内侧髌股韧带重建术治疗复发性髌骨脱位的疗效研究

目的探讨游离肌腱移植重建内侧髌股韧带的手术方法及治疗复发性髌骨脱位的疗效。方法自2006年6月至2012年7月收治复发性髌骨脱位患者共40例（47膝）,男10例（12膝）,女30例（35膝）,年龄7～51岁,平均19．4岁。全部经膝关节镜检最后确诊,其中43膝采用游离自体半腱肌,4膝采用异体肌腱,通过髌骨双隧道移植重建内侧髌股韧带,镜下动态调整移植肌腱的张力,使髌股关节对合达到正常,并用挤压螺钉将肌腱游离端固定在股骨止点。其中8例（10膝）同时行髌韧带止点内移术。结果有36例（42膝）患者获得随访,随访时间3—70个月,平均随访23个月。临床疗效评价包括髌骨主观稳定性评估、Lysholm膝关节评分及Insall疗效标准（1976年）。术后髌骨外推试验和恐惧试验均为阴性。手术前后Lysholm评分术前平均为（63．1±9．1）分,术后评分为（87．1±6．4）分,手术前后的差异有统计学意义（t=21．7,P〈0．05）。按Insall疗效标准,优良率为85．7％。结论采用以游离肌腱重建MPFL为主的综合术式治疗复发性髌骨脱位,手术效果满意。     

Augmentation of anterior cruciate ligament reconstruction in dogs with prostheses of different stiffnesses

The purpose of this study was to investigate the biological and biomechanical properties of anterior cruciate ligament (ACL) reconstruction augmented with Dacron prostheses of three different stiffnesses. The ACLs of 36 adult mongrel dogs were removed and the ligament was reconstructed. In 18 dogs, one knee was reconstructed with patellar tendon alone, and the contralateral knee with Dacron augmented patellar tendon. In the remaining 18 dogs, reconstruction was with Dacron augmented patellar tendon with Dacron alone being used for the contralateral control knee. Death was 3 months after surgery, and the reconstructions were examined biologically and biomechanically. The mechanical data were compared with immediate postoperative data obtained from 45 reconstructed fresh cadaveric knees. Tensile testing demonstrated that an increase in failure load was found when the implanted patellar tendon graft was compared with the cadaveric reconstruction. The strength of the Dacron augmented reconstruction showed little change while the Dacron alone graft decreased in strength during the period of implantation. No clear difference was found between the performance of augmentation devices of different stiffnesses. Microangiography showed that grafts were totally revascularized in patellar tendon alone, but not well revascularized in Dacron augmented patellar tendon and Dacron alone reconstruction. The presence of the Dacron appeared to have an adverse effect on revascularization.     

Dacron augmentation in anterior cruciate ligament reconstruction in dogs

Substitution of the central third of the patellar tendon for the deficient anterior cruciate ligament was performed in 12 dogs (24 knees). In one-half of the knees the patellar tendon grafts were "augmented" with a 4-mm woven Dacron graft. It was hypothesized that Dacron augmentation would protect the patellar tendon graft during its revascularization stages. This was not the case, however. Only once did a Dacron ligament graft demonstrate superiority over the nonaugmented graft; indeed, five of the augmented grafts performed significantly worse.     

Arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using patellar tendon graft compared with hamstring tendon graft

Purpose

The purpose of this study was to compare the outcomes of arthroscopic transtibial single-bundle posterior cruciate ligament reconstruction using autologous patellar tendon and hamstring tendon grafts.

Methods

From 1998 to 2007, 59 patients with symptomatic isolated posterior cruciate ligament injury were included in this retrospective study. Twenty-five knees were reconstructed using bone-patellar tendon-bone graft, and 34 knees were reconstructed using hamstring graft. In both groups, surgical techniques were similar, except material of fixation screws. Patients were evaluated pre-operatively and post-operatively at the latest follow-up with several parameters, including symptoms, physical examination, outcome satisfaction, functional scores, radiography and complications.

Results

Average follow-up period was 51.6 months in patellar tendon group and 51.1 months in hamstring tendon group. Significantly more kneeling pain (32 vs. 3 %), squatting pain (24 vs. 3 %), anterior knee pain (36 vs. 3 %), posterior drawer laxity and osteoarthritic change were shown in patellar tendon group than in hamstring tendon group post-operatively. No significant differences were found in other parameters between both groups.

Conclusions

Several shortcomings, including anterior knee pain, squatting pain, kneeling pain and osteoarthritic change, have to be concerned when using patellar tendon autograft. In conclusion, hamstring tendon autograft may be a better choice for transtibial tunnel PCL reconstruction.     

Reconstruction of medial patellofemoral ligament for chronic patellar instability

Background:

Disruption of the capsule, medial patellar retinaculum, and/or vastus medialis obliqus has been associated with recurrent patellar instability. Biomechanical studies have shown that the medial patellofemoral ligament (MPFL) is the main restraint against lateral patella displacement and reconstruction of the MPFL has become an accepted surgical technique to restore patellofemoral stability in patients having recurrent patellar dislocation. We report a prospective series of patients of chronic patellar instability treated by reconstruction of medial patellofemoral ligament.

Materials and Methods:

Twelve patients (15 knees) with recurrent dislocation of patella, were operated between January 2006 and December 2008. All patients had generalised ligament laxity with none had severe grade of patella alta or trochlear dysplasia. The MPFL was reconstructed with doubled semitendinosus tendon. Patients were followed up with subjective criteria, patellar inclination angle, and Kujala score.

Results:

The mean duration of followup after the operative procedures was an average of 42 months (range 24–60 months) 10 knees showed excellent results, 3 knees gave good results, and 2 knees had a fair result. The average patellar inclination angle decreased from 34.3° to 18.6°. The average preoperative Kujala functional score was 44.8 and the average postoperative score was 91.9.

Conclusion:

MPFL reconstruction using the semitendinosus tendon gives good results in patients with chronic patellar instability without predisposing factors like severe patella alta and high-grade trochlear dysplasia, and for revision cases.     

关节镜辅助下小切口重建内侧髌股韧带治疗创伤性复发性髌骨脱位

目的探讨关节镜辅助下小切口同种异体肌腱重建内侧髌股韧带(MPFL)治疗创伤性复发性髌骨脱位的临床效果。方法回顾性分析自2006年1月～2010年4月共收治28例创伤性复发性髌骨脱位,所有患者在第一次脱位均为膝关节外伤所致,伤后患膝明显肿胀及髌骨脱位-复位感,此后出现髌骨脱位3次以上者。手术方法:先行关节镜检查,髌骨外侧支持带紧张者行松解术,关节镜监视下调整MFPL的张力并于其解剖止点以同种异体肌腱重建MFPL,术后接受正规功能康复锻炼。结果术后平均随访26个月(12～36个月)。重建术后无髌骨再次脱位发生,髌股关节稳定。术前、术后均采用Lysholm和Kujala膝关节评分标准,手术前后评分差异有统计学意义(P<0.05)。结论选择适当的病例,重建内侧髌股韧带是治疗创伤性复发性髌骨脱位的有效方法。     

Lowering of the patella secondary to anterior advancement of the tibial tubercle for the patellofemoral pain syndrome

Summary From a series of 72 patients treated with anterior advancement of the tibial tubercle for patellofemoral pain syndrome, secondary lowering of the patella was noted in eight. In all eight patients the results were poor following surgery, with severe disabling retro- and peripatellar pain and atrophy of the quadriceps muscle. We describe this complication and illustrate and discuss the biomechanical consequences. The shortening of the patellar ligament and lever arm of the ligament were determined from radiographs of the knee joints before and after surgery. A theoretical analysis was made of the compressive force in the patellofemoral joint in one of these patients. The Insall-Salvati index decreased from 0.88–1.25 (mean 1.07) preoperatively to 0.54–0.78 (mean 0.70) at follow-up, 1.0–2.5 years postoperatively. The lowering of the patella was correlated to a reduction of the lever arm of the patellar ligament in seven patients. The mechanism behind the lowering of the patella is obscure, but the reduced lever arm of the patellar ligament will increase the compressive force in the patellofemoral joint, and this might be one explanation of the poor results. Impaired congruity of the patellofemoral joint, increased tension in the patellar ligament, and increased pressure against the quadriceps tendon are other possible explanations.     

Magnetic resonance imaging of reconstructed anterior cruciate ligament.

After anterior cruciate ligament reconstruction with autologous patellar tendon, 23 patients who had clinically stable knees were studied prospectively with sequential magnetic resonance imaging 1, 2, 3, 6, and 12 months after surgery. The images of the anterior cruciate ligament were obtained with a 1.5 tesla magnetic resonance scanner in the oblique sagittal, coronal, and oblique axial planes. The cross-sectional area and signal intensity on the reconstructed anterior cruciate ligament were measured in an oblique axial image. The usefulness of the oblique axial image in evaluating the integrity of the reconstructed anterior cruciate ligament was seen. The result showed that the diameter of the graft increased by 70% of its initial size and the signal intensity of the reconstructed graft also showed a tendency to increase. In three patients, there was discontinuity in the graft direction on the oblique sagittal image, but on the oblique axial image there was no evidence of reconstructed anterior cruciate ligament rupture in the sequential images. This shows the value of the oblique axial image in evaluating the integrity of the reconstructed anterior cruciate ligament. Also, sufficient notchplasty in anterior cruciate ligament reconstruction may be needed to prevent graft impingement.     

Pain after use of the central third of the patellar tendon for cruciate ligament reconstruction: 33 patients followed 2-3 years

We performed reconstruction of the anterior cruciate ligament in 33 patients using the central third of the patellar tendon. In 20 patients we did an arthroscopies! ly-assisted procedure, while 13 patients had an additional mini-arthrotomy through the gap in the patellar tendon. After 2-3 years the subjective knee function, according to the Lysholm score, was excellent or good in 18 knees and fair or poor in 15 knees, mainly due to anterior knee pain. Although 18 patients complained about anterior knee pain, only 1 patient required further surgery. After the operatio the patella had a lower position. A flexion contractur was found in 7 patients, and 13 had heterotopic bon formation at the apex of the patella. Although stabilit was restored in 31 of the 33 reconstructed knees anterior knee pain was a frequent complicatior There were no correlations between the anterior kne pain and patellar height, flexion contracture or hetei otopic bone formation.     

Nerve regeneration during patellar tendon autograft remodelling after anterior cruciate ligament reconstruction: An experimental and clinical study

The innervation of the rat and human anterior cruciate ligament, patellar tendon, and patellar tendon autograft after reconstruction of the anterior cruciate ligament was investigated by immunohistochemical and histological methods. A rat model of reconstruction with patellar tendon autograft was evaluated during active graft remodelling (2–16 weeks) and compared with normal ligament and tendon. The knees of 10 patients who had undergone reconstruction with patellar tendon autograft were examined 5–37 months postoperatively (remodelling fully completed) with arthroscopy and biopsy. As a control, biopsies from normal ligament and tendon were obtained from four patients. Nerve fibers were identified using antisera for protein gene product 9.5, a general neural marker. Neuronal regeneration was assessed by the expression of growth-associated protein 43/B-50. The sensory type of innervation was characterized by assessing the distribution of nerves containing the sensory neuropeptides calcitonin gene related peptide and substance P. Immunoreactivity for all neural markers was found in both rat and human anterior cruciate ligament and patellar tendon. Two weeks after reconstruction, the rat autograft was acellular and no innervation could be identified. After 4 weeks, the grafts were viable, and immunoreactivity for protein gene product 9.5, growth associated protein 43/B-50, and calcitonin gene-related peptide was found until the 16th week postoperatively. Immunoreactivity for substance P was found in rat autografts at 4 weeks postoperatively only. All biopsies of human patellar tendon autograft showed signs of the remodelling process being fully completed, with revascularization and a sinusoidal collagen pattern with fibroblast repopulation. Neuropeptide immunoreactivity, however, was not found. The presence of immunoreactivity to sensory neuropeptides in the anterior cruciate ligament and patellar tendon may indicate a nociceptive and neuromodulatory function of these structures. The expression of sensory neuropeptides in the rat patellar tendon autograft suggests a possible involvement of sensory innervation during healing of the graft.     

Treatment of chronic patellar dislocation with a modified Elmslie-Trillat procedure

Background This paper describes a modification of the Elmslie-Trillat procedure that is usually performed in severe cases of habitual or recurrent patellar instability. Methods Eighteen knees (7 men and 8 women) treated for recurrent or habitual patellar dislocation were evaluated clinically and radiographically at a mean follow-up of 5 years (range 24 months to 9 years). The mean age at follow-up was 26.3 years (range 17–44 years). The IKDC and Kujala and Tegner scores were used for the clinical evaluation. Anteroposterior, lateral and Merchant views were done for radiographic monitoring. When the patella was still unstable during dynamic evaluation after execution of the Elmslie-Trillat procedure, the medial third of the patellar tendon was isolated and harvested with a corresponding 1 cm long and 0.5 cm wide bone plug, maintaining its insertion to the inferior medial side of the patella. This ligament was medialized and put under tension, trying to find a medial insertion that guaranteed patellar stability throughout the full range of motion. Results IKDC classified 11 knees as A (normal), 4 knees as B (almost normal), 2 knees as C (abnormal) and 1 knee as D (severely abnormal). The Kujala score showed excellent results in 16 knees, 1 fair and 1 poor knee. The mean Tegner score rose from 2 preoperatively to 5 at follow-up. The poor knee presented an over-correction of the congruence angle on radiography. On follow-up radiographs, the parameters were almost completely corrected. Statistical analysis showed a significant correction of radiograph parameters, and significantly worse results in patients who underwent trochleoplasty. Conclusion The technique described tries to achieve a dynamic stability of the patella throughout the full range of motion in severe patellar instability where the Elmslie-Trillat procedure is insufficient. No recurrence of patellar instability has been observed. The stability must be obtained with dynamic control in the initial degrees of flexion, trying to avoid an excessive patellar medialization.     

Sagittal plane kinematics of a mobile-bearing unicompartmental knee arthroplasty at 10 years: a comparative in vivo fluoroscopic analysis

This study compares in vivo sagittal plane kinematics of the Oxford mobile-bearing unicompartmental knee arthroplasty (UKA) at 1 and 10 years' postsurgery (10 knees) with a fixed-bearing total knee arthroplasty (TKA) (5 knees) and the normal knee (5 knees), using dynamic fluoroscopic measurement of the patellar tendon angle. The Oxford UKA preserved normal changes in patellar tendon angle with flexion, and this was maintained at 10 years. In contrast, an abnormal pattern was seen with the TKA. The results suggest that a normal pattern of sagittal plane knee kinematics exists following Oxford medial UKA and imply that anterior cruciate ligament function is maintained in the long term.     

髌腱复合体重建创伤性前后交叉韧带

目的：为了评价髌腱复合体(带骨块的髌韧带，即骨—髌膜—骨)对前后交叉韧带断裂后重建的手术疗效。方法：1995—2001年，收治32例前后交叉韧带损伤的患者给予髌腱复合体重建术。结果：所有病人患膝关节稳定性明显增强，术后抽屉试验全部阴性。结论：带骨块的髌韧带具有强抗牵拉力，固定可靠，等长重建，功能改善明显等优点。髌膜复合体是理想的前后交叉韧带替代材料。     

Lateral collateral ligament reconstruction using quadriceps tendon–patellar bone autograft with bioscrew fixation

The lateral collateral ligament is the primary stabilizer against varus stress and is also an important contributor in maintaining posterolateral knee stability. Quadriceps tendon–patellar bone autograft has been used for anterior or posterior cruciate ligament reconstruction. We introduce a reconstructive procedure to restore the lateral collateral ligament using a quadriceps tendon–patellar bone autograft. The procedure is designed for unstable knees with concomitant cruciate ligament tear and posterolateral complex injury. This is a reasonable choice especially when allograft tissue is not available or in patients who are not suited for the use of bone–patellar tendon–bone autograft.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 5 (May-June), 2001: pp 551–554     

Reconstruction of the anterior cruciate ligament in patients over 50 years

The records of patients aged 50 years or over who underwent primary reconstruction of the anterior cruciate ligament between 1990 and 2002 were reviewed. There were 35 knees in 34 patients that met the inclusion criteria. The mean age of the patients was 57 years (50 to 66) and the mean clinical follow-up was for 72 months (25 to 173). A total of 23 knees were reconstructed with patellar tendon allograft, and 12 with patellar tendon autograft. The mean pre-operative knee extension was 1 degrees (-5 degrees to 10 degrees) and flexion was 129 degrees (125 degrees to 150 degrees) and at follow-up these values were 0 degrees (-5 degrees to 5 degrees) and 135 degrees (120 degrees to 150 degrees), respectively. Pre-operatively there were 31 knees (89%) with a Lachman grade 2+ or 3+. Post-operatively, 33 knees (94%) were Lachman grade 0 or 1+. The mean pre- and post-operative International Knee Documentation Committee scores were 39 (23 to 72) and 90 (33 to 100) respectively. The mean pre- and post-operative Lysholm scores were 50 (18 to 68) and 92 (28 to 100) respectively and the mean University of California Los Angeles activity scores were 8.5 before injury (4 to 10), 4.3 (3 to 6) after injury and 8.3 (4 to 10) post-operatively. There were three graft failures (8.6%) requiring revision. We conclude that reconstruction of the anterior cruciate ligament in carefully-selected patients aged 50 years or over can achieve similar results to those in younger patients, with no increased risk of complications.     

Patellar tendon and anterior cruciate ligament have different mitogenic responses to platelet-derived growth factor and transforming growth factor β

The healing responses of the anterior cruciate ligament and the patellar tendon differ markedly. The anterior cruciate ligament fails to heal, whereas the patellar tendon heals slowly. The basis of these differences is unknown. Since cellular proliferation is a critical element of healing, we investigated the response to explants of anterior cruciate ligament and patellar tendon from sheep knees to platelet-derived growth factor-AB and transforming growth factor β1 as a function of time and dose. Explants cultured for 48, 72, and 96 hours with transforming growth factor β1 (0-100 ng/ml) or platelet-derived growth factor-AB (0-200 ng/ml) were radiolabeled for the final 24 hours with [³H]thymidine, and DNA synthesis was quantified as trichloroacetic acid-precipitable radioactivity normalized to dry tissue weight. Statistical analyses (analysis of variance) showed that transforming growth factor β1 induced a significant proliferative response in the anterior cruciate ligament at 96 hours with equivalent responses at 10.50, and 100 ng/ml, whereas the patellar tendon only responded to one condition, 10 ng/ml at 96 hours. Conversely, the patellar tendon had a significant dose-dependent response to platelet-derived growth factor-AB at 72 and 96 hours, whereas the anterior cruciate ligament showed no proliferative response to platelet-derived growth factor-AB. The minimal response of anterior cruciate ligament to platelet-derived growth factor-AB could explain, at least in part, the poor repair capacity of this tissue. The response of the anterior cruciate ligament to transforming growth factor β suggests that exogenous transforming growth factor β may promote initial healing. Although growth factors have the potential to modulate soft-tissue repair, tissue responses in tendons and ligaments may vary at different anatomic sites.     

A method of repair for quadriceps tendon or patellar ligament (tendon) ruptures without cast immobilization. Preliminary report

The quadriceps tendon and patellar tendon (ligament) were repaired with a Dacron vascular graft used as a tension suture material. In cases of quadriceps tendon ruptures, the Dacron graft is passed transversely through the patellar ligament just below the patella and crossed transversely at the level of the musculotendinous junction with two loops applying tension to the tendon, which brings the tendon ends together by creating a solid structure. In cases of patellar ligament ruptures, the Dacron graft is passed through a hole in the tibia posteriorly to the tibial tuberosity instead of through the patellar ligament below the patella. This technique enables early mobilization on the first day after surgery. The technique was first tested on six dogs with severed quadriceps tendons and patellar ligaments that were repaired with this suture method. All of the animals recovered from surgery and walked and ran normally on the repaired legs within 27 days and with only mild limping after 17 days. The technique was then used on six patients, four with complete quadriceps tendon rupture and two with complete tear (avulsion) of the patellar ligament (tendon). In all of the patients, excellent surgical results were obtained and leg immobilization was virtually eliminated. Physical therapy was prescribed the first day after surgery. The rehabilitation period was significantly reduced.     

Simultaneous ipsilateral ruptures of the anterior cruciate ligament and patellar tendon: a case report

The simultaneous diagnosis of ipsilateral patellar tendon rupture and anterior cruciate ligament tear is rare. Surgical repair is complicated by different rehabilitation regimens as well as anterior cruciate ligament graft choices. We present a case where at the same operative setting, the patellar tendon was repaired, and the anterior cruciate ligament reconstructed with autologous hamstring graft.     

Mechanoreceptors of patellar tendon used for ACL reconstruction: Rabbit experiments

In 17 Japanese white rabbits (weighing 2.6-3.7kg), the anterior cruciate ligament of the right knee was resected and then reconstructed, using the lateral half of the patellar tendon. The contralateral side served as control. Rabbits were killed 10, 20, or 30 weeks postoperatively. Then the reconstructed ligament was harvested and stained, using a modified gold chloride method. Under the light microscope, sensory nerve endings in serial sections were counted after being morphologically identified.

With respect to the number of Pacinian and Ruffini corpuscles, there were no significant differences between the reconstructed ligament and the control patellar tendon at any time after surgery.     

Chronic rupture of a patellar tendon: A technique for reconstruction with achilles allograft

Chronic ruptures of the patellar tendon fortunately are an uncommon event. These ruptures are often difficult to repair because they are generally accompanied by quadriceps muscle contracture and a great deal of scar tissue formation. We report the case of a repair of a chronic patellar tendon rupture. The patient's right patellar tendon was reconstructed approximately 10 months after the injury using quadricepsplasty and an Achilles tendon allograft with a suprapatellar wire for tension release. Four weeks postoperatively, he had attained 60° of flexion and full active extension. At 8 weeks, the suprapatellar wire was removed allowing the distribution of stresses on the reconstructed patellar tendon. At 6 months, the patient had 130° of flexion and full extension, but showed a persistent 40% deficit in right quad strength. The technique accomplished the preoperative goals of restoring quadriceps function, restoring the anatomic position of the patella, and allowing early mobilization after surgery. Although the use of a suprapatellar wire to reduce tension on the reconstructed tendon required a second operation for removal, it allowed early mobilization and better healing of the repair.