Ligament reconstruction

Volar ligament reconstruction is an effective technique for treating symptomatic laxity of the CMC joint of the thumb. The laxity may bea manifestation of generalized ligament laxity,post-traumatic, or metabolic (Ehler-Danlos). There construction reduces the shear forces on the joint that contribute to the development and persistence of inflammation. Although there have been only a few reports of the results of volar ligament reconstruction, the use of the procedure to treat Stage I and Stage II disease gives good to excellent results consistently. More advanced stages of disease are best treated by trapeziectomy, with or without ligament reconstruction.     

后交叉韧带合并内侧副韧带损伤的手术治疗（附14例报告）

自１９９０年２月～１９９６年２月，我们治疗１４例后交叉韧带合并内侧副韧带损伤患者。利用髌韧带中１／３腱条和内侧半月板联合重建后交叉韧带，同时行内侧副韧带重建和将股骨髁部附着点前移。１４例中１１例获得随访，有效率１００％，优良率９０．９％。本文对此类韧带损伤的特点和本组术式进行了分析和探讨。     

关节镜下人工韧带治疗膝后交叉韧带损伤

通过对11例膝后交叉韧带(PCL),对断裂患者在关节镜下行Gore-Tex人工韧带重建PCL,对近期随访结果进行分析,随访9～21个月,平均17个月。术后所有患膝不稳定症状消失。Lachnan试验阴性,后抽屉试验阴性,关节功能良好。根据Lysholm膝关节评分法,平均积分由术前的54分提高到术后的89分。认为关节镜下人工韧带治疗后交叉韧带损伤手术反应小,恢复快,近期疗效肯定,远期疗效尚待日后更深入的研究。     

Posterior Cruciate Ligament

Improved understanding of the anatomy and biomechanics of the posterior cruciate ligament (PCL) has led to the evolution and improvement of anatomic-based reconstructions. The PCL is composed of the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB). On the femoral side, the ALB spans from the trochlear point to the medial arch point on the roof of the notch, while the PMB occupies the medial wall from the medial arch point to the most posterior aspect of the articular cartilage. Because of these broad and distinct attachments, the bundles have a load-sharing, synergistic and codominant relationship. Both restrict posterior translation; however, the ALB has a proportionally larger role in restricting translation throughout flexion, whereas the PMB has a role comparable to that of the ALB in full extension. In addition, the PMB resists internal rotational at greater flexion angles (> 90°). Consequently, it is difficult to restore native kinematics with a single graft. Biomechanical analysis of single- versus double-bundle PCL reconstructions (SB PCLR vs DB PCLR) demonstrates improved restoration of native kinematics with a DB PCLR, including resistance to posterior translation throughout flexion (15°-120°) and internal rotation in deeper flexion (90°-120°). Similarly, clinical research demonstrates excellent outcomes following DB PCLR, including functional outcomes comparable to those of anterior cruciate ligament reconstructions, with no significant differences between isolated and multiligament PCL injuries. Compared to SB PCLR, systematic review has demonstrated the superiority of DB PCLR based on objective postoperative stress radiography and International Knee Documentation Committee scores in randomized trials. In addition to reconstruction techniques, recent research has identified other factors that impact kinematics and PCL forces, including decreased tibial slope, which leads to increased graft stresses, and incidence of native PCL injuries. As the understanding of these other contributing factors evolves, so will surgical and treatment algorithms that will further improve patients’ outcomes.     

Ligament replacements--clinical evaluation

Prosthetic ligament device evaluation techniques involve the following: stating the goals of the use of the prosthesis; obtaining adequate postoperative assessment by using standard clinical measurements of joint stability and performance; obtaining the patient's own evaluation of the reconstructive process; and periodically insuring that there is retention of the initial benefits obtained throughout the recovery period.     

腰椎间盘突出症与周围韧带的关系及组织学观察

目的　进一步了解腰椎周围软组织病变与腰椎间盘突出症之间的关系 ,探讨腰椎病变的病因。方法　测量 31例手术取得的黄韧带和椎板的厚度 ,对取得的标本进行组织学观察。结果　腰椎病变处的黄韧带和椎板明显增厚 ,韧带组织伴有纤维软骨化 ,胶元纤维排列紊乱。结论　除了外伤外 ,棘上韧带和黄韧带的退变是腰椎间盘脱出重要的发病因素。     

关节镜下人工韧带移植重建膝前后交叉韧带

目的回顾性研究关节镜下应用人工韧带重建膝交叉韧带的疗效。方法应用LARS人工韧带对16例交叉韧带损伤行关节镜下重建,术后予以早期康复锻练,对临床疗效进行回顾性分析。结果手术时间55～96min,平均65min。16例均随访3～30个月,平均16个月。术后无滑膜炎、韧带断裂、活动受限等并发症。按照IKDC评分标准及Lysholm膝关节功能评分进行评估,术后膝关节功能均得到良好恢复。结论LARS人工韧带的应用能避免取材部位的并发症,操作简便,可早期康复锻炼,极好的恢复关节屈伸度,获得满意疗效。     

Replacement of the Anterior Cruciate Ligament with a Polyethylene Prosthetic Ligament

The results of insertion of the Richards Polyflex® ligament in 9 patients to replace the anterior cruciate ligament are reported. In 3 of these 9 patients it had been necessary to remove the prosthetic ligament and in another patient the operation had not stabilized the knee. Half of the patients who still have a Polyflex ligament complained of pain. It is concluded that from the material-technical point of view the Polyflex ligament has not yet been satisfactorily developed, and the operation poses a great many technical problems. Technically and functionally this system must still be considered to be in the experimental stages and not yet properly developed for general use.     

Multiple Ligament Knee Reconstructions

Patients with multiligament knee injuries require a thorough examination (Lachman, posterior-drawer, varus, valgus, and rotational testing). Diagnoses are confirmed with magnetic resonance imaging as well as stress radiographs (posterior, varus, and valgus) when indicated. Multiple systematic reviews have reported that early (<3 weeks after injury) single-stage surgery and early knee motion improves patient-reported outcomes. Anatomic-based reconstructions of the torn primary static stabilizers and repair of the capsular structures and any tendinous avulsions are performed in a single-stage. Open anteromedial or posterolateral incisions are preferentially performed first to identify the torn structures and to prepare the posterolateral corner (PLC) and medial knee reconstruction tunnels. Next, arthroscopy allows preparation of the anterior cruciate ligament (ACL) and double-bundle (DB) posterior cruciate ligament (PCL) tunnels. Careful attention to tunnel trajectory minimizes the risk for convergence. Meniscal tears are preferentially repaired (root and ramp tears are commonly seen in this patient group). Graft passage is performed after all tunnels are reamed. The graft tensioning and fixation sequence is as follows: anterolateral bundle of the PCL to restore the central pivot, posteromedial bundle of the PCL, ACL, PLC (including fibular [lateral] collateral ligament), and posteromedial corner (including medial collateral ligament). Graft integrity and full knee range of motion should be verified before closure. Physical therapy commences on postoperative day 1 with immediate knee motion (flexion from 0°-90°; prone for DB-PCL reconstruction) and quadriceps activation. Patients are nonweightbearing for 6 weeks. Patients with ACL-based reconstructions wear an immobilizer for 6 weeks then transition to a hinged ACL brace. Patients with PCL-based reconstructions transition into a dynamic PCL brace once swelling subsides and wear it routinely for 6 months. Functional testing and stress radiography are performed to validate return to sports.     

Medial Patellofemoral Ligament Reconstruction: A Novel Technique Using the Patellar Ligament

In patients with chronic patellofemoral instability, more than 2 episodes of dislocation, and an anterior tuberosity trochlear groove of less than 20 mm as measured on computed tomography or nuclear magnetic resonance imaging, we have developed a technique for medial patellofemoral ligament reconstruction that uses a medial strip of the patellar ligament (PL). The incision started proximally at the level of the superior margin of the patella, centrally between the patellar medial margin and the medial epicondyle. A descending incision was then made, directed toward the superomedial margin of the tibial tubercle. We performed a plane-by-plane dissection up to the peritenon of the PL. With an osteotome, we could remove a 2-cm bone fragment concerning the medial third of the distal insertion of the PL or keep the distal end free. Using a No. 11 scalpel blade, we carefully detached the PL from the patella up to the transition between the proximal third and medial third of the patella. We placed the stitches between the periosteum and the ligament using FiberWire absorbable threads (Arthrex, Naples, FL) to safely rotate the graft. After that, we dissected the medial capsule and approached the femoral medial epicondyle. Then we placed a Krackow suture in the free tendon end using absorbable threads or anchored the threads into 2 holes that were previously drilled, and we secured the end with an absorbable interference screw or anchors. The fixation should be performed with the knee at 15° to 30° of flexion. Then we sutured the distal edge of the vastus medialis muscle to the graft, which bestows a dynamic component upon the reconstruction, and we immobilized the knee with a removable brace.     

Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration

Ligament and tendon injuries are common problems in orthopedics. There is a need for treatments that can expedite nonoperative healing or improve the efficacy of surgical repair or reconstruction of ligaments and tendons. Successful biologically-based attempts at repair and reconstruction would require a thorough understanding of normal tendon and ligament healing. The inflammatory, proliferative, and remodeling phases, and the cells involved in tendon and ligament healing will be reviewed. Then, current research efforts focusing on biologically-based treatments of ligament and tendon injuries will be summarized, with a focus on stem cells endogenous to tendons and ligaments. Statement of clinical significance: This paper details mechanisms of ligament and tendon healing, as well as attempts to apply stem cells to ligament and tendon healing. Understanding of these topics could lead to more efficacious therapies to treat ligament and tendon injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:7–12, 2020     

Development of a Tissue‐Engineered Artificial Ligament: Reconstruction of Injured Rabbit Medial Collateral Ligament With Elastin‐Collagen and Ligament Cell Composite Artificial Ligament

Ligament reconstruction using a tissue‐engineered artificial ligament (TEAL) requires regeneration of the ligament‐bone junction such that fixation devices such as screws and end buttons do not have to be used. The objective of this study was to develop a TEAL consisting of elastin‐coated polydioxanone (PDS) sutures covered with elastin and collagen fibers preseeded with ligament cells. In a pilot study, a ring‐type PDS suture with a 2.5 mm (width) bone insertion was constructed with/without elastin coating (Ela‐coat and Non‐coat) and implanted into two bone tunnels, diameter 2.4 mm, in the rabbit tibia (6 cases each) to access the effect of elastin on the bond strength. PDS specimens taken together with the tibia at 6 weeks after implantation indicated growth of bone‐like hard tissues around bone tunnels accompanied with narrowing of the tunnels in the Ela‐coat group and not in the Non‐coat group. The drawout load of the Ela‐coat group was significantly higher (28.0 ± 15.1 N, n = 4) than that of the Non‐coat group (7.6 ± 4.6 N, n = 5). These data can improve the mechanical bulk property of TEAL through extracellular matrix formation. To achieve this TEAL model, 4.5 × 10⁶ ligament cells were seeded on elastin and collagen fibers (2.5 cm × 2.5 cm × 80 µm) prior to coil formation around the elastin‐coated PDS core sutures having ball‐shape ends with a diameter of 2.5 mm. Cell‐seeded and cell‐free TEALs were implanted across the femur and the tibia through bone tunnels with a diameter of 2.4 mm (6 cases each). There was no incidence of TEAL being pulled in 6 weeks. Regardless of the remarkable degradation of PDS observed in the cell‐seeded group, both the elastic modulus and breaking load of the cell‐seeded group (n = 3) were comparable to those of the sham‐operation group (n = 8) (elastic modulus: 15.4 ± 1.3 MPa and 18.5 ± 5.7 MPa; breaking load: 73.0 ± 23.4 N and 104.8 ± 21.8 N, respectively) and higher than those of the cell‐free group (n = 5) (elastic modulus: 5.7 ± 3.6 MPa; breaking load: 48.1 ± 11.3 N) accompanied with narrowed bone tunnels and cartilage matrix formation. These data suggest that elastin increased the bond strength of TEAL and bone. Furthermore, our newly developed TEAL from elastin, collagen, and ligament cells maintained the strength of the TEAL even if PDS was degraded.     

Das mediale patellofemorale Ligament

The medial patellofemoral ligament or MPFL is the prime soft tissue stabilizer of the patella. The MPFL is a non-isometric ligament lying in the second fascial layer of the knee; it is tight in extension and lax in flexion. The ligament is always torn in acute patellar dislocations. As “form follows function” we believe that the MPFL should be reconstructed in such a way that it stabilizes the patella without changing its movement pattern.     

Ligamentäre Handwurzelverletzungen

Trauma und Berufskrankheit - An der Hand treten, bei privaten Unfällen und im Rahmen der beruflichen Tätigkeit, neben Frakturen, Sehnen- und Weichteilverletzungen auch gehäuft...