前交叉韧带四骨道双束重建的解剖学及临床研究

目的 对应用相关解剖结果进行的关节镜下前交叉韧带(ACL)四骨道双束重建手术进行初步分析.方法 对22个25～45岁的男性健康膝关节前交叉韧带的前内束(AMB)和后外束(PLB)的股骨和胫骨止点的足印(footprint)大小和分布、位置及AMB和PLB的纤维走行方向进行了解剖测量.将解剖测量结果用在411例患者的413个膝关节的关节镜下ACL四骨道双束重建中,并对临床资料进行了初步分析.其中左膝222个,右膝191个.平均年龄(27.6±7.2)岁.结果 每例AMB和PLB的股骨和胫骨足印的分布和尺寸都不同.定位AMB股骨骨道可以使用距离髁间窝后拱门12:00向外侧壁下方(7.9±1.4)mm、保留1 mm骨道后壁的方法.PLB股骨骨道中心点在屈膝90°下距离髁间窝外侧壁下软骨缘(5.0±0.8)mm、距离前软骨缘(8.6±1.5)mm、后软骨缘(8.6±1.5)mm的位置.还对两个股骨骨道和两个胫骨骨道的钻取方向进行了解剖测量.将这些解剖结果用在关节镜下ACL双束苇建中,移植物从双束2股到双束9股不等,移植物的股骨端固定以Endo-Button为主,胫骨端固定以可吸收介面螺钉加门形钉固定为主.在使用自体半腱肌腱和股薄肌腱的患者中,95.9%的患者的PLB骨道卣径为5～6 mm,72.8%患者的AMB骨道直径为5～7 mm.对75例患者随访28个月以上的结果显示重建的膝关节稳定.结论 ACL四骨道双束重建的手术技术在骨道定位和骨道方向都应该建立在对膝关节的解剖测量的基础上.在使用自体肌腱时,因为95.9%的PLB股骨和胫骨骨道直径≤6 mm,从翻修手术考虑,ACL双束重建技术是安全的.关节镜下ACL四骨道双束解剖蘑建术可以重建膝关节的稳定性.

Anatomic and clinical study OB 4-bone-tunnel double-bundle anterior cruciate ligament reconstruction

Objective To conduct a primary clinical analysis on 411 cases of arthroscopic 4 bone-tunnel double-bundle anterior cruciate ligament (ACL) reconstruction done by one operator on the basis of anatomic measurements of cadaver knees. Methods Twenty-two adult male Chinese cadaver knees of 25-45 years old were dissected. The sizes, distributions and positions of femoral and tibia footprints of anterior medial bundle (AMB) and posterior lateral bundle (PLB) of ACL and their fiber's orientations were measured and recorded. The anatomy and measurement results were used by one operator in 413 doable-bundle ACL reconstruction knees of 411 cases with arthroscopic 4 bone-tunnel technique. Among them, 297 males and 114 females, there were 222 left knees and 191 right knees. The average age was 27.61±7.23 years old. Results The anatomy results showed the locations and sizes of AMB and PLB footprints in both femoral and tibia sides were different for different individuals. It was suggested to locate AMB femoral tunnel 7.95±1.40 mm inferior to 12:00 o'clock position on the posterior edge of the lateral wall of intercondylar fossa with 1 mm thick of the posterior wall of finished AMB femoral tunnel. With the knee flexed to 90°, the PLB tunnel was 5.05±0.76 mm superior to the lower cartilage edge of the lateral wall of intercondylar fossa,8.60±1.52 mm away from the anterior cartilage edge and 8. 65±1.54 mm from the posterior edge. The anatomic orientations of tibia and femoral tunnels were also measured. The study results were used in arthroscopic double-bundle ACL reconstructions of 413 knees. In double-bundle ACL reconstruction operations, the grafts were used in the way from 2-strip double-bundle to 9-strip double-bundle. For most cases, Endo-Button was used for femoral fixation and bio-absorbable interference screw and staple were used for tibia fixation. For the patients adopting autologous semitendinosus and gracilis tendons (STG), the diameter of PLB bone tunnels was 5-6 mm in 95.9% cases, while that of AMB bone tunnel 5-7 mm in 72. 4% cases. After a 28-month follow-up in 75 cases, the results showed that double-bundle ACL reconstruction could better reconstruct the stability of knees. Conclusion In 4-bone-tunnel double-bundle arthroscopic ACL reconstruction, both bone tunnel positions and their orientations should be determined according to the anatomic measurement results. Since the PLB diameters of 95.9% cases were 5-6mm,considering the operative outcome of ACL revision, the double bundle ACL reconstruction technique was safe. A better knee stability could be reconstructed by this technique.