股骨远端关节面几何学特征在人工关节设计中的意义

目的从几何学角度分析正常国人股骨远端关节面特征,探讨与膝关节运动学的关系及其在人工膝关节假体设计中的意义。方法收集10具尸体膝关节标本进行解剖,通过内外上髁轴钻孔后进行MR检查,同时收集20例正常成人志愿者膝关节MR图像资料。以几何学最小二乘法分析正常志愿者及尸体膝关节标本的股骨远端关节面特征,同时测量尸体膝关节标本通过内外上髁的钻孔与股骨远端关节面之间的关系。结果矢状位关节面拟合后得到股骨内外髁远端及后髁关节面相切的两个圆弧,钻孔通过滑车部位后十字韧带止点附近。经统计学分析,内外侧后髁圆弧半径及关节面圆弧半径之间比较差异无显著性意义(P>0.05);远端外髁关节面半径大于远端内髁(P<0.01),但内侧远端关节面弧度远远大于外侧(P<0.01);内髁远端曲面半径与内侧后髁曲面半径之比为1.89,外髁远端曲面半径与外侧后髁曲面半径之比为2.01,二者之间接近倍数关系。相关性检验显示内侧髁远端关节面半径与内侧后髁关节面半径有明显相关(r=0.814,P<0.01),外侧髁远端关节面半径与外侧后髁关节面半径有明显相关(r=0.740,P<0.01)。通过内外上髁轴的钻孔孔道近似于股骨远端后髁关节面的固定轴心。结论矢状位股骨髁内外侧关节面可被两个相切的圆弧所代表,其圆心近似于内外上髁轴,可看作膝关     

固定平台后稳定型假体全膝关节置换术后的运动学研究

 目的 探讨固定平台后稳定型假体全膝关节置换(total knee arthroplasty,TKA)术后膝关节在负重屈膝下蹲时的运动学特征。方法 选取10名健康志愿者和10例固定平台后稳定型假体TKA术后患者。制作骨骼及膝关节假体三维模型,在持续X线透视下完成负重下蹲动作,膝关节屈曲度每增加15°截取一幅图像。通过荧光透视分析技术完成三维模型与二维图像的匹配,再现股骨与胫骨在屈膝过程中的空间位置,通过连续的图像分析比较正常与固定平台后稳定型假体TKA术后膝关节在负重下蹲时股骨内、外髁前后移动及胫骨内外旋转幅度。结果 负重下蹲时,正常膝关节平均屈曲136°,股骨内、外髁分别后移(7.3±1.2) mm和(19.3±3.1) mm,胫骨平均内旋23.8°±3.4°;TKA术后膝关节平均屈曲125°,股骨内、外髁分别后移(1.4±1.6) mm和(6.4±1.7) mm,胫骨平均内旋8.5°±3.4°。结论 固定平台后稳定型假体TKA术后膝关节运动与正常膝关节相似,均表现出股骨内、外髁后移及胫骨内旋运动,但幅度小于正常膝关节,且在屈膝过程中存在股骨矛盾性前移及胫骨外旋现象。     

半腱肌腱等长重建膝关节后外侧复合体

目的通过研究膝关节外侧副韧带在股骨髁上的等长点,采用半腱肌腱等长重建膝关节后外侧复合体,并探讨其临床结果。方法自2001年2月至2005年2月,对18例膝关节后外侧复合体陈旧性损伤患者采用自体同侧半腱肌腱等长重建。男12例,女6例;年龄19～52岁,平均39岁。术中将半腱肌腱双折后从腓骨头外侧副韧带止点的骨隧道穿入,从腘腓韧带止点的骨隧道穿出;然后分别固定在其股骨外侧髁的等长点上。通过观察膝关节内翻和外旋的稳定性,判断膝关节后外侧结构的稳定性。结果外侧副韧带腓骨附着点至股骨附着点的前方或前下方8￣10mm处具有较好的等长性;而腓骨后上方的腘腓韧带附着点与腘肌腱股骨附着点相对等长。重建术后随访12￣24个月,平均14个月。18例患者完全伸直位均无内翻不稳,屈膝30°位时膝关节Ⅰ度内翻不稳2例。3例屈膝30°和90°位小腿外旋增加5°￣8°,平均6°;14例外旋和健侧相同;1例外旋减小。结论应用半腱肌腱等长重建膝关节后外侧复合体能有效恢复膝关节后外侧结构的稳定性,手术创伤相对较小,是一种理想的重建方法。     

确定股骨远端旋转力线在膝关节置换中的意义

目的应用MRI测量探讨股骨远端各旋转轴线的关系,为人工全膝关节置换术(TKA)股骨远端旋转力线提供参考。方法选取苏浙地区健康汉族成人106例,膝关节共197个。对所选膝关节行MRI平扫,在MRI横断面图像上进行定位参照轴线,包括外科经股骨上髁轴线(STEA)、临床经股骨上髁轴线(CTEA)、前后轴线(APL)及股骨后髁轴线(PCL)。对轴线参数股骨后髁角(PCA)、髁扭转角(CTA)及前后轴线的垂线与后髁轴线的夹角(PAPA)进行测量。比较各角度不同性别、不同侧别均数的差异是否具有统计学意义。结果PCA平均为3.56°±0.26°,CTA平均为6.35°±0.72°,PAPA平均为4.08°±0.22°。不同性别、侧别的PCA均数差异无统计学意义(P0.05),不同性别、侧别的CTA、PAPA均数差异有统计学意义(P0.05)。结论应用MRI测量确定股骨远端轴线参数是一种可靠的方法,不同性别、侧别PCA相对恒定,STEA可作为TKA中股骨远端假体旋转参照力线。     

膝内翻全膝关节置换术软组织平衡方法探讨

目的分析骨性关节炎膝内翻角度的组成,探讨全膝关节置换术(totalkneearthroplasty,TKA)中软组织平衡方法。方法分析1999年1月～2003年12月因骨性关节炎行TKA的100例145侧膝内翻患者,其中男18例25个膝关节,女82例120个膝关节。平均年龄62.4岁(45～80岁)。膝关节HSS(hospitalofspecialsurgery)评分38.0±3.2分。根据下肢力线情况准确截骨,恢复膝关节静态骨性对线,然后根据内翻角度组成情况决定软组织松解部位及范围。软组织松解分3步进行,即截骨前暴露时松解、截骨时松解和截骨后安装假体前彻底松解。松解要点包括:韧带及关节囊松解、骨赘清除及髌骨外侧支持带松解。结果术前膝内翻总角度为9.2±3.1°,软组织失衡性内翻占53.2%,胫骨结构性内翻占46.8%,二者差异无统计学意义(P>0.05)。胫骨结构性内翻中胫骨骨性内翻占22.8%,胫骨平台关节面磨损及破坏占24.0%。术后结果表明,平均胫骨平台截骨角度为4.3°,占膝内翻矫正度数的27.9%;软组织平衡术矫正的度数为10.7°,占膝内翻矫正度数的72.1%。术后HSS评分为87.0±4.5分,与术前比较差异有统计学意义(P<0.05)。结论骨性关节炎膝内翻角度由两方面组成:即胫骨结构性内翻和膝关节侧副韧带及软组织失衡导致的内翻。其中后者占膝内翻角度的主要部分,通过松解内侧软组织进行矫正,松解的关键部位为内侧侧副韧带胫骨侧止点及后关节囊。松解时应循序渐进,随时测试,且勿松解过度。     

成人正常膝关节的运动状态分析

目的分析成人正常膝关节运动状态,为改进和设计符合国人解剖特点的膝关节假体提供参考数据。方法随机选取120名(240膝,男女各半)膝关节正常的中国成年人,年龄21～40岁,平均30.6岁,身高1.60～1.75m。受试者作膝关节的过屈膝运动,通过X线透视成像技术,获得双侧膝关节不同体位时的连续侧位X线片。股骨髁上前方的关节球面为伸展面(extensionfacet,EF),后方的关节球面为屈曲面(flexionfacet,FF);两个球面的圆心分别定义为伸展面球心(extensionfacetcenter,EFC)和屈曲面球心(flexionfacetcenter,FFC)。然后测量关节在不同体位时,后部胫骨皮质与同侧股骨髁后方关节面球心的间距,通过胫骨内外侧软骨下骨性标志中最突出的两个点引一条直线,再引第二条直线垂直于前者,并与后部的胫骨皮质正切。屈曲面球心FFC到第二条直线的距离为d1,伸展面球心EFC到第二条直线的距离为d2,分别测量关节在不同体位时d1和d2的长度。不同体位时d1、d2长度变化的绝对值即为膝关节屈曲时股骨和胫骨的相对运动范围。所得数据用SAS软件进行双因素方差分析。结果不同性别、侧别间膝关节股骨内侧髁及外侧髁的运动范围差异均无统计学意义。成人正常膝关节屈曲时股骨和胫骨的相对运动范围:内侧髁(1.4±0.3)mm,外侧髁(15.9±4.7)mm。结论国人正     

锚钉固定治疗膝关节内侧副韧带附着点断裂

膝关节内侧副韧带（medial collateral ligaments,MCL）是膝关节内侧的主要稳定结构,膝关节外侧暴力常常导致其损伤,MCL损伤在膝关节韧带损伤中常见,其中股骨内上髁及胫骨内髁附着点的断裂又占相当比例。自2004年8月至2007年8月用锚钉治疗膝关节内侧副韧带附着点断裂,取得显著疗效,报告如下。     

膝骨关节炎患者股骨后髁软骨磨损差异对人工全膝关节置换术中股骨假体旋转定位的影响

目的通过测量膝骨关节炎患者股骨内、外侧后髁软骨厚度以及后髁角(posterior condylar angle,PCA),探讨其对人工全膝关节置换(total knee arthroplasty,TKA)术中截骨的影响。方法选择2011年5月-12月拟行TKA治疗的53例(60膝)膝骨关节炎患者作为研究对象(骨关节炎组),男12例(14膝),女41例(46膝);年龄57～82岁,平均71.9岁。胫股角为(183.2±2.6)°。以15例(30膝)健康志愿者膝关节作为对照(对照组),男6例,女9例;年龄59～68岁,平均66.3岁。将MRI扫描膝关节获得数据导入Mimics10.01交互式医学影像控制系统,测量内、外侧股骨后髁软骨厚度和包括与不包括后髁软骨时的PCA,进行统计学分析。结果对照组股骨内、外侧后髁软骨厚度分别为(1.85±0.33)mm及(1.92±0.27)mm,包括与不包括后髁软骨时的PCA分别为(5.0±0.9)°和(5.1±0.8)°,差异均无统计学意义(P>0.05)。骨关节炎组股骨内、外侧后髁软骨厚度分别为(0.45±0.40)mm及(1.78±0.51)mm,包括与不包括后髁软骨时的PCA分别为(3.3±1.7)°和(4.8±1.8)°,差异均有统计学意义(P<0.05)。骨关节炎组股骨内、外侧后髁软骨厚度差为(1.33±0.45)mm,与包括与不包括后髁软骨时的PCA角度差(1.5±1.3)°成正相关(r=0.75,P=0.01)。结论膝骨关节炎患者股骨后髁软骨磨损程度存在差异,导致内、外侧后髁软骨厚度和包括与不包括后髁软骨时的PCA存在差异,TKA术中行截骨时,应将股骨后髁软骨厚度差异纳入考虑范围内。     

侧方应力摄片测量和膝关节MRI诊断内侧副韧带损伤的临床研究

目的:研究双膝外翻应力位摄片对膝关节内侧副韧带损伤的诊断意义。方法:自2008年1月至2011年6月收治膝关节内侧副韧带损伤46例,31例行手术治疗,15例保守治疗,其中1例保守治疗3个月无效后手术。其中男32例,女14例;年龄28～72岁,平均(49.46±22.54)岁;左膝22例,右膝24例。常规行损伤侧、正常侧的应力位下和非应力位下X线摄片和MRI检查,对于内侧间隙明显增宽和MRI表现有深层断裂及后交叉韧带损伤的择期行切开内侧副韧带行缝合或重建术。以胫骨平台内侧髁和外侧髁作一条连线记为A线,将此线向上平移至股骨内侧髁最内缘记为B线,然后测量这2条线的垂直距离记为C。间隙差比值(R)计算方法为(患侧应力下间隙-患侧无应力下间隙)/(健侧应力下间隙-健侧无应力下间隙)。总结R值区间与术中所见韧带损伤种类的关系。结果:46例中17例有韧带浅层撕裂,21例深层断裂,8例合并有后关节囊或后交叉韧带断裂,当比值介于1.51～5.24时,内侧副韧带损伤表现为浅层撕裂的有15例,实际损伤为17例,诊断正确率为88.24%;当比值介于5.28～13.85时,表现为深层断裂的有19例,实际损伤为21例,诊断正确率为90.48%;当比值介于15.61～26.25时,表现为合并后关节囊或交叉韧带断裂的有7例,实际损伤为8例,诊断正确率为87.50%。结论:以膝关节受伤侧关节间隙差值与正常侧差值的比值作为衡量标准,可以提供膝关节内侧副韧带损伤的量化分级。     

急性膝关节后内侧角损伤

[目的]探讨急性膝关节后内侧角损伤的诊断与治疗。[方法]自2000年12月～2004年1月收治急性膝关节损伤12例(12膝),病人均表现为伸膝位和屈膝30°位外翻应力试验阳性和伤膝旋转不稳定,于伤后2～12d接受了关节镜检查及内侧开放探查,12膝均有后内侧角损伤和内侧副韧带损伤,4膝伴前、后交叉韧带断裂;2膝伴前交叉韧带断裂;4膝伴后交叉韧带断裂。12膝均一期手术修复后内侧角和内侧副韧带。8周后,12例病人中8人接受二期关节镜下手术,前交叉韧带重建3例,前后交叉韧带联合重建3例,后交叉韧带重建2例。[结果]一期手术后8周评估表明12膝均恢复内后侧稳定性,伸膝位和屈膝30°位外翻应力试验均为阴性。12例病人随访10～20个月,平均12.0±3.2个月,Lysholm膝关节功能评分87.08±6.28。IKDC综合评定正常(A级)4例,接近正常(B级)7例,异常(C级)1例。[结论]急性膝关节后内侧角损伤见于较高能量损伤,多为复合损伤,表现为伸膝位和屈膝30°位外翻应力试验阳性和伤膝旋转不稳定。应一期手术修复后内侧角和内侧副韧带,二期酌情重建交叉韧带。     

Fixed‐bearing medial unicompartmental knee arthroplasty restores neither the medial pivoting behavior nor the ligament forces of the intact knee in passive flexion

Medial unicompartmental knee arthroplasty (UKA) is an accepted treatment for isolated medial osteoarthritis. However, using an improper thickness for the tibial component may contribute to early failure of the prosthesis or disease progression in the unreplaced lateral compartment. Little is known of the effect of insert thickness on both knee kinematics and ligament forces. Therefore, a computational model of the tibiofemoral joint was used to determine how non‐conforming, fixed bearing medial UKA affects tibiofemoral kinematics, and tension in the medial collateral ligament (MCL) and the anterior cruciate ligament (ACL) during passive knee flexion. Fixed bearing medial UKA could not maintain the medial pivoting that occurred in the intact knee from 0° to 30° of passive flexion. Abnormal anterior–posterior (AP) translations of the femoral condyles relative to the tibia delayed coupled internal tibial rotation, which occurred in the intact knee from 0° to 30° of flexion, but occurred from 30° to 90° of flexion following UKA. Increasing or decreasing tibial insert thickness following medial UKA also failed to restore the medial pivoting behavior of the intact knee despite modulating MCL and ACL forces. Reduced AP constraint in non‐conforming medial UKA relative to the intact knee leads to abnormal condylar translations regardless of insert thickness even with intact cruciate and collateral ligaments. This finding suggests that the conformity of the medial compartment as driven by the medial meniscus and articular morphology plays an important role in controlling AP condylar translations in the intact tibiofemoral joint during passive flexion. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1868–1875, 2018.

     

Comparison of Complete Distal Release of the Medial Collateral Ligament and Medial Epicondylar Osteotomy during Ligament Balancing in Varus Knee Total Knee Arthroplasty

Background

During ligament balancing for severe medial contracture in varus knee total knee arthroplasty (TKA), complete distal release of the medial collateral ligament (MCL) or a medial epicondylar osteotomy can be necessary if a large amount of correction is needed.

Methods

This study retrospectively reviewed 9 cases of complete distal release of the MCL and 11 cases of medial epicondylar osteotomy which were used to correct severe medial contracture. The mean follow-up periods were 46.5 months (range, 36 to 78 months) and 39.8 months (range, 32 to 65 months), respectively.

Results

There were no significant differences in the clinical results between the two groups. However, the valgus stress radiograph revealed significant differences in medial instability. In complete distal release of the MCL, some stability was obtained by repair and bracing but the medial instability could not be removed completely.

Conclusions

Medial epicondylar osteotomy for a varus deformity in TKA could provide constant medial stability and be a useful ligament balancing technique.     

关节镜下修复重建膝关节脱位合并多发韧带损伤的疗效观察

目的 探讨关节镜下重建断裂的前交叉韧带(anterior cruciate ligament,ACL)和后交叉韧带(posteriorcruciate ligament,PCL)及修复膝关节内部结构,治疗膝关节脱位合并多发韧带损伤的临床疗效.方法 2003年7月-2006年8月,收治24例膝关节脱位患者,采用关节镜下重建ACL和PCL,修复内侧副韧带(medial collateral ligament,MCL)、外侧副韧带(lateral collateralligament,LCL)和其他膝关节损伤结构.男19例,女5例;年龄20～69岁,平均42岁.均为单膝损伤,其中左膝11例,右膝13例.于伤后4h～6个月入院.ACL、PCL、MCL及LCL损伤8例,ACL、PCL及MCL损伤12例,ACL、PCL及LCL损伤4例.合并腓总神经损伤1例,内侧半月板损伤3例,外侧半月板损伤7例.评估患者术后并发症、膝关节活动范围和手术前后症状改善情况,Lysholm评分评估手术前后膝关节功能情况.结果 术后患者均获随访11～36个月,平均25个月.4例出现轻微关节僵硬,3例出现轻微关节疼痛,均未作特殊处理.11例(45.8%)运动功能恢复至伤前运动水平;13例(54.2%)显著改善,不需要辅助独立行走.24例Lachman试验、膝内外翻应力试验及前、后抽屉试验均为阴性,胫骨前后移动均<5 mm.1例腓总神经损伤者感觉运动恢复良好.Lysholm膝关节功能评分术前(41.8 ±4.3)分,术后(87.0±6.0)分:关节活动范围术前(87.5±12.5).术后(125.0 ±9.2)°术前、后比较差异均有统计学意义(P<0.05).结论 膝关节脱位后关节镜下重建ACL、PCL和修复其他膝关节结构是治疗膝关节脱位的一种有效方法.     

Isolierte und kombinierte Kniebandverletzungen

Complex knee ligament injuries are characterized by simultaneous rupture of the anterior cruciate ligament (ACL) and/or the posterior cruciate ligament (PCL) and at least one collateral ligament. Isolated injury to the medial collateral ligament (MCL) and PCL have a high healing capacity and can be treated conservatively in many cases. Ruptures of the MCL can also be treated conservatively in complex injuries if the cruciate ligaments are reconstructed. Ruptures of the lateral structures usually need surgical reconstruction. Indications for acute surgical repair include meniscus dislocation, entrapment of collateral ligament portions in the joint, knee dislocation with severe knee instability, and displaced bony avulsions. The anatomy of the knee ligaments must be carefully respected in surgical reconstruction. Acute repair of collateral ligament injuries is possible only in the first 2 weeks after trauma. Acute arthroscopy is indicated only in combination with reconstructive surgery.     

Case Reports: A Stener-like Lesion of the Medial Collateral Ligament of the Knee

When the superficial fibers of the medial collateral ligament of the knee are torn without tearing of the deep fibers, the anterior superficial fibers may displace over the pes anserinus tendons, so that healing back to the tibial insertion site may be jeopardized. As only the anterior superficial and not the posterior superficial or deep fibers are disrupted, the knee will not have increased valgus laxity in extension whereas there is not a firm end point in 30° flexion. The clinical findings could be confused with those of a Grade 2 medial collateral ligament sprain that generally is not associated with displacement of the anterior fibers over the pes anserinus tendons. We describe the diagnostic findings confirmed with surgical exploration of two Stener-like disruptions of the medial collateral ligament of the knee.     

Complex instability of the anterior knee

Complex knee instability involves the anterior cruciate ligament (ACL) and one or more major stabilizers of the knee [medial collateral ligament (MCL), lateral collateral ligament (LCL), posterior cruciate ligament (PCL)]. The medial side has a high healing potential and does not need operative treatment in most cases if ACL reconstruction is performed. Reconstruction of the medial ligament complex is indicated in gross instability of the medial meniscus fixation, dislocation of the MCL into the joint, and large dislocated bony avulsions. Injuries on the lateral side do not heal spontaneously and require acute operative treatment (first 2 weeks). Frank knee dislocations and gross multiligament injuries should be reduced acutely, and the integrity of the vascular structures must be examined closely. In a European multicenter study, operative treatment with reconstruction of both cruciate ligaments and functional rehabilitation gave better results than conservative treatment with immobilization of the joint.     

Semimembranosus Release as the Second Step of Soft Tissue Balancing in Varus Total Knee Arthroplasty

There have been limited clinical data on the effect of semimembranosus release in patients with varus knees treated with total knee arthroplasty (TKA). The purposes of this study were to determine the effect of semimembranosus release and to evaluate the effectiveness of our release technique based on the three-step algorithm which consisted of sequential release of 1) deep medial collateral ligament (MCL), 2) semimembranosus, 3) superficial MCL in 104 consecutive varus knees treated with TKA. Semimembranosus release had the desired effect on gap balancing in varus knees and our algorithmic medial release approach to the varus knee has shown to be favorable in correcting varus deformities during TKA.     

Medial collateral ligament avulsion from both tibial and femoral attachments: a case report

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee joint. Proximal MCL tears occur more frequently than do distal ones. We report a 28-year-old man with a valgus injury of his left knee joint after a fall from a motorcycle. Magnetic resonance imaging of the affected knee joint revealed complete avulsion of the superficial MCL from both its femoral and tibial insertions. The meniscofemoral portion of the deep part of the MCL was also torn and the medial meniscus was subluxated. Such a pattern, an MCL tear with subluxation of the medial meniscus, is rare.