Comparison of minimally invasive reduction through a bone tunnel combined with Jail screwing and posterolateral locking plating for simple posterolateral tibial plateau fractures北大核心CSCD

Objective To compare the clinical effects of minimally invasive reduction through a bone tunnel combined with Jail screwing and those of posterolateral locking plating in the treatment of simple posterolateral tibial plateau fractures. Methods A retrospective analysis was conducted of the data of 48 patients who had been operatively treated and completely followed up at Department of Orthopedics, Suqian Hospital of Nanjing Drum Tower Hospital Group for simple posterolateral tibial plateau fractures from October 2016 to October 2020. There were 26 males and 22 females, aged from 35 to 68 years. They were divided into a minimally invasive group (25 cases subjected to minimally invasive reduction through a bone tunnel combined with Jail screwing) and an incision group (23 cases subjected to posterolateral locking plating) according to their surgical methods. The operation time, incision length, intraoperative blood loss, fracture healing time, cumulative fluoroscopy time, hospital stay and posterior inclination angles of the tibial plateau and Hospital for Special Surgery (HSS) knee function scores at 1, 3, 6, 9, and 12 months after operation were compared between the 2 groups. Complications in the 2 groups of patients were recorded. Results There was no significant difference in the preoperative general data between the 2 groups, showing comparability (P>0.05). The 48 patients were followed up for 12 to 36 months (average 16.5 months). The minimally invasive group was significantly better than the incision group in operation time [(42.6±9.1) min versus (65.7±11.5) min], incision length [(4.0±0.4) cm versus (15.0±1.5) cm], intraoperative blood loss[(22.6±5.8) mL versus (31.5±8.8) mL], hospital stay [(7.6±1.4) d versus (11.1±2.4) d], and HSS score one month after operation [(84.8±1.9) points versus (72.9±4.1) points], but the cumulative fluoroscopy time in the incision group [(4.1±1.4) s]was significantly less than that in the minimally invasive group [(22.3±4.2) s] (P<0.05). There were no significant differences in fracture healing time, HSS scores at 3, 6, 9, or 12 months after operation, or posterior inclination angle of the tibial plateau between the 2 groups (P>0.05). There were no such complications as wound infection, vascular injury, internal fixation failure, nonunion or malunion of fractures in either of the 2 groups. Two cases in the incision group presented with symptoms of common peroneal nerve injury but recovered 3 months after operation. Conclusions Although both minimally invasive reduction through a bone tunnel combined with Jail screwing and posterolateral locking plating can achieve satisfactory outcomes in the treatment of simple posterolateral tibial plateau fractures, the minimally invasive technique is preferable because it shows the advantages of a smaller incision, less bleeding, shorter operation time, a lower operation risk, quicker postoperative recovery and shorter hospital stay. © 2022 Chinese Journal of Orthopaedic Trauma. All rights reserved.     

改良全关节镜下胫骨Inlay技术重建后十字韧带的实验研究

目的 探讨采用改良全关节镜下胫骨Inlay技术重建膝关节后十字韧带(posterior cruciate ligament,PCL)手术方法的特点及优势.方法 设计专门的胫骨隧道形态及配套的胫骨钻头,设计移植物的形态和固定方法.在5具成人膝关节标本上模拟操作,年龄25～65岁;左膝2例,右膝3例.设计出全关节镜下胫骨Inlay技术重建PCL的手术操作流程(包括建立胫骨隧道的方法,移植物的引入等).操作完成后切开实验标本,进行二次观察,观察胫骨隧道内口的形态和位置是否达到设计的要求.通过对30张正常MRI片进行测量,确定胫骨隧道的角度,明确术中PCL定位器的角度.结果 胫骨隧道内口设计成14 mm×7 mm×15 mm的圆锥状,外口为直径7 mm的圆柱状,配套的胫骨钻头设计成分体式,钻头在体外装配.胫骨平台后缘斜坡与水平成36°～47°,定位器角度设定为50°.移植物使用异体跟腱,移植物骨块设计成圆锥状,与胫骨隧道内口相匹配,移植物胫骨隧道外口使用纽扣钢板固定.5例标本手术均获得成功,切开行二次检查结果显示,其中4例移植物和胫骨隧道匹配,另1例隧道外口直径偏小,移植物无法完全嵌入.结论 改良全关节镜下胫骨Inlay技术重建膝关节PCL手术具有操作简单、准确、快速、固定牢靠的特点.

Abstract：

Objective To improve the arthroscopic posterior cruciate ligament (PCL) reconstruction using tibial Inlay technique. Methods The special arthroscopic device and related fixation technique were designed. Five cadaveric knees were used to simulate the process of arthroscopic posterior cruciate ligament reconstruction using tibial Inlay technique. The knees were cut open to observe whether the outlet of the tibial tunnel shape and location met the design requirements. Thirty normal MRI films were measured to identify tunnel angle and localizer angle. Results The inner outlet of tunnel was conical shape(14 mm×7 mm×15 mm) and the outer outlet was cylinder-shaped (a diameter of 7 mm). The tibial drill was designed into a split structure and could be assembled in vitro. According to the data obtained from MRI films, the angle between the plane of posterior cruciate ligament and horizontal place was 36°-47°, and the localizer was fixed at 50°.The achilles tendon was used as implant and the allogft bones were designed into conical shape to fit the inner outlet of tunnel. The other end of implant to the proximal tibia was fixed with button plate. All reconstruction operations were performed under arthroscopy. The outcomes of procedure were satisfactory. There were no vascular or peripheral nerve injuries in the cadaveric knees The tunnel position was accurate and the shape of tunnel had met the design requirements. Conclusion Our results imply that improved arthroscopic of posterior cruciate ligament using tibial Inlay technique is simple, accurate, rapid and stable fixation.     

Akagi胫骨前后轴在全膝关节置换术中的定位作用

Objective To investigate the relationship between tibial anteroposterior axis and other anatomic landmarks in determining the rotation of tibial prosthesis in total knee arthroplasty using computed tomography. Methods Transverse CT scans of 40 volunteers' right knee in full extension were made. The anteroposterior axis of the tibia was defined as a line which was perpendicular to the transepicondylar axis and passing through the middle point of the posterior crnciate ligament. At the tibial plateau and optimum re-section level, the mean medial percentage width of intersection point of the patellar tendon anti the antero-posterior axis was measured. The mean angle between the anteroposterior axis and a line connecting the middle of the posterior cruciate ligament and the medial of the patellar tendon and the medial 1/3 of the patellar tendon were measured. Results At the tibial plateau level, the mean medial percentage width of intersection point of the patellar tendon was 10.1%±8.3%. At the optimum resection level, the mean medial percentage width of intersection point of the patellar tendon was 0.2%±10.0%. At the optimum resection lev-el, the mean angle between the anteroposterior axis and a line connecting the middle of the posterior cruciate ligament and the medial of the patellar tendon was 0.1°±2.7°. The mean angle between the anteroposterior axis and a line connecting the middle of the posterior cruciate ligament anti the medial 1/3 of the patellar tendon was 10.3°±3.6°. Conclusion There was a tendency to align the tibial component in external rotation relative to the femoral component when the medial 1/3 of the patellar tendon was used. The line connecting the middle of the posterior cruciate ligament and the medial of the patellar tendon can be used as a reliable axis for correct rotational orientation of the tibial component.     

Anterolateral rotatory instability in vivo correlates tunnel position after anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft

AIM To quantitatively assess rotatory and anterior-posterior instability in vivo after anterior cruciate ligament(ACL) reconstruction using bone-patellar tendon-bone(BTB) autografts, and to clarify the influence of tunnel positions on the knee stability.METHODS Single-bundle ACL reconstruction with BTB autograft was performed on 50 patients with a mean age of 28 years using the trans-tibial(TT)(n = 20) and trans-portal(TP)(n = 30) techniques. Femoral and tibial tunnel positions were identified from the high-resolution 3 D-CT bone models two weeks after surgery. Anterolateral rotatory translation was examined using a Slocum anterolateral rotatory instability test in open magnetic resonance imaging(MRI) 1.0-1.5 years after surgery, by measuring anterior tibial translation at the medial and lateral compartments on its sagittal images. Anterior-posterior stability was evaluated with a Kneelax3 arthrometer.RESULTS A total of 40 patients(80%) were finally followed up. Femoral tunnel positions were shallower(P 0.01) and higher(P 0.001), and tibial tunnel positions were more posterior(P 0.05) in the TT group compared with the TP group. Anterolateral rotatory translations in reconstructed knees were significantly correlated with the shallow femoral tunnel positions(R = 0.42, P 0.01), and the rotatory translations were greater in the TT group(3.2 ± 1.6 mm) than in the TP group(2.0 ± 1.8 mm)(P 0.05). Side-to-side differences of Kneelax3 arthrometer were 1.5 ± 1.3 mm in the TT, and 1.7 ± 1.6 mm in the TP group(N.S.). Lysholm scores, KOOS subscales and reinjury rate showed no difference between the two groups.CONCLUSION Anterolateral rotatory instability significantly correlated shallow femoral tunnel positions after ACL reconstruction using BTB autografts. Clinical outcomes, rotatory and anterior-posterior stability were overall satisfactory in both techniques, but the TT technique located femoral tunnels in shallower and higher positions, and tibial tunnels in more posterior positions than the TP technique, thus increased the anterolateral rotation. Anatomic ACL reconstruction with BTB autografts may restore knee function and stability.     

In vitro study of knee stability after two-band two-tunnel posterior cruciate ligament reconstruction

Objective: To compare the ability of three different reconstruction procedures in restoring the posterior displacement of tibia and the posterior stability of the knee joint from 0°to 120°flexion. Methods: Three posterior cruciate ligaments (PCL) reconstruction procedures were performed, namely two-band two-tunnel reconstruction, one-band anterior tunnel reconstruction and one-band posterior tunnel reconstruction. The posterior displacement of the tibia in relation to the femur was measured when a 200 N posterior force was applied. Results: Within the flexion range of 0°to 30°, the displacement in the one-band posterior tunnel reconstruction showed little difference from that of an intact knee (P>0.05). But when the flexion exceeded 30°, especially when it exceeded 60°, the displacement in one band posterior tunnel reconstruction was much greater than that of an intact knee (P<0.01). In two-band two-tunnel reconstruction and one-band anterior tunnel reconstruction, the displacement was approximately the same as that of an intact knee ranging from 0°to 120°(P>0.05), while a slight over-restriction might be found at some angles. Conclusions: Two-band reconstruction could effectively restrict the posterior displacement of the tibia and restore anterior, posterior stability of the knee joint within its full range of flexion. One-band anterior tunnel reconstruction also could maintain the posterior stability of the knee, while the result of one-band posterior tunnel reconstruction is the most unsatisfactory.     

Comparison of hook thin plate compression technique with conventional screw-plate fixation for tibial tubercle avulsion fractures in adolescents北大核心CSCD

Objective To compare the outcomes between hook thin plate compression technique and conventional screw-plate fixation in the treatment of adolescent tibial tubercle avulsion fractures. Methods A retrospective analysis was performed of the 43 adolescent patients with tibial tubercle avulsion fracture who had been treated at Department of Orthopedics and Traumatology, Beijing Jishuitan Hospital from January 2018 to October 2020. There were 42 males and one female, aged from 13 to 17 years. According to their treatment methods, they were divided into an observation group (9 cases) treated with hook thin plate compression technique and a control group (34 cases) treated with fixation with cannulated screws alone or in addition with a 1/3 tube plate. The maximum range of knee flexion, Böstman score, and cases returning to school at one month after operation, as well as fracture union time, Böstman score and cases with complications at the last follow-up were compared between the 2 groups. Results There were no significant differences in the preoperative general data between the 2 groups, showing comparability (P>0.05). By the postoperative one month, the maximum range of knee flexion [90.0° (85.0°, 102.5°)], Böstman score [21.0 (18.5, 21.0)] and cases returning to school (7) in the observation group were significantly better than those in the control group [22.5° (15.0°, 30.0°), 11.0 (10.0, 13.0), and 0] (P<0.001). The last follow-up revealed no significant differences between the 2 groups in frature union time [(2.7±0.5) months versus (2.8±0.5) months], Böstman score [30.0 (30.0, 30.0) versus 30.0 (30.0, 30.0), 30.0)] or cases with complications (1 versus 2) (P>0.05). Conclusion In the treatment of adolescent tibial tubercle avulsion fractures, compared with conventional fixation with cannulated screws alone or in addition with a 1/3 tube plate, hook thin plate compression technique may lead to better outcomes, because it allows early rehabilitation to shorten the postoperative immobilization time and promote early functional recovery. © 2022 Chinese Journal of Orthopaedic Trauma. All rights reserved.     

Proximal tibial osteotomy for genu varum: Radiological evaluation of deformity correction with a plate vs external fixator

BACKGROUND High tibial osteotomy(HTO) is a well-known procedure for the correction of knee varus. The purpose of this study was to compare the radiological results and accuracy of deformity correction performed using two different techniques: acute opening wedge correction using a plate and gradual correction with a monolateral external fixator.AIM To compare of the radiological results of two different techniques: acute opening wedge correction(a plate and screw) and gradual correction(external fixator).METHODS A total of 43 patients with plates and 36 patients with external fixators were included. All patients had moderate uniplanar varus deformities. We measured radiographic parameters, including the mechanical axis deviation(MAD), medial proximal tibial angle(MPTA), Caton-Deschamps Index(CDI), posterior proximal tibial angle, and joint line obliquity angle(JLOA). The accuracy of MAD correction was calculated based on a correction goal of neutral or overcorrection for medial compartment arthritis.RESULTS Demographics including age, body mass index, sex, and preoperative deformities were similar between the groups. The MAD significantly improved from 23.6 mm medial to the midline(SD = 8.2 mm) to 6.9 mm lateral to the midline(SD = 5.4 mm)(P 0.001). The accuracy of MAD correction did not differ between the groups and was 96.1%(SD = 8.1%) in the plate group and 98.2%(SD = 5.2%) in the external fixator group(P = 0.18). The MPTA significantly improved from 83.9°(SD = 2.9°) to 90.9°(SD = 3.3°)(P 0.001), and the change was similar between the groups. Differences were noted in patella height, with a CDI change of-19.2%(SD = 13.7%) and 3.1%(SD = 8.0%) for the plate and external fixator groups, respectively(P 0.001). The change in JLOA was 1.6 degrees(SD = 1.1 degrees) and 0.9 degrees(SD = 0.9 degrees) for the plate and external fixator groups, respectively(P = 0.04).CONCLUSION Reliable correction of moderate varus alignment was achieved with both the acute opening wedge technique with a plate and the gradual monolateral external fixator technique. The patellar height decreased with the open wedge plate technique. Joint line obliquity decreased to a greater degree with the open wedge plate technique, perhaps as a result of medial collateral ligament release. The appropriate technique should be selected based on surgeon and patient preferences; however, external fixation may be a better choice when the preservation of patellar height is deemed important.     

Anatomic assessment of femoral tunnel by transtibial drilling technique in double-bundle anterior cruciate liga- ment reconstruction： an in vivo study

Objective： To evaluate the anatomy of femoral tunnels created by simulated transtibial technique in double-bundle anterior cruciate ligament （ACL） reconstruction. Methods： Two tibial tunnels, anteromedial （AM） and posterolateral （PL）, were drilled 45° and 55° to tibial plateau respectively. On the femoral side, the AM and PL tunnels were drilled through anteriomedial portal. After the four tun- nels were established, the shaft of a reamer was introduced into the joint through tibial tunnel and reached against the lateral wall of intercondylar notch. The position that the reamer shaft can reach was marked and recorded. Results： Neither femoral AM nor PL tunnel opening can be fully or partially reached by the reamer shaft through the tibial AM tunnel in all cases. The evaluation through the tibial PL tunnel showed that only in 8 of 50 cases （16%） the femoral AM tunnel opening and in 4 cases （8%） the PL opening can be fully reached. On the other hand, in 12 cases （24%） the femoral AM tunnel opening and in 10 cases （20%） the PL opening can be partially reached by the shafts through the tibial PL tunnel. Conclusion： The result strongly suggests that transtibial technique is not well competent for femoral tun- nel drilling in anatomic double-bundle ACL reconstruction as we have hypothesized.     

记忆合金加压钉抑制脊柱矢状面生长的实验研究

目的 探讨记忆合金加压钉植入后非融合性抑制胸段脊柱矢状面生长的作用.方法 将18只幼年雌性山羊随机分为长钉组、短钉组、对照组各6只.长钉组和短钉组通过前路手术在前凸的T6～11胸椎节段植入记忆加压长钉(齿长7 mm)、短钉(齿长4 mm),对照组不予手术.分别于术前、术后3个月行X线片检查,测量Cobb角,对手术前后组间数据及组内自身对照数据进行统计学分析,并计算后凸增加率.大体观察被固定节段脊柱是否融合.结果 全部样本无脱失,均进入结果分析.T6～11 Cobb角,短钉组术前为7.0°±2.3°,术后3个月为12.7°±4.7°,后凸增加率为81.4%;长钉组术前为6.2°±4.0°,术后3个月为14.0°±4.9°,后凸增加率为125.8%;术前及术后长钉短钉两组组间比较,差异均无统计学意义(术前P=0.655;术后P=0.596).将长钉组和短钉组分别与对照组比较,术前差异均无统计学意义(分别为P=0.929和P=0.720);术后差异均有统计学意义(分别为P=0.007和P=0.021).大体观察证实,植入记忆合金加压钉节段脊柱未融合.结论 在山羊胸椎正前方植入记忆合金加压钉可以非融合性控制山羊胸椎的矢状面生长,增加后凸角度.

Abstract：

Objective To present that Nickel-Titanium (NT) memory alloy staples in fusionlessly controlling the growth of the vertebrates in the sagittal plane. Methods Eighteen infant female goats were selected and equally divided into 3 random groups:long staple group, short staple group and blank control group. Five long staple (the legs' length = 7 mm) and five short staple (the legs' length =4 mm) were implanted into each goat in long and short staple groups repecetively by anterior approach, right on the front of the thoracic vertebrae from T6 to T11. The control group was not given any treatment. X-ray examination was performed pre-operatively and post-operatively. Cobb angle of lateral radiograph was measured and the data of Cobb angle were statistically analyzed. At the end of the experiment, whether the staples implanted spinal columns were fused or not were evaluated by gross observation. Results Finally, all of the goats were included in the final results. Before the operations, T6-11 sagittal Cobb angle was 7.0°±2.3°in short staple group, and 6.2°±4.0°in long staple group. And after the operation, the T6-11 Cobb angle was increased to 12.7°±4.7°in short staple group with the increased rate of 81.4%, and 14. 0°±4. 9° in long staple group with the increased rate of 125.8%, respectively. Before and after the surgery, there were no significant differences between long staple group and short staple group in terms of Cobb angle ( pre-operation P=0. 655, post-operation P = 0. 596). Before the surgery, there were no differences in terms of Cobb angle,between long staple groups and control group ( P =0.929), and short staple groups and control group( P=0.720). At the end of the experiment, there were significant differences between long staple group and control group in terms of Cobb angle ( P = 0. 007), and between short staple group and control group (P=0.021).The staples implanted spinal columns were not fused which was proved by gross observation. Conclusions The memory alloy staple implantation by anterior approach, right on the front of the thoracic vertebrae of goats, can control the growth of thoracic vertebrates leading to kyphosis.     

Biplane osteotomy and bone transport combined external locking plating for sequential treatment of massive tibial bone defects北大核心CSCD

Objective To evaluate biplane osteotomy and bone transport combined external locking plating for sequential treatment of massive tibial bone defects. Methods Twenty-eight patients with massive tibial bone defects were reviewed who had been treated at Department of Repair and Reconstruction, Wuhan Puai Hospital from October 2013 to October 2019. They were divided into a bone transport group and a combined bone transport group (bone transport combined external locking plating) according to their surgical methods. In the bone transport group of 14 cases, there were 10 males and 4 females with an age of (38. 6 ±3. 2) years and a bone defect of (8. 0 ± 0. 5) cm; in the combined bone transport group of 14 cases, there were 9 males and 5 females with an age of (39. 1 ± 3. 9) years and a bone defect of (8. 3 ± 0. 3) cm. The time for wearing external fixator, fracture healing time, dock-in-site healing time, postoperative function assessment and complications were observed and compared between the 2 groups. Results There was no significant difference between the 2 groups in their preoperative general data, showing they were comparable (P > 0. 05). The bone transport group were followed up for 12 to 28 months (average, 18. 4 months) and the combined bone transport group for 12 to 26 months (average, 16. 8 months) . The time for wearing external fixator in the combined bone transport group [(8.4±0.7) months] was significantly shorter than that [(13.3±1.4) months ] in the bone transport group (P< 0. 05). No significant difference was observed between the 2 groups in either the fracture healing time [ (8. 4 土1.3) months versus (7. 4 ± 1. 2) months] or the dock-in-site healing time [(210. 2 ±9.1) months versus (206. 2 ± 9. 8) months ] (P > 0. 05). By the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring, the bone healing was excellent in 6, good in 5 and fair in 3 cases in the bone transport group while excellent in 8, good in 4 and fair in 2 cases in the combined bone transport group, showing no significant difference between the 2 groups in the excellent to good rate (P > 0. 05). By the postoperative functional assessment of the lower extremity, there were 7 excellent, 3 good, 3 fair and one poor cases in the bone transport group while 8 excellent, 5 good and one poor cases in the combined bone transport group, showing no significant difference between the 2 groups in the excellent to good rate (P > 0. 05). In the bone transport group, there were 3 cases of pin track infection, one case of dock-in-site nonunion, 2 cases of poor alignment of lower extremities, 2 cases of skin depression, one case of nail loosening, 5 cases of joint stiffness and 3 cases of delayed union of the distracted bone; in the combined bone transport group, there were one case of pin track infection, 2 cases of poor alignment of lower extremities, 3 cases of skin depression, 3 cases of joint stiffness, 2 cases of delayed union of the distracted bone and one case of refracture. Conclusion In the sequential treatment of massive tibial bone defects, biplane osteotomy and bone transport combined external locking plating can reduce the time for wearing external fixator and increase the satisfaction of patients. © The Author(s) 2022.     

Histological comparison of fate of ligamentous insertion after reconstruction of anterior cruciate ligament: autograft vs allograft

Objective: To analyze the histological results and the biological remodeling of ligamentous insertion after the reconstruction of anterior cruciate ligament ( ACL) with autograft or allograft tendon. Methods: Extensor digitorum tendon was harvested from hind limb as graft material and transplanted to reconstruct the resected ACL in 12 mongrel dogs. Each free tendon end was secured by holding sutures and then the sutures were tied to the post screw at the femoral and tibial bony tunnel outlet after transplantation respectively. Autograft was randomly performed on one side of knee while allograft on the other side of knee. After transplantation, the histological analysis was undertaken at the 6th, 12th weeks and the 6th month using hematoxylin-eosin (HE) stain under light microscope. Results: The insertion structure of normal ACL typically consisted of four layers, i. e. , dense connective tissue, fibrocartilage, mineralized fibrocartilage and bone. There was a distinct regular tidemark line between fibrocartilage and mineralized fibrocartilage. At the 6th week postoperativcly, loose connective tissue presented in the interspace between graft and bony tunnel wall in both autograft and allograft groups. At the 12th week postoperatively, the collagenous fibers between autograft and tunnel wall became well organized and the four layers of insertion with discontinuous tidemark line were demonstrated indistinctly in autograft group but not in allograft group. At the 6th month postoperatively, both of a clear and continuous tidemark line and distinct four layers could be seen in autograft group. In allograft group, only a waved discontinuous tidemark line was shown and either the anatomic morphology or the maturity of insertion was inferior to that of autograft group. Conclusions: At the 6th month postoperatively, although the ligament-cartilage insertion is primarily formed after ACL reconstruction with autograft or allograft tendon, the histological morphology and the maturation of insertion of autograft tendon are better than those of allograft group, which suggests that postoperative rehabilitation should be paid more attention and could be safer if little delayed during ACL reconstruction with allograft tendon.     

Patient specific guides for total knee arthroplasty are ready for primetime

AIM: To present the radiological results of total knee arthroplasty(TKA) with use of patient specific matched guides(PSG) from different manufacturer in patients suffering from severe osteoarthritis of the knee joint.METHODS: This study describes the results of 57 knees operated with 4 different PSG systems and a group operated with conventional instrumentation(n = 60) by a single surgeon. The PSG systems were compared with each other and subdivided into cut- and pin PSG. The biomechanical axis [hip-knee-ankle angle(HKA)], varus/valgus of the femur [frontal femoral component(FFC)] and tibia(frontal tibial component) component, flexion/extension of the femur [flexion/extension of the femur component(LFC)] and posterior slope of the tibia [lateral tibial component(LTC)] component were evaluated on long-leg standing and lateral X-rays. A percentage of 3° deviation was seen as an outlier. RESULTS: The inter class correlation coefficient(ICC) revealed that radiographic measurements between both assessors were reliable(ICC 0.8). Fisher exact test was used to test differences of proportions. The percentage of outliers of the HKA-axis was comparable between both the PSG and conventional groups(12.28% vs 18.33%, P 0.424) and the cut- and pin PSG groups(14.3% vs 10.3%, P 1.00). The percentage of outliers of the FFC(0% vs 18.33%, P 0.000), LFC(15.78% vs 58.33%, P 0.000) and LTC(15.78% vs 41.67%, P 0.033) were significant different in favour of the PSGgroup. There were no significant differences regarding the outliers between the individual PSG systems and the PSG group subdivided into cut- and pin PSG.CONCLUSION: PSG for TKA show significant less outliers compared to the conventional technique. These single surgeon results suggest that PSG are ready for primetime.     

异体胫前肌腱"Y"形双束双隧道重建后十字韧带的疗效分析

Objective To investigate the clinical results of posterior cruciate ligament (PCL) reconstruction by double bundle-double tunnel Y-shape of the anterior tibialis tendon allograft. Methods From March 2001 to January 2008, 47 patients underwent PCL reconstruction were included. The allogeneic adult anterior tibialis tendon was prepared into the Y-shape double bundles with the length of 130 mm; A bundle was defined as A-side; B-side was two short bundle (B1, B2 bundle). A bundle was 70 mm in length with a diameter of 10-12 mm. B1 bundle (anterolateral bundle) was 55 mm long with a diameter of 6 mm; B2 bundle(posteromedial bundle) was about 50 mm with a diameter of 6 mm. The allograft ligament was installed through the antero-medial approach. Absorbable interface screws were fixed in the tibial tunnel firstly, and then in the femoral tundles. When being fixed, anterolateral bundle was in flexion of 90°, postero-medial bundle was in 30°. Assisted exercise with knee an angle-locked walking aid had continued for 8-10 weeks. Results The average operating time were 45 min. The average follow-up time was 49.5 months. Preoperative Lachmann was positive in all cases while Lachmann was negative in 39 cases, weakly positive in 5 cases, and positive in 4 cases postoperatively. Post-operative KT-1000 testing, Lysholm score and Tegner activity levels has improved significantly compare with the pre-operative ones. Conclusion The double folded bundles of adult anterior tibialis tendon has sufficient length and diameter for posterior cruciate ligament reconstruction with power tension. The methods of ligament passing through the tunnel has improved to ease the procedure.     

异体胫前肌腱"Y"形双束双隧道重建后十字韧带的疗效分析

Objective To investigate the clinical results of posterior cruciate ligament (PCL) reconstruction by double bundle-double tunnel Y-shape of the anterior tibialis tendon allograft. Methods From March 2001 to January 2008, 47 patients underwent PCL reconstruction were included. The allogeneic adult anterior tibialis tendon was prepared into the Y-shape double bundles with the length of 130 mm; A bundle was defined as A-side; B-side was two short bundle (B1, B2 bundle). A bundle was 70 mm in length with a diameter of 10-12 mm. B1 bundle (anterolateral bundle) was 55 mm long with a diameter of 6 mm; B2 bundle(posteromedial bundle) was about 50 mm with a diameter of 6 mm. The allograft ligament was installed through the antero-medial approach. Absorbable interface screws were fixed in the tibial tunnel firstly, and then in the femoral tundles. When being fixed, anterolateral bundle was in flexion of 90°, postero-medial bundle was in 30°. Assisted exercise with knee an angle-locked walking aid had continued for 8-10 weeks. Results The average operating time were 45 min. The average follow-up time was 49.5 months. Preoperative Lachmann was positive in all cases while Lachmann was negative in 39 cases, weakly positive in 5 cases, and positive in 4 cases postoperatively. Post-operative KT-1000 testing, Lysholm score and Tegner activity levels has improved significantly compare with the pre-operative ones. Conclusion The double folded bundles of adult anterior tibialis tendon has sufficient length and diameter for posterior cruciate ligament reconstruction with power tension. The methods of ligament passing through the tunnel has improved to ease the procedure.     

Innex膝关节假体置换术后活动度与假体设计及手术技术的关系

目的 探讨Innex膝关节假体置换术后膝关节活动度与假体设计及手术技术的关系.方法 2003年9月至2005年12月使用CS型Innex假体行全膝关节置换88例(98膝),均患膝关节骨关节炎,体重指数20～30 kg/m2,内外翻畸形、屈曲畸形＜15°,为初次全膝关节置换并使用相同的手术技术.随访63例(70膝),随访时间4～6年,平均5.3年.分析活动度与股骨后髁偏心距和胫骨平台后倾角的相关性.根据术后、术前股骨后髁偏心距的差值大小将患者分为:1组,＜-2 mm;2组,-2～0 mm;3组,0～2 mm,4组,＞2 mm.分析各组术前体重指数、屈曲畸形、活动度、特种外科医院膝关节评分及术后活动度的差异.结果 随访患者术前膝关节活动度平均96.2°±11.9°,末次随访时平均109.8°±13.0°;术前股骨后髁偏心距平均(24.0±3.5)mm,术后平均(24.5±3.3)mm;术后胫骨平台后倾角平均5.5°±1.8°.膝关节活动度的差值与股骨后髁偏心距的差值相关,术后膝关节活动度与术后胫骨平台后倾角不相关.四组患者术前体重指数、屈曲畸形、活动度、特种外科医院膝关节评分差异无统计学意义,而术后活动度的差异有统计学意义.结论 Innex膝关节假体置换术后膝关节活动度良好.术中行股骨后方截骨时需注意恢复股骨后髁偏心距,以增加术后活动度.术后膝关节活动度与胫骨平台后倾角无关.

Abstract：

Objective To analysis the influence of component design and related surgical technique on knee range of motion (ROM) after total knee replacement using Innex knee system. Methods Between September 2003 and December 2005, 88 patients with 98 knees had consecutively undergone posterior cruciate-sacrificing TKA with Innex systems. The posterior condylar offset, post-operative tibial slope and knee ROM were measured in 63 patients (70 knees). The relationship of the change in posterior condylar offset and postoperative tibial slope with knee ROM was assessed using a scatterplot graph and Pearson's regression analysis. According to change of posterior condylar offset, which was measured by postoperative minus preoperative posterior condylar offset, patients were divided into 4 groups. The preoperative body mass index,flexion contracture, knee ROM, HSS score and the postoperative knee ROM of four groups were evaluated.Results The mean knee ROM had improved from 96.2°±11.9° preoperative to 109.8°±13.0° at final followup. The mean pre- and post-operative posterior condylar offset was (24.0±3.5) mm and (24.5±3.3) mm, respectively. The mean postoperative tibial slope was 5.5°±1.8°. There was statistical correlation between the difference in the posterior condylar offset and the change in knee ROM after TKA and no correlation between the postoperative tibial slope and knee ROM postoperatively. The preoperative body mass index, flexion contracture, knee ROM, HSS score did not show difference among four groups. There was a statistically difference in postoperative knee ROM among groups. Conclusion Restoration of posterior condylar offset is important to the maximum range of postoperative knee ROM when Orthopedic surgeons perform TKA with Innex systems.There was no correlation between the postoperative tibial slope and postoperative ROM.     

小腿后部各区穿支间的关系与皮瓣设计

Objective To study the anastomotic relationships of perforators in each zone of the poste-rior leg and design perforating flaps for clinic. Methods Six fresh cadavers underwent a whole body, intra-arterial injection of a lead oxide and gelatine preparation. The posterior part of leg is divided into upper, mid-die and below equal parts, Observe topography of the perforating branches in every district by layer, and mea-sured their location, diameter, course, branches and anastomosis pattern. Radiographs of tissue specimens were digitally analyzed. Results There were 13 perforators that diameter≥ 0.5 mm, the average external diameter was 0.8 mm. The areas of each perforator supplied was average 38 cm2. Perforators from popliteal artery was identified an area 4 cm wide, around the intersection of two lines, a line drawn between the medial and lateral epicondyles of the femurs, and the midline of posterior leg. The areas of the every perforator sup-plied was 55 cm2. These vessels were large in diameter and create multiple true anastomoses with the perfora-tors from the posterior tibial artery or fibular artery. Perforating branches were small in the below part, a long perforator chain comprised of two to three perforators accompanies the Achilles tendon. Conclusion The perforator flaps deviced by perforators from the posterior leg may be transplanted to the lower limbs and the other part of the body. The perforators located in the middle zone of the leg are larger. Free posterior tibial or peroneal perforator-based flaps are reliable, relatively large, and have thin flaps. The upper and lower zones were the larger donor site for the proximal or distally pedicled perforator flap harvest.     

小腿后部各区穿支间的关系与皮瓣设计

Objective To study the anastomotic relationships of perforators in each zone of the poste-rior leg and design perforating flaps for clinic. Methods Six fresh cadavers underwent a whole body, intra-arterial injection of a lead oxide and gelatine preparation. The posterior part of leg is divided into upper, mid-die and below equal parts, Observe topography of the perforating branches in every district by layer, and mea-sured their location, diameter, course, branches and anastomosis pattern. Radiographs of tissue specimens were digitally analyzed. Results There were 13 perforators that diameter≥ 0.5 mm, the average external diameter was 0.8 mm. The areas of each perforator supplied was average 38 cm2. Perforators from popliteal artery was identified an area 4 cm wide, around the intersection of two lines, a line drawn between the medial and lateral epicondyles of the femurs, and the midline of posterior leg. The areas of the every perforator sup-plied was 55 cm2. These vessels were large in diameter and create multiple true anastomoses with the perfora-tors from the posterior tibial artery or fibular artery. Perforating branches were small in the below part, a long perforator chain comprised of two to three perforators accompanies the Achilles tendon. Conclusion The perforator flaps deviced by perforators from the posterior leg may be transplanted to the lower limbs and the other part of the body. The perforators located in the middle zone of the leg are larger. Free posterior tibial or peroneal perforator-based flaps are reliable, relatively large, and have thin flaps. The upper and lower zones were the larger donor site for the proximal or distally pedicled perforator flap harvest.     

小腿后部各区穿支间的关系与皮瓣设计

Objective To study the anastomotic relationships of perforators in each zone of the poste-rior leg and design perforating flaps for clinic. Methods Six fresh cadavers underwent a whole body, intra-arterial injection of a lead oxide and gelatine preparation. The posterior part of leg is divided into upper, mid-die and below equal parts, Observe topography of the perforating branches in every district by layer, and mea-sured their location, diameter, course, branches and anastomosis pattern. Radiographs of tissue specimens were digitally analyzed. Results There were 13 perforators that diameter≥ 0.5 mm, the average external diameter was 0.8 mm. The areas of each perforator supplied was average 38 cm2. Perforators from popliteal artery was identified an area 4 cm wide, around the intersection of two lines, a line drawn between the medial and lateral epicondyles of the femurs, and the midline of posterior leg. The areas of the every perforator sup-plied was 55 cm2. These vessels were large in diameter and create multiple true anastomoses with the perfora-tors from the posterior tibial artery or fibular artery. Perforating branches were small in the below part, a long perforator chain comprised of two to three perforators accompanies the Achilles tendon. Conclusion The perforator flaps deviced by perforators from the posterior leg may be transplanted to the lower limbs and the other part of the body. The perforators located in the middle zone of the leg are larger. Free posterior tibial or peroneal perforator-based flaps are reliable, relatively large, and have thin flaps. The upper and lower zones were the larger donor site for the proximal or distally pedicled perforator flap harvest.     

小腿后部各区穿支间的关系与皮瓣设计

Objective To study the anastomotic relationships of perforators in each zone of the poste-rior leg and design perforating flaps for clinic. Methods Six fresh cadavers underwent a whole body, intra-arterial injection of a lead oxide and gelatine preparation. The posterior part of leg is divided into upper, mid-die and below equal parts, Observe topography of the perforating branches in every district by layer, and mea-sured their location, diameter, course, branches and anastomosis pattern. Radiographs of tissue specimens were digitally analyzed. Results There were 13 perforators that diameter≥ 0.5 mm, the average external diameter was 0.8 mm. The areas of each perforator supplied was average 38 cm2. Perforators from popliteal artery was identified an area 4 cm wide, around the intersection of two lines, a line drawn between the medial and lateral epicondyles of the femurs, and the midline of posterior leg. The areas of the every perforator sup-plied was 55 cm2. These vessels were large in diameter and create multiple true anastomoses with the perfora-tors from the posterior tibial artery or fibular artery. Perforating branches were small in the below part, a long perforator chain comprised of two to three perforators accompanies the Achilles tendon. Conclusion The perforator flaps deviced by perforators from the posterior leg may be transplanted to the lower limbs and the other part of the body. The perforators located in the middle zone of the leg are larger. Free posterior tibial or peroneal perforator-based flaps are reliable, relatively large, and have thin flaps. The upper and lower zones were the larger donor site for the proximal or distally pedicled perforator flap harvest.     

小腿后部各区穿支间的关系与皮瓣设计

Objective To study the anastomotic relationships of perforators in each zone of the poste-rior leg and design perforating flaps for clinic. Methods Six fresh cadavers underwent a whole body, intra-arterial injection of a lead oxide and gelatine preparation. The posterior part of leg is divided into upper, mid-die and below equal parts, Observe topography of the perforating branches in every district by layer, and mea-sured their location, diameter, course, branches and anastomosis pattern. Radiographs of tissue specimens were digitally analyzed. Results There were 13 perforators that diameter≥ 0.5 mm, the average external diameter was 0.8 mm. The areas of each perforator supplied was average 38 cm2. Perforators from popliteal artery was identified an area 4 cm wide, around the intersection of two lines, a line drawn between the medial and lateral epicondyles of the femurs, and the midline of posterior leg. The areas of the every perforator sup-plied was 55 cm2. These vessels were large in diameter and create multiple true anastomoses with the perfora-tors from the posterior tibial artery or fibular artery. Perforating branches were small in the below part, a long perforator chain comprised of two to three perforators accompanies the Achilles tendon. Conclusion The perforator flaps deviced by perforators from the posterior leg may be transplanted to the lower limbs and the other part of the body. The perforators located in the middle zone of the leg are larger. Free posterior tibial or peroneal perforator-based flaps are reliable, relatively large, and have thin flaps. The upper and lower zones were the larger donor site for the proximal or distally pedicled perforator flap harvest.