trend toward a greater failure risk using the hybrid graft existed in many of the included studies. Three potential causes of hybrid graft ACL reconstruction failure that are absent in autograft ACL reconstruction are different levels of graft revascularization and ligamentization, differences in the tendon-bone healing capacity between the allograft and autograft portions in the bone tunnel, and processing of the graft. Research advances in these areas will further reduce the failure risk of hybrid graft ACL reconstruction.     

Editorial Commentary: Goldilocks and the Three Grafts: Managing Tendon Harvest and Graft Length Problems in Autograft Anterior Cruciate Ligament Reconstruction

Autograft hamstring tendon harvest in anterior cruciate ligament (ACL) reconstruction can occasionally result in a graft length that is inadequate for creation of a robust ACL graft. Patients at risk for an abnormally short hamstring may also be high risk for ACL reinjury. Graft augmentation with allograft may be a suboptimal solution to this problem. Therefore, a reliable means for preoperative estimation of hamstring tendon length by magnetic resonance imaging measurement could avoid this pitfall. However, even with a reliable correlation between magnetic resonance imaging measurement and actual harvested tendon length, establishing a simple, clinically relevant threshold below which hamstring grafts should be avoided remains elusive. By contrast, all-soft-tissue quadriceps autograft avoids the potential length problems inherent to both bone tendon bone (graft–tunnel mismatch) and hamstring tendon grafts, but intermediate- and long-term outcome studies are still needed to validate all-soft-tissue quadriceps autograft in ACL reconstruction.