Anterior cruciate ligament reconstruction of the knee

Anterior cruciate ligament (ACL) injuries affect more than 175,000 patients annually. Located in the center of the knee joint, the ACL is the major stabilizing ligament of the knee. If the ACL is injured, then the knee becomes unstable and can buckle when the person pivots. Surgeons can use autograft or allograft tissue to accomplish ACL reconstruction by using a single-bundle or double-bundle type of repair. The surgeon performs the reconstruction arthroscopically, using two ports and a small incision over the anteromedial surface of the tibia to facilitate passage of the graft and for distal fixation of the graft. Correct placement of the tibial and femoral tunnels is the most important technical aspect of the procedure. After reconstruction, the patient must undergo intense physical therapy starting one or two days after surgery. If diligent with physical therapy, then the patient can return to full activity as soon as four months after surgery.     

Anterior cruciate ligament reconstruction in skeletally immature patients

The management of pediatric patients with an anterior cruciate ligament (ACL) tear can be a challenging endeavor for physicians, athletic trainers, coaches, and parents alike. In particular, the significant longitudinal growth that arises from the physes about the knee creates a unique set of circumstances that must be considered in this patient population. The purpose of this review is to provide a summary of the most recent current literature for the management of skeletally immature patients with an ACL tear.     

前交叉韧带重建及其腱-骨愈合特点

近年来，随着自体胭绳肌腱前交叉韧带重建术的广泛开展，腱骨愈合的影响因素和促进方法成为运动医学研究的热点。影响腱-骨愈合的相关因素主要包括移植物的固定方式、骨的性质、应力刺激以及移植肌腱与隧道的匹配关系等，促进腱-骨愈合的方法主要包括生长因子、金属蛋白酶阻断剂、骨保护素等试剂和间充质干细胞、物理方法的运用。目前在促进腱-骨愈合方面已探索出一些较有潜力的方法，但是这些方法大多数尚处于动物实验阶段或者牵涉到复杂的实验室技术，在进入临床应用之前，对这些方法的可行性尚需进。步的研究。     

LARS人工韧带移植重建膝关节前交叉韧带28例

背景:以往的人工韧带容易出现材料疲劳而导致断裂,并且因为组织相容性的问题容易出现关节的滑膜炎.目的:随访观察LARS人工韧带在前交叉韧带损伤移植重建中的应用效果.设计、时间及地点:自身对照,随访观察,于2004-08/2007-01在上海长征医院骨科关节外科进行.参试者:前交叉韧带损伤患者28例,运动伤16例,车祸伤12例.材料:LARS人工韧带由法国LARS公司产品,材料主要成分为高韧性的聚酯纤维(聚对苯二甲酸乙二醇脂).方法:对28例前交叉韧带损伤的患者行关节镜下LAPS人工韧带重建,并进行平均20个月的随访.主要观察指标:移植前和随访时患者的前抽屉试验、Lysholm评分、关节活动度.结果:28例患膝不稳定症状消失,前抽屉试验阴性,关节功能良好,伸屈度5.71°～129.64°.根据Lysholm膝关节评分法,平均积分由移植前的(45.74±9.82)分提高到移植后的(86.5±6.44)分(P<0.001).所有病例均于移植后2个月左右恢复正常活动,无急慢性滑膜炎出现,无材料宿主反应.结论:LARS人工韧带是较安全的移植材料,特别适合运动导致的前交叉韧带损伤.中短期随访结果显示优良.     

重建前交叉韧带中Endo-Button和可吸收界面螺钉固定的对比

背景：应用腘绳肌肌腱重建前交叉韧带过程中仍有许多的争议及未知因素需进一步探讨和研究。目的：比较分析腘绳肌肌腱重建前交叉韧带过程中股骨端分别使用Endo-Button系统和可吸收界面螺钉两种不同固定方式的疗效。方法：选择45例在关节镜下使用4股自体腘绳肌腱进行前交叉韧带重建患者,实验组25例股骨端使用Endo-Button钢板固定,对照组20例使用可吸收界面螺钉固定。重建后用相同的方法进行康复锻炼。结果与结论：经过6-21个月的随访,患者膝关节屈伸活动度均达正常范围。Lachman试验中实验组Ⅰ度阳性2例,对照组Ⅰ度阳性3例;轴移试验均阴性。两组重建后膝关节Lysholm评分均较治疗前明显改善,两组间差异无显著性意义。两组随访早期均有较高的骨道扩大发生率,但组间差异无显著性意义;对照组骨道增宽程度强于实验组（P〈0.05）。说明两组早期总体临床效果相近。     

重建前交叉韧带中Endo-Button和可吸收界面螺钉固定的对比

背景:应用腘绳肌肌腱重建前交叉韧带过程中仍有许多的争议及未知因素需进一步探讨和研究。目的:比较分析腘绳肌肌腱重建前交叉韧带过程中股骨端分别使用Endo-Button系统和可吸收界面螺钉两种不同固定方式的疗效。方法:选择45例在关节镜下使用4股自体腘绳肌腱进行前交叉韧带重建患者,实验组25例股骨端使用Endo-Button钢板固定,对照组20例使用可吸收界面螺钉固定。重建后用相同的方法进行康复锻炼。结果与结论:经过6-21个月的随访,患者膝关节屈伸活动度均达正常范围。Lachman试验中实验组Ⅰ度阳性2例,对照组Ⅰ度阳性3例;轴移试验均阴性。两组重建后膝关节Lysholm评分均较治疗前明显改善,两组间差异无显著性意义。两组随访早期均有较高的骨道扩大发生率,但组间差异无显著性意义;对照组骨道增宽程度强于实验组(P<0.05)。说明两组早期总体临床效果相近。     

Anterior and posterior cruciate ligament injuries

Knee pain is a common complaint in the primary care setting, and ACL and PCL injuries are common causes of knee pain. Therefore, it is important for the primary care physician to be skilled in the diagnosis and initial management of these injuries and to be aware of potential associated knee injuries. By understanding the history, mechanism of injury, physical examination maneuvers, and imaging modalities related to ACL and PCL injuries, primary care physicians can prepare themselves to make an accurate diagnosis. Then they can counsel the patients on the available treatments, initiate conservative treatment if appropriate, and facilitate an effective referral to a primary care sports medicine physician or orthopedic surgeon.     

腘绳肌腱重建前交叉韧带移植肌腱的固定

目的:腘绳肌腱重建前交叉韧带曾出现过多种固定器材,分析近年来关于腘绳肌腱重建前交叉韧带的文献资料,了解肌腱固定方式的发展趋势。资料来源:通过计算机检索Medline1995-01/2006-09有关腘绳肌腱重建前交叉韧带移植肌腱固定方式的文献,检索词为“anteriorcruciate ligament,reconstruction,hamstring”,限定文章语言种类为English;另外检索中文期刊全文数据库2000-01/2006-03有关腘绳肌腱重建前交叉韧带移植肌腱固定方式的文献,检索词为“前交叉韧带,重建术,腘绳肌腱”,限定文章语言种类为中文。资料选择:选取有关腘绳肌腱重建前交叉韧带的文章,纳入标准:①随机或自身前后对照的临床研究。②观点明确。③有关于固定方式的评论。排除标准:①综述。②重复性研究。资料提炼:共检索到60篇关于腘绳肌腱重建前交叉韧带的文章,选择其中符合标准的33篇进行综合分析。资料综合:固定方式经历了一个由皮质骨外固定到骨隧道内固定的演变过程,Transfix是目前较为理想的固定方式,肌腱结嵌压固定是最新出现的一种固定方式,其临床效果尚需进一步验证。在固定位置的选择上,多数学者认为应该遵循等距重建。通过对固定方式的比较发现,隧道内固定能减轻术后骨隧道的扩大程度。结论:腘绳肌腱重建前交叉韧带的固定方法越来越趋于隧道内固定,并朝着利于腱骨愈合、减轻骨隧道扩大的方向发展。在固定位置的选择上,学者们尚无统一的意见,其趋势可能是向解剖固定发展。     

Minimally invasive cruciate ligament reconstruction

Over the past 20 years, there has been an increasing interest in surgery for the anterior cruciate ligament (ACL) deficient knee. With this increase, there has been the concomitant development of surgical technique, in particular, the minimally invasive arthroscopically-assisted procedure.

As an alternative, we have developed a technique that does not require the use of the increasingly expensive equipment for an arthroscopically-assisted reconstruction. The Mayday ‘rhino horn’ jig is a hand-held device that can accurately and simply place the tibial tunnel required for cruciate reconstruction. Use of the jig reduces soft tissue dissection and allows for a faster operative procedure without the need for a thigh tourniquet. These factors have allowed us to offer ACL reconstruction as a day case procedure.     

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.     

Anterior cruciate ligament tears and associated injuries

Anterior cruciate ligament (ACL) tears are a commonly sustained sports injury, often occurring in association with meniscal tears and trauma to other ligamentous structures around the knee. Diagnosis can often be made clinically, but assessment may be difficult in the acute setting when there is a large joint effusion and severe pain. Plain radiographs may detect the presence of a joint effusion and any associated fractures. However, magnetic resonance imaging is vital for assessing acute knee injuries and plays an important role in deciding treatment options and planning surgical intervention. Some of the associated meniscal and ligamentous injuries can be subtle and may easily be overlooked if these structures are not scrutinized closely. This article will discuss the anatomy of the ACL and the mechanisms and initial clinical assessment of ACL injuries, and review the imaging features of ACL tears and some of the associated injuries, including the posterolateral corner structures. These associated injuries have important implications for determining treatment options and subsequent return to athletic activities.     

膝关节前交叉韧带损伤

膝关节前交叉韧带损伤后的康复治疗过程中有一些问题需要注意和探讨.①康复训练介入的时机选择问题何时开始进行何种训练,目前只能是采用时间来判定,缺乏比较明确的量化指标,基本上依靠经验.②具体实施的康复训练内容缺乏统一性,容易造成康复训练的片面性,哪些因素的训练对ACL的恢复是有用的,哪些是没有意义的.③对采用不同ACL重建手术方法的患者应采用不同康复训练程序,目前的研究基本上是不区分手术类型都采用同一套康复治疗手段.④缺乏统一的康复疗效评价指标基本上停留在关节活动度和肌力的评价上,缺乏患者残疾、残障方面的评价.     

后交叉韧带作为间接MR影像在前交叉韧带损伤中的诊断价值

目的评价后交叉韧带(PCL)作为间接MR影像在前交叉韧带(ACL)损伤中的诊断价值.方法回顾分析78例经关节镜证实的膝关节MRI资料,其中ACL损伤33例,正常45例.盲法分析MR影像的以下PCL参数:PCL线、PCL角和PCL指数.结果阳性PCL线诊断ACL 损伤的敏感性和特异性分别是75.6% 和 97.8%,PCL角小于109°分别是66.7% 和96.6%.ACL 损伤的PCL角为(102±10.1)°,正常时PCL角为(116±9.8)°(P< 0.001).ACL 损伤时PCL指数为3.76±0.93,正常为4.95±0.63(P<0.01).结论 PCL角小于109°和阳性PCL 线的高特异性说明可以用其诊断ACL损伤.PCL角度和PCL指数越小,ACL损伤的可能性越大.     

Pediatric anterior cruciate ligament reconstruction outcomes

Treatment of pediatric anterior cruciate injuries have become an area of controversy sparking much debate about best management strategies. Delaying surgery until skeletal maturity has often been shown to result in unfavorable outcomes due to concomitant meniscal and chondral injuries in this population. There have been numerous techniques used to reconstruct the ACL in the skeletally immature patient; however, most studies are limited by small patient numbers and other methodological concerns. With recent publications reporting failure rates as high as 15–25 % and growth disturbances being uncommon but now reported within almost every technical category, patient and caregiver education become of paramount importance. Key principles will be outlined that may help to avoid some of the pitfalls that occur when dealing with this unique population.     

前交叉韧带重建后的感染

背景：前交叉韧带重建后感染的发生率比较低,但这种感染会导致灾难性的结果,目前对这种感染的诊断和治疗还没有取得一致的意见。目的：探讨导致前交叉韧带重建术后感染的原因、如何早期诊断,并探讨合适的治疗方案,以尽量保护膝关节的功能。方法：以＂anterior cruciate ligament,reconstruction,infection＂为检索词,检索Pubmed数据库（2007至2012年）;以＂前交叉韧带,重建,感染＂为检索词,检索万方数据库（2007至2012年）。以与前交叉韧带重建后感染的相关文献为评价指标,纳入与前交叉韧带重建后感染相关的内容,排除重复研究。结果与结论：细菌污染手术工具或者韧带移植物是导致前交叉韧带重建后感染的最常见原因,移植物固定的方式和重建后感染之间可能有一定的关系。典型的前交叉韧带重建术后感染的症状和普通的化脓性关节炎的症状类似,但有的前交叉韧带重建后感染的病例并没有感染的典型表现。前交叉韧带重建后感染的诊断需要依靠临床症状、实验室检查（C-反应蛋白和血沉）、膝关节穿刺等方法。大多数外科医师选择静脉使用敏感的抗生素、膝关节灌洗并保留移植物作为自体移植物重建前交叉韧带后感染的首选治疗方法。当感染难以控制或者移植物看起来确实有感染迹象时应该考虑取出移植物。     

Anterior cruciate ligament reconstruction creating the femoral tunnel through the anteromedial portal. Surgical technique

The anterior cruciate ligament reconstruction is a common procedure that improves stability and function of the knee. The surgical technique continues to evolve and many issues are still under debate. These mainly include: (1) graft selection (patellar tendon, hamstring, quadriceps tendon, or allografts), (2) surgical technique (double versus single bundle), and (3) femoral tunnel drilling. Currently, the most controversial one is the femoral tunnel drilling (transtibial vs. anteromedial portal drilling). Common opinion is that drilling the femoral tunnel through the anteromedial (AM) allows a more anatomic placement of the graft and a better rotational stability; therefore, this technique is gaining in popularity compared with the transtibial drilling despite a greater difficulty and the risk of medial condyle damage, tunnel back wall blowout, and inadequate socket length. The aim of this article is to describe the surgical technique of the anterior cruciate ligament reconstruction (single and double bundle), drilling the femoral tunnel through the AM portal.     

关节镜下前交叉韧带重建材料及其重建的理论研究与临床应用

背景:前交叉韧带是膝关节内的核心结构,近年来前交叉韧带损伤的发生率逐渐增高.目的:就前交叉韧带的损伤机制、手术方法、移植物选择、等长重建、重建韧带翻修等问题进行综述,为临床治疗前交叉韧带损伤提供一定的参考.方法:应用计算机检索Medline数据库(1996-01/2009-03),以Anterior cruciate ligament.implant、reconstruction、repair为检索词;应用计算机检索重庆维普数据库(1996-01/2009-03)、清华同方数据库(1996-01/2009-03),以前交叉韧带、移植物、重建、修补为检索词.结果与结论:共收集200篇关于关节镜下前交叉韧带重建的文献,排除发表时间较早、重复及类似研究,纳入18篇符合标准的文献.前交叉韧带是稳定膝关节的重要结构,运动及日常生活中多种因素可导致其损伤,治疗不当将严重影响运动能力或丧失运动能力.为恢复膝关节结构和功能,对损伤的前交叉韧带需要进行重建已成为共识.随着技术的不断进步和手术器械的研制创新,关节镜下重建术已成为当今治疗前交叉韧带损伤的主流方法.尽管治疗前交叉韧带损伤的手术方法很多,但还没有哪一种能完全复制前交叉韧带的解剖关系,手术是否能减少前交叉韧带伤后的继发损害目前还没有定论.对手术方式、移植物的选择、术后康复以及其他辅助治疗等方面仍有大量工作需要完善.