前交叉韧带解剖双束重建中股骨隧道建立路径的比较研究

目的前瞻性研究在关节镜下前交叉韧带（ACL）解剖双束重建术中，采用经胫骨隧道与经前内人路定位建立股骨隧道的可行性与准确性。方法在连续30例ACL患者的解剖双束重建术中，首先分别以45°、55°角钻取胫骨隧道，关节内出口分别在ACL胫骨解剖附丽区印记的前内和后外，保留1～2mm间隔骨桥；关节外入口分别位于胫骨结节内侧和内侧副韧带前缘的前方，间隔以两枚Washer不重叠为准，分别用于前内侧束和后外侧束的移植重建。然后分别经两胫骨隧道，将两根球头空心钻的钻杆自胫骨隧道插入关节内，观察两钻头杆能否到达理想的股骨隧道，录像记录并进行统计学分析。结果在本组30例患者中，经胫骨前内侧束隧道插入的钻头杆，在股骨侧的指向全部偏高、偏前，无一例能完全或部分到达股骨侧前内侧或后外侧束隧道口；而经胫骨后外侧束隧道的钻头杆，经屈或伸膝调整角度后，5例（16．7％）可完全到达、8例（26．7％）可部分到达股骨的前内侧束隧道口；有2例（6．7％）可完全到达、6例（20．0％）部分到达股骨的后外侧束隧道口。而经前内入路屈膝120°后，28例（93．3％）定位可达到理想位置。结论在ACL解剖双束移植重建中，经胫骨隧道定位钻取股骨隧道的方法不可靠、准确性差、变异较大、可重复性差；而经前内入路方法可调节性强、准确性好、股骨隧道短、不受胫骨隧道方向、角度和直径的影响、简便易行、重复性好；但应注意要在较大的屈膝角度下定位钻取。

Comparative study on the femoral tunnel creation in anatomic double-bundle anterior cruciate ligament reconstruction

Objective Prospectively to evaluate the ability and accuracy to create the femoral tunnels in anatomic double-bundle anterior erueiate ligament reconstruction with trans-tibial means. Methods In a consecutive 30 cases of anatomic double-bundle anterior cruciate ligament reconstruction, the ability and accuracy of trans-tibial technique to reach the anatomic ACL insertion sites and tunnels in the femora were observed. Firstly, the two tibial tunnels, anteromedial tunnel （ AM ） and posterolateral tunnel （PL） , were drilled with 45° and 55° tibial tunnel guide respectively, the intraartieular outlets of two tunnel were positioned at anteromedial portion and posterolateral portion of duck foot-like ACL footprint with 1 -2 mm bony bridge left between two tunnels. The tibial tunnel insertion point for AM bundle was placed just medially to the tibial tuberosity, for the PL bundle was placed at anteromedial aspect to medial collateral ligament and keeping a certain distance between two tunnels to avoid Washers overlapped. Then the acorn reamer was introduced into the joint through tibial tunnel and reached the notch wall. The position where the reamer shaft could be reached were clarified and recorded with mainly focusing on weather it could reach the femoral tunnel opening. Results In this group of consecutive 30 cases, the reamer shaft through tibial AM tunnel was 100% high and shallow and none could reach AM or PL tunnel at femoral side, when altered shaft to the tibial PL tunnel, 5 cases（ 16.7% ） could fully reach and 8 （26. 7% ） could partially reach the femoral AM tunnel opening after flexed or extended the knee in some degree in attempt to reach the tunnels, meanwhile, femoral PL tunnel could fully reach in 2 cases （6.7%） and partially reach in 6 cases （20.0%）. Whereas the femoral tunnels drilled through AM portal could be placed at desired position in 28 cases （93.3 ek ）. Conclusions Femoral tunnels positioned and created by means of transtibial approach are unreliable, inaccurate, w