前交叉韧带损伤膝关节侧副韧带长度的变化

背景:侧副韧带对膝关节的稳定性起着重要的作用,通过2D/3D图像配准技术可以实现膝关节的运动还原并获得前交叉韧带损伤后生理屈曲过程中内侧副韧带和外侧副韧带长度变化规律.目的:对前交叉韧带损伤膝关节侧副韧带长度变化进行运动还原体内稳定性研究.方法:选择单侧膝关节前交叉韧带断裂而对侧正常的8例患者,在生理负重屈曲采集0°,15°,30°,60°和90°时的相互垂直的2D图像,与CT(3D)图像在虚拟X射线投射系统进行2D/3D图像配准,还原膝关节不同角度时的股骨和胫骨相对3D位置关系,并通过韧带止点还原的方法对内侧副韧带、外侧副韧带进行韧带长度分析,并对比两侧.结果与结论:内侧副韧带损伤后在0°,15°和30°患膝内侧副韧带长度较健膝增加;内侧副韧带损伤后在0°、15°和30°患膝外侧副韧带长度较健膝减少,差异均有显著性意义(P＜0.05).结果提示,在0°、15°和30°,前交叉韧带损伤后患膝内侧副韧带长度较健膝增加,而外侧副韧带长度较健膝缩短.     

Effect of a functional knee brace on knee flexion and extension strength after anterior cruciate ligament reconstruction

OBJECTIVES: To investigate the effect of a knee brace on knee flexion and extension muscular strength of patients after anterior cruciate ligament (ACL) reconstruction and to evaluate whether the effect of the brace depends on patient symptoms and muscular strength. DESIGN: Repeated measures. SETTING: A university-based outpatient orthopedic clinic and musculoskeletal assessment laboratory. PARTICIPANTS: Twenty-seven patients (14 women, 13 men; mean age, 28+/-11 y) having undergone arthroscopically assisted ACL reconstruction by using a semitendinosus and gracilis autograft. INTERVENTION: A custom-fit ACL functional knee brace. MAIN OUTCOME MEASURES: The brace effect was calculated as the change in peak torque observed with the brace, expressed as a percentage of peak torque observed without the brace, during isokinetic concentric knee flexion and extension movements performed at 90 degrees /s. Patient symptoms were quantified by using a disease-specific health-related quality of life questionnaire. RESULTS: Knee flexion strength decreased significantly with the brace (mean brace effect=-7.3%, P<.05). The brace effect during knee flexion varied considerably (-52% to 47%) and was significantly related to peak torque observed without the brace (r=-.50, P<.01). All other comparisons and correlations were not significant. CONCLUSIONS: These findings suggest that brace effects depend on patient strength. A brace may inhibit knee flexion strength of stronger patients, yet result in no change or even improvements in strength of weaker patients. Future research is required to further elucidate which patients may derive most benefit or detriment from bracing.     

内侧副韧带断裂膝关节内前交叉韧带单束和双束的重建☆

背景:对于前交叉韧带和内侧副韧带复合损伤患者,在保守治疗内侧副韧带、手术重建前交叉韧带时,前交叉韧带重建的手术方式选择存在争议。目的:在内侧副韧带断裂的膝关节内,观察前交叉韧带单束重建和双束重建的生物力学差别。方法:将16具成年猪的膝关节随机分为两组,每组8具。膝关节切断内侧副韧带和前交叉韧带后,一组进行前交叉韧带的单束重建,一组进行双束重建。利用Robot分别测量每组膝关节在完整膝关节、内侧副韧带和前交叉韧带切断、前交叉韧带单束重建和双束重建4种状态下不同屈膝角度的胫骨前向位移、内旋和外旋角度。结果与结论:膝关节切断前交叉韧带和内侧副韧带,可以显著增加胫骨的前向位移和内、外旋转角度。前交叉韧带重建,可以降低胫骨的前向位移和内、外旋转角度。前交叉韧带双束重建在降低胫骨的外旋方面优于单束重建。结果提示对于内侧副韧带和前交叉韧带复合损伤患者,在保守治疗内侧副韧带断裂、前交叉韧带重建时,应优先选择前交叉韧带双束重建,以便更好地控制胫骨的外旋,增加膝关节前内旋转的稳定性。     

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200N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。     

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200N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。     

On the coupling between anterior and posterior cruciate ligaments,and knee joint response under anterior femoral drawer in flexion: a finite element study

OBJECTIVE: To investigate the extent of coupling between the anterior and posterior cruciate ligaments as well as the role of the posterior cruciate ligament in the knee joint response under anterior femoral force at different flexion angles. DESIGN: A developed finite element model of the tibiofemoral joint is used to perform non-linear elastostatic analyses. BACKGROUND: The structural properties of the posterior cruciate ligament subsequent to an injury (either left untreated or replaced by a graft) would likely change, an event that alters the function of not only the ligament itself but also the other intact cruciate ligament and the entire joint. METHODS: The model consists of two bony structures and their articular cartilage layers, menisci and four principal ligaments. Under 100 N anterior femoral load at different flexion angles from 0 degrees to 90 degrees, kinematics, forces in ligaments and contact forces in the fully unconstrained joint were computed in intact cases and following alterations in joint ligaments. RESULTS: Collateral ligaments were the primary structures to resist the force at full extension under 100 N anterior femoral load with a moderate contribution from the posterior cruciate ligament. With joint flexion up to 90 degrees, however, force in the posterior cruciate ligament substantially increased whereas that in collateral ligaments diminished. CONCLUSIONS: A remarkable coupling was found between the posterior cruciate ligament and the anterior cruciate ligament in flexion; a structural alteration in one of them significantly influenced the mechanical role of both ligaments and not just the one affected. A tauter or stiffer ligament increased the force in both ligaments while an excessive laxity or rupture in one diminished forces in both. RELEVANCE: Alterations in ligament stiffness or initial tautness during reconstruction surgery or following injuries markedly influence the normal role of both cruciate ligaments. Consideration of cruciate ligaments coupled together rather than in isolation should be the rule in the management of ligament injuries towards a successful long-term outcome.     

可调式膝关节支具在前交叉韧带重建术后康复护理中的应用

[目的]探讨前交叉韧带重建术后应用可调式膝关节支具的康复护理效果。[方法]选取2009年3月—2011年9月前交叉韧带断裂病人32例(32膝),在前交叉韧带重建术后运用可调式膝关节支具指导病人康复锻炼,并应用Lysholm评分对膝关节功能恢复情况进行评定。[结果]32例病人术后7个月随访时膝关节Lysholm评分(87.25分±4.65分)较术前(54.75分±9.71分)明显提高(t=6.04,P<0.01)。[结论]可调式膝关节支具可帮助病人行早期适宜功能锻炼,提高临床疗效。     

Knee joint movements in subjects without knee pathology and subjects with injured anterior cruciate ligaments

BACKGROUND AND PURPOSE: Although weight-bearing (WB) exercise and increased hamstring muscle activity may contribute to knee joint stability in knees with an injured anterior cruciate ligament (ACL), the relationship among ACL integrity, muscle activity, and joint surface motion is not fully understood. The purpose of this study was to investigate whether knee joint rolling and gliding movements and electromyographic (EMG) activity differed between subjects with injured ACLs and subjects without knee pathology. SUBJECTS: Fifteen subjects with injured ACLs (9 men and 6 women; mean age=26 years, SD=7, range=18-36) and 15 age- and sex-matched subjects without knee pathology (9 men and 6 women; mean age=25 years, SD=6, range=18-36) participated in the study. METHODS: Sagittal-plane knee joint rolling and gliding movements and lower-extremity EMG activity were measured during non-weight-bearing (NWB) and WB movements. Mixed-model analyses of variance were conducted to analyze rolling and gliding and EMG data. RESULTS: During NWB knee extension, greater joint surface gliding occurred in knees with injured ACLs at full knee extension. During WB knee extension, greater gliding occurred in knees with injured ACLs throughout the range of motion tested. No differences in EMG activity occurred between groups. DISCUSSION AND CONCLUSION: The results suggest that, in the absence of increased hamstring muscle activity, anterior tibial displacement is not reduced in knees with injured ACLs during WB movement.     

Hop testing symmetry improves with time and while wearing a functional knee brace in anterior cruciate ligament reconstructed athletes

BackgroundThere is currently no consensus among orthopaedic surgeons as to when patients with anterior cruciate ligament reconstruction are ready to return to sport or whether or not patients should wear a functional knee brace during athletic activity. The purpose of the present study was to determine the effects of time since return to sport and of a functional knee brace on hop distance and loading symmetry during hop testing in patients with anterior cruciate ligament reconstruction.MethodsTwenty-eight patients with anterior cruciate ligament reconstruction completed hop testing after being released to return to sport and again 3 months later, both with and without wearing a custom fit extension constraint functional knee brace. The loadsol® captured plantar loading data (100 Hz) to quantify peak impact force, loading rate, and impulse during the final landing of every hop test. A limb symmetry index was calculated between surgical and non-surgical limbs for hop distance and loading measures.FindingsWearing a knee brace increased hop distance symmetry during the single and crossover hop tests and peak impact force symmetry on each test (all p < 0.05). While single (p = 0.022) and triple (p = 0.002) hop distance symmetry increased with time, there was no effect of time on any loading symmetry outcomes.InterpretationThese results support using a functional knee brace during athletic activities for improving symmetry in the early return to sport period. These results also support previous findings that while hop distance symmetry improves with time, asymmetrical landing mechanics do not and should be addressed clinically.     

Influence of an unloader brace on lower limb electromyographic activity in individuals with predominant lateral osteoarthritis after anterior cruciate ligament reconstruction

ObjectiveTo determine the immediate effects of a varus unloader knee brace on lower-limb electromyographic activity in individuals with lateral knee osteoarthritis and valgus malalignment after anterior cruciate ligament reconstruction.MethodsElectromyographic data were recorded in 19 individuals with lateral knee osteoarthritis and valgus malalignment after anterior cruciate ligament reconstruction during walking under three conditions: (i) no brace, (ii) unadjusted brace (no varus adjustment), and adjusted brace (varus adjustment). Variables of interest were statistically analyzed using repeated measures analysis of variance.ResultsThere were no significant differences in muscle co-contraction between the three test conditions. The adjusted brace resulted in delayed offset of gluteus maximus (mean difference [95% CI]: 72 ms [24, 119]), and earlier onset of gluteus medius (59 ms [21, 97]) compared to no brace. The adjusted brace delayed onset of lateral gastrocnemius compared to no brace (53 ms [28, 78]) and the unadjusted brace (39 ms [7, 71]) and reduced average activation amplitude of gluteus maximus (−4 mV [−6, −1]) and lateral gastrocnemius (−9 mV [−16, −2]) compared to no brace.ConclusionsThe unloader brace did not produce significant changes in muscle co-contraction in individuals with lateral knee osteoarthritis and valgus malalignment after anterior cruciate ligament reconstruction. Significant changes in gluteal and gastrocnemius muscle activation timing and amplitude were observed, however, it is not clear whether these changes are of clinical importance.     

平衡促进训练对膝关节前交叉韧带损伤重建术后患膝本体感觉的影响

目的:研究平衡促进训练对膝关节前交叉韧带(ACL)损伤重建术后患膝本体感觉的影响。方法:选取124例ACL损伤重建术后患者,全部进行常规康复训练12周,术后第12周采用随机数字法分成两组(对照组62例,训练组62例),训练组在第12周开始进行平衡促进训练,持续至第16周;对照组继续进行患肢肌力和步态训练,持续至第16周。采用专业平衡功能评定系统,分别在术后第12周和第16周对两组进行平衡功能测定。结果:术后第16周测定结果:①睁眼状态下,训练组与对照组在指标LFS指数和覆盖90%椭圆区域面积指数无显著差异(P>0.05)。②闭眼状态下,训练组与对照组在指标LFS指数和覆盖90%椭圆区域面积指数差异具有显著性意义(P<0.05)。结论:平衡促进训练对ACL损伤重建术后患者膝关节本体感觉能力恢复具有显著提高作用。     

膝交叉韧带重建术的护理配合

随着社会经济的不断发展,由于交通及运动损伤引起的膝关节损伤日趋增多.交叉韧带是维持膝关节稳定的重要结构,韧带的断裂会引起关节不稳,若时间长会发展成创伤性关节炎,严重影响病人的工作与生活.膝交叉韧带重建术,尤其在关节镜监视下重建是近年来发展起来的一项新技术,通过手术能有效地恢复关节的稳定与功能,但手术的效果优劣在很大程度上取决于手术技术及术中医护配合的好坏[1].2000年7月-2003年7月,我院共行膝交叉韧带重建术236例,现将护理配合报告如下.……     

MR斜冠状位薄层质子加权像对前交叉韧带损伤的诊断作用

目的：探讨MR斜冠状位薄层质子加权像对膝关节前交叉韧带（ACL）损伤的诊断价值.方法：98只外伤膝关节行常规MR扫描,包括斜矢状位、冠状位、横断位,所有病例均行在斜矢状位图像基础上平行于ACL的快速自旋回波（FSE）序列斜冠状位薄层无间隔质子密度加权扫描,成像结果与关节镜检查结果进行对比,分别评价常规MRI及斜冠状位薄层质子像诊断ACL损伤的真实性.结果：常规MRI诊断ACL损伤的敏感度为76.92％、特异度为87.88％、总符合率为80.61％、漏诊率为23.08％、约登指数为0.66、阳性预测值为92.59％、阴性预测值为65.91％;MR斜冠状位薄层质子像诊断ACL损伤的敏感度为96.92％、特异度为87.88％、总符合率为93.88％、漏诊率为3.08％、约登指数为0.85、阳性预测值为94.03％、阴性预测值为93.55％.常规MRI扫描和关节镜对于ACL损伤的诊断一致性一般,MR斜冠状位薄层质子像和关节镜对于ACL损伤具有较高的诊断一致性,Kappa值分别为0.60和0.86.结论：MR斜冠状位薄层质子像可以提高ACL损伤诊断的敏感性和准确性,并可避免不必要的关节镜检查.     

膝骨关节炎模型内侧副韧带的生物力学特性

背景:膝骨关节炎多由力学和理化因素导致软骨基质退变而引起。目前对发病的理化因素和软骨基质的退变研究较多,力学研究较少。目的:观察兔膝骨关节炎模型内侧副韧带拉伸力学性质的改变。方法:左后肢伸直位石膏固定制动法建立兔模型。在BoseElectroForce3300疲劳试验机上对正常对照组和模型组各6个试样进行拉伸实验。拉伸实验的速度为5mm/min,计算机每0.1s自动记录一个数据,直到将试样拉断。结果与结论:正常对照组最大应力为(17.92±3.18)MPa,最大应变为(10.7±2.07)%,最大位移为(2.76±0.37)mm,弹性模量(316.19±74.55)MPa;模型组最大应力为(11.34±1.05)MPa,最大应变为(7.97±1.65)%,最大位移为(2.08±0.31)mm,弹性模量(279.77±33.91)MPa。正常对照组各项拉伸性能指标显著大于模型组(P<0.05)。提示膝骨关节炎对膝关节韧带的生物力学特性具有一定影响。     

电针围刺对运动性膝关节侧副韧带损伤的疗效观察

目的:观察电针围刺治疗运动性膝关节侧副韧带损伤的临床疗效,并与毫针齐刺的疗效进行对比观察。方法:将64例运动性膝关节侧副韧带损伤患者随机分为电针组33例、毫针组31例,分别采用电针和毫针刺激膝部痛点,进行疗效比较。结果:电针组总有效率为97%,毫针组总有效率为87%。两组有效率差异有显著性意义(χ2=12.33,P<0.01)。结论:电针围刺治疗可明显提高运动性膝关节侧副韧带损伤的疗效。     

Functional measurement of knee joint position sense after anterior cruciate ligament reconstruction

OBJECTIVE: To examine for differences in joint position sense (JPS) between knees with reconstructed anterior cruciate ligaments (ACLs) and uninjured knees by using a functional weight-bearing measurement method. DESIGN: Two-way repeated-measures in a convenience sample. SETTING: An Australian university rehabilitation laboratory. PARTICIPANTS: Nine subjects presenting at 12 to 16 months after unilateral ACL reconstruction using the semitendinosus/gracilis graft who were recruited from 2 orthopedic surgeons. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: JPS of the reconstructed and uninjured knees was examined by using the Peak Motus motion measurement system to record target joint angles and to calculate reproduced angles after limb movement into flexion and extension, performed in a weight-bearing position. RESULTS: There were no significant differences in JPS between reconstructed and uninjured knees (P=.68) or between the flexion and extension tasks (P=.47). CONCLUSION: There was no deficit in knee JPS 12 to 16 months after ACL reconstruction, as measured by a functional weight-bearing method. Further studies should examine the clinical utility of the method as a way to evaluate functional aspects of knee joint proprioception.     

Sonographic guided insertion of electrodes into the cruciate ligaments of the knee.

The present cadaver study examined the probability of accurate ultrasound guided insertion of electrodes into the anterior (ACL) and posterior (PCL) cruciate ligament with a fine needle. Visualisation of the structures appeared clearest from the posterior approach. From this approach 24 electrodes were inserted into the PCL and six into the ACL. From the anterior 16 were inserted into the ACL and six into the PCL. Twenty-one out of 24 electrodes were placed correctly into the PCL from the posterior view, and four out of six were placed correctly from the anterior view. From the posterior view four out of six were placed correctly in the ACL, and eight electrodes out of 16 were placed correctly from the anterior view. In conclusion, ultrasound guided insertion of electrodes from the posterior view can be performed with high accuracy into the PCL, whereas insertion into the ACL seems to be less accurate, probably because it is more difficult to visualise.     

Magnetic resonance imaging of the collateral ligaments and the anatomic quadrants of the knee

Injuries to the lateral and medial supporting structures of the knee can be significantly disabling and somewhat difficult to detect and evaluate clinically. An accurate imaging evaluation of these structures requires the use of the appropriate MR imaging sequences and the detailed knowledge of the anatomic structures that are present in these locations. Normal function is dependent on the integrity of the complex functional structures and effective clinical treatment, including surgical repair, of these structures is predicated on an optimal diagnostic evaluation. A successful diagnostic evaluation can expedite treatment and provide the best opportunity for a favorable long-term outcome.     

Effect of lower limb dominance on knee joint kinematics after anterior cruciate ligament reconstruction

Background

Normal ambulatory kinematics of the knee joint is often not fully restored after anterior cruciate ligament reconstruction, which may increase the risk for cartilage degeneration and premature osteoarthritis in the involved knees. Lower limb dominance may have impacts on knee joint kinematics after anterior cruciate ligament reconstruction, which may lead to a different prevalence of cartilage degeneration. This study aimed to evaluate the knee joint kinematics among patients with reconstruction on the dominant and non-dominant side.

Methods

Forty-one subjects with unilateral anterior cruciate ligament reconstruction (19 dominant, 22 non-dominant) were recruited after being discharged from rehabilitation programs. Twenty healthy subjects were recruited as the control group. Six degrees-of-freedom tibiofemoral motion during level walking was determined using a redundant point cluster-based marker set. Tibiofemoral joint motion and its bilateral differences were compared within each group and between groups.

Findings

The non-dominant reconstructed knees had less extension compared to their contralateral knees at heel strike and during middle stance phase (P = 0.02); whereas, the dominant reconstructed knees exhibited significantly reduced varus rotation (− 2.1° on mean, P = 0.027) and internal tibial rotation (P = 0.034) compared to their contralateral knees during both stance and swing phases.

Interpretation

The results show that different kinematics has been developed between the involved dominant and non-dominant knees after anterior cruciate ligament reconstruction, especially the secondary rotations. The differences are consistent with the unequal prevalence of cartilage degeneration in the knee joint. The findings demonstrated that the lower limb dominance had a significant effect on post-surgery knee kinematics.