关节镜下双股半腱及股薄肌腱经双胫骨隧道解剖重建膝前交叉韧带

目的：介绍在关节镜下应用自体双股半腱和股薄肌腱(DLSTG)经双胫骨隧道解剖重建膝前交叉韧带(ACL)的手术方法及术后随访结果。方法：在关节镜下对15例ACL断裂的患者行双胫骨隧道解剖重建：移植体股、胫骨端均采用近ACL解剖止点之Press-fit技术固定：结果：全部患者于术后6～8周恢复了正常的关节活动和行走步态：手术12～16周后恢复了低风险体育运动：术后1年，2名患者的Lachman试验Ⅰ度阳性；15名患者的IKDC评分为正常或接近正常；Tegner评分显示12名患者已恢复伤前运动水平；X线片示全部患者股骨、胫骨隧道无扩大：结论：关节镜下利用自体DLSTG及Press—fit固定技术施行双胫骨隧道的ACL解剖重建在技术上可行，并有利于伤膝功能的快速恢复。     

关节镜下半腱肌腱与骨-髌腱-骨重建膝前交叉韧带的比较

目的比较四股半腱肌腱与骨-髌腱-骨重建膝前交叉韧带的临床效果。方法将膝关节镜确诊的65例膝前交叉韧带断裂患者随机分为A、B两组,A组行四股半腱肌腱前交叉韧带(ACL)重建,B组行骨-髌腱-骨重建,随访1~5年,采用Lysholm评分标准评价膝关节功能,前抽屉试验、Lachman试验和轴移试验评定关节稳定性,记录并发症。结果两组Lysholm评分和关节稳定性评价差异无统计学意义,P>0.05;术后并发膝部疼痛肿胀A、B组分别是18.18%(6/33)和40.63%(13/32),P=0.047,其他并发症未达到统计意义。结论四股半腱肌腱与骨-髌腱-骨重建膝前交叉韧带疗效相似,但骨-髌腱-骨重建更易发生膝关节疼痛肿胀,两种术式的优劣利弊仍需要大样本随机对照研究佐证。     

关节镜下双股半腱肌腱单端固定法重建膝交叉韧带

目的观察膝关节镜下双股半腱肌腱单端固定法重建膝前、后交叉韧带的方法及疗效,探讨其优缺点。方法应用双股半腱肌腱,单端固定,重建前交叉韧带损伤38例,后交叉韧带24例。结果所有患者术后随访6～36个月,平均18个月。按Lysholm膝关节评分标准,由术前43分提高到术后93分。结论双股半腱肌腱,单侧固定法重建前、后交叉韧带具有创伤小,操作简便,是重建前、后交叉韧带的理想方法之一。     

关节镜下采用半腱肌肌腱和微型纽扣钢板重建前交叉韧带

前交叉韧带(ACL)损伤是膝关节常见损伤。目前关节镜下ACL重建被公认为膝关节外科中常规、经典的微创治疗方法。自2001年1月～2003年6月．笔者在关节镜下采用四股半腱肌肌腱和微型纽扣钢板重建ACL 10例,取得良好效果。     

关节镜下半腱肌、股薄肌腱重建前交叉韧带

目的关节镜下以半腱肌、股薄肌腱重建膝前交叉韧带,分析影响疗效的因素。方法自2002年12月至2004年6月,关节镜下endobuttonl固定四股腘绳肌腱修复膝前交叉韧带损伤66例72膝。膝前小切口取半腱肌腱、股薄肌腱修整、对折后成四股,分别建立胫骨隧道及股骨隧道,用Endobutton和门形钉固定肌腱,重建ACL的解剖结构和生理功能。术后即行功能锻练。结果66例患者得到随访,随访时间13-30个月,平均22.25个月。术前Lachman征( ),术后Lachman征(-)。术前Lysholm评分从27分到71分,平均53.75分;术后Lysholm评分从70分到99分,平均90.83分,术前、术后评分有显著性差异(t=2.23,P<0.05)。结论腘绳肌腱具有良好的抗拉强度和刚度,在关节镜下用四股腘绳肌腱重建膝前交叉韧带是一种疗效可靠的治疗方式。     

半腱肌重建前交叉韧带进展

前交叉韧带是稳定膝关节的重要结构。前交叉韧带损伤后股骨与胫骨在负重时半脱位 ,可以导致半月板后角撕裂、膝关节不稳定、退行性变、功能丧失。为了恢复膝关节结构及功能 ,前交叉韧带损伤必须及时处理。近年来 ,前交叉韧带重建手术中 ,半腱肌得到广泛应用 ,现综述如下。1　半腱肌的生物力学研究ＢＹＦｒａｎｋ[1] 、Ｋｅｎｅｄｙ[2 ] 等研究证明 ,以正常ＡＣＬ强度173 0Ｎ(1牛顿 =0 .0 3ｋｇ)为 10 0 % ,则单股半腱肌强度 (12 16± 5 0 )Ｎ为 70 %～ 75 %。Ｂｒｏｗｎ[3 ] 证实双股半腱肌的强度约是正常前交叉韧带的 1.5倍 ,四股半腱肌的…     

关节镜下4股半腱肌肌腱重建前交叉韧带疗效观察

目的关节镜下以半腱肌肌腱重建膝前交叉韧带（ACL）,分析影响治疗效果的因素。方法关节镜下4股半腱肌肌腱修复膝ACL损伤25例。膝前小切口取半腱肌肌腱对折后成4股,分别建立胫骨隧道及股骨隧道,重建膝ACL的解剖结构和生理功能,术后早期行功能锻练。结果 25例均获随访,时间12~36个月。术前Lachman征（＋）,术后Lachman征（-）。Lysholm评分从术前27~71（53±13.22）分提高到术后78~94（87±3.42）分。结论半腱肌肌腱具有良好的抗拉强度和刚度,在关节镜下用4股半腱肌肌腱重建膝ACL是一种疗效可靠的治疗方式。     

关节镜下采用半腱肌和股薄肌肌腱重建后交叉韧带

目的评价四股半腱肌肌腱、两股股薄肌肌腱重建后交叉韧带的临床疗效。方法对12例后交叉韧带断裂患者,在关节镜下采用四股半腱肌肌腱和两股股薄肌肌腱进行重建。结果所有患者随访12～24个月,所有患者术后膝关节不稳定症状消失,胫骨后坠征阴性,后抽屉试验阴性。术后1年,根据Lysholm膝关节功能评分,优10例,良2例,平均积分85±4.1。结论关节镜下采用四股半腱肌肌腱、两股股薄肌肌腱和微型纽扣钢板重建后交叉韧带,手术创伤小,重建韧带强度大,临床效果满意。     

关节镜下双股半腱肌腱转移重建后交叉韧带

目的：报告关节镜下双股半腱肌腱转移重建后交叉韧带及分析影响其手术效果因素。方法：采用开口螺旋肌腱剥离器，保留肌腱远侧附着点，在近侧腱肌交界处切断半腱肌腱，对折两股编织转移镜下重建后交叉韧带。隧道内口侧可吸收挤压螺钉固定，股骨隧道外口加强固定。结果：手术28例，平均随访33个月，按照日本骨科协会制定的膝关节疗效评定标准，优良率为85．7％。结论：(1)关节镜下双股半腱肌腱转移重建后交叉韧带，较B-PT-B通过隧道时柔顺通畅；(2)隧道内口可吸收钉挤压固定，愈后内口消失，避免韧带撞击内口使之逐渐扩大引起重建韧带松驰。(3)隧道内外口的坚强固定，使重建后交叉韧带有足够刚强度。     

关节镜下半腱肌腱和股薄肌腱双隧道重建前十字韧带

目的探讨关节镜下联合应用半腱肌腱和股薄肌腱重建前十字韧带(anteriorcruciateligament,ACL)的方法及疗效。方法回顾自1998年4月～2000年5月在关节镜下联合应用半腱肌腱和股薄肌腱重建ACL的患者12例。于ACL前内侧束和后外侧束的附着部分别钻直径4.5mm的隧道,用半腱肌腱重建前内侧束,股薄肌腱重建后外侧束,保留半腱肌腱和股薄肌腱的附着点,在股骨隧道外口将半腱肌腱和股薄肌腱打结固定,不行内固定。所有患者术前及术后18个月行膝关节屈曲30°、60°、90°前抽屉试验,Lysholm评分方法评定膝关节功能。结果术后随访18～43个月,平均26个月。术前所有患者前抽屉试验均为阳性,术后9例阴性,2例屈膝30°位阳性,1例屈膝30°、60°位阳性。术前Lysholm评分为40～58分,平均50.5分,手术后18个月为62～92分,平均85分,总优良率为91.7%。结论应用半腱肌腱和股薄肌腱联合重建ACL,术后膝关节动态稳定性好,疗效满意。     

Indications and contraindications for double-bundle ACL reconstruction

Over recent years, double-bundle reconstruction has gained popularity after studies showed significant advantages of adding a second bundle with regard to outcomes and biomechanics; in particular, it resulted in less rotational instability than after reconstruction with a traditional single-bundle technique. As the focus shifted further towards the restoration of the native anatomy, both single-bundle and double-bundle ACL reconstruction were performed in an anatomical fashion and yielded similar results. To date, no consensus has developed as to whether double-bundle reconstruction is better than single-bundle reconstruction or vice versa. However, after surgeons started to individualise their surgical approach to the patient, it has been found that both the anatomical single- and double-bundle techniques have their own set of indications and contraindications. Reconstruction of the ligament should focus on restoration of the native functional and anatomical properties and should take the size, shape and orientation of the ACL into account. When indications and contraindications for the technique used are based on native anatomical characteristics, either a single-bundle or a double-bundle procedure can be performed according to the same double-bundle concept.     

Arthroscopic double-bundle posterior cruciate ligament reconstruction surgical technique

The keys to successful posterior cruciate ligament (PCL) reconstruction are to identify and treat all pathology, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, use a mechanical graft tensioning device, use primary and back-up graft fixation, and use the appropriate postoperative rehabilitation program. Adherence to these technical principles results in successful single-bundle and double-bundle arthroscopic transtibial tunnel PCL reconstruction based on stress radiography, arthrometer, knee ligament rating scales, and patient satisfaction measurements.     

Comparison of fixation methods of double-bundle double-tibial tunnel ACL reconstruction and double-bundle single-tunnel technique

An experimental study was conducted in order to evaluate biomechanical methods of single-bundle reconstruction in ACL and compare it with a new double-bundle double-tibial tunnel technique. Twenty-four porcine cadaver knees, divided into 4 groups of 6 knees each and 48 proper extensors of the fourth toe tendons, were used for the fixation techniques. In groups A and B, a double-bundle technique with a single femoral and tibial tunnel was used, fixed to a femoral and tibial post with screws and with buttons, respectively. In groups C and D, a double-bundle technique (technique Delta) with two separate tibial tunnels was used, fixed to a femoral and tibial post with screws and with buttons, respectively. A material testing system (Instron) was used for anteriorly translating the tibia until failure. The femoral and tibial post as a fixation method is superior to the conventional buttons technique. The more anatomical double-bundle reconstruction technique provided significantly higher structural properties and smaller loss of fixation compared with the single-bundle reconstruction technique. The comparison of the two techniques gave superior results to the femoral and tibial screws over the buttons. The double-bundle technique attempts to restore the anterior stability of the knee joint.     

Arthroscopic treatment of flexion deformity after ACL reconstruction

After anterior cruciate ligament (ACL) reconstruction, one frequent complication is the restriction of the range of motion and loss of extension. In addition to the presence of adhesions in the suprapatellar pouch, it is possible to detect two different pathological findings in the intercondylar notch: a misplacement of graft causing an intercondylar impingement, or the presence of hypertrophic tissue originating from the graft that blocks the last degrees of extension, causing an "anterior impingement." We reviewed 18 consecutive cases treated by arthroscopic release. All patients had knee range-of-motion restriction after an ACL procedure. The follow-up at 1 and at 6 months shows that good results have been obtained in cases of anterior impingement, whereas in cases of intercondylar impingement a restricted range of motion, especially of flexion, did remain. In all cases, after arthroscopic treatment the postoperative extension was between 5 and 10 degrees, but this deficit regressed after 6 months in 12 patients, whereas a dropout case was necessary in the remaining 6 patients.     

自体腘绳肌腱和同种异体半腱肌腱双束重建前十字韧带的比较研究

目的 对比自体腘绳肌腱和同种异体半腱肌腱双束重建前十字韧带的初期临床疗效.方法 2006年2月至8月,对单纯前十字韧带完全断裂患者分别采用自体腘绳肌腱(简称自体组,38例)和同种异体半腱肌腱(简称异体组,23例)行前十字韧带双束重建手术.客观指标包括:双侧膝关节前向松弛度差异、Lachman试验、轴移试验和双下肢周径差别;应用Tegner评分表、Lysholm评分表和IKDC评分表进行膝关节功能的主观评估.结果 自体组平均随访27个月,异体组平均随访26个月.末次随访时Lachman试验:自体组35例阴性,3例Ⅰ度阳性;异体组20例阴性,2例Ⅰ度阳性,1例Ⅲ度阳性.两组各有1例轴移试验阳性.双侧膝关节前向松弛度差异:自体组34例差异范围0～2 mm,4例3～5mm;异体组20例0～2mm,2例3～5 mm,1例>10 mm.双下肢周径差别:自体组(0.62±0.43)cm,异体组(0.57±0.42)cm.Tegner评分:自体组(6.21±0.84)分,异体组为(6.17±1.15)分.Lysholm评分:自体组(95.00±4.40)分.异体组(94.57±8.83)分.IKDC评分:自体组(90.26±2.92)分,异体组(89.48±7.27)分.结论 应用自体腘绳肌腱和同种异体半腱肌腱双束重建前十字韧带均能取得优良的初期临床结果.     

Prospective clinical comparisons of semitendinosus versus semitendinosus and gracilis tendon autografts for anatomic double-bundle anterior cruciate ligament reconstruction

Background

The data available from the previously reported clinical studies remains insufficient concerning the hamstring graft preparation in double-bundle anterior cruciate ligament (ACL) reconstruction.

Objective

To test the hypothesis that there are no significant differences between the semitendinosus tendon alone and the semitendinosus and gracilis tendon graft fashioning techniques concerning knee stability and clinical outcome after anatomic double-bundle ACL reconstruction.

Methods

A prospective study was performed on 120 patients who underwent anatomic double-bundle ACL reconstruction according to the graft fashioning technique. The authors developed the protocol to use hamstring tendon autografts. When the harvested doubled semitendinosus tendon is thicker than 6 mm, each half of the semitendinosus tendon is doubled and used for the anteromedial (AM) and posterolateral (PL) bundle grafts (Group I). On the other hand, when the harvested semitendinosus tendon is under 6 mm in thickness, the gracilis tendon is harvested additionally. The distal half of the semitendinosus and gracilis tendons are doubled and used for the AM bundle graft, and the remaining proximal half of the semitendinosus tendon is doubled and used for the PL bundle grafts (Group II). Sixty-one patients were included in Group I, and 59 patients in Group II. The two groups were compared concerning knee stability and clinical outcome 2 years after surgery.

Results

The postoperative side-to-side anterior laxity averaged 1.3 mm in both groups, showing no statistical difference. There were also no significant differences between the two groups concerning the peak isokinetic torque of the quadriceps and the hamstrings, the Lysholm knee score, and the International Knee Documentation Committee evaluation.

Conclusion

There were no significant differences between the two graft fashioning techniques after anatomic double-bundle ACL reconstruction concerning knee stability and postoperative outcome. The present study provided orthopedic surgeons with important information on double-bundle ACL reconstruction with hamstring tendons.

Level of evidence

Level II; prospective comparative study.     

关节镜下股四头肌腱双束重建后交叉韧带

目的　介绍一种新的后交叉韧带重建手术方法及早期临床疗效。　方法　对 2 0例后交叉韧带损伤病例采用关节镜下前外束及后内束双束重建术。选择一端带骨块的自体股四头肌腱并制备“Y”形双束移植物 ,股骨侧双隧道 ,胫骨侧单隧道。分别在伸膝及屈膝 90°位拉紧固定双束。同时或分次处理复合韧带损伤。　结果　 2 0例均得到随访 ,随访期 6～ 12个月 ,平均 7 5个月。其中单纯后交叉韧带 8例 ,均为Ⅱ°及Ⅲ°损伤。复合损伤 12例。新鲜伤 5例 ,陈旧伤 15例。主观评分示 :Lyshlom评分优者 5例 ( 2 5 %) ,良 14例 ( 70 %) ,差 1例 ( 5 %) ;IKDC评分A级 1例 ( 5 %) ,B级 16例( 80 %) ,C级 2例 ( 10 %) ,D级 1例 ( 5 %)。客观评分 :KT 10 0 0测定 :胫骨后移由术前平均 11 0mm改善至术后 5 5mm。应力X线片测量示胫骨后移由术前平均 11 5mm改善至术后 5 2mm。失效 1例。结论　后交叉韧带双束重建手术是一种有效、可行的重建方法 ,早期临床效果满意。股四头肌腱是后交叉韧带重建的理想移植物。应充分重视复合韧带损伤 ,特别是后外复合体损伤。     

关节镜下采用四股半腱肌肌腱和缝线钢板重建前十字韧带

目的在关节镜下利用四股半腱肌肌腱和缝线钢板重建前十字韧带.方法对51例陈旧性前十字韧带断裂的患者,在关节镜下利用四股半腱肌肌腱进行重建.术中将取得的半腱肌肌腱切成等长的两段,然后对折成四股.移植物近端固定在横跨于股骨隧道外口的缝线钢板上,移植物远端固定在覆盖于胫骨隧道外口的钮扣上.术后进行1～2年系统的随访,并按照特定的康复训练方案进行康复指导.定期检查膝关节活动度、膝关节稳定性、大腿肌肉功能、日常活动功能和跑步能力的恢复情况.结果术后3个月时,所有病例患膝的活动度均恢复正常.术后2年时,患侧的股四头肌/绳肌峰力矩比超过正常侧的90%.KT-1000检查显示,术后患侧膝关节的前向稳定性有所下降,但是术后2年时仍有73.8%的病例患侧膝关节前向稳定性等于或者好于健侧.按照Lysholm膝关节评分标准,术前膝关节功能评分为56.7±7.4,术后2年时为98.5±0.3,差异有显著性意义(P<0.05);术后2年时,合并关节软骨损伤组评分为96.44±2.36,不合并关节软骨损伤组评分为99.47±0.24.统计学分析显示其差异有显著性意义(P<0.05).术后1年时,所有患者均能恢复向前变速跑步能力而无跛行.结论关节镜下利用四股半腱股肌腱和缝线钢板重建前十字韧带是一种可恢复膝关节功能的可靠方法;合并的关节软骨损伤对前十字韧带重建的珠膝关节功能有影响.