外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效

 目的 探讨采用外侧入路联合前内侧入路治疗肘关节“恐怖三联征”的手术疗效。方法 回顾性分析2008年7月至2011年1月,采用外侧入路联合前内侧入路治疗23例肘关节“恐怖三联征”患者,其中21例获得完整随访资料,男17例,女4例;年龄17~63岁,平均38.4岁;坠落伤15例,运动损伤4例,交通伤2例;受伤至手术时间为2~8 d,平均4 d。尺骨冠突骨折O’Driscoll分型：A1型5例,A2型12例,B2型4例;桡骨头骨折Mason分型：Ⅰ型2例,Ⅱ型12例,Ⅲ型7例;软组织损伤仲飙等分型：Ⅰ型6例,Ⅱ型12例,Ⅲ型3例。先采用Kocher入路内固定或人工桡骨小头置换治疗桡骨小头骨折,暂时修补外侧副韧带复合体,而后通过前内侧入路固定冠突骨折并修补内侧副韧带损伤;术后采用铰链式外固定支具辅助固定。术后分别采用Mayo肘关节评分（Mayo elbow performence score, MEPS）和Broberg-Morrey分级评估患者肘关节功能及创伤性关节炎程度。结果 21例患者均获得随访,随访时间24~48个月,平均32个月。末次随访时,患者肘关节屈伸及前臂旋转平均活动度分别为126°（范围,115°~135°）和139°（范围,125°~145°）;MEPS评分为85~100分,平均95分,其中19例评定为优,2例为良,优良率为100%,无一例发生肘关节复发不稳定。术后1周,1例发生伤口浅表感染,经清创及静脉使用抗生素治疗后愈合;术后3个月,发生异位骨化症2例,桡骨头骨折骨不连1例,尺神经麻痹1例,均未行手术处理。结论 采用外侧入路联合前内侧入路治肘关节“恐怖三联征”具有一期同时重建骨结构和恢复软组织稳定性的优势,术后患者能早期进行功能锻炼,利于肘关节功能恢复。     

慢病毒介导的shRNA干扰PTEN表达促皮层神经元轴突再生及脊髓损伤修复

 目的 观察慢病毒介导特异性短发夹RNA（short hairpin RNA,shRNA）干扰第l0号染色体同源丢失性磷酸酶张力蛋白基因（phosphatase and tensin homology deleted on chromosome ten,PTEN）表达对皮层神经元轴突再生及脊髓损伤修复的影响。方法 体内实验和体外实验两部分各分四组：阴性对照组（DMEM）、空载慢病毒组（Lenti��control）、空白载体组（Lenti��scramble）、慢病毒介导shRNA组（Lenti��shRNA）。体外神经元转染72 h后,Western blot检测各组PTEN表达情况,免疫荧光检测神经元轴突再生能力;体内载体注射1周后,Western blot检测各组PTEN表达情况;6周后荧光显微镜观察皮质脊髓束穿越脊髓损伤局部周围增强绿色荧光蛋白荧光强度及突触素表达情况。采用大鼠脊髓损伤评分评价大鼠后肢运动恢复情况。结果 慢病毒介导shRNA组体外转染神经元后PTEN表达水平比阴性对照组下降83.75%±2.85%,与其他组比较具有统计学意义（F=4277,P< 0.05）;轴突长度（249.70±10.70）μm,大于阴性对照组（95.71±20.24） μm、空载慢病毒组（97.00 ± 22.82）μm及空白载体组（87.57±19.34）μm,差异具有统计学意义（F=84.74,P< 0.05）;每个神经元一级突起数量（5.800±0.359）个,大于阴性对照组（2.800±0.678）个、空载慢病毒组（2.900±0.389）个及空白载体组（3.000±0.877）个,其差异具有统计学意义（F=16.47,P< 0.05）;神经元突起穿越硫酸软骨素蛋白多糖基质的百分比20.60%±1.80%,大于阴性对照组6.70%±1.45%、空载慢病毒组5.50%±1.69%、空白载体组5.60%±1.77%,其差异具有统计学意义（F=94.90,P<0.05）。慢病毒介导shRNA注射大脑皮层运动区后,第6周大鼠脊髓损伤评分达（13.29±0.42）分,高于阴性对照组（7.00±1.48）分,空载慢病毒组（6.43±1.43）分,空白载体组（6.29±1.22）分,其差异具有统计学意义（F=44.85,P< 0.05）。皮层组织PTEN表达水平下降84.57%±1.87%,损伤中心尾端见绿色荧光,突触素染色阳性面积明显增大。结论 慢病毒介导shRNA下调PTEN基因表达后可明显提高脊髓损伤后轴突再生能力,促进神经功能修复。     

脊髓损伤后脑萎缩对运动功能恢复的影响

 目的 探讨脊髓损伤后脑部萎缩情况以及脑萎缩对患者运动功能恢复的影响。方法 回顾性分析2012年10月至2014年3月,25例接受脊柱内固定治疗的脊髓损伤患者完整随访资料,根据随访6个月后的运动功能恢复情况分为恢复较好组和恢复一般组,同时另选取25例年龄、性别相匹配的健康人作为对照组。恢复较好组10例,男6例,女4例;年龄24~55岁,平均（37.9±13.9）岁;入院时ASIA评级A级1例,B级4例,C级3例,D级2例;6个月后ASIA评级均有一个以上好转,其中A级0例,B级1例,C级3例,D级3例,E级3例;入院时ASIA运动评分为（71.9±16.3）分,6个月后为（85.5±1.5）分。恢复一般组15例,男8例,女7例;年龄24~55岁,平均（35.8±11.5）岁;入院时ASIA评级A级7例,B级3例,C级3例,D级2例）;6个月时ASIA评级未见明显改善;入院时ASIA运动评分为（71.9±16.3）分,6个月后为（85.5±1.5）分。对照组25名,男15名,女10名,年龄（36.5±9.3）岁。采用MRI扫描三组受试者脑部结构信息,运用CIVET软件及DtiStudio软件对比三组大脑灰质和白质萎缩的区域。运用Pearson相关性分析探讨脑皮层萎缩与患者运动功能恢复率之间的相关性。结果 与健康对照组相比,脊髓损伤恢复较好组和恢复一般组均存在双侧初级运动皮层的灰质萎缩,但恢复一般组的萎缩程度更广泛和严重,同时还出现右侧辅助运动区和运动前区的灰质萎缩。恢复较好组未见明显的脑内皮质脊髓束萎缩,而恢复一般组脑内皮质脊髓束初级运动皮层区域及内囊区域均出现白质萎缩。此外,脊髓损伤患者辅助运动区的灰质体积（r=0.75,P< 0.001）及初级运动皮层的白质体积（r=0.76,P< 0.001）与患者6个月后的运动恢复率存在正相关关系。结论 在脊髓损伤早期,运动感觉中枢即可出现明显的萎缩现象,同时这种萎缩对患者的运动功能恢复存在不利影响。     

股骨颈骨折空间移位的三维重建研究

 目的 通过三维重建研究并测量移位型股骨颈骨折中股骨头的空间移位,探讨股骨颈骨折严重程度及判断预后。方法 收集80例移位型股骨颈骨折患者（Garden分型Ⅲ型40例、Ⅳ型40例）双侧股骨近端多层螺旋CT扫描的薄层原始数据（DICOM格式）,导入三维重建软件生成双侧股骨近端三维模型。在健侧股骨近端生成患侧的镜像模型并与健侧相配准,使患侧镜像模型在健侧处形成新的蒙罩,在蒙罩上进行关键点标记,通过三维测量技术来计算股骨头空间移位参数,并对数据进行整理和分析。结果 GardenⅢ型骨折股骨头小凹最深点位移为（23.70±10.00）mm,Ⅳ型（30.24±8.96） mm,两者比较差异有统计学意义;GardenⅢ型骨折中股骨头中心的位移为（14.36±5.61）mm,Ⅳ型为（18.77±5.45） mm,两者比较差异有统计学意义;GardenⅢ型骨折中股骨头空间偏转的角度为29.18°±15.74°,Ⅳ型为39.08°±17.08°,两者比较差异有统计学意义。移位型股骨颈骨折股骨头移位方向主要为后下方。结论 Garden分型对移位型骨折的认识存在一定局限性;三维重建及空间测量技术能更科学、准确地评价股骨颈骨折后股骨头移位的程度,为骨科医生评估骨折类型、严重程度及预后,制定更合理的手术方案提供更为宽广的临床思路。     

全膝关节置换治疗血友病关节炎围手术期处理及短期疗效评价

 目的 探讨血友病关节炎全膝置换围手术期管理、凝血因子调控及早期临床疗效。方法 回顾性分析2009年3月至2014年3月采用全膝关节置换治疗8例（10膝）血友病膝关节炎患者资料,均为男性患者,年龄31~47岁,平均（38.3±5.0）岁;术前活化部分凝血活酶时间为（63.9±4.0） s,凝血因子活性为2.6%±0.9%;膝关节均有屈曲畸形,伸膝-12.0°±5.9°,屈膝-88.0°±11.4°。其中3例（3膝）合并外翻畸形,外翻角平均-3.0°±5.4°;2例（4膝）合并内翻畸形,内翻角平均-4.5°±6.0°。8例患者中,甲型6例,乙型2例,分别补充冻干人凝血八因子和凝血酶原复合物后手术。骨缺损根据AORI分型方法,T1、T2型采用骨水泥充填,T3包容型采用同种异体骨打压植骨、螺钉支撑内固定修复,T3节段型通过自体骨结构性植骨,并加用胫骨延长杆修复。采用美国特种外科医院（hospital for special surgery, HSS）膝关节评分评价膝关节功能。结果 8例患者均获得随访,随访时间9~26个月,平均14.3个月。末次随访时伸膝0°,屈膝98.5°±6.7°;HSS评分由术前（42.3±10.9）分提高到术后（88.3±4.6）分;X线片示植骨存活,假体、螺钉均未见松动、断裂。结论 全膝关节置换治疗血友病关节炎短期疗效满意,术前的预输试验有助于确定凝血因子的补充剂量。     

围截骨区卫星棒技术在严重脊柱畸形三柱截骨术中的应用

 目的 探讨严重脊柱畸形三柱截骨术中围截骨区卫星棒技术的可行性,并评估其临床应用价值。方法 回顾性分析2012年7月至2014年1月期间应用卫星棒技术行严重脊柱畸形三柱截骨并有完整临床及影像学资料的13例患者,男6例,女7例;年龄12~57岁,平均（30.9±19.1）岁。分别测量患者手术前后及末次随访时侧凸Cobb角、最大后凸Cobb角（global kyphosis,GK）、冠状面平衡（distance between C₇ plumb line and center sacral vertical line,C₇PL-CSVL）和矢状面平衡（sagittal vertical axis,SVA）。患者初诊及每次随访均填写SF-36量表。结果 随访时间平均为（15.8±3.8）个月。术前侧凸Cobb角平均为86.3°±22.6°,术后为45.2°±19.7°,较术前明显改善,平均矫正率为47.7%±19.1%;末次随访为39.9°±19.8°,随访期间未见明显矫正丢失。术前GK为80.9°±18.7°,术后为35.1°±14.5°,平均矫正率为57.8%±13.8%;末次随访时未见明显丢失,平均为36.3°±10.0°。手术前后C₇PL-CSVL分别为（43.7±36.8） mm、（18.8±5.6） mm,术后有明显改善;末次随访时维持良好,平均为（19.2±8.3） mm。SVA由术前平均（55.0±51.5） mm减小至术后（29.3±19.5） mm,末次随访为（34.2±17.5） mm,亦无明显矫正丢失。13例患者术中监测均无信号异常。术后1例患者1枚螺钉位置偏上穿出上终板,1例患者1枚螺钉位置偏外。患者随访期间均无明显矫形丢失及断钉、断棒等内固定并发症。结论 严重脊柱畸形三柱截骨引入卫星棒技术既满足坚强固定需要又起到分散应力作用,术后矫形效果满意,随访期间矫正丢失及内固定失败等并发症少。     

手术治疗创伤致神经源性单纯肩外展功能障碍

 目的 探讨手术治疗肩部创伤致肩胛上神经与腋神经同时损伤的疗效。方法 回顾性分析2003年7月至2011年9月,手术治疗13例男性肩部创伤后诊断为肩胛上神经与腋神经同时损伤的患者资料,年龄8~59岁,平均28 岁;受伤至手术时间为2~7个月,平均3.7个月。其中肩胛颈和锁骨同时骨折2例,浮肩损伤3例,肱骨颈及关节盂骨折1例,锁骨骨折3例,肩峰骨折1例,肩胛骨骨折2例,寰枢椎骨折1例。13例临床检查均示单纯肩外展、外旋功能完全丧失,三角肌及冈上、下肌肌力均为0级。电生理检查示腋神经、肩胛上神经完全失神经支配。肩胛上神经断裂10例,其中6例通过1股腓肠神经移植修复,1例通过1股颈丛浅支移植修复,3例因远端撕脱而放弃神经修复;另3例肩胛上神经仅进行松解。腋神经断裂12例,其中10例采用2~3股腓肠神经移植修复,2例采用正中神经束支移位修复;另1例腋神经于四边孔处进行松解。13例患者中,10例患者的肩胛上神经及腋神经同时断裂。结果 13例患者随访时间36~134个月,平均85个月;7例肩关节上举恢复正常达180°,该7例的三角肌力均为4级,肩外旋40°~70°,平均56°;5例肩外展达30°~50°,平均38°;该5例肩外旋为-40°~30°,平均10°,三角肌肌力4级1例,3级2例,2级2例;另1例无恢复。结论 对于肩部创伤后出现的单纯肩关节外展、外旋功能完全丧失,应考虑肩胛上神经与腋神经同时损伤的可能。此种类型的神经损伤修复后的效果满意,应尽早进行神经移植修复。     

髂腰内固定治疗创伤性脊柱骨盆分离

 目的 探讨创伤性脊柱骨盆分离的临床特点及后路髂腰内固定治疗该损伤的临床效果。方法 回顾性分析2008年7月至2012年12月收治12例创伤性脊柱骨盆分离患者资料,男8例,女4例;年龄18~50岁,平均（34.6±9.2）岁。致伤原因：坠落伤11例,车祸伤1例。所有骨折均为闭合性损伤,均有不同程度的合并伤。骶骨骨折按形态学分型：U型4例,H型6例,Y型2例。Roy-Camille分型：Ⅱ型6例,Ⅲ型6例。采用髂腰固定对12例患者进行手术治疗,并对6例有明显神经损害表现且有明确手术指征的患者同时行神经减压术。临床疗效评价采用Majeed标准,神经损伤按照Gibbons评价方法进行评定。结果 12例患者均获得随访,随访时间12~36个月,平均（15.5±6.3）个月。9例患者在受伤早期存在误诊或漏诊,12例患者均有不同程度的神经损害表现。术后所有骨折均获得愈合,骨折愈合时间4~8个月,平均（4.8±2.8）个月。根据Majeed标准,优4例、良4例、可2例、差2例,优良率66.7%（8/12）。12例患者术后患肢感觉、运动功能恢复率为91.7%（11/12）。6例行神经减压术的患者术后感觉、运动功能恢复率为83.3%（5/6）。末次随访时,Gibbons神经评分由术前平均（3.25±0.75）分降至术后平均（1.67±0.99）分,差异有统计学意义。结论 创伤性脊柱骨盆分离是一种少见的高能量损伤,其合并伤及神经损害的发生率很高;后路髂腰内固定是一种值得推荐的治疗方式,对有指征的患者早期行神经减压有利于神经功能的恢复。     

颈椎人工椎间盘置换术后异位骨化与小关节退变程度的相关性研究

 目的 探讨颈椎人工椎间盘置换术后发生异位骨化（hetrotopicossification, HO）的原因及与颈椎小关节退变程度的相关性。方法 回顾性分析2009年5月至2012年5月采用Discover假体行颈椎人工椎间盘置换术的133例完整患者资料,男74例,女59例;年龄23~56岁,平均（42.63±4.15）岁;单节段109例,双节段24例。在颈椎X线片上测量术前及末次随访时手术节段活动度;在颈椎CT片上采用Park等颈椎小关节退变程度分级标准对小关节的退变程度进行分级;在颈椎侧位X线片上采用McAfee标准对异位骨化进行分级。统计不同随访时间节点手术节段异位骨化的发生率和分级。根据是否发生异位骨化将患者分为异位骨化组和无异位骨化组,并比较两组患者手术节段活动范围、术前小关节退变程度。结果 133例患者均获得随访,随访时间2.0~4.8年,平均2.9年。末次随访时,25例（18.80%,25/133）患者出现异位骨化,其中手术节段的活动度异位骨化组（6.8°±3.9°）明显小于无异位骨化组（9.1°±2.4°）,两者比较差异有统计学意义;异位骨化组患者术前颈椎小关节退变程度明显重于无异位骨化组。相关性分析结果显示术后异位骨化的发生与术前小关节退变呈正相关（r=0.683, P=0.033）。结论 颈椎人工椎间盘置换术后异位骨化的发生与术前患者小关节的退变具有相关性。术后发生异位骨化的患者术前颈椎小关节的退变程度明显重于未发生异位骨化的患者,异位骨化分级越高,术前小关节的退变越严重。     

严重僵硬型颈椎后凸畸形的手术入路选择

 目的 探讨严重僵硬型颈椎后凸畸形的影像学特征及不同类型的手术入路选择。方法 回顾性分析2007年1月至2012年1月,治疗17例严重僵硬型颈椎后凸畸形患者完整资料,男8例,女9例;年龄21~72岁,平均49.7岁;炎症3例,退变3例,神经纤维瘤病3例,全椎板切除术后3例,特发性2例,陈旧性颈椎骨折2例,神经肌肉源性疾病1例;后凸累及节段（4.3±1.2）个。患者临床均表现为颈部疼痛,视觉模拟评分（visual analogue scale, VAS）（7.6±1.5）分,颈椎后凸畸形进行性发展,其中合并脊髓病变4例、神经根痛2例、不能平视3例、吞咽困难1例。患者术前均摄颈椎过伸、过屈位及颈椎牵引位X线片,并通过矢状位CT重建片评价颈椎僵硬来源。继续颅骨牵引下,根据脊髓压迫情况、后凸累及节段及僵硬来源等因素分别采用前路、后路及前后路联合手术入路,术后根据颈椎后凸Cobb角恢复及Odom标准评价疗效。结果 术后17例患者均获得随访,随访时间2~5年。根据CT检查结果,17例患者中,僵硬来源于前方骨性强直7例、后方6例、前后方4例。采用前路手术4例,后路2例,前后路5例,后前路3例,前-后-前路1例,后-前-后路2例。术前Cobb角平均49.3°±14.6°,末次随访平均2.1°±6.8°,平均矫正角度47.2°;Odom 标准：优7例,良8例,可2例,优良率88.2%（15/17）。1例患者术后3个月出现近端交界区后凸,遂行翻修术;17例患者术后均获骨性融合,随访期内无一例发生后凸矫正角度显著丢失。结论 CT有利于判断颈椎后凸畸形的僵硬来源;手术入路的选择取决于脊髓是否受压、后凸累及节段的长短、颈椎后凸畸形的僵硬来源等因素;僵硬来源于颈椎前方骨性强直采用前路手术,来源于后方强直采用后路手术,来源于前后方强直需前后路联合手术。     

Comparison of Clinical Outcomes between Anteromedial and Transtibial Techniques of Single-Bundle Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis

This study compared clinical outcomes obtained after single-bundle anterior cruciate ligament (ACL) reconstruction using the anteromedial (AM) and transtibial (TT) techniques, which comprise the conventional transtibial (cTT) and modified transtibial (mTT) techniques. This study included clinical randomized controlled trials and prospective and retrospective controlled trials with AM and TT techniques from the PubMed and Embase databases and the Cochrane Library. All databases were searched from January 2010 to July 2020. Two independent evaluators verified the quality of the included studies using the Cochrane Collaboration’s risk of bias tool and the Newcastle-Ottawa Scale (NOS). Outcome measures analysed included the Lachman test, pivot-shift test, side-to-side difference (SSD), Lysholm score, Tegner activity scale, International Knee Documentation Committee (IKDC) grade and score. Ten randomized controlled trials (RCTs) and 16 prospective and retrospective controlled trials were included with a total of 2202 patients. There were 1180 patients and 1022 patients in the AM and TT groups, respectively. Compared to the cTT group, superior postoperative results were observed in the AM group based on the negative rate of the Lachman test and the pivot-shift test, IKDC grade and score, Lysholm score, Tegner activity scale and SSD (p < 0.05). However, there was no significant difference between the AM and mTT groups (p > 0.05). Compared to the conventional TT technique, the AM technique exhibited superior clinical outcomes. Nevertheless, the modified TT and AM techniques had comparable results. With neither of the techniques (mTT or AM) producing significantly superior outcomes, surgeons can choose either of them depending on their preferences.Key points

• This meta-analysis was conducted based on the latest studies about the cTT, mTT and AM techniques.
• Compared to the cTT technique, the AM technique showed superior clinical outcomes.
• The mTT and AM techniques had comparable clinical outcomes.
• Surgeons can choose the one between the mTT and AM techniques, depending on their preferences.

Key words: Anterior cruciate ligament reconstruction, anteromedial, transtibial, modified transtibial, meta-analysis     

How Important is the Tunnel Position in Outcomes Post-ACL Reconstruction: A 3D CT-Based Study

BackgroundDrilling the femoral and tibial tunnels at their anatomical locations are critical for good outcomes and involve seeing the footprints well. We intended to compare two techniques of drilling the tunnels and the patient-reported outcomes and knee stability of patients undergoing single bundle ACL reconstruction using 3D CT to evaluate if the tunnels were anatomical or not.Materials and MethodsSixty single bundle ACL reconstructions were analyzed, 30 each with Technique A and B. Pre-operative and after a minimum 27 month follow-up Lysholm, IKDC, Tegner score, hop test, and Lachman test were noted. 3D CT was done to classify femoral tunnels positions as being well placed, slightly or grossly misplaced and tibial tunnels as optimal or suboptimal and compared.ResultsSixty ACL reconstructions had full follow-up with a mean follow-up of 34 months. There was no significant difference between tunnel positions between the two techniques. Well-placed femoral tunnel had better Lysholm score (62.2 ± 16.2 v/s 48.5 ± 17.2, p 0.002) and IKDC score (62.5 ± 14.3 v/s 52.7 ± 15.1, p 0.012).). Those who had their surgeries within 3 months of their injury had better hop test (4.4 ± 0.9 v/s 3.9 ± 1, p 0.034) and IKDC scores (62.5 ± 15.8 v/s 33.2 ± 13.8, p 0.026) as compared to those that had surgery done after 3 monthsConclusionTibial tunnel positions were optimal in most cases and did not differ between the two techniques. Well-placed femoral tunnels and surgeries done within 3 months of the injury produced best results.     

Association of KT-1000 measurements with clinical tests of knee stability 1 year following anterior cruciate ligament reconstruction.

STUDY DESIGN: Prospective, observational study. OBJECTIVES: To determine the association between KT-1000 measurements with an anterior translation force of 89 N and other measures of outcome (the Tegner activity score, the modified Lysholm score, subjective rating of instability, Lachman test, and pivot-shift test) 1 year following anterior cruciate ligament (ACL) reconstruction. BACKGROUND: Health care professionals often use the side-to-side difference measured with the KT-1000 arthrometer to determine ACL integrity during passive motion. It has been postulated that a 5-mm or greater difference between impaired and nonimpaired knees represents a procedural failure. METHODS AND MEASURES: Ninety patients (46 men, 44 women) with a mean age of 30 +/- 8 years were examined 1 year after surgery. Patients were classified in 1 of 3 groups depending on the amount of laxity between the impaired knee and the nonimpaired knee. Seventy percent of the subjects had a side-to-side difference less than or equal to 3 mm (tight), 13% had a difference of between 3 and 5 mm (moderate), and 17% had a difference greater than or equal to 5 mm (loose) on examination using the KT-1000. RESULTS: Mean Lysholm and Tegner scores did not differ significantly among groups. Side-to-side differences in KT-1000 measurements at 89 N were not associated with the Lysholm score (r = -0.09) or Tegner score (r = 0.02). Lachman tests were related to involved-knee KT-1000 measurements (r = 0.39) but not to side-to-side differences in KT-1000 measurements (r = 0.15). Similarly, pivot-shift tests were related to involved-knee KT-1000 measurements (r = 0.26) but not to side-to-side differences (r = -0.08). CONCLUSIONS: These results suggest that side-to-side KT-1000 measurements obtained with an anterior translation force of 89 N should not be used in isolation to determine ACL reconstruction success or failure 1 year following surgery.     

Patellar tendon or hamstring graft anterior cruciate ligament reconstructions in patients aged above 50 years

Background:

The treatment of anterior cruciate ligament (ACL) injury consists of arthroscopic ACL reconstruction with patellar tendon or hamstring graft. Satisfactory results have been reported so far in the younger age group. Dilemma arises regarding the suitability of ACL reconstruction in patients aged 50 years and above. This retrospective analyses the outcome of ACL reconstruction in patients aged 50 years and above.

Materials and Methods:

55 patients aged 50 years and above presented to our institution with symptomatic ACL tear and were managed with arthroscopic reconstruction with patellar tendon/hamstring graft. 22 patients underwent ACL reconstruction with bone- patellar tendon-bone graft and the remaining 33 with a hamstring graft. Evaluation of functional outcome was performed using International Knee Documentation Committee (IKDC) and Lysholm scoring in the preoperative period, at the end of 1 year and at the final followup. Radiographic evaluation was performed using the Kellgren–Lawrence grading system.

Results:

The mean preoperative IKDC score was 39.7 ± 3.3. At the end of 1-year following the operation, the mean IKDC score was 73.6 ± 4.9 and at the final followup was 67.8 ± 7.7. The mean preoperative Lysholm score was 40.4 ± 10.3. At the end of 1-year following the intervention, the mean Lysholm score was 89.7 ± 2.1 and at final followup was 85.3 ± 2.5. Overall, 14 out of 42 patients who underwent radiographic assessment showed progression of osteoarthritis changes at the final followup after the intervention.

Conclusion:

In our study, there was a statistically significant improvement in the IKDC and Lysholm scores following the intervention. There was a slight deterioration in the scores at the final followup but the overall rate of satisfaction was still high and most of the patients were able to do their routine chores and light exercises suitable for their age group. Around one-third of patients show progression of radiographic changes in the postoperative period and this requires long term evaluation.     

An extra-articular procedure improves the clinical outcome in anterior cruciate ligament reconstruction with hamstrings in female athletes

Purpose

A positive glide is a common finding after ACL reconstructions, especially in women. The aim of this study was to prospectively evaluate the role of Cocker-Arnold’s extra-articular procedure in reducing the incidence of a residual postoperative rotational knee laxity.

Methods

Sixty patients affected by an ACL injury with a +2 (clunk) or +3 (gross shift) pivot-shift test entered this prospective study; they were randomly assigned to group A (control group, hamstrings) or group B (study group, hamstrings plus Cocker-Arnold). Thirty-two patients entered group A and 28 group B. At follow-up, patients underwent clinical evaluation, KT-1000 arthrometer and Lysholm, Tegner, VAS and subjective and objective IKDC form.

Results

At a mean follow-up of 44.6 months, the same expert surgeon reviewed 55 patients (28 group A and 27 group B). The comparison of the results of the evaluation scales used and of the KT-1000 arthrometer did not show statistically significant differences (p?>?0.05). Lachman test was negative (S/S) in all the patients of both groups (100 %). A residual positive pivot-shift (glide) was found in 16 patients (57.1 %) of group A and in five patients (18.6 %) of group B (p?<?0.05).

Conclusions

The extra-articular MacIntosh procedure modified by Cocker-Arnold in combination with ACL reconstruction significantly reduces the rotational instability of the knee.     

关节镜下保留残端重建前交叉韧带的临床前瞻性对照研究

目的 前瞻性评估保留残端对于前交叉韧带重建临床疗效的意义.方法 2008年8月至2009年9月共70例有韧带残端存留的前交叉韧带损伤患者入选本研究组,随机分为保留残端组(n=35)和对照组(n=35).分别采取关节镜下保留残端重建前交叉韧带和切除残端的前交叉韧带重建手术技术,移植物均使用同种异体肌腱.术后随访分别进行膝关节功能评分(IKDC分级和Lysholm评分)、客观稳定性评估(Lachman试验、轴移试验和KT-1000测量)、本体感觉功能测量和二次关节镜手术探查.结果 70例患者中共61例(87%)获得随访,平均随访时间13.1个月.两组的功能评分无显著差异:Lysholm评分:保留残端组96.4分,对照组94.9分(P=0.71);IKDC分级中A和B级:保留残端组30例,对照组29例(P=0.586).两组的客观稳定性评估无显著差异:KT-1000测量的侧-侧差值:保留残端组1.69 mm,对照组1.65 mm(P=0.83);Lachman试验阴性例数:保留残端组29例,对照组28例(P=1.00);轴移试验阴性例数:保留残端组31例,对照组27例(P=0.225).本体感觉的角度重复试验结果无显著差异:保留残端组4.56°,对照组4.28°(P=0.522).二次手术探查时发现的移植物滑膜覆盖率无显著差异:保留残端组85%,对照组84.2%.结论 保留残端同时使用异体肌腱移植重建前交叉韧带,对术后膝关节主观功能评分、稳定性和本体感觉和移植物滑膜覆盖程度并无促进作用.

Abstract：

Objective To evaluate the clinical significance of arthroscopic anterior cruciate ligament (ACL)reconstruction using the remnant-preserved technique.Methods From August 2008 to September 2009,70 cases with the remnant of injured ACL were included in the trials,which were randomized into the remnant preservation(RP)group and the control group,35 cases in each group.All patients in the two groups underwent arthroscopic ACL reconstruction surgeries,with ACL-remnant preserving technique in RP group and ACL-remnant resection in control group,respectively.The injured ACL was reconstructed with allograft in all cases.Postoperative follow-up assessment included the International Knee Documentation Committee(IKDC)grading and Lysholm score,Lachman test,pivot shift test and KT-1000 measurement,proprioception measurements and the arthroscopic second look evaluation.Results Sixty-one(61/70,87%)cases were available for an average of 13.1 months follow-up assessment postoperatively.There were no significant differences between the RP and control group in functional outcome as evaluated with Lysholm score(96.4 vs.94.9,P = 0.71)and IKDC grading(cases with A and B gradings:30 vs.29,P = 0.586).Regarding objective stability,there were no differences between the 2 group in mean side-to-side difference of KT-1000(1.69 mm vs.1.65 mm,P =0.83),Lachman test(negative cases:29 vs.28,P = 1.00)and pivot shift test(negative cases:31 vs.27,P =0.225).There was also no difference between the groups in proprioception evaluation measured with angle repetitive test(4.56°vs.4.28°,P=0.522).During second look arthroscopic examination,the grafts synoveal coverage rates were found to be 85% in the RP group and 84.2% in the control group,without significant difference(P＞0.05).Conclusions Arthroscopic ACL reconstruction with the remnant preserving technique using tendon allograft do not improve the postoperative knee-joint function scores,stability,proprioception and synovial coverage of grafts.     

Outcome of double bundle anterior cruciate ligament reconstruction using crosspin and aperture fixation

Background:

Double bundle anterior cruciate ligament (DBACL) reconstruction is said to reproduce the native anterior cruciate ligament (ACL) anatomy better than single bundle anterior cruciate ligament, whether it leads to better functional results is debatable. Different fixation methods have been used for DBACL reconstruction, the most common being aperture fixation on tibial side and cortical suspensory fixation on the femoral side. We present the results of DBACL reconstruction technique, wherein on the femoral side anteromedial (AM) bundle is fixed with a crosspin and aperture fixation was done for the posterolateral (PL) bundle.

Materials and Methods:

Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing.

Methods:

Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing.

Results:

The KT-1000 results were evaluated using paired t test with the P value set at 0.001. At the end of 1 year, the anteroposterior side to side translation difference (KT-1000 manual maximum) showed mean improvement from 5.1 mm ± 1.5 preoperatively to 1.6 mm ± 1.2 (P < 0.001) postoperatively. The Lysholm score too showed statistically significant (P < 0.001) improvement from 52.4 ± 15.2 (range: 32-76) preoperatively to a postoperative score of 89.1 ± 3.2 (range 67-100). According to the IKDC score 90% patients had normal results (Category A and B). The AM femoral tunnel initial posterior blow out was seen in 4 patients and confluence in the intraarticular part of the femoral tunnels was seen in 6 patients intraoperatively. The quadriceps strength on isokinetic testing had an average deficit of 10.3% while the hamstrings had a 5.2% deficit at the end of 1 year as compared with the normal side.

Conclusion:

Our study revealed that the DBACL reconstruction using crosspin fixation for AM bundle and aperture fixation for PL bundle on the femoral side resulted in significant improvement in KT 1000, Lysholm and IKDC scores.     

前交叉韧带单束重建股骨不同定位点的疗效评价

目的比较关节镜下前交叉韧带（ACL）单束重建股骨定位点在右膝11点（A点）与右膝10点（B点）术后疗效的差别。方法将97例ACL损伤患者随机分成两组：A组50例,B组47例。在关节镜下四股腘绳肌腱单束重建ACL,A组股骨定位点在A点,B组股骨定位点在B点,两组胫骨骨道定位保持一致。术后进行前抽屉试验、Lachman试验、外旋试验、KT-2000检查,并进行术前与术后的Lysholm、IKDC评分,评价两者之间疗效的差别。结果 A组术后1周与术后1年的ADT及Lachman试验阳性例数变化差异有统计学意义（P〈0.05）;两组外旋试验及KT-2000在134 N下屈膝30°位膝关节前后位移情况差异均有统计学意义（P〈0.01）,B组优于A组。术前两组Lysholm和IKDC评分差异无统计学意义（P〉0.05）,术后1年Lysholm及IKDC评分明显优于术前（P〈0.01）,术后Lysholm评分两组差异无统计学意义（P〉0.05）,但IKDC评分两组差异有统计学意义（P〈0.01）,B组优于A组。结论股骨骨道选择在A点和B点单束重建ACL,可使患者关节稳定性得到明显改善;B点在控制关节旋转稳定性比A点好,早期A点比B点易发生重建韧带松驰。     

单束与双束解剖重建前交叉韧带临床疗效的荟萃分析

目的 通过荟萃分析评价单束与双束重建前交叉韧带在恢复膝关节前直向、旋转稳定性及膝关节功能评分方面的临床疗效,为前交叉韧带重建方法的选择提供依据.方法 计算机检索Ovid Medline和Pubmed、Embase、Cochrane图书馆、中国生物医学文献数据库、维普中文科技期刊数据库关于单束和双束解剖重建前交叉韧带的临床随机对照研究.阅读评价文献质量并提取有效数据,采用RevMan 5.0.23软件进行统计分析,两种手术方法的KT测量值、Lysholm评分采用加权均数差评价,轴移试验及国际膝关节文献委员会(IKDC)分级评分采用优势比评价.结果 共纳入前瞻性临床随机对照研究8篇.荟萃分析结果显示两种重建交叉韧带方法KT测量值差异具有统计学意义,加权均数差值-0.35 mm[95%CI(-0.61～0.08),P=0.01],但差异不具有临床意义;轴移试验合并优势比1.64[95%CI(0.85～3.16),P=0.14];IKDC分级评分优势比1.80[95%CI(0.98～3.31),P=0.06);Lysholm评分加权均数差值-1.91[95%CI(-3.45～0.37),P=0.01],差异有统计学意义.结论 双束解剖重建前交叉韧带的近期临床疗效不优于单束重建.     

Two-stage procedure in anterior cruciate ligament revision surgery: a five-year follow-up prospective study

Purpose

The purpose of this study was to show that this two-stage procedure for ACL (anterior cruciate ligament) revision surgery could be straight-forward and provide satisfactory clinical and functional outcomes.

Materials

This is a five-year prospective analysis of clinical and functional data on 30 patients (19 men and 11 women; average age 29.1 ± 5.4) who underwent a two-stage ACL revision procedure after traumatic re-rupture of the ACL. Diagnosis was on Lachman and pivot-shift tests, arthrometer 30-lb KT-1000 side-to-side findings, and on MRI and arthroscopic assessments.

Results

Postoperative IKDC and Lysholm scores were significantly improved compared to baseline values (P < 0.001). At the last follow up, 20 of 30 patients (66.7 %) had returned to preoperative sport activity level (nine elite athletes, 11 county level), seven had changed to lower sport levels, and three had given up any sport activity. At the same appointment, 11 patients had degenerative changes. All these patients reported significantly lower Lysholm scores compared to patients without any degenerative change (p < 0.001).

Conclusions

In ACL revision surgery, when the first femoral tunnel has been correctly placed, this procedure allows safe filling of large bony defects, with no donor site comorbidities. It provides comfortable clinical, functional and imaging outcomes.