Symptomatische Partialrupturen des vorderen Kreuzbands

The anterior cruciate ligament (ACL) consists of two anatomical and functional bundles, the anteromedial (AM) and posterolateral (PL) bundles. Different injury pattern demonstrate a wide spectrum of partial ACL tears. Clinical interest has recently focused on performing selective ACL augmentation according to the specific injury pattern. Theoretically, sparing the intact parts of the ACL may increase vascularization and proprioception, can optimize the accuracy of ACL reconstruction and result in better stability and improved clinical outcome for the patient. However, isolated reconstruction of the AM or PL bundle is an advanced arthroscopic procedure that requires precise preoperative and intraoperative diagnostic assessment of the injury pattern, exact anatomical definition of the insertion sites and careful debridement and bone tunnel placement while preserving the intact parts of the ACL. This article presents the concept of partial ACL rupture, describes the clinical, radiological and arthroscopic assessment of partial tears as well as the arthroscopic reconstruction.     

Revisionsrekonstruktion des vorderen Kreuzbandes mit begleitender Korrekturosteotomie

ACL revision reconstruction and simultaneous osteotomy is indicated in patients with recurrent instability and symptomatic malalignement. Detailed clinical examination is essential for finding of subjective main pathology. Extensive apparative screening helps avoiding serious intraoperative complications. This includes weight bearing, x-rays in full extension and 30° flexion and CT scan for evaluation of bone cavity measurement. According to IKDC rating scale ACL revision reconstruction and simultaneous osteotomy rarely leads to excellent results (1/19) due to the preexisting cartilage damage but significantly increases quality of life (18/19) of these patients.     

Prevention and Management of Post-operative Complications Following ACL Reconstruction

Purpose of Review

The goal of this paper is to review the current management and prevention of post-operative complications after anterior cruciate ligament (ACL) reconstruction. Trends in rehabilitation techniques will be presented, in addition to suggestions for interventions and expected milestones in ACL reconstruction recovery.

Recent Findings

ACL reconstruction protocols have evolved to more of a criterion-based progression rather than a tissue-healing time frame. Given the evolution of ACL surgical reconstruction techniques and rehabilitation protocols, the risk of post-operative complications can arise both early and late in the recovery process. This paper will discuss the role of preventative measures as it applies to the post-operative patient with ACL reconstruction.

Summary

Short-term complications following ACL reconstruction include infection and deficits to knee motion and strength, whereas long-term complications include secondary ACL injury to either the involved or contralateral knee and lack of ability to return to high-level sports following this procedure. Future research should continue to address the multifactorial causes of secondary ACL injury and limited ability of patients to return to high level activities.

     

镜下前交叉韧带重建术中止血带应用的探讨

随着人们运动意识水平的增强和社会交通的快速发展,关节损伤患者的数量也大幅增加,而前交叉韧带(ACL)损伤是关节损伤中最常见的韧带损伤.目前治疗ACL损伤的标准手术方式是在关节镜下使用止血带进行前交叉韧带重建手术(ACLR),在ACLR中使用止血带可以减少患者出血,为术者提供一个清晰的手术视野,可为手术提供极大的便利,但...     

Second time around: evaluating the postoperative anterior cruciate ligament

Anterior cruciate ligament (ACL) injuries are especially common in the younger athletic population. In 1998, more than 100,000 ACL reconstructions were performed. MR imaging examination has proved to be valuable in imaging and evaluating ACL reconstructions. This article reviews different surgical reconstruction procedures, indications for postoperative MR imaging, and the MR imaging appearance seen in routine ACL reconstructions and in complications associated with ACL reconstructions.     

Ersatzplastik des vorderen Kreuzbandes bei offenen Wachstumsfugen

The natural history of ligamentous tears of the anterior cruciate ligament (ACL) in children is unfavourable because of the high number of secondary meniscus lesions and early manifestation of osteoarthritis. Although their incidence still is relatively small, the number of ACL tears in children has increased over the last years. There is controversy about the treatment of these lesions, especially considering the long-term conservative approach. Recent studies have shown that ACL reconstructions in children can yield good clinical results and few complications if performed in a technically correct way with respect to the specific anatomy of childrens knees – even before puberty. The functional demands of the patient and the complication potential should be considered while indicating the procedure. A precise knowledge of the anatomical specificities of the childs knee and a large experience in ACL reconstruction surgery should be mandatory when taking care of these injuries. The present review gives a current overview of the management of these lesions in pre-adolescent children.     

关节镜下联合应用Rigidfix、Endobutton和Intrafix系统固定腘绳肌腱重建前交叉韧带

背景：关节镜下前交叉韧带重建是治疗膝关节前交叉韧带损伤的金标准,但在肌腱的固定方式方面仍有分歧。目的：观察联合运用Rigidfix、Endobutton和Intrafix系统在关节镜下进行自体腘绳肌腱重建前交叉韧带的临床效果。方法：选取2009-05/2010-05在郑州大学第一附属医院关节外科应用Rigidfix、Endobutton和Intrafix系统行关节镜下自体腘绳肌腱重建前交叉韧带的患者30例,该组患者关节镜下均证实为膝关节前交叉韧带损伤断裂。其中男22例,女8例,年龄16~45岁。将患者股骨端用Endobutton、Rigidfix固定,胫骨端用Intrafix固定,观察术后近期疗效,以Lysholm评分、IKDC评分评价膝关节功能。结果与结论：对30例患者随访5~17个月（平均12个月）,随访期间无严重并发症发生,所有患者患膝关节活动度正常,平均Lysholm评分和IKDC评分分别由术前的（50.0±6.0）分和（49.5±5.5）分提高到术后的（85.5±3.5）分和（87.0±2.5）分（P〈0.05）。说明联合应用Rigidfix、Endobutton和Intrafix系统进行自体腘绳肌腱重建前交叉韧带的方法具有近期疗效佳、移植物固定可靠、并发症少等优点,能够达到良好的临床康复效果。     

Pediatric anterior cruciate ligament reconstruction

An increasing number of anterior cruciate ligament (ACL) injuries are seen in children now than in the past due to increased sports participation. The natural history of ACL deficient knees in active individuals, particularly in children is poor. Surgical management of ACL deficiency in children is complex due to the potential risk of injury to the physis and growth disturbance. Delaying ACL reconstruction until maturity is possible but risks instability episodes and intra-articular damage. Surgical options include physeal-sparing, partial transphyseal and complete transphyseal procedures. This article reviews the management of ACL injured skeletally immature patients including the functional outcome and complications of contemporary surgical techniques.     

Verschiedene Techniken zur Ersatzplastik des vorderen Kreuzbands

A wide variety of proven methods for anterior cruciate ligament (ACL) surgery is known for treating a very mixed group of patients. The gold standard for ACL replacement today is anatomic single bundle reconstruction using hamstring tendon, patellar tendon or quadriceps tendon as autologous graft. An indication for ACL double bundle reconstruction is seen in patients with large insertion zones. The double bundle concept also includes replacement of a partial rupture or remnant augmentation. Graft choice should be adapted to the individual patient. For specific graft choice age, gender, activity, sports, professional and religious habits should be considered.     

关节镜下LARS人工韧带在重建前交叉韧带中的临床应用

目的探讨在关节镜下运用韧带增强重建系统（LARS）人工韧带重建前交叉韧带的手术方法和临床疗效。方法 2007年6月起运用法国LARS人工韧带治疗前交叉韧带断裂14例。等距点建立胫骨和股骨骨道,置入韧带后游离纤维位于关节腔内,挤压螺钉固定。结果经平均18个月随访,术后Lysholm评分平均92分,优9例,良5例,优良率为100%。术后无感染、无韧带断裂,无膝关节疼痛。结论运用＂LARS人工韧带＂重建前交叉韧带可达到解剖重建,可有效恢复膝关节稳定性;关节镜下手术拥有创伤小、康复快、疗效好等微创特点。     

Bildgebung postarthroskopischer Komplikationen nach Knieverletzungen

The most common joint injuries in professional and recreational sports participants and also in the total population are knee injuries. Arthroscopy is indicated if this modality will improve the patient outcome and potential long-term complications can be avoided. Although uncommon, complications following arthroscopy are mostly evaluated by magnetic resonance imaging (MRI). For planning further therapy strategies following postarthroscopic complications, e.g. if anterior cruciate ligament (ACL) reconstruction is required, digital radiographs and computed tomography (CT) are helpful. This article provides an overview of the different procedures for surgical treatment which are a prerequisite for the analysis of postarthroscopic images. In addition typical complications after treatment of meniscal and chondral injuries as well as after ACL reconstruction are described and typical signs in MRI, radiography and CT are explained in detail.     

Agreement Between Isokinetic Dynamometer and Hand-held Isometric Dynamometer as Measures to Detect Lower Limb Asymmetry in Muscle Torque After Anterior Cruciate Ligament Reconstruction

BackgroundTwo commonly used instruments to assess muscle strength after anterior cruciate ligament reconstruction are the isokinetic dynamometer, which measures isokinetic torque and the hand-held dynamometer, which measures isometric torque. Isokinetic dynamometers are considered superior to other instruments but may not be commonly used in clinical settings. Hand-held dynamometers are small, portable, and more clinically applicable devices.PurposeThe purpose of this study was to assess agreement between a hand-held dynamometer and an isokinetic dynamometer, used to assess lower limb symmetry in knee muscle torque one year after anterior cruciate ligament (ACL) reconstruction.Study designCross-sectional measurement studyMethodsSeventy-two participants who had undergone ACL reconstruction (35 men, 37 women; age= 25.8 ± 5.4 years) were included. Isokinetic muscle torque in knee flexion and extension was measured with an isokinetic dynamometer. Isometric flexion and extension knee muscle torque was measured with a hand-held dynamometer. Bland & Altman plots and Cohen’s Kappa coefficient were used to assess agreement between measurements obtained from the instruments.ResultBland & Altman plots showed wide limits of agreement between the instruments for both flexion and extension limb symmetry index. Cohen´s Kappa coefficient revealed a poor to slight agreement between the extension limb symmetry index values (0.136) and a fair agreement for flexion limb symmetry index values (0.236). Cross-tabulations showed that the hand-held dynamometer detected a significantly larger number of participants with abnormal flexion torque limb symmetry index compared to the isokinetic dynamometer.ConclusionThe wide limits of agreements and Cohen’s Kappa coefficients values revealed insufficient agreement between the measurements taken with the two instruments, indicating that the instruments should not be used interchangeably. The hand-held dynamometer was more sensitive in detecting abnormal limb symmetry index in flexion torque, which promotes the option of use of hand-held dynamometers to detect differences between the injured and uninjured leg after ACL reconstruction.Level of evidence3b     

Current and future of anterior cruciate ligament reconstruction techniques

In recent years, anterior cruciate ligament (ACL) reconstruction has generally yielded favorable outcomes. However, ACL reconstruction has not provided satisfactory results in terms of the rate of returning to sports and prevention of osteoarthritis (OA) progression. In this paper, we outline current techniques for ACL reconstruction such as graft materials, double-bundle or single-bundle reconstruction, femoral tunnel drilling, all-inside technique, graft fixation, preservation of remnant, anterolateral ligament reconstruction, ACL repair, revision surgery, treatment for ACL injury with OA and problems, and discuss expected future trends. To enable many more orthopedic surgeons to achieve excellent ACL reconstruction outcomes with less invasive surgery, further studies aimed at improving surgical techniques are warranted. Further development of biological augmentation and robotic surgery technologies for ACL reconstruction is also required.     

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。     

岛状背阔肌肌皮瓣乳房再造加腋前皱襞重建术的护理配合

目的探讨乳腺癌根治术后Ⅱ期应用岛状背阔肌肌皮瓣加乳房假体行乳房再造术及腋前皱襞重建手术的护理配合。方法回顾性总结13例乳腺癌根治术后1—4年胸壁严重缺损患者行Ⅱ期岛状背阔肌肌皮瓣加乳房假体行乳房再造术及腋前皱襞重建的手术配合,包括术前人员、器械、物品及病人的准备,术中护士的配合方法。结果13例手术均获得成功,未发生由于器械或配合不良耽误手术,术中、术后皮瓣成活,切口无感染、均Ⅰ期愈合,无并发症发生,乳房外形良好,患者满意。结论术前物品准备充分及做好心理护理,取得患者的最佳配合;术中熟练的手术配合技巧是手术顺利完成的重要保证。     

关节镜下异体骨-髌腱-骨前交叉韧带重建术围手术期的护理

目的探讨膝关节镜下异体骨-髌腱-骨前交叉韧带(ACL)重建术后早期功能锻炼的方法,最大限度地减少合并症及功能障碍等不良反应。方法对8例前交叉韧带损伤患者实施异体骨-髌腱前交叉韧带重建术,术后通过使用可调式支具外固定、被动活动器(CPM)、被动及主动功能锻炼等康复护理。结果8例术后均获随访,时间为27~77个月,平均41个月。按Lukianov的ACL重建术后功能评定标准,优8例。随访结果显示,术前7例Lanchman试验阳性,术后均阴性;术前6例前抽屉试验阳性,术后均呈阴性;术前6例有明显膝关节不稳定感,术后均消失;术后8例功能锻炼后膝关节活动度可达0~90°。结论ACL重建术后早期进行综合康复训练明显有利于膝关节功能的恢复。     

Das hohe mediale Portal

An overview of the lateral condyle of the femur and the complete insertion field of the anterior cruciate ligament (ACL) is difficult using a standard portal. For this reason we place the arthroscope for preparation of the femoral tunnel in an additional higher anteromedial portal. The instruments (portal target instrument and borer) are introduced into the joint via a deep set anteromedial portal. The surgeon has an excellent overview of the insertion field of the ACL during the whole tunnel preparation procedure via the high anteromedial portal. We employ this technique for single and double-bundle reconstruction procedures.     

关节镜下横杆悬挂法重建前交叉韧带

背景：固定移植腱的方法多种多样,每种系统各有其优势,对于用何种方法固定移植的肌腱,目前国际上仍没有一个统一的标准。目的：观察关节镜下横杆悬挂固定法固定自体腘绳肌腱重建膝关节前交叉韧带的临床疗效。方法：选择2008-09/2010-01于安徽医科大学第一附属医院骨二科行膝关节前交叉韧带重建的患者20例。所有患者均应用股骨端横杆悬挂固定和胫骨端界面螺钉组成前交叉韧带固定系统行自体腘绳肌腱前交叉韧带单束重建。重建后随访6～16个月（平均10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,无严重并发症发生,重建后膝关节活动度均正常。所有患者术前Lysholm膝关节评分为（60.20±11.54）分,重建后6个月为（92.95±3.55）分,较术前明显提高（P〈0.05）。截至重建后6个月,IKDC评分18例正常,其余2例接近正常。说明关节镜下应用自体腘绳肌腱横杆悬挂固定法重建前交叉韧带是一种疗效确切的固定方法。     

关节镜下四股自体腘绳肌重建膝前交叉韧带的疗效观察

目的探讨关节镜下四股腘绳肌腱治疗膝前交叉韧带损伤的手术方法和疗效。方法对25例前交叉韧带损伤者实施关节镜下四股腘绳肌静力重建。结果随访3—38个月,24例膝关节不稳症状消失,膝活动度0°～112°,平均（107．3±1．24）°。1例术后出现膝内侧疼痛;1例术后患膝伸直型僵直,经关节镜下松解后有效改善。根据Lysholm膝关节评分法,患膝评分由术前（47．71±2．52）分提高到术后（82．35±1．01）分。结论膝前交叉韧带损伤重建应依据患者对关节功能需求和韧带损伤程度酌情选择重建术式,关节镜下自体腘绳肌重建前交叉韧带取材方便,Endo—Button“悬吊”四股胭绳肌腱的长度和强度合理,术后骨一腱愈合程度满足膝关节功能需要。     

Doppelbündel- vs. Einzelbündelrekonstruktion

The discussion on advantages and disadvantages of double bundle (DB) anterior cruciate ligament (ACL) reconstruction is controversial in the literature. The ACL consists of two functional bundles, an anteromedial (AM) bundle and a posterolateral (PL) bundle showing a distinct synergetic tensioning pattern. The PL bundle tightens in extension and is slack in flexion whereas the AM bundle is tight in extension, loses tension up to a flexion of 30° and then tightens rapidly in further flexion. Using a DB ACL reconstruction approach these two bundles are restored separately. Several biomechanical studies have shown that the tensioning pattern of the bundles could be restored better by this approach compared to a single bundle (SB) reconstruction. In vitro knee kinematics in terms of a-p translation and rotational stability was also restored better using DB reconstruction. Clinical studies support these findings. Most of the outcome studies found that there was better stability (KT 1000 and pivot shift test) when an anatomical DB reconstruction was used. In clinical outcome scores most of the studies could not demonstrate a superiority of DB versus SB reconstruction. The biomechanical advantages of DB reconstruction are counteracted by several disadvantages (e.g. increased risk of tunnel malplacement and revision surgery). Therefore an anatomical single bundle approach should be the gold standard in ACL reconstruction. An anatomical double bundle approach should only used in specific centers with high numbers of ACL cases.