关节镜下半腱肌腱股薄肌腱单端固定法重建交叉韧带24例分析

目的总结膝关节镜下同侧半腱肌腱、股薄肌腱单端固定法重建后交叉韧带的方法及疗效,分析其优缺点。方法应用同侧半腱肌腱、股薄肌腱单端固定,重建后交叉韧带损伤24例。结果术后随访6～36个月,平均18个月。按lysholm膝关节评分标准,由术前43分提高到术后93分。结论同侧半腱肌腱、股薄肌腱单端固定法重建后交义韧带创伤小、操作简便,是重建后交叉韧带的理想方法之一。     

关节镜下自体四股腘绳肌腱重建膝前交叉韧带

目的评估关节镜下自体四股腘绳肌腱重建膝前交叉韧带(ACL)的技术和效果方法1999年10月-2003年12月共56例患者经关节镜检查证实为ACL断裂,26例伴半月板破裂,7例伴内侧副韧带损伤,12例伴后交叉韧带断裂。均于关节镜下行自体四股腘绳肌腱ACL重建术,采用Bionx生物可吸收挤压螺钉或钛挤压螺钉解剖位固定重建韧带。结果本组术后早期均未发生严重并发症。术后随访6-48个月,平均20个月,Lysholm膝关节功能评分由术前45-80分(平均58.36分),提高至随访时70-100分(平均92.77分)(P<0.01)。国际膝关节文件编制委员会(IKDC)综合评定由术前异常(C级)14例、显著异常(D级)42例,改进为随访时正常(A级)23例、接近正常(B级)29例、异常(C级)4例(P<0.01)。56例患者中,52例恢复伤前运动水平,4例运动水平较伤前降低。结论关节镜下自体四股腘绳肌腱重建膝ACL具有手术损伤较小、术后膝关节功能恢复良好的优点,值得采用。     

关节镜下自体髌腱重建前交叉韧带

目的探讨关节镜下自体髌腱中1/3重建前交叉韧带(ACL)术效果的影响因素。方法对15例前交叉韧带损伤患者,在关节镜下行自体骨-髌腱-骨(B-PT-B)中1/3重建ACL。其中同时行侧副韧带修复1例,半月板损伤部分切除3例,半月板结合部缝合1例。结果按照日本骨科学会制定的膝关节疗效评定标准,优6例,良7例,中2例,优良率为86.7%。结论术中选择等长点,测量关节内重建韧带的长度,获取标准的髌腱两端骨块及胫骨、股骨隧道,并正确使用挤压螺钉固定两骨块于隧道中是减少并发症、提高手术效果的关键。该手术创伤小,对关节内环境影响小,可同时进行关节内其他手术,术后恢复快,是ACL重建的优良方法     

关节镜下双股半腱肌重建前交叉韧带

前交叉韧带（ＡＣＬ）损伤是常见膝部损伤，有关诊断、关节镜下修复重建的问题已引起临床界的重视〔１、２〕。采用我科自行研制的配套器械行双股半腱肌关节镜下重建ＡＣＬ手术，临床治疗５０例前交叉韧带损伤患者，随访资料完整３９例，取得满意的临床效果。１资料与方法...     

半腱肌股薄肌腱打结骨栓嵌入固定镜下重建前交叉韧带的初步观察

目的　探讨自体半腱肌、股薄肌腱中间打结、骨栓嵌入挤压固定法在关节镜下重建前交叉韧带 (ACL)的可行性。　方法　 15例前ACL损伤 ,采用自体半腱肌、股薄肌腱中间打结 ,骨栓嵌入挤压固定法镜下重建ACL。半腱肌腱和股薄肌腱预张力后 ,肌腱中间打结嵌入 12mm×6mm骨栓。经ACL导向器打入导针 ,用环钻建立股骨和胫骨隧道。胫骨和股骨隧道下 1 3的直径为 5～ 7mm ,股骨隧道近 2 3为 11mm。将肌腱从股骨隧道的近端经关节腔牵入胫骨隧道 ,将肌腱拉紧、膝关节屈伸活动 2 0次 ,使肌腱结和骨栓完全嵌入瓶颈状股骨隧道内。将 4股肌腱从胫骨隧道和其下方 10mm处分别穿出 ,交叉打结并缝合固定在骨桥上。　结果　 15例患者得到随访 ,关节稳定 ,功能恢复正常。按膝关节疗效评定标准 ,优 11例 ,良 2例 ,可 2例 ,优良率 86.7%。　结论自体肌腱打结骨栓嵌入固定法重建ACL为生物固定 ,创伤小 ,固定可靠 ,费用低 ,有利于愈合 ;可免除金属内固定物 ,术后不影响MRI检查     

半腱肌腱和股薄肌腱重建前交叉韧带后Cyclops综合症临床研究

目的:研究采用自体半腱肌腱和股薄肌腱重建前交叉韧带(ACL)后膝关节内Cyclops综合症的发生情况。方法:回顾性研究2004~2005年197例采用半腱肌腱和股薄肌腱重建ACL后取出内固定患者,平均年龄25.85岁。取内固定时通过病史、体征、X线及KT-2000评估膝关节功能,手术同时进行膝关节镜探查,观察关节内髁间窝增生物情况,并进行统计分析。结果:所有患者中发现有髁间窝结节样增生物(统称为Cyclops病变)形成28例,其中2例伴有伸膝受限(同健侧膝关节比较),Cyclops综合症的发生率为1.02%(2/197)。无Cyclops病变的患者中伸膝受限5例。根据是否存在Cyclops病变将所有患者分为Cyclops组和非Cyclops组,两组伸膝受限发生率的差异无统计学意义(2χ=0.268)。Cyclops病变的病理表现为增生变性的瘢痕样组织,无骨性成分。Cyclops组患者取钉时KT-2000检查结果显示134N下差值平均为1.8mm,有24例均恢复到原来的运动水平。结果表明,采用半腱肌腱和股薄肌腱重建前交叉韧带后Cyclops病变发生率较高,但产生伸膝受限(Cyclops综合症)的发生率低。     

自体半腱肌腱股薄肌腱重建前交叉韧带术后肌腱再生的临床研究

目的 :应用超声仪观察切取半腱肌腱股薄肌腱重建前交叉韧带后肌腱的再生情况。方法 :39例用自体半腱肌腱股薄肌腱重建前交叉韧带患者 ,术后平均 13个月行双侧半腱肌腱股薄肌腱超声检查 ,了解肌腱再生情况并对比其长度和截面积的变化。结果 :超声检查显示 39例患者中有肌腱再生 2 6例 ,再生率为 72 %。再生肌腱长度和截面积与对侧肌腱相比无明显差异。 2 6例患者半腱肌腱股薄肌肌腹有萎缩。结论 :切取半腱肌腱股薄肌腱重建前交叉韧带后肌腱能够再生。     

关节镜下4股半腱肌腱单束重建前交叉韧带部分损伤

目的 介绍关节镜下单束蕈建增强治疗前交叉韧带(anterior cruciate ligament,ACL)后外侧束部分损伤方法 ,探讨其临床效果. 方法 对26例单纯ACL后外侧柬部分损伤患者,在关节镜下采用自体半腱肌腱进行单束解剖重建.按照国际膝关节评分委员会(internationalknee documentation committee,IKDC)和Lysholm膝关节功能评分表对患膝功能进行评估,通过KT-1000检查比较膝关节的前向松弛度. 结果 术后无活动受限,屈膝活动度130°～150°,平均142°.术后随访12～18个月,最后随访时IKDC评分为A级25例(96%),B级1例(4%);IKDC评分从术前的(71.4±3.7)分提高到随访结束时的(95.8±3.4)分(t=9.836,P<0.01).屈膝25°位KT-1000检查,双侧膝关节胫骨结节前移差异从术前的(5.1±1.2)mm减少到终末随访的(2.1±1.3)mm(t=10.48,P<0.01).患者术前Lysholm膝关节功能评分为(76.7±3.2)分,终末随访时为(95.7±2.4)分(t=7.356,P<0.01). 结论 在关节镜下采用自体半腱肌腱单束解剖重建增强治疗ACL后外侧束部分损伤,能取得良好效果.     

应用半腱肌、股薄肌和髌韧带在关节镜下重建前交叉韧带65例

目的 探讨应用髌韧带（bone-patellar tendon-bone,BTB)和半腱肌、股薄肌（bone-ham-string-bone,BHB)在关节镜下修复前交叉韧带（anterior cruciate ligament,ACL)损伤的临床疗效。手术要点及关节功能改善情况。方法 在膝关节镜直视下,选用自体BTB和BHB行ACL竽建手术65例,其中BTB重建30例,BHB重建31例,股四头肌腱重建4例,结果 随访时间1个月-3年,手术前Lachman和Piveot shift试验从阳性转为阴性,按日本骨科学会膝关节疗效评定标准,优48例,良7例,可10例,本组病人2个月后均恢复原来日常活动,半年后恢复体育活动,结论 应用BTB、BHB在关节镜下修复ACL损伤,术中等长点的选择是手术关键,坚强固定是早期康复训练的前提。     

关节镜下髌韧带与腘绳肌腱重建前交叉韧带的疗效比较

目的比较分析膝关节镜下自体髌韧带与腘绳肌腱移植重建前交叉韧带(ACL)的疗效。方法回顾分析49例膝关节镜下自体髌韧带移植重建ACL及54例自体腘绳肌腱移植重建ACL的情况，随访24～48个月，平均31．6个月。采用Lysholm膝关节评分、国际膝关节文献编制委员会分级评估标准和KT-1000关节测量仪测定稳定性评价疗效。结果两组间患者满意度、关节稳定性及功能差异均无统计学意义。髌韧带重建组膝痛发生率较腘绳肌腱组高(37％比11％)。结论关节镜下髌韧带与腘绳肌腱移植重建ACL的疗效相同。ACL重建中等长重建、牢固固定及早期康复锻炼对疗效更有决定作用。     

Arthroscopic anterior cruciate ligament reconstruction with periosteum-enveloping hamstring tendon graft

Tendon–bone incorporation of a tendon graft within the bone tunnel is of priority concern when using for anterior cruciate ligament (ACL) reconstruction. Superior healing process and stronger healing strength can be achieved when periosteum is sutured on the tendon inserted into a bone tunnel. We applied this idea to ACL reconstruction for enhancing tendon graft–bone tunnel healing. This is a prospective clinical outcome study with this surgical technique at minimal 2 years follow-up. Periosteum-enveloping hamstring tendon graft has been used in 68 patients. Data from 62 patients who had been followed up completely were analyzed. All patients suffered from a grade 3 or higher grade of Lachman and anterior drawer test with a positive pivot-shift test. Clinical assessments included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, KT-1000 instrumented testing, thigh muscle assessment, and radiographic evaluation. The median Lysholm knee score was 59 (40–70) and 94 (60–100) points (P<0.01) before and after surgery. After reconstruction, 81% of patients were able to return to moderate or strenuous activity. Four (6%) patients were found to exhibit grade 2 or more ligament laxity. Complete range of motion could be achieved in 86% of patients. Three patients (5%) had positive pivot shift. Finally, 92% of patients were assessed as normal or nearly normal rating by IKDC guideline. Bone tunnels enlargement of more than 1 mm was identified in 5% of femoral tunnels and 6% of tibial tunnels. The study shows that a satisfactory result can be achieved with the periosteum-enveloping hamstring tendon graft in ACL reconstruction. Periosteum can be easily harvested at the proximal tibia from a routine incision for hamstring tendon harvesting. Besides the potential for improving tendon–bone healing, enveloped periosteum may help to seal the intra-articular tunnel opening in the early postoperative period, and thus avoid synovial fluid reflux into the tunnel. Bone tunnel enlargement could be reduced.     

Arthroscopic anterior cruciate ligament double-bundle reconstruction using hamstring tendon grafts-fixation with two interference screws: technical note

In this article, an original double-bundle anterior cruciate ligament reconstruction technique is described. The procedure is developed using hamstring tendon grafts while maintaining tibial osseous insertion. Two tibial tunnels are drilled and a simplified and precise outside-in double tunnel femoral drilling technique is utilized. The graft fixation is made using only two interference screws.     

Arthroscopic posterior cruciate ligament reconstruction with hamstring tendon autograft: results with a minimum 4-year follow-up

This study prospectively evaluates the outcomes at a minimum 4-year follow-up after PCL reconstruction using quadruple hamstring tendon autograft with an arthroscopic double fixation technique. During 1996–1999, hamstring tendon autograft graft has been used in 57 patients. Data from 52 patients who had been followed up completely were analyzed. All patients suffered from a grade 3 or higher grade of posterior drawer test and posterior sag sign with MRI image confirmation. Twelve knees had combined posterior and posterolateral instability, which were simultaneously reconstructed. Clinical assessments included Lysholm knee score, International Knee Documentation Committee (IKDC) scores, KT-1000 instrumented test, thigh muscle assessment, and radiographic evaluation. The mean Lysholm score was 54 (40–65) and 91 (65–100) points (P<0.01) before and after surgery. Thirty (58%) patients could return to moderate or strenuous activity. The evaluation of AP translation has been performed with KT-1000. The average posterior displacement measured with KT-1000 was 11.69±2.01 mm preoperatively and 3.45±2.04 mm postoperatively. Forty-two (81%) patients demonstrated ligament laxity of less than 5 mm. Forty-two (81%) patients were rated as normal or nearly normal based on IKDC scores. Forty-six (88%) patients achieved a minimum of 80% recovery of extensor strength and 44 (85%) patients achieved a minimum of 80% recovery of flexor strength. Statistically significant differences existed in thigh girth, extensor strength, and flexor strength before and after reconstruction. Arthroscopic reconstruction for PCL with four-strand hamstring tendon graft produced satisfactory results. The semitendinosus and gracilis tendon graft is adequate in graft size, technically easier to perform and more reproducible, and had a satisfactory result.     

The influence of tibial fixation on tunnel enlargement after hamstring tendon anterior cruciate ligament reconstruction

The retrospective study was designed to evaluate tibial-tunnel enlargement after anterior cruciate ligament reconstruction with hamstring autograft. Forty-three patients (43 knees) were enrolled, among whom a spiked washer was used for the tibial side fixation in 20 knees (Group SW) and the WasherLoc was used in 23 knees (Group WL). After an average 16 (range 12–32) months follow-up, the distance between the sclerotic margins of the tibial tunnel was measured at the joint level, and 1 and 2 cm distal to the joint level on the lateral view radiographs, from which the tibial-tunnel enlargement at each point (E1, E2, and E3 respectively) was determined. Anterior knee laxity was also measured using a KT-1000 or KT-2000 arthrometer at follow-up. E1, E2, and E3 were 2.3±1.3 mm (mean±standard deviation), 1.8±0.8 mm, and 1.5±0.8 mm respectively in Group SW, and 2.6±1.0 mm, 2.6±1.2 mm, and 2.9±1.6 mm in Group WL. Group WL had a larger mean value than Group SW at each level of measurement, with a statistically significant difference in E2 and E3. Fifty percent of the tunnels were the cone type in Group SW, whereas reversed cone-type tunnels were the most common (39%) in Group WL. The side-to-side difference in anterior knee laxity was –0.6±5.2 mm in Group SW and 1.8±9.0 mm in Group WL, which was significantly different between the groups. No statistical relationship was found between tunnel enlargement and side-to-side difference in anterior knee laxity in Group SW, whereas there was a slight negative correlation between E1 or E2 and anterior knee laxity in Group WL. It is possible that there is greater tension applied to the graft when the WasherLoc is used, which creates larger compressive forces on the posterior wall of the tibial tunnel by the graft. This was probably the reason for the greater tunnel enlargement and the high incidence of the reversed cone-type tunnel in Group WL.     

Isokinetic quadriceps and hamstring muscle strength and knee function 5 years after anterior cruciate ligament reconstruction: comparison between bone-patellar tendon-bone and hamstring tendon autografts

Existing clinical studies have not proven which graft is to be preferred in anterior cruciate ligament (ACL) reconstruction. In recent years, bone-patellar tendon-bone and hamstring tendons have been the most frequently used graft types. Muscle strength deficit is one of the consequences after ACL reconstruction. The aim of this study was to evaluate possible differences in hamstring and quadriceps muscle strength and knee function 5 years after ACL reconstruction between the BPTB and the STG groups. The study group consisted of 288 patients (132 women, 156 men) with a unilateral ACL rupture who had received a BPTB (175 patients) or STG (113 patients) ACL reconstruction. Lower extremity concentric isokinetic peak extension and flexion torques were assessed at the angular velocities of 60°/s and 180°/s. The International Knee Documentation Committee (IKDC), the Tegner activity level, the Lysholm knee and the Kujala patellofemoral scores were also collected. Isokinetic quadriceps peak torque (percentage of the contralateral side) was 3.9% higher in the STG group than in the BPTB group at the velocity of 60°/s and 3.2% higher at the velocity of 180°/s and the isokinetic hamstring peak torque 2% higher in the BPTB group than in the STG group at the velocity of 60°/s and 2.5% higher at the velocity of 180°/s. In both groups the subjects had weaker quadriceps and hamstring muscle strength in the injured extremity compared with the uninjured one. In the single-leg hop test (according to the IKDC recommendations) there was a statistically significant difference (P = 0.040) between the groups. In the STG group, 68% of the patients had the single-leg hop ratio (injured vs. uninjured extremity) ≥90%, 31% of the patients 75–89% and 1% of the patients <75%, while in the BPTB group the corresponding percentages were 72, 21 and 7%. However, no statistically significant differences in clinical outcome were found between the groups as determined by the IKDC, Tegner activity level, Lysholm knee and Kujala patellofemoral scores.     

The mid- to long-term results of the anterior cruciate ligament reconstruction with hamstring tendons using Transfix technique

In this study, mid to long-term results of anterior cruciate ligament reconstruction with hamstring tendons and Transfix technique were evaluated. Anterior cruciate ligament (ACL) reconstruction with four-strand hamstring tendon was performed with Transfix technique on 271 (198 males, 73 females; mean age 25.7; 17–52) patients with anterior cruciate ligament ruptures. The patients were followed up with clinical examination, Lysholm and Tegner activity scales, IKDC scoring system, KT-1000 test and radiological examination. The mean follow-up period was 82 (48–100) months; 204 (75%) patients had no subjective complaints. According to the KT-1000 test, only 14 (5%) patients had more than 5 mm laxity postoperatively, whereas, 161 (59%) patients had more than 5 mm laxity preoperatively. In addition to this, only 19 (7%) patients had Lysholm scores less than 80 postoperatively, whereas 154 (57%) patients scored less than 80 preoperatively. When compared with Tegner activity scale, 189 (70%) patients scored <6 preoperatively and only 24 (8%) postoperatively; 78 (29%) patients scored D preoperatively and only 5 (2%) patients scored D postoperatively on the basis of the IKDC scoring system. Our functional results were found to be satisfactory in more than 90% of patients. Commonly seen problems in ACL reconstruction such as inaccurate graft placement and tunnel widening were found to be consistent with the values in relevant literature. However, we demonstrated that the functional results and the stability of the knee were not related with tunnel widening. This study concludes that the reconstruction of ACL with hamstring tendons and the Transfix technique is reasonably successful, safe and causes low morbidity. Furthermore, we believe that proper graft preparation, accurate tunnel placement, notch-plasty, fixation and rehabilitation program are all as important as the choice of graft and fixation material.     

One-stage anatomic double-bundle anterior and posterior cruciate ligament reconstruction using the autogenous hamstring tendons

This is the first report of an anatomic double-bundle ACL and PCL reconstruction procedure with the autogenous hamstring tendons. We prepare two pairs of the doubled tendon grafts, to which a polyester tape and an Endobutton-CL are attached using our original technique at the tibial and femoral ends, respectively. Under arthroscopic and fluoroscopic observations, two tibial tunnels for PCL reconstruction are created so that they pass through the posteromedial and anterolateral bundle attachments, respectively. Then, we create two tibial tunnels for anatomic double-bundle ACL reconstruction so that each tunnel axis is aimed at a targeted point on the femoral condyle. Using the outside-in technique, two femoral tunnels for PCL reconstruction are created so that the tunnel outlets are located at the center of the anterolateral and posteromedial bundle attachments. Then, two femoral tunnels for anatomic double-bundle ACL reconstruction are created with the trans-tibial tunnel technique. After the two grafts have been placed for PCL reconstruction, the two grafts are placed for ACL reconstruction. After all the femoral graft ends are fixed, the knee joint is reduced to the full extension position, and then, the four tibial tape portions are simultaneously fixed with the turn-buckle stapling technique.     

The role of periosteal flap in the prevention of femoral widening in anterior cruciate ligament reconstruction using hamstring tendons

Tunnel widening in anterior cruciate ligament reconstruction has been reported for many years, whatever the type of plasty (allo- or autograft) or graft (patellar or hamstring tendons). Recently, the hypothesis has been formulated that widening would be responsible for later laxity of the knees. Micromobility of the graft or biological factors are classically responsible for the enlargement. In order to improve the biological conditions around the graft within the tunnel, we have developed a surgical technique using a periosteal flap. The periosteal flap is harvested at the superior and medial metaphysis of the tibia and wrapped around the proximal part of the four strands of gracilis and semitendinosus tendons near the outlet of the femoral tunnel. Forty-one patients with isolated rupture of the ACL were included in a prospective and randomized study: the first group of 20 patients had femoral fixation by Transfix and resorbable screw, the second group of 21 patients had femoral fixation by Transfix and periosteal flap. The diameters of the tunnel were measured between the sclerotic margins at the tunnel entrance and 1 cm above, and compared to the peroperative drill size. The percentage change in diameter was calculated as: (tunnel diameter–drill size)/drill size. The two groups of patients were comparable as to gender, side, age, KT-1000 side to side difference, femoral tunnel diameter and follow-up. At 2.5 months and 11 months postoperatively on average, there was a significant reduction of enlargement at the outlet of the tunnel with the use of a periosteal flap but widening was constant.     

Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon autograft: clinical outcome in 4–7 years

Surgical reconstruction of the anterior cruciate ligament (ACL) is indicated in the ACL-deficient knee with symptomatic instability and multiple ligaments injuries. In the present study, we describe the clinical results of quadriceps tendon-patellar bone autograft for ACL reconstruction. From 1996 to 1998, the graft has been used in 38 patients. Thirty-four patients with complete final follow-up for 4–7 years were analyzed. The average follow-up time was 62 (48–84) months. Thirty-two patients (94%) achieved good or excellent results by Lysholm knee rating. Twenty-six patients (76%) could return to moderate or strenuous activity after reconstruction. Twenty-eight patients (82%) had ligament laxity of less than 2 mm. Finally; 31 patients (91%) were assessed as normal or nearly normal rating by IKDC guideline. Twenty-five patients (73%) had less than 10 mm difference in thigh girth between their reconstructed and normal limbs. Thirty-two (94%) and 31 (91%) patients could achieve recovery of the extensor and flexor muscle strength in the reconstructed knee to 80% or more of normal knee strength, respectively. A statistically significant difference exists in thigh girth difference, extensor strength ratio, and flexor strength ratio before and after reconstruction. Tunnel expansion with more than 1 mm was identified in 2 (6%) tibial tunnels. Our study revealed satisfactory clinical subjective and objective results at 4–7 years follow-up. Quadriceps tendon autograft has the advantage of being self-available, relatively easier arthroscopic technique, and having a suitable size, making it an acceptable graft choice for ACL reconstruction. There is little quadriceps muscle strength loss after quadriceps harvest. A quadriceps tendon-patellar autograft is an adequate graft choice to ACL reconstruction.