膝关节后交叉韧带损伤对侧副韧带生物力学的影响☆

背景：目前对膝关节后交叉韧带损伤后的研究多集中于软骨、后外侧结构及关节的松弛度等方面。 目的：观察后交叉韧带断裂对膝关节内、外侧副韧带生物力学的影响。 方法：取12具正常成人新鲜尸体膝关节标本,在200 N载荷下,测试膝关节屈曲0°,30°,60°,90°位时,内、外侧副韧带中点的应变,后将12具标本的后交叉韧带全部切断再进行相同的测试。 结果与结论：膝屈曲0°和30°位时,后交叉韧带断裂前后内、外侧副韧带中点的应变均为压应变,且差异无显著性意义 (P > 0.05);膝屈曲30°~90°位时,内侧副韧带中点的应变随着角度增加而逐渐增大;膝屈曲60°和90°位时,后交叉韧带断裂后拉应变较断裂前明显增大(P < 0.05),其中内侧副韧带中点的应变均为拉应变,而外侧副韧带中点的应变在后交叉韧带完整情况下膝屈曲60°时为压应变。说明后交叉韧带完全断裂对30°内的膝关节运动无明显影响,但是随着屈曲角度的增加,内、外侧副韧带受到的影响逐渐增大。     

Anterior cruciate ligament tear induces a sustained loss of muscle fiber force production

Introduction: Patients with anterior cruciate ligament (ACL) tears have persistent quadriceps strength deficits that are thought to be due to altered neurophysiological function. Our goal was to determine the changes in muscle fiber contractility independent of the ability of motor neurons to activate fibers. Methods: We obtained quadriceps biopsies of patients undergoing ACL reconstruction, and additional biopsies 1, 2, and 6 months after surgery. Muscles fiber contractility was assessed in vitro, along with whole muscle strength testing. Results: Compared with controls, patients had a 30% reduction in normalized muscle fiber force at the time of surgery. One month later, the force deficit was 41%, and at 6 months the deficit was 23%. Whole muscle strength testing demonstrated similar trends. Discussion: While neurophysiological dysfunction contributes to whole muscle weakness, there is also a reduction in the force generating capacity of individual muscle cells independent of alpha motor neuron activation. Muscle Nerve 58 : 145–148, 2018     

关节镜下自体肌腱及同种异体肌腱重建膝关节前后交叉韧带*

背景：自体肌腱移植重建膝关节前后交叉韧带已广泛应用,但是供区容易出现并发症,同种异体肌腱移植越来越多应用于重建膝关节前后交叉韧带,是一种重要的替代材料。 目的：比较关节镜下自体肌腱及同种异体肌腱移植重建膝关节前后交叉韧带的临床疗效差异。 方法：40 例前后交叉韧带损伤患者分为2组：自体肌腱组为自体半腱肌及股薄肌重建膝关节前后交叉韧带,异体肌腱组为应用由山西骨组织库提供的同种异体肌腱重建膝关节前后交叉韧带。 结果与结论：全部病例均获得6个月以上随访,最长随访时间36个月。重建前后两组大腿周径患健侧差值、Lachman 试验、中立位前抽屉试验(ADT)和国际膝关节评分委员会(IKDC)、Lysholm 及Tegner 评分差异均有显著性意义(P < 0.01),两组间术后各项指标差异均无显著性意义(P > 0.05)。结果表明,自体肌腱与单纯深低温冷冻同种异体肌腱移植在重建膝关节前后交叉韧带疗效无明显差异。     

关节镜下异体跟腱单双束重建后交叉韧带的随机对照*☆

背景：关节镜下重建后交叉韧带主要有单束重建和双束重建两种方式。目的：随机对比应用异体跟腱单双束重建后交叉韧带损伤的临床疗效。方法：选择青岛市市立医院骨科2006-01/2009-01的后交叉韧带损伤患者共70例,随机分为单束重建组和双束重建组,分别行异体跟腱单束重建及双束重建。结果与结论：术后顺利完成康复计划并获得随访的病例共52例。双束重建组手术时间较单束重建组长,行关节腔穿刺的病例数较单束重建组多(P < 0.05)。手术后18个月随访结果显示,单束组重建及双束重建组的膝关节活动度、Lysholm评分、IKDC评分与术前比较有明显提高(P < 0.05),两组膝关节屈曲30°和90°时用KNEELAX3测量胫骨端后移距离明显低于术前(P < 0.05)。两组术后Lysholm评分、 IKDC评分、两组膝关节屈曲30°和90°时用KNEELAX3测量胫骨端后移距离未见明显差别(P > 0.05)。说明与单束重建比较,双束重建后的早期临床疗效无明显提高,且双束重建的手术创伤大,手术时间长,术后关节肿胀重,故不推荐作为首选手术方式,其远期疗效优待进一步观察。     

计算机导航技术在后交叉韧带重建胫骨隧道定位中的应用

背景：后交叉韧带重建中胫骨隧道的定位一直是手术的难点,把计算机导航技术运用到后交叉韧带重建中,希望能提高胫骨隧道定位的精度。 目的： 采用计算机导航系统在重建膝关节后交叉韧带中准确定位胫骨隧道的方法,评价其在后交叉韧带重建中的应用价值。 方法：甲醛防腐成人下肢标本50侧,切断标本后交叉韧带后分别用聚氨酯海棉粘贴包裹模拟软组织覆盖的完整标本。随机分成两组,分别采用计算机辅助导航系统(导航组)及传统关节镜(对照组)定位胫骨隧道。观察两组标本胫骨隧道的出口位置,透视后测量胫骨隧道的矢状角度及长度,记录透视次数。 结果与结论：导航组胫骨虚拟隧道矢状角度和长度术中定位及术后实测比较差异均无显著性意义(P > 0.05)。导航组术后实测胫骨隧道矢状角度为(61.88±0.94)°、透视次数为(3.0±0.5)次,对照组分别为(52.63±1.04)°及(9.0±2.7)次;导航组隧道出口位于后交叉韧带生理附着区23例,对照组为15例;两组比较差异均有显著性意义(P < 0.05)。结果提示透视导航技术可以辅助后交叉韧带重建手术中胫骨隧道的定位,具有隧道定位准确性高、辐射及手术污染机会减少的特点。     

关节镜下半腱肌和股薄肌双束重建前交叉韧带后膝关节本体感觉的功能评定

背景：前交叉韧带重建是前交叉韧带损伤的主要治疗方案,近年来,前交叉韧带重建后膝关节本体感觉的研究进展迅速。 目的：对关节镜下半腱肌和股薄肌双束重建膝关节前交叉韧带后的本体感觉进行评定。 设计、时间及地点：病例对照,于2007-08/2008-06在潍坊医学院附属医院骨科完成。 对象：用14例关节镜下半腱肌和股薄肌双束重建前交叉韧带的男性患者作为试验组和14例健康男性作为对照组。 方法：所有患者前交叉韧带重建都经过12个月神经肌肉康复训练,通过在负重的条件下屈伸运动重现设定的角度来评定关节的位置觉,测试健康的受试者和患者的双膝伸膝运动、屈膝运动关节位置重现偏差。 主要观察指标：患者的患侧膝关节、健侧膝关节和健康受试者膝关节在伸膝运动和屈膝运动时主动关节位置重现测试的比较。 结果：患者患膝与健膝关节位置重现偏差、患者侧膝与健康者关节位置重现偏差及患者健膝与健康者关节位置重现偏差比较,差异均无显著性意义(P > 0.05)。 结论：前交叉韧带重建后12个月的患膝和健康膝关节在承重条件下的位置觉无明显差别。     

Neuromuscular electrical stimulation alters gene expression and delays quadriceps muscle atrophy of rats after anterior cruciate ligament transection

Introduction: Neuromuscular electrical stimulation (NMES) is used to improve quadriceps mass after anterior cruciate ligament (ACL) injury. We studied the effect of NMES on mRNA levels of atrophy genes in the quadriceps muscle of rats after ACL transection. Methods: mRNA levels of atrogin‐1, MuRF‐1, and myostatin were assessed by quantitative PCR and the polyubiquitinated proteins by Western blot at 1, 2, 3, 7, and 15 days postinjury. Results: NMES minimized the accumulation of atrogenes and myostatin according to time period. NMES also prevented reduction in muscle mass in all muscles of the ACLES group at 3 days. Conclusions: Use of NMES decreased the accumulation of atrogenes and myostatin mRNA in the quadriceps muscles, inhibiting early atrophy at 3 days, although it did not prevent atrophy at 7 and 15 days after ACL transection. This study highlights the importance of therapeutic NMES interventions in the acute phase after ACL transection. Muscle Nerve 49 : 120–128, 2014     

Ossification of the posterior longitudinal ligament

Two non-Japanese patients with ossification of the cervical posterior longitudinal ligament were described.

This abnormality is very common in Japan, but rare in non-Japanese people. The reason is unknown.

Although the disease appears to be generally asymptomatic, it can cause a myelopathy. The clinical picture, the diagnostic important X-ray examinations and the histopathological findings are revealed. The similarity to the vascular pattern in the lumbar spine in cases of intermittent neurogenic claudication is noted.     

Pathology of spinal cord lesions caused by ossification of the posterior longitudinal ligament

Summary The pathologic changes in the spinal cord of three autopsied cases associated with ossification of the posterior longitudinal ligament (OPLL) are reported. Compression of the spinal cord was marked at the level of the intervertebral disc, and the spinal cord was strikingly flattened antero-posteriorly. Intensive damage was seen in the gray matter as compared to the white matter. The white matter showed demyelination and axon loss with status spongiosus, which was more marked in the postero-lateral than in the anterior columns. The most seriously damaged parts of the spinal cord showed tissue necrosis and cavity formation which extended from the central parts of the gray matter to the ventral parts of the posterior columns. Adventitial fibrous thickening of the vein, hyaline degeneration of the walls of the arterioles, and compression of the anterior spinal vein were observed in the damaged regions. It was evident that secondary circulatory disturbance due to the compression produced by the ossification was of significance in the pathogenesis of the spinal cord damage. A tangle of peripheral nerves, ectopic and reactive, with Schwann cell proliferation was present in the posterior median fissure and the postero-lateral columns in one case. The spinal nerve roots that showed marked demyelination and axon loss were damaged by ossification at the places where the anterior nerve roots emerged from the spinal cord and where the roots penetrate the dura. There was ossification of the dura mater in all cases examined.     

双目视觉技术在前交叉韧带重建手术导航系统中的应用

针对传统前交叉韧带重建手术中钻孔位置误差较大而导致手术失败的现状，介绍了运用双目立体视觉技术，在C臂透视图像的基础上，合理规划手术，动态辅助医生完成钻孔手术的过程。文中以自主研制的可见光双目视觉定位系统为平台，提出了选用黑白棋盘格标记物简化立体匹配过程的方法。利用标定后的系统对标记物之间的距离进行测量，在距双目视觉传感单元1.5 m范围内误差小于1 mm。在前交叉韧带重建手术导航实验中的应用表明，该系统具有稳定、可靠、成本低、标定方法简单、匹配准确、定位精度高的特点，能够满足外科手术导航的要求。     

自体腘绳肌双束与单束重建膝关节前交叉韧带

背景：前交叉韧带重建的方式是决定修复效果的关键因素。自体腘绳肌双束与单束重建膝关节前交叉韧带是临床上常用的修复方法。目的：比较自体腘绳肌双束与单束重建膝关节前交叉韧带的临床疗效。方法：回顾分析了2005-05/2009-06于中南大学湘雅二医院住院的56例急性前交叉韧带Ⅲ度损伤的患者,其中36例行单束自体腘绳肌重建术,20例行双束自体腘绳肌重建术,所有患者前交叉韧带的重建均由同一医师完成,术后随访16~42个月,评估患者的关节活动度、稳定性等指标。结果与结论：随访期间,所有患者的关节活动度均恢复正常,无伸膝受限。两种重建术后患者的Lysholm-Tegner和IKDC膝关节综合功能评定结果、KT-1000检测结果差异均无显著性意义(P > 0.05),术后1年,取出界面螺钉时行关节镜检查,所有患者均未见明显的重建韧带松弛,说明双束与单束自体腘绳肌重建急性前交叉韧带损伤疗效相近。     

Postoperative paralysis following posterior decompression with instrumented fusion for thoracic myelopathy caused by ossification of the posterior longitudinal ligament

A 60-year-old man presented with thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL). His spinal cord was severely impinged anteriorly by a beak-type OPLL and posteriorly by ossification of the ligamentum flavum at T4/5. He underwent surgical posterior decompression with instrumented fusion (PDF). Immediately after surgery, he developed a Brown-Séquard-type paralysis, which spontaneously resolved without requiring the addition of OPLL extirpation. This example highlights that the risk of postoperative neurological deterioration cannot be eliminated even when PDF is selected as the surgical procedure for thoracic OPLL, especially in instances in which the spinal cord is severely compressed.     

Inhibition by CCK of ascending contraction elicited by mucosal stimulation in the duodenum of the rat

CCK released by intraluminal stimuli modifies duodenal activity contributing to a decrease in gastric emptying. However, the neural mechanisms by which CCK controls motility are not well known. The aim of this study was to investigate the interaction between CCK and the enteric nervous system through the study of the effects of CCK‐8 on ascending excitation. Anaesthetized Sprague‐Dawley rats were prepared with a strain‐gauge sutured to the duodenum wall. An electrode holder was placed in the duodenum lumen to elicit ascending contraction. Electrical field stimulation of the duodenal mucosa (4 Hz, 0.6 ms, 30 V) induced an ascending excitation which was blocked by hexamethonium (10 mg kg^–1; n=5) and atropine (0.3 mg kg^–1; n=5), but enlarged by L ‐NNA (10^–5 mol kg^–1; n=5). CCK‐8 (3 × 10^–9 mol kg^–1 10 min^–1) blocked ascending excitation and an inhibition of the induced phasic activity was observed instead (n=18). Individually, none of the CCK receptor antagonists (L‐364 718 and L‐365 260) (3 × 10^–7 mol kg^–1; n=6 each) blocked the inhibition of ascending excitation induced by CCK‐8. However, simultaneous infusion of both antagonists abolished CCK‐8 effect on electrical stimulation (n=5). Similarly, none of the CCK‐8 agonists (A‐71623, A‐71378, gastrin) modified the ascending excitation. In contrast, the simultaneous infusion of A‐71623 and CCK‐4 (n=4) induced an effect similar to CCK‐8. In conclusion, CCK‐8 blocked ascending contraction elicited by electrical field stimulation of duodenal mucosa by means of simultaneous activation of CCK‐A and CCK‐B receptors.     

Clinical and neurophysiological abnormalities before and after reconstruction of the anterior cruciate ligament of the knee

OBJECTIVES: We aimed to study knee proprioception and somatosensory evoked potentials (SEPs) to stimulation of the common peroneal nerve (CPN) in 7 patients with lesion of the anterior cruciate ligament (ACL) before and after ACL reconstruction. MATERIALS AND METHODS: We recorded the spinal N14 and scalp P27 potentials in 5 patients, while in the remaining 2 patients we calculated scalp SEP maps by 20 electrodes. The knee proprioception was tested by comparing the sensitivity to movement of both the knees. RESULTS: Before surgery, all patients showed decreased knee position sense and lack of the cortical P27 potential on the side of the ACL lesion. Arthroscopic reconstruction of the ligament improved neither the knee proprioception nor the somatosensory central conduction. CONCLUSION: We suggest that the loss of the knee mechanoreceptors can be followed by modifications of the central nervous system, which are not compensated by other nervous structures.     

Mid- to long-term outcomes of posterior decompression with instrumented fusion for thoracic ossification of the posterior longitudinal ligament

Posterior decompression with instrumented fusion (PDF) surgery has been previously reported as a relatively safe surgical procedure for any type of thoracic ossification of the longitudinal ligament (OPLL). However, mid- to long-term outcomes are still unclear. The aim of the present study was to elucidate the mid- to long-term clinical outcome of PDF surgery for thoracic OPLL patients. The present study included 20 patients who had undergone PDF for thoracic OPLL and were followed for at least 5 years. Increment change and recovery rate of the Japanese Orthopaedic Association (JOA) score were assessed. Revision surgery during the follow-up period was also recorded. Average JOA scores were 3.5 preoperatively and 7.1 at final follow-up. The average improvement in JOA score was 3.8 points and the average recovery rate was 47.0%. The JOA score showed gradual increase after surgery, and took 9 months to reach peak recovery. As for neurological complications, two patients suffered postoperative paralysis, but both recovered without intervention. Six revision surgeries in four patients were related to OPLL. Additional anterior thoracic decompression for remaining ossification at the same level of PDF surgery was performed in one patient. Decompression surgery for deterioration of symptoms of pre-existing cervical OPLL was performed in three patients. One patient had undergone lumbar and cervical PDF surgery for de novo ossification foci of the lumbar and cervical spine. PDF surgery for thoracic OPLL is thus considered a relatively safe and stable surgical procedure considering the mid- to long-term outcomes.     

Influence of muscle contraction and intensity of stimulation on the cutaneous silent period

We evaluated the influence of stimulus intensity (SI) and the amount of voluntary muscle contraction (VMC) on parameters of the cutaneous silent period (CSP). The CSP was measured in 15 healthy subjects at 20%, 40%, and 60% of maximal VMC and after an electric stimulus of 10, 15, and 20 times the sensory threshold. Average EMG amplitudes prior to stimulus and during the CSP increased with the amount of VMC. The CSP duration increased, and suppression index decreased, with increasing SI. The CSP onset and end latencies seemed to shorten and prolong, respectively, with the increasing SI, although this was not statistically significant. Considering the more meaningful temporal parameters of the CSP and the suppression index, it is not necessary to control the VMC, but it is advisable to control the SI.     

Severe cervical stenosis due to ossification of the posterior longitudinal ligament without neurological manifestations ("silent OPLL")

We report a case of severe cervical spinal stenosis due to ossification of the posterior longitudinal ligament (OPLL) whose clinical examination showed no symptoms or signs of neurological damage (“silent OPLL”). Questions about the diagnosis and the treatment of silent OPLL are discussed in the light of published data.

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Sommario Viene riportato un caso di grave stenosi del canale cervicale dovuta ad ossificazione del legamento longitudinale posteriore (OPLL) che all'esame clinico non mostrava alcun sintomo o segno di danno neurologico (OPLL “silente”). I problemi diagnostici e terapeutici dell'OPLL silente vengono discussi alla luce dei dati riportati in letteratura.

     

一端带骨块同种异体深冻下肢肌腱重建前交叉韧带的应用*

背景：关节镜辅助下重建前交叉韧带的移植物及固定方法的选择存在很多争论,各种固定方法均有其优缺点。目的：评估一端带骨块深冻同种异体肌腱股骨侧嵌入重建膝关节前交叉韧带的效果。方法：纳入2008-01/2009-09 在承德医学院附属医院骨科就诊的15例关节损伤患者(15膝),经关节镜检查证实为前交叉韧带断裂,其中运动损伤7例,交通事故伤6例,摔伤2例。均于关节镜下行一端带骨块的同种异体腱前交叉韧带重建术,记录患者膝关节Lysholm功能评分、KT-1000测量值。结果与结论：对15例患者随访12~24个月,均未发生血管神经损伤、排异、感染等并发症。 KT-1000测量值术前双侧膝关节前向松弛度差值为3~5 mm 4例(27%),6~10 mm 9例(60%),>10 mm 2例(13%);末次随访时0~2 mm 12例(80%),3~5 mm 3例(20%)。同时,Lysholm膝关节功能评分也由术前的(65.60±10.13)分提高到末次随访时的(90.93±4.06)分(P < 0.05)。说明嵌入骨块在重建膝关节前交叉韧带中可增加股骨侧固定的可靠性,治疗效果满意。     

后方经椎弓根入路脊髓减压术治疗胸椎后纵韧带骨化

目的 探讨后方经椎弓根入路脊髓减压术治疗的临床效果.方法 回顾性分析自2006年3月至2009年12月北京宣武医院神经外科行后方经椎弓根脊髓减压术的7例胸椎后纵韧带骨化的患者,通过手术前后症状改善和手术疗效对比,评估该方法的安全性和有效性.结果 术后随访时间平均13.7个月,5例术后下肢运动功能显著改善,1例术后一过性单侧下肢肌力下降,1例左下肢瘫痪.神经根性症状和二便功能术后均有较好缓解.末次随访时JOA评分较术前提高2.9分,术后复查脊柱稳定性良好.结论 后方经椎弓根入路脊髓减压术治疗胸椎后纵韧带骨化是安全有效的.