异体前十字韧带移植重建兔后十字韧带的生物力学研究

目的探讨以兔异体前十字韧带为移植物解剖重建后十字韧带的生物力学变化。方法在研究正常兔前、后十字韧带解剖学和生物力学特性的基础上,用异体前十字韧带移植物解剖重建后十字韧带。应用无菌取材、新鲜冰冻技术制备异体骨-前十字韧带-骨移植物,-80℃保存14d以上待用。24只成年新西兰大白兔,随机选取其一侧后腿作为实验组,重建后十字韧带,对侧为对照组。分别于术后6、12、26、52周取材,测定股骨-移植物-胫骨的几何学特点、断裂部位、结构力学特性和材料力学特性。结果移植物平均长度在52周时为对照组正常后十字韧带的101%(P=0.90),平均横截面积为142%;强度在术后52周时为对照组正常后十字韧带的83%,最大拉长量为72%,刚度为92%;最大应力在术后52周时为对照组正常后十字韧带的58%,最大应变为72%,弹性模量为65%。断裂部位均位于移植物体部。移植物的几何学特点、结构力学特性和材料力学特性均有逐渐接近对照组正常后十字韧带的趋势。结论相同材料力学特性的移植物重建后十字韧带后生物力学特性转归良好,移植物的相同材料力学特性是影响后十字韧带重建效果的重要因素。     

LARS人工韧带重建前交叉韧带术后骨隧道变化特点的研究

目的 探讨LARS人工韧带重建前交叉韧带(ACL)术后骨隧道的变化特点及可能的影响因素.方法 2004年8月至2007年4月应用LARS人工韧带重建43例单纯ACL损伤患者,男31例,女12例;左膝19例,右膝24例;年龄17～48岁,平均27.5岁.于术后l、3、6、12、24、36个月分别行膝关节X线片和CT检查,记录各个时间点胫骨和股骨骨隧道的宽度.骨隧道增宽采用Peyrache等提出的分级方法进行评定.末次随访时根据Lysholm评分标准评定膝关节功能,应用KT-1000TM测量膝关节的松弛度. 结果 43例患者术后获36 ～49个月(平均39.5个月)随访.末次随访时仅3例患者出现骨隧道l级增宽,均为术后6个月发生于股骨隧道近关节面水平,平均增宽(2.5 ±0.3) mm.无一例患者出现2级和3级骨隧道增宽.不同时间点股骨、胫骨骨隧道宽度比较差异均无统计学意义(P＞0.05).X线片与CT测量结果基本一致,二者比较差异均无统计学意义(P＞0.05).末次随访时3例骨隧道l级增宽患者Lysholm评分平均为(94.5±4.6)分,KT-1000TM前移差值平均为(1.5±1.1)mm;40例0级增宽患者Lysholm评分平均为(95.6±4.8)分,KT-1000TM前移差值平均为(1.4±1.5)mm.结论 LARS人工韧带重建ACL术后骨隧道增宽并不显著,这种变化特点可能与LARS人工韧带移植物的特性及固定方法不同有关.     

Biomechanics of the anterior cruciate ligament:Physiology,rupture and reconstruction techniques

The influences and mechanisms of the physiology,rupture and reconstruction of the anterior cruciate ligament(ACL)on kinematics and clinical outcomes have been investigated in many biomechanical and clinical studies over the last several decades.The knee is a complex joint with shifting contact points,pressures and axes that are affected when a ligament is injured.The ACL,as one of the intra-articular ligaments,has a strong influence on the resulting kinematics.Often,other meniscal or ligamentous injuries accompany ACL ruptures and further deteriorate the resulting kinematics and clinical outcomes.Knowing the surgical options,anatomic relations and current evidence to restore ACL function and considering the influence of concomitant injuries on resulting kinematics to restore full function can together help to achieve an optimal outcome.     

The progression of anterior translation after anterior cruciate ligament reconstruction in a caprine model.

Large post-operative anterior-posterior translations are frequently reported after quadruped anterior cruciate ligament (ACL) reconstructions. To determine when the translation increases occur and the mechanism responsible, we followed the anterior and posterior translation limits in 18 goat knees for six months. Reconstructions were performed using grafts 4 or 7 mm wide placed in initially tight or lax positions. The anterior and posterior translation limits at 50 N were monitored using Roentgen stereophotogrammetric analysis. Graft bone block stability and soft tissue segment lengths were also assessed. Large (> 2 mm) increases in anterior translation were noted in 71% of the subjects at two weeks, and in 88% at eight weeks. The translations in the lax and tight groups were indistinguishable after two weeks. Joints with wide grafts had less anterior translation compared to narrow grafts at all time periods, but were significant different only at 26 weeks. The posterior translation limit moved anteriorly over the 26 weeks. Eight of nine joints had stable graft bone markers and/or increases in graft soft tissue lengths. In conclusion, increased anterior translation occurred soon after ACL reconstruction, was associated with graft soft tissue changes, and appeared to be reduced by larger grafts. A post-surgical decrease in posterior translation limit was also observed.     

前交叉韧带重建术后膝关节功能及三维运动步态分析

目的 探讨前交叉韧带(ACL)重建术后膝关节稳定性、功能及三维步态运动学情况.方法 回顾性分析2015年7月到2017年7月在佛山市中医院运动学科采用自体腘绳肌腱行ACL重建并进行了二次关节镜探查的270例病例,其中男164例,女106例.采用Lysholm评分、国际膝关节评分委员会(IKDC)评分、Tenger评分、...     

Effect of immobilization of the knee joint on mechanoreceptors in anterior cruciate ligament of the rabbit

We investigated the morphologic distribution of mechanoreceptors in the anterior cruciate ligament of the knee in rabbits and the effects of immobilization of the knee joint, and evaluated the qualitative and quantitative morphologic changes of the mechanoreceptors after resumption of movement of the knee joint. There was no significant difference in the total number of mechanoreceptors present after 4-week immobilization compared with the number of mechanoreceptors on the unfixed control side. However, there was a significant increase in Pacinian corpuscles and Ruffini receptors with an atypical morphology. When immobilization was performed for 6 weeks, the total number of mechanoreceptors, including typical and atypical ones, showed a significant decrease compared to the control. After 12 and 24 weeks of remobilization, the total number of mechanoreceptors had returned to a level not significantly different from that on the control side, but typical mechanoreceptors were still significantly decreased and the atypical mechanoreceptors had increased. These results suggest that immobilization brings about morphologic changes and a reduction in the number of mechanoreceptors. The total number of mechanoreceptors recovers after re-mobilization, but the typical mechanoreceptors do not return, and the number of atypical mechanoreceptors increas. These changes are thought to be irreversible.     

前十字韧带重建中的移植物位置偏移

目的 计算可吸收界面螺钉导致的移植物偏离隧道位移,探讨其对前十字韧带重建产生的影响.方法 19个新鲜尸体膝关节标本,随机选取5个,采用7 mm、8 mm、9 mm界面螺钉固定自体肌腱,测定偏移距离.另外14个膝关节分为等长组和解剖组,等长组膝关节测量界面螺钉固定后及校正位置的移植物拉长距离;解剖组膝关节于膝关节生物力学测试仪上分别测定ACL完整组、ACL缺失组、偏移组和校正组在134 N前向负荷下膝关节屈曲0°、15°、30°、60°和90°位的胫骨前向位移.结果 (1)肌腱偏移:直径7mm、8 mm、9mm的界面螺钉分别使移植物偏移(2.36±0.11)mm、(2.72±0.06)mm、(3.00±0.06)mm.(2)等长性:初始拉长小于3 mm,偏移拉长大于3 mm,校正拉长小于3 mm.(3)生物力学:屈膝0°、15°位,ACL完整组与偏移组、校正组差异无统计学意义.屈膝30°、60°、90°位ACL完整组与其他各组比较差异均有统计学意义,屈膝30°、60°位偏移组与校正组比较差异有统计学意义.结论 无论等长重建还是解剖重建,界面螺钉均影响移植物的股骨隧道口位置.前十字韧带重建预先校正股骨隧道口位置,移植物基本会处于预先的理想位置.

Abstract：

Objective To investigate the impact of graft position shift on anterior cruciate ligament reconstruction induced by femoral fixation of interference screw. Methods Nineteen fresh cadaveric knees were used and assigned to three groups. 1) Study of graft position shift: 5 knees were randomly selected, interference screws of 7 mm, 8 mm and 9 mm were used in autologous tendon fixation, then the graft position shift were measured. 2) Study of isometry: 7 knees were randomly divided into the isometric reconstruction group (D group). In the D group, Retrobutton, interference screw and interference screw in location-corrected bone tunnel were used respectively as fixation. The isometry of grafts was evaluated. 3) Study of tibia anterior translation: 7 knees were randomly divided into the anatomic reconstruction group (J group). In the J group,the tibia anterior translation was measured in four different conditions in the same joint: intact knee joint,knee joint without ACL, ACL anatomic reconstruction by interference screw fixation, and ACL anatomic reconstruction by interference screw fixation with corrected bone tunnel location. Results 1) With 7 mm, 8mm and 9 mm interference screw fixation, graft position shift were (2.36±0.11) mm, (2.72±0.06) mm and (3.00±0.06) mm respectively. 2) Graft length change: graft length change in Retrobutton group and corrected bone tunnel group were less than 3 mm, while graft length change in those fixed with interference screw were stretched in more than 3 mm. 3) Study of tibia anterior translation: there was no difference among the intact group, the anatomic group and the corrected group at 0° and 15°. However, the difference was found between the intact group and other groups at 30°、60° and 90° of flexion, as well as between these two reconstructed methods at 20° joint flexion (P＜0.05). Conclusion In both isometric and anatomic ACL reconstruction with interference screw, the graft is pushed tightly toward the femoral tunnel wall, which shifts the graft away from the desired position. In our study we find out that the corrected location of the femoral bone tunnel significantly improves the isometry of ACL reconstruction and anatomic reconstruction.     

半月板撕裂和切除对前交叉韧带断裂力学稳定性的影响

目的探讨半月板对前交叉韧带断裂及重建术后胫骨前向稳定性的影响。 方法收集2017年1月至2018年10月期间前交叉韧带重建患者,排除前交叉韧带部分断裂和多发韧带损伤病例。所有不稳定半月板撕裂均行半月板部分切除术,根据半月板损伤部位及程度进行分组。采用KT-1000测量术前、术后3个月和6个月的胫骨前平移量(ATT)。组间对照采用独立样本t检验。 结果共纳入158例前交叉韧带断裂患者,其中半月板正常组61例,内侧半月板后角撕裂组49例(19例为撕脱<总宽度40%;30例为撕脱≥总宽度40%);外侧半月板撕裂组35例(12例为撕脱<总宽度40%;23例为撕脱≥总宽度40%);内侧半月板前角或体部撕裂组13例(6例为撕脱<总宽度40%;7例为撕脱≥总宽度40%)。术前内侧半月板后角撕裂≥总宽度40%患者的胫骨前平移量较半月板正常患者明显增加,差异有统计学意义(t＝12.141,P<0.01)。术后3个月及6个月,各个半月板撕裂组的ATT值与半月板正常患者相比均无差异(P >0.05)。 结论内侧半月板后角撕裂与前交叉韧带断裂可增加膝关节的不稳定性,半月板部分切除术对前交叉韧带重建术后患者的膝关节稳定性无影响。     

兔保留与切除残迹前交叉韧带重建生物力学的比较

目的比较兔保留与切除残迹前交叉韧带（ACL）重建的生物力学差异,探讨保留残迹的意义。方法新西兰兔10只,体重（2．66±0．32）kg。切断双侧ACL,右侧股骨与胫骨端各保留残迹2mm,左侧完全切除两端残迹。切取跟腱制备移植物,对应ACL印迹解剖位分别建立胫骨与股骨隧道,重建双侧ACL。于术后8周,行单轴拉力测试。SPSS19．0软件进行数据统计。结果术后8周,保留残迹组的最大载荷（t=2．931,P〈0．05）、屈服载荷（t=2．680,P〈0．05）、刚度（t=5．411,P〈0．05）明显高于切除残迹组,两组之间差异均有统计学意义;保留残迹组拉伸长度显著低于切除残迹组,两组差异有统计学意义（t=-3．872,P〈0．05）。两组损毁模式不同,保留残迹组多表现为移植物关节内断裂,而切除残迹组多表现为移植物自骨隧道拔出。Fisher精确检验表明两组的样本损毁模式有统计学差异（P〈0．05）。结论保留残迹ACL重建的生物力学特征优于切除残迹ACL重建,提示临床采用保留残迹技术重建ACL有可能促进移植物腱-骨愈合和“韧带化”,从而改进治疗效果。     

前交叉韧带切除后半月板变化及α2-巨球蛋白干预效果的初步研究

目的探讨兔骨关节炎(OA)模型膝关节前交叉韧带切除(ACLT)术后半月板的变化,及对关节腔内注射α2-巨球蛋白(α2M)对该变化的干预情况。方法健康的新西兰大白兔24只,按随机数字表分成5个时间点组,前2组各6只,后3组各4只,双侧膝关节自体对照。ACLT术后4、8、11和15周时,左侧膝关节注射用无菌生理盐水稀释成145mg/L的α2M为治疗侧,右侧膝关节注射等量无菌生理盐水为阴性对照侧,每次每侧0.4ml。术后4、8、11、15和21周行膝关节正侧位X光检查、半月板masson染色和电镜检查。结果ACLT模型建立成功,建模的时间越长,阴性对照侧的半月板病变越明显,ACLT后21周时,双侧膝未见明显关节间隙、骨赘及骨缺损等改变,而masson染色和电镜观察结果显示双侧关节半月板组织结构和细胞结构在4周时已发生较轻微的病理改变。与α2M治疗侧比较,阴性对照侧8～21周间半月板病变加重,21周后阴性对照侧的病变转变为不可逆的损伤;与阴性对照侧比较,α2M治疗侧的半月板退变速度稍慢,半月板纤维和细胞情况较好,但伴有滑膜的增生、侵袭。结论α2M可以减缓动物模型关节炎病变的进展速度,对滑膜增生的抑制作用较弱,α2M可能适合OA发病初期的保护性治疗和研究。     

前交叉韧带囊肿的临床表现与关节镜治疗

目的：探讨膝关节前交叉韧带囊肿的临床表现和关节镜手术疗效.方法：回顾性分析自2005年1月至2010年12月收治的12例症状性膝关节前交叉韧带囊肿的资料.男8例,女4例;年龄19～53岁,平均（33.7±9.5）岁;左膝5例,右膝7例;病程3～48个月,平均（15.8±13.2）个月.术中关节镜下完整切除前交叉韧带囊肿.记录术前术后膝关节的活动度,膝关节功能采用Lysholm评分标准进行评定.结果：术后患者切口均Ⅰ期愈合,无相关并发症发生.12例均获随访,时间24～48个月,平均（32.3±6.6）个月.患膝关节疼痛、肿胀、交锁症状均消失,随访期间无复发.术后关节活动度及Lysholm评分均较术前明显改善.结论：关节镜诊治症状性前交叉韧带囊肿具有创伤小、恢复快的优点,是治疗症状性膝关节前交叉韧带囊肿的有效治疗手段.     

前十字韧带重建术骨隧道区的骨密度测量

 目的 比较前十字韧带（anterior cruciate ligament,ACL）重建术股骨侧与胫骨侧骨隧道区域的骨密度,为选择界面螺钉大小提供参考。方 法 招募30名年龄18~35岁的健康志愿者,用双能X线吸收（Dual-energy X-ray absorptiometry,DEXA）骨密度仪进行右下肢股骨侧与胫骨侧骨隧道区域骨密度 测量;以CT薄层扫描右侧膝关节,利用三维立体成像技术分别确定经过骨隧道中心轴的股骨与胫骨隧道截面并测量灰度值。2010年8至10月ACL撕裂确诊患者9例 ,在重建手术过程中完整取出股骨侧与胫骨侧骨隧道内松质骨柱,应用阿基米德原理测量体积骨密度。结果 DEXA测量股骨侧隧道区域骨密度为（1.162±0.034 ） g/cm2,胫骨侧为（0.814±0.038） g/cm2,两者差异有统计学意义（t=9.11,P=0.000）;骨隧道区域CT股骨侧灰度值为（211.7±11.5） Hu,胫骨侧为 （104.9±7.4） Hu,两者差异有统计学意义（t=10.15,P=0.000）;股骨侧骨柱体积骨密度为（2.80±0.88） g/cm3,胫骨侧骨柱为（1.88±0.59） g/cm3, 两者差异有统计学意义（t=4.32,P=0.002）。结论 ACL重建术股骨侧隧道松质骨密度大于胫骨侧。     

Subject variation in caprine anterior cruciate ligament reconstruction.

We studied the subject and treatment contributions to anterior cruciate ligament (ACL) reconstruction biomechanics by reexaming the results of two bilateral reconstruction studies. Bilateral reconstruction allows a comparison between treatments exposed to the same subject related healing factors. The studies examined the effects of gamma irradiation and the effects of initial graft size and initial graft laxity. In both studies different treatments were applied to contralateral limbs. We found that the subject was the best predictor of outcome, while the surgical treatments had little influence on outcome. There was a large variation between subjects despite similar treatments, and little difference between contralateral limbs despite different surgical treatments. At 26 weeks, the graft cross sectional area and modulus were most strongly influenced (p < 0.002) by the subject. We interpret this as a subject related factor is regulating the quantity and quality of the healing tissue. Potential sources of subject related factors include the subject's pre-operative condition, the activity during the post-operative period, and an intrinsic biologic response. By better understanding the source of subject variation, more successful and consistent ACL reconstructions might be achieved.     

单隧道双束和单束ACL重建的生物力学比较研究

目的比较单隧道双束和单隧道单束ACL重建膝关节稳定性的差异。方法选用6侧人体膝关节标本,保留完整的关节囊及周围韧带,行单隧道双束和单束ACL重建,在MTS-858生物材料试验系统上测试膝关节在胫前加载(134N)和旋转加载(5N·m内旋胫骨)下屈曲0°、15°、30°、60°、90°位时的运动学反应。每个膝关节在4个不同条件下进行测试:ACL完整、ACL损伤、单隧道双束重建ACL以及单隧道单束重建ACL,其中单隧道双束及单束ACL均采用双股腘绳肌腱。结果 (1)胫前加载:双束组在屈曲30°、60°和90°位,单束组在屈曲90°位时关节前后稳定性获得良好恢复(P0.05);在屈曲60°位时双束组的胫前位移明显低于单束组,差异有统计学意义(P0.05)。(2)旋转加载:与ACL完整组相比较,双束组的胫骨内旋角度在屈曲0°、60°位时无明显变化(P0.05),屈曲90°位时明显减少(P0.05);单束组在屈曲0°时无明显变化(P0.05)。屈曲60°和90°位时双束组的胫骨内旋角度明显小于单束组,差异有统计学意义(P0.05)。结论与单隧道单束ACL重建相比,单隧道双束ACL重建能够更好地恢复膝关节前后稳定性及旋转稳定性。     

The relationship between knee strength and functional stability before and after anterior cruciate ligament reconstruction.

Functional stability of the knee is dependent on an intact ligamentous system and the timely and efficient contraction of supporting musculature. The aim of this study was to assess the relationship between muscle strength and functional stability in 31 patients pre- and post-operatively, following a unilateral anterior cruciate ligament rupture. All subjects underwent reconstructive surgery using semitendonosis and gracilis tendons. Isokinetic strength assessment of quadriceps and hamstring muscles was performed at a rate of movement of 60 degrees /s and 120 degrees /s. Functional stability was determined by performance during five functional stability tests that included the shuttle run, side step, carioca, single and triple hop tests. Pearson's correlation coefficient statistics were applied to pre-operative and post-operative data respectively. These analyses demonstrated a significant positive correlation between quadriceps strength indices at both testing speeds and the two hop tests pre-operatively (p's<0.007) and between quadriceps strength indices at both speeds and all five functional tests post-operatively (p's<0.01). Assessed using Steiger's formula, there was a significant increase in the correlation between quadriceps strength indices and three functional tests post-operatively compared to pre-operatively (p<0.05). No significant correlation between hamstring strength indices and functional scores existed pre- or post-operatively. This study has shown a significant correlation exists between quadriceps strength indices and functional stability both before and after surgery, this relationship does not reach significance between hamstring strength indices and functional stability.     

前交叉韧带双束与单束重建术临床结果比较的Meta分析

目的比较前交叉韧带双束重建术和单束重建术的中长期临床疗效。方法依照Cochrane系统评价方法比较随机对照或半随机对照试验,计算机检索Scopus,Pubmed,Medline和Cochrane等数据库,选择符合条件文献并作出方法学评估后,统计分析在Revman5．1上进行。结果纳入文献25篇,双束重建的结果在KT-1000（WMD=-0．31,P〈0．05;WMD=-0．59,P〈0．01）,IKDC评分（RR=1．43,P〈0．05;RR=1．17,P〈0．01）,长期Lachman（RR=1．32,P〈0．01）和长期Tegner运动评分（RR=0．37,P〈0．01）优于单束重建;轴移试验中期随访结果双束组更好（RR=1．20,P〈0．01）,但长期效果无区别。结论通过Meta分析本文发现相比单束重建术,双束重建术能更好的恢复膝关节的生物力学。由于双束重建后生物力学性质更接近正常,可能更好的保护包括软骨在内的关节内组织。因此认为双束重建术总体临床效果优于单束重建术。     

Use of patellar tendon autograft for anterior cruciate ligament reconstruction in the rabbit: a long-term histologic and biomechanical study

To assess the degree of success of anterior cruciate ligament (ACL) replacement using the patellar tendon (PT) autograft, 29 New Zealand white rabbits underwent ACL reconstruction using a medial one-third PT autograft. The femur-ligament-tibia complexes were evaluated at 0, 6, 30, and 52 weeks postoperatively for gross and histologic appearances and tensile load to failure properties. Grossly, the autografts did not resemble the control ACLs. Histologically, the autografts progressed from being hypercellular with a random collagen fiber bundle organization to having a near normal cellularity with a more parallel collagen fiber bundle pattern. Anteroposterior knee laxity was more than two times that of the control knees 52 weeks after reconstruction. Biomechanically, the PT autografts plateaued at 30 weeks postoperatively. The ultimate load and stiffness were 15 +/- 5% and 24 +/- 6% of the control ACLs, respectively. At 52 weeks, the appearance of the PT autograft had some general histologic similarities as compared with the native ACL. However, these similarities did not extend to the functional properties of the autograft.     

前交叉韧带重建术后膝关节位置觉和运动觉的早期观察研究

目的观察关节镜下自体胭绳肌腱单双束重建前交叉韧带患者术后早期膝关节位置觉和运动觉的恢复情况,并比较有无差异。方法50例单侧前交叉韧带损伤后重建患者非随机分为两组,单束重建组26例,双束重建组24例,移植物均为自体胭绳肌腱;正常对照组12例。术后对患者进行KT2000关节测量,膝关节被动位置重现和运动感知阈值测量,同时对其IKDC2000膝关节主观功能评分和Lysholm膝关节评分进行观察;对照组进行双侧膝关节被动位置重现和运动感知闽值测量。结果比较两组病例术后膝关节的前向稳定性和功能评分以及位置觉和运动觉结果,差异均无统计学意义（P〉0．05）;两病例组与正常对照组相比较,位置觉和运动觉结果差异均有统计学意义（P〈0．05）。结论前交叉韧带重建术后早期患者膝关节的位置觉和运动觉并未恢复到正常水平;前交叉韧带单束重建术和双束重建术患者术后早期膝关节位置觉和运动觉恢复水平并无差异。