内侧副韧带Ⅱ度损伤保守或手术修复对前交叉韧带重建后膝关节前后稳定性的影响

目的 探讨Ⅱ度内侧副韧带（MCL）损伤手术或保守治疗对前交叉韧带（ACL）重建前后稳定性的影响.方法 以54例膝关节ACL合并急性Ⅱ度MCL损伤患者为研究对象,所有患者受伤时间均〈1周,术前MRI检查示ACL连续性中断,MCL股骨、胫骨止点高信号,术前查体示前抽屉试验阳性,0°外翻应力试验阴性,30°外翻应力试验阳性.对所有患者术前行KT1000测量胫骨相对股骨前移度,膝关节活动度（ROM）,IKDC主观评分.将所有患者随机分为A、B两组,对A组患者采取关节镜下ACL异体单束重建＋MCL切开修复术;B组行单纯ACL异体单束重建,MCL采取支具固定保守治疗6周.术后1年对所有患者行IKDC评分、ROM测量、KT1000评价临床效果.结果 所有患者术后1年IKDC评分、KT 1000测量较术前均有统计学差异 （ t=13.699,9.553;P〈0.05）;A组患者IKDC主观评分与B组比较结果无统计学差异（2=6.273,P〉0.05）,两组患者术前术后关节活动度无统计学差异（t=0.672,P〉0.05）,A组患者术后膝关节前后稳定性改善（KT 1000测量值）较B组明显改善,且结果比较有统计学意义（t=0.932,P〈0.05）.结论 膝关节Ⅱ度MCL损伤合并ACL损伤建议MCL修复＋ACL重建一期手术完成.     

The combination of medial patellofemoral ligament reconstruction with vastus medialis advancement for chronic patellar dislocation

Background The medial patellofemoral ligament (MPFL) reconstruction is popular in clinical practice for chronic patellar dislocation. However, addressing the combination with vastus medialis advancement is rare. The aim of this study was to evaluate the clinical outcome of the combination of MPFL reconstruction with vastus medialis advancement. Methods Sixty nine patients with chronic patellar dislocation between July 2004 to October 2008 were analyzed retrospectively in the present study, with twenty eight cases with the isolated MPFL reconstruction (group I) and forty one cases with the combination of MPFL reconstruction with vastus medialis advancement (group C). All patients have CT scan of knee flexion at 30 degree including the congruence angle, patellar tilt angle; and the patellar later shift was also measured. Physical apprehension test was examined and the redislocation was recorded. In addition, knee function was evaluated with the Kujala score and subjective questionnaire. Results All patients were followed up at a mean of 42 months (12-65 months) and none of them had recurrent dislocation reported. All indexes on postoperative CT scan were within the normal range without statistical difference between two groups. As apprehension test, 8 patients in group I and 3 in group C had patellar later shift exceeding 1.5 cm with hard end point, with significant statistical difference between two groups (x2=4.135, P=0.042). The Kujala score improved statistically significant from (51.3±4.5) to (79.9±6.2) in group I, (53.7±5.2) to (83.9±6.5) in group C, without statistical difference between groups (95% CI: -8.481-0.414, P=0.074). However, the subjective questionnair revealed the statistical difference between groups (x2=6.723, P=0.035), including 12 excellent, 7 good and 9 fair in group I and 30 excellent, 6 good and 5 fair in group C. Conclusion The combination of MPFL reconstruction with vastus medialis advancement is better than isolated reconstruction in improvement of the subjective effect and decrease of the patellar instability rate for chronic patellar dislocation.     

四隧道保留残端后十字韧带重建术的近期疗效

目的 探讨关节镜下采用胫骨斜对角位点四隧道保留残端后十字韧带(posterior cruciate ligment,PCL)重建术的近期临床疗效.方法 2006年6月至2008年6月施行四隧道保留残端PCL重建术21例,男15例,女6例;年龄18～40岁,平均28岁.胫骨双隧道位点在PCL原不规则四边形止点的斜对角处,内下点为后内侧柬,外上点为前外侧束;股骨双隧道位于PCL附着足印区,前外侧束位点在10:30(左)或1:30(右),后内侧束在8:30(左)或3:30(右).术中保留后十字韧带残端纤维,并同时治疗合并损伤.移植物采用深低温冷冻同种异体胫前肌腱,对折双束两端缝合,使用可吸收界面螺钉固定.结果 全部病例随访12～18个月,平均14个月.后抽屉试验(posterior drawer test,PDT)术前(++)不稳15例,(+++)不稳6例;术后(-)15例,(+)不稳5例,(++)不稳1例.IKDC评分术前平均(62.14±4.9)分,术后(93.95±3.6)分,差异有统计学意义(t=10.3,P<0.05).其中正常17例,接近正常3例,不正常1例.Lysholm评分由术前(52.33±4.9)分提高到术后(91.19±3.6)分,差异有统计学意义(t=11.6,P<0.05).结论 采用胫骨双隧道斜对角位点四隧道保留残端PCL重建术能更多地保留残端纤维,保留隧道间骨桥,符合解剖重建,稳定性良好.     

前十字韧带重建中的移植物位置偏移

目的 计算可吸收界面螺钉导致的移植物偏离隧道位移,探讨其对前十字韧带重建产生的影响.方法 19个新鲜尸体膝关节标本,随机选取5个,采用7 mm、8 mm、9 mm界面螺钉固定自体肌腱,测定偏移距离.另外14个膝关节分为等长组和解剖组,等长组膝关节测量界面螺钉固定后及校正位置的移植物拉长距离;解剖组膝关节于膝关节生物力学测试仪上分别测定ACL完整组、ACL缺失组、偏移组和校正组在134 N前向负荷下膝关节屈曲0°、15°、30°、60°和90°位的胫骨前向位移.结果 (1)肌腱偏移:直径7mm、8 mm、9mm的界面螺钉分别使移植物偏移(2.36±0.11)mm、(2.72±0.06)mm、(3.00±0.06)mm.(2)等长性:初始拉长小于3 mm,偏移拉长大于3 mm,校正拉长小于3 mm.(3)生物力学:屈膝0°、15°位,ACL完整组与偏移组、校正组差异无统计学意义.屈膝30°、60°、90°位ACL完整组与其他各组比较差异均有统计学意义,屈膝30°、60°位偏移组与校正组比较差异有统计学意义.结论 无论等长重建还是解剖重建,界面螺钉均影响移植物的股骨隧道口位置.前十字韧带重建预先校正股骨隧道口位置,移植物基本会处于预先的理想位置.

Abstract：

Objective To investigate the impact of graft position shift on anterior cruciate ligament reconstruction induced by femoral fixation of interference screw. Methods Nineteen fresh cadaveric knees were used and assigned to three groups. 1) Study of graft position shift: 5 knees were randomly selected, interference screws of 7 mm, 8 mm and 9 mm were used in autologous tendon fixation, then the graft position shift were measured. 2) Study of isometry: 7 knees were randomly divided into the isometric reconstruction group (D group). In the D group, Retrobutton, interference screw and interference screw in location-corrected bone tunnel were used respectively as fixation. The isometry of grafts was evaluated. 3) Study of tibia anterior translation: 7 knees were randomly divided into the anatomic reconstruction group (J group). In the J group,the tibia anterior translation was measured in four different conditions in the same joint: intact knee joint,knee joint without ACL, ACL anatomic reconstruction by interference screw fixation, and ACL anatomic reconstruction by interference screw fixation with corrected bone tunnel location. Results 1) With 7 mm, 8mm and 9 mm interference screw fixation, graft position shift were (2.36±0.11) mm, (2.72±0.06) mm and (3.00±0.06) mm respectively. 2) Graft length change: graft length change in Retrobutton group and corrected bone tunnel group were less than 3 mm, while graft length change in those fixed with interference screw were stretched in more than 3 mm. 3) Study of tibia anterior translation: there was no difference among the intact group, the anatomic group and the corrected group at 0° and 15°. However, the difference was found between the intact group and other groups at 30°、60° and 90° of flexion, as well as between these two reconstructed methods at 20° joint flexion (P＜0.05). Conclusion In both isometric and anatomic ACL reconstruction with interference screw, the graft is pushed tightly toward the femoral tunnel wall, which shifts the graft away from the desired position. In our study we find out that the corrected location of the femoral bone tunnel significantly improves the isometry of ACL reconstruction and anatomic reconstruction.     

聚乙烯颗粒对糖尿病模型兔假体周围骨溶解中TNF-α变化影响的实验研究

目的 了解TNF-α在聚乙烯颗粒诱导糖尿病模型假体周围骨溶解中的作用及其机理.方法 糖尿病模型造模成功后,向兔子的一侧股骨下端置入一枚假体,每2周向实验组手术侧膝关节注射超高分子聚乙烯颗粒混悬液,向对照组注射生理盐水,取兔子的膝关节进行观察,然后取双组股骨下端和关节囊、滑膜分别做组织学检查.ELISA法测定假体周围界膜组织TNF-α的浓度.结果 实验组邻近假体的滑膜组织增生,模拟假体周围有骨坏死,可以见到多核巨细胞及破骨细胞存在;对照组临近假体周围可见成熟的骨组织,有成骨细胞生成,未见异物颗粒和多核巨细胞生成,对照组的滑膜组织正常.实验组TNF-α含量明显高于对照组.结论 超高分子聚乙烯颗粒可抑制糖尿病模型假体周围新生骨组织形成,激活单核巨噬细胞,使之释放多量的TNF-α,在诱导糖尿病模型假体周围发挥骨溶解作用.     

髋臼翻修过程中固定螺钉安全区的解剖学研究

目的 探讨评估髋臼翻修过程中假体同定螺钉的安全区域,测试四象限系统的有效性.方法 2006年12月至2008年1月,制备11例(22髋)正常国人冷冻骨盆髋标本,剔除肌肉组织后每例标本固定在仰卧位置,安装假体前后拍摄X线片,测量髋臼旋转中心的位置变化.右侧半髋用于评估超大(Jumbo)髋臼假体和高中心髋臼假体同定螺钉的安全区.左侧半髋用于评估3种重建加强环固定螺钉的安全区(臼内区和臼外区).结果 超大髋臼假体前上象限和前下象限发生了神经或血管损伤.高中心髋臼时除了后上象限后半部和后下象限以外其余象限均发生了神经或血管损伤.Müller重建环在前上象限(臼内12(和臼外区)发生了神经或血管损伤.Ganz重建环在前上象限(臼内区和臼外区)和臼顶区发生了神经或血管损伤,Butch-Schneider重建网笼在前上象限(臼内区和臼外区)和坐骨同定钉(当出骨长度大于15 mm时)发生了神经或血管损伤.结论 应用Jumbo非骨水泥假体和重建环时可以参照初次全髋关节置换时叙述的安全区.高中心髋臼手术时,我们常用的阴象限方法需要改进,前上象限及后上象限前部和臼顶区为不安全区域.     

滑膜炎颗粒治疗膝关节骨关节炎的临床试验

[目的]评价滑膜炎颗粒治疗膝关节骨关节炎的有效性和安全性。[方法] 467例单膝骨性关节炎患者纳入本研究，随机分为两组。其中，用药组350例，口服滑膜炎颗粒1袋/次，3次/d；含夏枯草、女贞子、功劳叶、黄芪、防己、薏苡仁、土茯苓、丝瓜络、泽兰、丹参、当归、川牛膝、豨莶草13味药中药；对照组117例，口服滑膜炎颗粒模拟剂，1袋/次，3次/d，其外观、性状、气味与滑膜炎颗粒基本一致，不含任何有效成份。两组患者疗程均为24周。比较两组临床、超声检测与血液检测结果。[结果]试验过程中，不良反应率用药组为2.0%，对照组为2.6%；差异无统计学意义（P>0.05）。随时间推移，两组患者膝关节周径、WOMAC评分和VAS评分均显著减少（P<0.05），综合有效率均显著增加（P<0.05）。治疗前两组间上述指标差异均无统计学意义（P>0.05），但是，治疗后12周，用药组膝关节周径[(36.6±2.8) mm vs (37.4±2.9) mm, P<0.001]、WOMAC评分[(27.0±21.5) vs (46.5±28.9), P<0.001]、VAS评分[...