膝关节内侧副韧带、前交叉韧带、后交叉韧带联合损伤的手术治疗

目的探讨关节镜下膝关节前交叉韧带(ACL)、后交叉韧带(PCL)、内侧副韧带联合损伤(Ⅲ度膝关节外翻伤)的手术治疗方法。方法关节镜下同时联合重建ACL、PCL并修复内侧副韧带和内侧关节囊，8例交叉韧带重建材料来源于自体双侧髌腱中1／3骨-腱-骨结构，8例采用同种异体髌腱重建，交叉韧带重建的同时进行膝关节内侧副韧带和关节囊的修补。术后佩戴可调式卡盘支具3个月，并给予严格的康复训练。结果术后随访6～18个月，所有患者主观感觉以及膝关节稳定程度恢复良好，均进行正常生活与工作，同种异体髌腱移植重建比自体髌腱移植重建前后交叉韧带手术时间短，效果更好，没有发现明显的排异反应和感染传染性疾病的现象。结论1期行关节镜手术治疗膝关节内侧副韧带、前交叉韧带／后交叉韧带联合损伤，使用安全，效果满意；同种异体髌腱是重建物是一个可以选择的来源，效果优于自体髌腱移植重建。     

同种异体骨-中1/3髌腱-骨、骨-跟腱移植重建羊膝关节后交叉韧带的比较研究

目的对同种异体骨-中1／3髌腱-骨(B-PT-B)、骨-跟腱移植重建后交叉韧带(PCL)后的组织学演变及力学特性进行初步分析．以了解其临床应用的可行性及影响因素：方法选用健康成年羊25只，A组为取材组(5只)．B、C组为实验组(各10只)；分别以新鲜冷冻异体B-PT-B和异体骨-跟腱移植重建PCL．分别以健侧为自身对照组．采用形态学及生物力学手段、对术后1个月和6个月两组移植物(供体)重建PCL后的组织学演变及术后6个月力学特性进行初步分析。结果常规组织学染色显示：重建PCL6个月后两种移植物与正常PCL结构相似；生物力学测试结果表明，同种异体骨-跟腱移植重建后的PCL的抗拉伸强度比同种异体B-PT-B重建的PCL高，且具有与正常PCL接近的力学特性。结论同种异体骨-跟腱移植重建的PCL具有与正常PCL接近的力学特性．更适合临床应用。     

同种异体组织重建关节韧带临床疗效的初步观察

目的评价同种异体组织重建膝关节前交叉韧带(ACL)、后交叉韧带(PCL)、内侧副韧带(MCL)、外侧副韧带(LCL)和肩关节喙锁韧带(CCL)的疗效. 方法回顾调查43例患者,将其分为3组,A组ACL或ACL/MCL损伤34例;B组PCL或PCL/LCL 损伤6例;C组完全肩锁关节损伤3例.分别应用同种异体骨-髌腱-骨(B-PT-B) 、半腱肌腱与股薄肌腱、胫后肌腱、跟腱-骨重建. 结果平均随访19个月, A、B两组术前Lysholm评分63.0±5.6,术后89.0±5.9,手术前后差异有非常显著性意义(P<0.01); 术后国际膝关节文献委员会(IKDC)评分A级3例(8%),B级23例(58%),C级12例(30%),D级2例(5%).KT2000测定A组手术前后胫骨前移分别为(13.10±0.29)mm和(4.70±1.37)mm;B组胫骨后移则分别为(10.53±2.50)mm和(5.74±1.33)mm,手术前后差异有非常显著性意义 ( P<0.01).术后健患侧比较A、B两组健患差异<3 mm 33例(83%);>5 mm 4例(10%);前后抽屉试验36例(90%)由术前3度恢复至术后平均1.3度.合并MCL/LCL损伤患者的侧方应力试验由术前3度恢复至术后平均1.2度,并呈现明显的硬终点;单纯与复合性ACL或PCL损伤,伸屈正常分别占91%和88%.喙锁韧带重建后X线片显示肩锁关节间隙基本正常,肩锁与肩肱关节活动良好. 结论同种异体移植物重建膝关节ACL、PCL、MCL、LCL与肩关节喙锁韧带疗效满意,是自体组织重建的良好替代物.     

关节镜下应用同种异体跟腱双束重建后交叉韧带

目的:探讨应用同种异体跟腱双束重建后交叉韧带(posterior crucial ligament,PCL)的方法并观察其早期效果.方法:2003年3月～2004年8月,对10例PCL受损患者实施关节镜下采用同种异体跟腱双束重建PCL术.其中2例合并前交叉韧带(anterior crucial ligament,ACL)损伤,同期取自体半腱股薄肌腱重建ACL;3例合并半月板后外侧角损伤,同期取自体半腱股薄肌腱重建后外侧角.术后随访6～24个月,平均13.2个月,其中6例获得12个月以上的随访.结果:采用Lysholm评分法评价患者手术前后患膝关节功能,术前平均50.3分,术后平均91.2分.客观检查结果显示,术前所有患者均出现胫骨结节后沉,后抽屉试验及Lachman试验阳性;术后所有患者后抽屉试验及Lachman试验阴性,有3例病史较长(大于1年)的患者胫骨结节有轻度后沉.合并ACL损伤的2例患者,膝关节屈曲活动轻度受限(5°～20°).结论:应用同种异体跟腱双束重建PCL可减少自体取材造成的损伤及相应的并发症;提前制作供材,软腱端容易通过骨道,缩短镜下操作时间,减轻手术创伤.     

深低温保存的异体骨-髌腱-骨重建膝关节前交叉韧带

目的评价深低温保存的异体骨-髌腱-骨(bone-patellar tendon-bone,B-PT-B)重建膝关节前交叉韧带的方法和初步疗效.方法采用异体B-PT-B重建膝关节前交叉韧带共15例,平均年龄25.9岁,平均随访时间23.7个月.手术前后采用Lysholm评分评定关节功能.结果术后恢复均顺利.Lysholm评分,由术前(60.1±5.8)分提高至术后(90.8±5.2)分(P＜0.01),优良率80%.结论采用深低温保存的异体B-PT-B重建膝关节交叉韧带是一种较好的、可供选择的手术方式.     

关节镜下股骨双隧道“Y”形LARS人工韧带移植重建膝后交叉韧带

目的 探讨在关节镜下应用人工LARS韧带重建膝关节后交叉韧带(PCL)的手术技巧及临床疗效. 方法 选择2006年6月- 2010年8月关节镜下采用LARS人工韧带重建PCL断裂患者14例,其中男10例,女4例;年龄19 ～58岁,平均38岁.致伤原因:运动扭伤9例,交通伤3例,摔伤2例.左侧5例,右侧9例.病程10 d ～1个月,平均15.7d.MRI示:PCL完全撕裂直接征象14例,前交叉韧带(ACL)完全撕裂直接征象2例,合并内侧半月板损伤5例,合并外侧半月板损伤3例,合并髋臼后壁骨折1例.Lysholn膝关节功能评分20～55分[(40 ±7.9)分].按照国际膝关节文件编制委员会( IKDC)评分:C级3例,D级11例.PCL在股骨及胫骨止点、隧道均用定位器完成. 结果 本组所有患者伤口均为Ⅰ/甲愈合,术后无慢性滑膜炎、韧带断裂、韧带松动、活动明显受限等并发症.所有患者均获随访6 ～ 60个月,平均20.5个月.Lysholm膝关节功能评分84 ～93分[(88±3.6)分],与术前比较差异有统计学意义(P＜0.05).术后12个月根据IKDC评分标准分级:A级10例,B级4例. 结论 在关节镜下运用LARS人工韧带重建膝PCL有效恢复了膝关节稳定性,避免了采用自体肌腱重建取材的并发症,也避免了同种异体肌腱移植材料的排斥及传染疾病的并发症.其手术操作简便,创伤小,康复快.     

关节镜下应用LARS人工韧带同时重建前、后交叉韧带

目的 探讨关节镜下应用LARS人工韧带重建前交叉韧带(ACL)、后交叉韧带(PCL)同时损伤的方法及疗效. 方法 关节镜下同时重建13例ACL、PCL损伤的患者,重建材料采用LARS人工韧带.术后随访12～36个月,采用国际膝关节文件编制委员会(IKDC)韧带标准评价表和Lysholm膝关节功能评分表评估患膝功能,通过KT-1000检查膝关节前后松弛度.结果 术后无膝关节感染发生;均无伸膝受限,屈膝活动度105°～125°,平均117°.术后随访时IKDC评分:A类10例(77%),B类3例(23%).屈膝25°位KT-1000检查:双侧膝关节前向松弛度差异＜2 mm 12例,3～5 mm 1例;屈膝70°位检查:＜2 mm 12例,2～4 mm 1例.术前Lysholm膝关节功能评分为(63.8 ±2.9)分(49～69分),终末随访时为(91.1±2.7)分(88～95分),差异有统计学意义(P＜0.01). 结论 关节镜下同时重建膝关节ACL、PCL是目前治疗ACL、PCL同时损伤的一种微创、安全、有效的手术方法,近期疗效佳.     

兔异体前交叉韧带移植重建后交叉韧带的组织学研究

目的:观察兔异体骨-前交叉韧带-骨移植重建后交叉韧带(PCL)术后移植物的组织学转归。方法:24只骨骼成熟新西兰大白兔,随机选取每只兔的一侧后腿进行无菌取材,用新鲜冰冻异体骨-前交叉韧带-骨移植重建兔后交叉韧带,分别于术后第6周、12周、26周、52周对重建后的移植物进行组织学观察。结果:重建后的移植物在关节内经历了细胞长入、胶原纤维再生和再塑形过程,术后52周时移植物类似于正常PCL,细胞形态、大小及排列接近正常,胶原纤维束排列规律、致密,甲苯胺蓝异染物质分布类似于正常PCL,移植物外包绕的滑膜趋于正常,其Ⅲ型胶原含量下降,Ⅰ型胶原明显增多,但移植物内Ⅰ、Ⅲ型胶原的含量及分布仍与正常PCL有区别。结论:兔异体前交叉韧带移植重建后交叉韧带术,移植物的组织学特性对PCL重建效果有明显影响,提示应用同种组织类型移植物可取得更好的重建效果。     

膝关节后交叉韧带损伤重建技术研究进展

后交叉韧带（Posterior eruciate ligament,PCL）损伤在急性膝关节韧带损伤中大约占1％～40％,其中交通事故引起的约占56．5％,运动损伤引起的约占40％。随着对PCL的解剖结构、生物力学等研究的不断认识和提高,膝关节PCL损伤的重建已成为运动医学和骨外科学研究和争论的热点问题。膝关节PCL重建成功的关键是对隧道的准确定位、移植物的强度、减少移植物的扭曲、使用移植物预张器、移植物的最佳固定方式和使用的材料以及术后膝关节康复功能锻炼。目前随着关节镜技术的开展和手术器械的不断改进,通过借鉴前交叉韧带重建的成功经验,后交叉韧带损伤重建技术也取得了长足的进步。现将后交叉韧带重建技术综述如下。     

三种移植物关节镜下重建前交叉韧带的临床疗效比较

目的比较分析膝关节镜下自体骨-髌腱-骨（B-PT-B）、同种异体跟腱和LARS（1igament advanced reinforce．mentsystem,LARS）人工韧带重建前交叉韧带（anterior cruciate ligament,ACL）的临床疗效差异。方法从2008年2月-2010年11月,对156例膝关节ACL损伤患者行关节镜下ACL重建术,其中自体骨-髌腱-骨（B-PT-B）组39例,同种异体跟腱组53例,LARS人工韧带组64例。通过一般情况、前抽屉试验、Lachman试验、轴移试验、Lysholm、IKDC膝关节评分进行临床疗效评价。结果所有患者随访12-38个月,平均21个月,术后3、6个月各组膝关节Lysholm、IKDC评分,LARS组明显高于其余2组（P〈O．05）。异体跟腱组与自体B-PT-B组相比,差异无统计学意义（P〉0．05）。术后12月及最后随访时,LARS组略高于其余2组,但3组间差异无统计学意义（P〉0．05）。结论在关节镜下应用3种不同移植物重建前交叉韧带的近期疗效均较为满意,LARS组可在术后早期进行膝关节功能活动近期效果优于自体B-PT-B组和异体跟腱组。对于年轻患者．尤其是运动员ACL损伤。LARS人工韧带是一种理想移植材料。     

Graft selection in surgicalreconstruction of the multiple-ligament-injured knee

Knowledge of the various graft options available for reconstruction of the knee with multiple ligamentous injuriesis necessary for the surgeon and patient to make an informed decision. Allograft is frequently used for such reconstructions, because multiple grafts are often necessary. Allograft avoids the morbidity associated with autograft harvest, allows smaller incisions, and saves operative time. A concern with the use of allograft, however, is the small but serious risk of disease transmission, including viral and bacterial infections. Allograft is also expensive and its availability may be limited. Some patients may prefer reconstruction with autograft tissue. Bone-patellar tendon-bone autograft is strong, stiff, and allows bony fixation at both ends. Harvest complications, primarily anterior knee pain, are drawbacks to using this source. Hamstring tendon autograft harvest results in less donor-site morbidity and comparable strength to bone-patellar tendon-bone autograft when bundled. Quadriceps tendon autograft also has been used in knee reconstruction, offering a strong graft with less morbidity than bone-patellar tendon-bone autograft harvest. Quadriceps tendon harvest is technically challenging, however. Achilles tendon and anterior tibialis allografts, as well as both autograft/allograft patellar tendon, quadriceps tendon, and hamstring tendon can all be used to reconstruct the anterior cruciate ligament, posterior cruciate ligament, or collateral ligament complexes. Ultimately, the choice of graft is dependent on surgeon and patient preference, availability of graft sources, and the number of ligaments requiring reconstruction or augmentation.     

Low-velocity knee disclocation associated with sports injury

A knee dislocation usually involves injury to both the anterior cruciate ligament and posterior cruciate ligament,and to either the medial collateral ligament or the lateral structures of the knee. Acute surgical repair of all structures has led to a high rate of arthrofibrosis. We describe a treatment algorithm for treatment based on the healing potential of each structure. The medial collateral ligament can heal with a short duration of serial casting. The posterior cruciate ligament can heal without treatment, and patients with laxity of 2+ have similar outcomes to patients with less laxity. The anterior cruciate usually does not heal, but ACL reconstruction can be performed on an elective basis when the acute inflammatory response has subsided.     

Postoperative rehabilitation of the multiple-ligament reconstructed knee

Rehabilitation following multiple-ligament reconstruction continues to evolve although basic scientific principles continue to form the foundation for all current protocols. The protocols presented have been implemented following anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL), ACL/PCL/posterolateral complex (PLC), ACL/PCL/medial cruciate ligament (MCL), and ACL/PLC reconstructive procedures. They are designed to allow for optimal healing during the maximum and moderate protection phases, and to restore mobility and function during the final stage. These protocols should serve as guidelines only, and modifications may be necessary based on graft selection, presence of articular cartilage involvement, and surgeon preference.     

Potential pitfalls of a double PCL sign

The double posterior cruciate ligament (PCL) sign is seen on a midline sagittal MR image of the knee as a low-signal-intensity linear band paralleling the antero-inferior part of the PCL. Although the sign has a high specificity for a displaced bucket-handle tear of the medial meniscus, it can be mimicked by several normal and abnormal structures in the intercondylar region. Familiarity with these variants and identifying the other features supportive of meniscal injury will help to make a confident diagnosis of bucket-handle tear of the medial meniscus     

ACL/PCL reconstruction: the role of double-bundle PCL reconstruction

Our approach to combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries depends on the timing of the injury and concomitant ligament and bony pathology. In the acute setting (within 3 weeks), we prefer to perform single-bundle ACL and PCL reconstruction because we have seen consistently good results. However, chronic combined injuries do not fare as well because single-bundle PCL reconstruction in these injuries has not consistently corrected posterior laxity. Because of this clinical data, we now utilize a double-bundle PCL technique for knees with chronic, combined ligament deficiency with instability. This particular patient population has significant anterior, posterior, and, in many cases, posterior lateral laxity. Once the decision has been made to proceed with this procedure, attention to the technical details is critical to achieving good results. In this article, we will outline important general and specific technical details that will facilitate the procedure and optimize the clinical outcome.     

Arthroscopic reconstruction of the anterior cruciate ligament with Leeds-Keio ligament in non-professional athletes

We report our experience using the Leeds-Keio artificial ligament for anterior cruciate ligament (ACL) reconstruction. The study relates the results of the first 40 patients subjected to arthroscopic reconstruction of the ACL with a Leeds-Keio ligament, with a mean follow-up of 73 months. No associated peripheral procedures were carried out on any patient. The average age of the patients at the time of the operation was 31 years (range 26–35 years). The rehabilitation protocol followed by all patients aimed at resumption of sport 4 months after the operation. Clinical assessment included IKDC and the Lysholm scoring scale. The KT-2000 system was used for instrumented evaluation of joint laxity. All patients underwent a radiographic check-up. Clinically there were 55% excellent or good results when using the IKDC scale, while with the Lysholm score, satisfactory results were obtained in 80%. Complete post-traumatic rupture of the ligament was observed in three patients. No patient suffered an episode of either hydrarthrosis or reactive synovitis, which indicates good tolerance to the ligament. The radiographic evaluation of the operated knees showed a close correlation between the appearance of degenerative phenomena and performance of arthroscopic meniscectomy. The results achieved with the Leeds-Keio artificial ligament 5 years after application, although not completely satisfactory and inferior to those obtained with autologous biological ligaments, should be considered an encouragement to promote new efforts in this interesting research field.     

Simultaneous bilateral anterior cruciate ligament tears in a female beginner skier

We present a case of simultaneous bilateral ACL tears in a woman injured while skiing for the first time. We discuss the role of intercondylar notch stenosis as a high-risk factor for tearing the ACL, the injury mechanism, prevention measures, and the therapeutic strategy. Received: 10 January 2000 Accepted: 10 April 2000     

单纯后交叉韧带断裂继发关节内损伤的临床研究

自 1 973年至 2 0 0 2年间我所诊治单纯后交叉韧带断裂共 5 4例 ,其中进行了关节内探查的有 40例 ,急性伤 9例 (≤ 6周 ) ,慢性伤 3 1例 ( >6周 )。分别对这 40例病例的关节软骨损伤发生率、损伤部位和损伤程度及半月板损伤的发生率、损伤部位及损伤类型进行了统计学研究 ,同时对前、后交叉韧带断裂之间和运动员与非运动员之间的继发关节内损伤进行了统计学比较 ,对创伤机制也进行了相应的研究。结果显示 ,后交叉韧带断裂最常见创伤机制为胫前伤 ( 5 1 85 % )。非运动员中摩托车伤最多见 ( 2 3 5 3 % )。伤后慢性期软骨损伤发生率明显高于急性期 (P <0 0 5 )。前、后交叉韧带断裂后急性期与慢性期之间及运动员与非运动员之间软骨损伤发生率无明显差异。后交叉韧带断裂后软骨损伤最易发生于髌股关节 (P <0 0 1 ) ,其次为股骨内髁负重区 ,与前交叉韧带断裂更易发生于内、外髁相比 ,明显不同。非运动员软骨损伤程度要重于运动员 (P <0 0 5 )。后交叉韧带断裂后急慢性期半月板损伤发生率相近。慢性期外侧半月板损伤居多 (P <0 0 1 )。运动员更易发生半月板损伤 (P <0 0 1 )。后交叉韧带断裂后内外侧半月板损伤均少于前交叉韧带 ,慢性期尤甚 (P <0 0 0 1 )。后交叉韧带断裂后半月板损伤的部位以外侧