高分辨力超声评价风湿性关节炎病人腕关节外部韧带的改变

摘要目的与健康志愿者相比,评估风湿性关节炎(rheumatoid arthritis,RA)病人腕关节外部韧带的超声特点。方法比较21例RA病人[男12例,女9例,平均年龄(57±14.6)岁]和21例健康志愿者[男12例,女9例,平均年龄(54±12.1)岁]。以腕骨作为参考,利用超声评价腕关节掌侧和背侧的韧带,包括桡舟头韧带、桡尺三角韧带、掌侧尺月韧带、掌侧尺三角韧带、背侧桡三角韧带、背侧尺三角韧带、桡侧副韧带及腓侧副韧带。     

兔交叉韧带解剖学及生物力学特性研究

目的:为建立交叉韧带修复与重建动物模型和进行相关研究提供解剖学及生物力学实验依据。方法:6只雄性骨骼成熟新西兰大白兔,后腿自股骨近端截断,配成6对膝关节。取兔正常前、后交叉韧带进行解剖学、几何学和生物力学特性测定。结果:兔交叉韧带在大体解剖学方面与人类基本相同;兔前交叉韧带的材料力学特性与后交叉韧带基本一致,平均长度、横截面积、结构力学特性明显强于后交叉韧带。结论:兔是建立交叉韧带修复与重建动物模型和进行相关实验研究的合适动物,兔前、后交叉韧带在形态结构及材料力学方面的一致性为采用材料力学特性相同的移植物重建交叉韧带提供了实验依据。     

踝关节距腓前韧带和跟腓韧带的解剖学特点

目的:观察踝关节不同体位下距腓前韧带(anterior talofibular ligament,ATFL)和跟腓韧带(calcaneofibular ligament,CFL)的形态学变化,并测量其基本参数、止点面积及韧带间的角度,为临床外踝韧带损伤的诊断和治疗提供参考.方法:选取47例国人踝关节标本,解剖外踝结构直...     

桡骨远端截骨术后桡腕关节的解剖学及生物力学变化

目的：研究桡骨远端截骨术后新桡腕关节的解剖学特点及生物力学变化。方法：选择甲醛固定的尸体腕标本（观察组）26只,模拟桡骨远端截骨术后观测桡腕关节面;纵行剖开桡腕关节,描拓桡腕关节的匹配曲线;选用26只新鲜标本（对照组）牙托粉包埋后,用压敏片在双轴液压材料测试系统上测试正常及术后桡腕关节的接触面积和压力变化。结果：对照组桡腕关节匹配曲线良好,桡骨远端截骨术后匹配性略差。腕中立位下,平均腕单位面积负荷为（22.9±4.3）N/cm^2,观察组为（13.9±4.0）N/cm^2,两组相比,差异显著（P〈0.05）。结论：桡骨远端截骨术后形成新桡腕关节的解剖学和生物力学均显著异常。     

前交叉韧带股骨止点临床解剖学研究

目的:通过尸体标本研究前交叉韧带(ACL)股骨止点,进一步明确其解剖学特点,为双束重建ACL准确定位股骨止点提供临床解剖学数据。方法:对30例福尔马林处理的成人膝关节标本进行解剖研究。在屈膝60°时根据ACL纤维张力情况区分前内束和后外束,观察两束在膝关节屈伸过程中的张力变化特性,然后从股骨止点切断韧带,测量止点的相关数据。结果:在屈膝60°位ACL中松弛的纤维束最多。ACL在屈膝过程中沿矢状面发生旋转,其轴心大约位于股骨止点的近前角,接近over-the-top位置,该区域的纤维束在屈膝过程中始终处于紧张状态,具有良好的等长性。ACL股骨止点的长径与短径分别为19.32±2.42mm与10.52±2.24mm,前内束和后外束股骨止点的面积分别为69.37±20.2mm2和86.60±30.22mm2,前内束股骨止点的面积略小于后外束;两束中心点连线的距离为9.42±1.51mm,连线与股骨纵轴的夹角为26.90±8.56°;后外束中心点到over-the-top点连线的距离为11.8±1.60mm,连线与股骨纵轴的夹角为26.26±7.78°;后外束中心到股骨外髁软骨缘的最小距离为6.16±1.00mm;前内束股骨止点中心点位于10∶10±7′(右膝)或1∶49±5′(左膝);over-the-top点位于10∶45±8′(右膝)或1∶08±9′(左膝)。结论:前交叉韧带可被分为功能不同的前内束和后外束,前内束在膝关节的运动中始终保持紧张,具有较好的等长性,前内束止点前上部接近over-the-top区纤维是其旋转轴心,与前内束中心点的纤维相比等长性更好,是手术重建时的关键点。后外束只有在接近伸直和屈曲较大角度时紧张。后外束的定位缺乏解剖标记,本研究通过测量其中心点与前内束中心点、over-the-top点距离及到股骨外髁软骨缘最短距离确定后外束中心点位置,为双束重建ACL提供准确的骨道定位依据。     

膝关节后交叉韧带及板股韧带临床解剖学研究

目的:探讨后交叉韧带分束情况及板股韧带的作用,为临床重建后交叉韧带提供解剖学基础。方法:30例成人膝关节标本,在无载荷与后抽屉试验两种条件下分别观察其后交叉韧带纤维束及板股韧带的紧张-松弛模式,根据纤维束紧张与松弛情况对后交叉韧带分束,确定各束中最能代表该束功能的纤维束,即"功能束"及其止点位置,明确板股韧带的作用。结果:后交叉韧带中未见等长纤维束。无载荷条件下屈伸膝关节,后交叉韧带中各纤维束处于较松弛状态(过伸与过屈位除外);后抽屉试验条件下,不同纤维束紧张,维持胫骨后向稳定性。后交叉韧带可以恒定地分为前外侧束与后内侧束,两束作用不同。前外侧束与后内侧束中均存在"功能束",两者的"功能束"联合作用可基本维持膝关节活动范围内胫骨的后向稳定性,"功能束"止点与两束止点中心不吻合。前、后板股韧带的出现率分别为3%与90%,二者横截面积均较小,前者的紧张-松弛模式类似于后交叉韧带前缘纤维,后者则与后内侧束相一致,二者均有维持胫骨后向稳定性的作用,后者还有在最大屈膝位防止后交叉韧带与股骨髁间窝后缘发生撞击的作用。结论:后交叉韧带是不等长的复杂的纤维结合体,其双束重建应根据"功能束"止点位置进行骨道定位,板股韧带在有条件时应予以保留。     

桡腕背侧韧带MRI成像条件研究

目的 研究桡腕背侧(dorsal radiocarpal, DRC)韧带MRI成像的最佳扫描参数.方法 解剖15例无明显关节病变的腕关节标本,分离出桡腕背侧韧带,测量桡腕背侧韧带与水平面所成的角度α1,然后过桡骨远端背侧Lister结节作一条与桡骨长轴垂直的水平直线L1,并经DRC韧带的起止点连线作一条直线L2,测量L1 和L2 2条直线所成的夹角α2.根据解剖所得结果,制订扫描方案,对15例健康志愿者进行腕关节MRI扫描,扫描方位包括冠状面及斜断面,扫描角度为解剖所得角度,扫描序列包括T1WI和Turbo 3D T1WI.并对T1WI和Turbo 3D T1WI序列图像进行比较,得到桡腕背侧韧带MRI成像的最佳层面及序列.结果 桡腕背侧韧带在冠状面上显示最完全清晰,扫描角度冠状面为0°、斜断面为20°时显示最佳,T1WI扫描序列显示最清,Turbo 3D T1WI序列显示并不满意.结论 MRI评价桡腕背侧韧带时,选择合适的层面及序列可以达到最佳效果,有利于对其损伤进行诊断.     

翼状韧带的影像解剖学研究

目的探讨翼状韧带的位置、形态及走行，并深入研究其断面解剖形态及CT和MRI表现。方法采用经福尔马林固定的正常成人头颅标本12例，其中3例用于大体解剖观察，3例制成5．0mm厚的冰冻切片，6例制成0．5mm厚的薄层切片；选取2组各51例健康志愿者分别行CT和MRI检查。结合大体和断面解剖，分析翼状韧带的CT和MRI表现，并对其进行影像学测量。结果大体和断层解剖均能清晰显示翼状韧带的位置、形态及走行。齿状突上部的横断面和齿状突中部的冠状面是显示翼状韧带的理想层面。翼状韧带在CT和MRI横断面、冠状面及矢状面上的显示率均为100％（51／51）。对于翼状韧带结构的显示，MRI优于CT，尤其是质子密度加权成像的显示效果最佳。翼状韧带宽度在男女性别及左右侧别间的差异无统计学意义（P〉0．05）。结论CT和MRI均能较好地显示翼状韧带，结合大体和断层解剖进行研究，可为翼状韧带创伤、畸形及感染等病变的诊断提供影像解剖学支持。     

腕骨间韧带射频紧缩术后的组织学改变

目的 探讨射频紧缩对腕关节骨间韧带组织学结构的影响.方法选取6具新鲜成年男性尸体的双侧前臂标本,右侧标本进行射频紧缩治疗,而左侧标本作为正常对照.将主要的腕骨间韧带制备成骨-韧带-骨结构,然后进行包埋、切片,分别进行HE、甲苯胺蓝、苦味酸天狼星红染色,以及Ⅲ型胶原的免疫组织化学染色,并通过图像分析软件比较染色结果.结果HE和甲苯胺蓝染色显示舟月骨间背侧韧带(SL-d)的组织结构与月三角掌侧韧带(LT-v)类似,而舟月掌侧韧带(SL-v)与月三角背侧韧带(LT-d)类似,舟月近侧韧带(SL-m)和月三角近侧韧带(LT-m)表现为无钙化的纤维软骨结构.射频紧缩对SL-d和LT-v的结构破坏较小,而对SL-v和LT-d的结构破坏较大.苦味酸天狼星红染色和Ⅲ型胶原免疫组化染色显示,射频紧缩前后仅SL-m和LT-m的Ⅰ型和Ⅲ型胶原的分布面积有显著变化.结论腕关节骨间韧带射频紧缩对SL-d和LT-v这类以致密胶原组织为主的韧带的结构破坏较小,而对SL-v和LT-d这类混含胶原和疏松结缔组织的韧带的结构破坏较大.

Abstract：

Objective To explore the histological changes of the wrist interosseous ligaments after radiofrequency electrothermal shrinkage. Methods Six frozen fresh male adult cadaver wrist ligaments were exploited for the research. The ligaments of the right wrists were treated with radiofrequency electrothermal shrinkage with Arthrocare system, while the ligaments of the left wrists were kept as the normal control. The bone-ligament-hone samples of all the scapholunate (SL) and lunotriquetral (LT) ligaments were prepared, sectioned and then stained with the regular HE staining, toluidine blue staining, Sirius-red staining and immunohistochemistry staining of collagen Ⅲ. The image analysis software was used to compare the staining results. Results The histological structures of SL dorsal ligaments (SL-d) and LT volar ligaments (LT-v) were very similar, and the structures of SL volar ligaments (SL-v) and LT dorsal ligaments (LT-d) were also very similar. The membrane parts of both SL and LT ligaments showed the fibrous cartilage structure. The histological structures of SL-d and LT-v were much less destroyed by the radiofrequency than those of SL-v and LT-d. After radiofrequency electrothermal shrinkage, only the distribution areas of collagen Ⅰ and collagen Ⅲ were significantly changed in the membrane parts of SL and LT ligaments. Conclusion Radiofrequency electrothermal shrinkage treatment can cause minor structural damage to the collagen-dominant ligaments such as SL-d and LT-v, while it can lead to quite severe structural damage to the ligaments containing collagen and lots of loose connective tissue, such as SL-v and LT-d.     

正常髌韧带和前交叉韧带的MRI测量与分析

目的:采用磁共振(MRI)获取并分析比较活体髌韧带(PL)和前交叉韧带(ACL)的长度.方法:选取157例汉族双侧正常PL和ACL矢状位MRI图像,采用同一工作站Radworks5.1测量PL和ACL长度.先由医生A测得所有数据,再由医生B和C测取左侧PL长度,将三组左侧PL长度数据行相关分析.分析比较左右侧、不同性别、不同年龄的膝关节韧带指标,采用直线相关分析左右膝PL长度与体重、身高及左右ACL长度之间的关系.结果:(1)测量者B、C与测量者A相关系数分别为1.000、0.997,B、C两者的相关系数为0.997.(2)不同年龄段PL、ACL长度及二者比值:15～24岁,男性分别为43.95±4.25mm、38.45±4.62mm、1.15±1.09,女性分别为42.03±0.94mm、36.00±1.06mm、1.18±0.11;25～64岁,男性40.99±4.45mm、36.06±3.74mm、1.14±0.09,女性39.84±0.64mm、36.50±0.81mm、1.11±0.02;65岁以上,男性41.43±3.08mm、36.62±3.44mm、1.15±0.09,女性38.9±0.79mm、34.36±0.85mm、1.13±0.07.(3)左、右两侧PL长度与同侧ACL长度相关系数分别为0.672(P<0.01)、0.664(P<0.01).结论:Radworks 5.1对测量者个体的依赖度较低,测量值稳定.初步建立了通过MRI测得的汉族人PL、ACL长度及二者比值的参考值.     

High-resolution ultrasound anatomy of extrinsic carpal ligaments

PURPOSE: Carpal ligaments can be classified as intrinsic and extrinsic. Extrinsic ligaments are often involved in carpal instability. The purpose of this article is to describe the sonographic appearance of extrinsic carpal ligaments on high-resolution ultrasound (HRUS) using magnetic resonance arthrography (MR arthrography) as a reference standard. MATERIALS AND METHODS: We studied both wrists in 18 healthy volunteers (ten men, eight women, age range 18-58 years, mean age 34 years) with a Philips iU22 US scanner equipped with a high-resolution linear-array broadband transducer (5-17 MHz). The scans were performed along the long axis of the extrinsic dorsal and ventral ligaments to assess their course, thickness and structure. Ten subjects were also studied with MR arthrography of the wrist. RESULTS: In all patients, the ligament components could be appreciated as thin fibrillar hyperechoic structures. The course of seven extrinsic carpal ligaments and their relationships with surrounding articular structures could be studied. The radioscapholunate and the ulnar collateral ligaments were not visible on US. MR arthrography depicted all ligaments except for the ulnar collateral, which was never visualised. CONCLUSIONS: The results obtained are consistent with those reported in the literature. HRUS provides good anatomical detail of the extrinsic carpal ligaments, but the role of US in planning the treatment of carpal instability disorders is yet to be demonstrated.     

Anatomy of the ankle ligaments: a pictorial essay

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.     

Anatomy of the ankle ligaments: a pictorial essay

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.     

Extrinsic carpal ligaments: normal MR arthrographic appearance in cadavers

PURPOSE: To describe the normal magnetic resonance (MR) arthrographic anatomy of the major carpal ligaments (excluding scapholunate and lunotriquetral ligaments) and their osseous attachments by using standard imaging planes. MATERIALS AND METHODS: MR images of 22 wrists derived from fresh human cadaveric hands were obtained after tricompartmental arthrography. The MR arthrographic appearance of the carpal ligaments and their bone attachments were analyzed and correlated to those seen on anatomic sections. Two readers determined in consensus which was the best plane to observe the course and attachment sites for each ligament. They further analyzed the size and sites of attachment of these ligaments in two orthogonal planes chosen for optimal viewing. RESULTS: Each ligament was well seen as a hypointense linear structure with MR arthrography. The radioscaphocapitate, radiolunotriquetral, radioscapholunate, dorsal radiotriquetral, palmar scaphotriquetral, and dorsal scaphotriquetral ligaments were best evaluated in the transverse plane. The palmar and dorsal ulnotriquetral and ulnolunate ligaments were best visualized in the sagittal plane. The radial collateral ligament was best analyzed in the coronal plane. The attachment sites of all ligaments were best analyzed either in the transverse or sagittal planes. CONCLUSION: MR arthrography allows visualization of the carpal ligaments. Detailed knowledge of the normal appearance of these ligaments can serve as a baseline for future studies in which MR arthrography is used to characterize wrist instability.     

Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments

This paper describes the anatomy of the posterior cruciate ligament (PCL) and the meniscofemoral ligaments (MFLs). The fibres of the PCL may be split into two functional bundles; the anterolateral bundle (ALB) and the posteromedial bundle (PMB), relating to their femoral attachments. The tibial attachment is relatively compact, with the ALB anterior to the PLB. These bundles are not isometric: the ALB is tightest in the mid-arc of knee flexion, the PMB is tight at both extension and deep flexion. At least one MFL is present in 93% of knees. On the femur, the anterior MFL attaches distal to the PCL, close to the articular cartilage; the posterior MFL attaches proximal to the PCL. They both attach distally to the posterior horn of the lateral meniscus. Their slanting orientation allows the MFLs to resist tibial posterior drawer.     

Ultrasonographic evaluation of normal extrinsic and intrinsic carpal ligaments: preliminary experience

Objective To determine normal anatomy of extrinsic and intrinsic carpal ligaments at ultrasonography (US).Design and volunteers In the first part of the study, two musculoskeletal radiologists retrospectively reviewed in consensus the photographs of anatomic sections and dissections derived from 20 cadaveric wrists. This cadaveric study gave the two readers the opportunity to learn the anatomy and orientation of the various extrinsic and intrinsic carpal ligaments and, thus, to develop a US protocol to facilitate the recognition of each carpal ligament. In the second part of the study, these two radiologists prospectively and independently evaluated the visibility of extrinsic and intrinsic carpal ligaments in 30 wrists of volunteers, using the same US protocol.Results With regard to extrinsic carpal ligaments, the radioscaphocapitate ligament (partially visible, 38%; completely visible, 62%), the radiolunotriquetral ligament (partially visible, 27%; completely visible, 73%), the palmar ulnotriquetral ligament (partially visible, 12%; completely visible, 88%), and the dorsal radiotriquetral ligament (partially visible, 7%; completely visible, 93%) were visualized at US. The dorsal ulnotriquetral ligament (partially visible, 21%; completely visible, 74%), the ulnolunate ligament (partially visible, 5%; completely visible, 70%), and the radial collateral ligament (partially visible, 18%; completely visible, 12%) were more difficult to recognize. The radioscapholunate ligament was never seen. With regard to intrinsic carpal ligaments, the dorsal (partially visible, 11%; completely visible, 89%) and palmar (partially visible, 38%; completely visible, 62%) scaphotriquetral ligaments as well as the dorsal scapholunate ligament (partially visible, 3%; completely visible, 97%) were visualized at US. The dorsal lunotriquetral ligament (partially visible, 39%; completely visible, 61%) and the palmar scapholunate ligaments (partially visible, 12%; completely visible, 81%) were more difficult to recognize.Conclusion US may be helpful in identifying the major extrinsic and intrinsic carpal ligaments.     

CT study of the carpal tunnel. The carpal tunnel syndrome

The authors describe the CT aspects of carpal tunnel syndrome. Seventy-seven patients with signs and symptoms of carpal tunnel syndrome were studied, together with 28 postoperative controls (8 with and 20 without recurrence of symptoms) and 10 normal subjects. CT studies were carried out according to the conventional technique employing 3 high-definition axial slices respectively at the proximal end, in the middle and at the distal end of carpal tunnel. The patients affected with carpal tunnel syndrome presented changes in median nerve volume, in synovial sheet thickness, and in shape and density of the flexor tendons. Postoperative CT patterns of asymptomatic patients were similar to those of normal subjects. In the group of patients presenting postoperative recurrence of symptoms, 3 main findings were observed: incomplete surgery, newly formed cysts on the volar surface of the tunnel, and abnormal soft tissue interposed between the tendons. All the above findings were histologically confirmed during a second surgery. The authors believe CT to be a very useful tool in the evaluation of carpal tunnel syndrome, for both the first diagnosis and the demonstration of the causes of postoperative recurrences.     

The carpal ligaments in MR arthrography of the wrist: correlation with standard MRI and wrist arthroscopy

We assessed the value of three-compartment magnetic resonance (MR) wrist arthrography in comparison with non-enhanced magnetic resonance imaging (MRI) for the evaluation of 13 individual wrist ligaments in 35 patients with refractory wrist pain. In 20 of these patients MR findings were correlated with the findings from multiportal wrist arthroscopy. For MR imaging (1.5-T magnet) a three-dimensional volume acquisition with a gradient-recalled echo sequence and 0.6-1.0 mm effective slice thickness was used. The delineation of individual wrist ligaments was rated as "good" in 10% of non-enhanced MR and 90% of MR arthrography images. Ligament evaluation was possible with high diagnostic confidence in 11% by non-enhanced MR imaging and 90% by MR arthrography. With wrist arthroscopy as the standard of reference, average sensitivities/specificities/accuracies for the diagnosis of full-thickness ligamentous defects were 0.81/0.75/0.77 for non-enhanced MR imaging and 0.97/0.96/0.96 for MR arthrography. Our findings suggest that MR arthrography is more accurate than standard MRI in delineating and evaluating the ligaments of the wrist.