两种不同移植物重建膝前交叉韧带的临床疗效比较

[目的]探讨自体髌腱与深低温冷冻同种异体髌腱重建膝关节前交叉韧带的临床疗效差异。[方法]72例ACL断裂患者于术前应用电脑随机抽样方法分为两组:A组36例为自体髌腱组,B组36例为单纯深低温冷冻保存同种异体髌腱组。两组病例均由同一术者采用标准关节镜技术完成前交叉韧带重建。通过一般情况比较、轴移试验、Lachman试验、Daniel单腿水平跳跃试验、IKDC评分、Lysholm-Tegner运动水平评分及KT-2000检测评价临床疗效。[结果]70例患者获得随访,平均随访时间A组(36例)39.5个月、B组(34例)36.3个月,2例失访。A组发生术中髌骨骨折1例、术后髌前痛2例,B组出现迟发感染1例。A组平均手术时间较B组长,术后发热天数较B组短。两组住院时间无差异。A、B两组轴移试验、Lachman试验及KT-2000检测的差异无统计学意义。A、B两组ACL重建失败率分别为8%、9%,差异无统计学意义。两组间Daniel单腿水平跳跃试验、IKDC评分及Lysholm-Tegner运动水平评分的差异无统计学差异。[结论]单纯深低温冷冻同种异体髌腱与自体髌腱相比较,重建前交叉韧带的术后短期疗效接近,可作为自体移植物重建前交叉韧带的一个良好的移植替代物。     

Intrafix固定四股腘绳肌腱重建前交叉韧带的临床研究

目的 探讨采用Intrafix固定腘绳肌腱重建前交叉韧带的临床疗效.方法 2005年3月至12月采用Intrafix螺钉重建前交叉韧带患者35例,由同一术者完成,均采用4股半腱肌腱和股薄肌腱.前交叉韧带股骨端采用Endobutton袢固定.3例患者失访,术后随访时间为12～20个月,平均15个月.其中15例进行膝关节功能评分、KT-2000及X线检查,11例患者术后行MRI检查;其余17例患者仅进行了膝关节功能评分.结果 术后国际膝关节委员会(IKDC)膝关节主观功能评分平均91分(83～97分),15例膝关节检查IKDC分级为A级10例,B级5例(为术后膝关节伸屈角度略大所致).Lysholm评分83～93分,平均89分,其中优17例,良15例.术后优良率为100%.术后KT-2000结果 为30°133 N下平均1.2 mm(0～2.0 mm),90°133 N下平均0.5 mm(-0.5～2.0 mm).术后MRI可见重建韧带形态较好.术后X线片可见定位准确.结论 采用Intrafix固定四股腘绳肌腱重建前交叉韧带能够恢复膝关节前向稳定性,术后临床效果好.     

前交叉韧带重建术胫骨端两种固定方法的比较

[目的]比较单独应用带鞘界面螺钉或联合运用带鞘界面螺钉与门型钉固定前交叉韧带胫骨骨道远端的临床效果。[方法]回顾性分析2014年1月~2016年8月71例接受前交叉韧带重建的患者。按胫骨固定方式分为两组,单螺钉组37例,采用单一带鞘界面螺钉固定胫骨侧;联合组34例,采用带鞘界面螺钉联合门型钉固定胫骨侧。比较两组围手术期、随访与影像资料。[结果]71例患者均成功接受手术,术中未出现神经和血管损伤。两组手术时间、住院时间的差异无统计学意义(P>0.05);单螺钉组的住院费用稍低于联合组,但差异无统计学意义(P>0.05)。术后两组患者的Lachman试验、轴移试验均转为阴性。所有患者随访12~24个月,平均(14.13±2.54)个月。末次随访时,两组共71例患者中,除带联合组3例患者仍有跪地疼痛外,其他患者均无明显交锁、疼痛打软腿等症状,所有患者生活均可自理。末次随访时两组患者的Lachman试验、轴移试验结果、伸屈ROM、IKDC2000评分和Lysholm评分差异均无统计学意义(P>0.05)。术后影像学检查示两组患者膝关节骨道位置良好。[结论]单纯使用界面螺钉固定与联合使用界面螺钉与门型钉在术后膝关节功能、膝关节稳定性方面效果相当,然而,联合使用界面螺钉与门型钉可能与术后跪地疼痛有关。     

双股腘绳肌腱重建解剖学形态的前交叉韧带

目的探讨经双股骨和3个胫骨隧道用双股腘绳肌腱移植,重建解剖学形态前交叉韧带的可行性和效果。方法使用关节镜技术准确的确立出前交叉韧带起止点位置,并钻取2个股骨和3个胫骨隧道,将双股腘绳肌腱分为3束重建解剖学形态的前交叉韧带。结果所有病例随访8~15个月,膝关节功能恢复满意。结论前交叉韧带重建技术更能发挥膝关节生物力学性能,具有广泛的应用前景。     

Functional results after anterior cruciate ligament reconstruction using the patellar ligament bone-tendon-bone technique

This study evaluates the outcome after surgical repair of the cruciate ligament in 129 patients (physical examination plus questionnaire) and another 49 patients (questionnaire only) after a mean interval of 3.2 years. A modified Lysholm score and the OAK score together with KT 1000 arthrometry were used. Ninety-five percent of patients evaluated the overall result as ‘excellent’ or ‘good’. The overall OAK objective score was good or excellent in 81%. Elongation as measured by KT 1000 arthrometry was 1.0 mm (67 N) and 1.2 mm (90 N) on average compared with the contralateral knee. Received: 6 May 2000     

Revision anterior cruciate ligament reconstruction: etiology of failures and clinical results

A retrospective study was performed to determine the etiology of failed primary anterior cruciate ligament (ACL) reconstruction and evaluate the clinical results of revision ACL surgery. From January 1989 to January 1996, 90 patients with failed ACL reconstructions underwent revision ACL surgery. The etiology of failed ACL reconstruction included 47 surgical technical errors, 22 traumatic reinjuries, 7 lack of graft incorporation, 3 loss of motion, 3 related to synthetic grafts, and 8 alignment or combined ligamentous instability patterns not addressed. Of 52 revision ACL patients with minimum 2-year follow-up, 43 responded to a questionnaire and underwent a comprehensive physical examination. The Hospital for Special Surgery knee ligament evaluation revealed 63% good/excellent results. Objective laxity test revealed 77% of all patients had 0/+1 grade on Lachman and a mean 2.86-mm KT 1000. The overall results of revision ACL surgery are encouraging in providing symptomatic relief and restoring stability; however, they are significantly lower than primary ACL surgery.     

自体腘绳肌腱单、双束重建前交叉韧带临床比较研究

目的 比较自体腘绳肌腱单、双束重建前交叉韧带的临床效果.方法 2005年5月至12月采用双束重建前交叉韧带患者33例(双束组),单束重建患者41例(单束组),均采用自体半腱肌腱和股薄肌腱.双束组4例失访,随访时间14～22个月,平均18个月;单束组8例失访,随访时间14-21个月,平均18个月.采用国际膝关节评分委员会评分标准(IKDC),Lysholm和Tegner评分、KT-2000及Biodex肌力测试评价.结果 双束组IKDC,Lysholm和Tegner评分分别由术前的60、66、4分显著上升至术后的85、94、6分.KT-2000在134 N下30°和90°位移情况由术前的5.8和2.4 mm减少为术后1.2和1.1 mm(P＜0.01).双束组伤侧膝关节伸膝及屈膝的峰力矩在60°/s下,相对于正常侧分别为81%和87%,120°/s下为76%和85%.各项值均显著低于对侧(P＜0.01).尽管在30°位KT-2000测量值和伸膝肌力的恢复方面,双束重建较单束重建表现出了更好的趋势,但功能评分,KT测量值和BIODEX测量的结果,单、双束组差异无统计学意义.结论 自体胭绳肌腱单、双束重建前交叉韧带均可以恢复膝关节稳定,改善关节功能,双束重建患者在30°位前后稳定性和伸膝肌力方面表现出了较单束重建更好的趋势.     

Extra-articular reconstruction of the anterior cruciate ligament: lateral procedures

Several extra-articular procedures have been shown to be successful in controlling anterolateral rotatory instability. These procedures are performed as an extra-articular reconstruction alone or are combined with an intra-articular reconstruction. The common goal of these extra-articular procedures is the control of the abnormal anterior subluxation of the lateral tibial plateau and, thus, the elimination of the lateral pivot shift phenomenon. This goal is achieved most readily by placing some portion of the iliotibial tract posterior to the transverse center of rotation of the knee in order to provide a check-rein effect on the lateral tibial plateau to prevent anterior subluxation as the knee approaches terminal extension.     

关节镜下横杆式固定重建膝前十字韧带的中期疗效观察

目的 评价关节镜下自体腘绳肌腱移植、横杆式固定(transfix)重建膝关节前十字韧带(anterior cruciate ligament,ACL)的中期临床疗效.方法 自2002年8月至2003年12月对38例膝关节ACL断裂患者应用自体腘绳肌腱重建ACL、股骨端采用横杆式固定、胫骨端采用界面螺钉固定.男21例,女17例;年龄19～48岁,平均28.4岁;左膝24例,右膝14例.运动伤27例,交通伤2例,跌倒扭伤2例,余7例无明显外伤.急性损伤6例,陈旧性损伤32例.术前体检:前抽屉试验阳性35例,弱阳性1例,阴性2例;Lachman征阳性37例,弱阳性1例.以Lysholm评分评价中期临床疗效,以MRI及X线观察移植物以及骨隧道变化情况.结果 38例患者中36例获得随访(随访率94.7％),随访时间6.3～7.6年,平均6.8年.所有患者关节活动度正常,Lysholm评分由术前(64.4±4.52)分提高到(85.6±4.60)分,差异有统计学意义.X线及MRI发现3例股骨及胫骨隧道均扩大,5例股骨隧道扩大,3例胫骨隧道近端扩大.未见关节间隙变窄.1例患者在术后4年因外伤再次致ACL断裂,行关节镜下ACL翻修术,采用同种异体肌腱移植物,股骨端及胫骨端采用可吸收挤压钉固定.结论 应用腘绳肌腱、股骨侧横杆式、胫骨侧界面挤压螺钉固定重建膝关节ACL可以获得较为满意的关节活动度及关节稳定性,中期疗效佳.     

前交叉韧带重建后翻修的临床研究

目的 探讨前交叉韧带(anterior cruciate ligament, ACL)翻修重建的手术适应证、手术方法和临床疗效.方法 2001年11月至2006年7月收治ACL重建后失稳接受翻修患者12例,其中男性9例,女性3例,年龄16～39岁,平均28岁,均在关节镜下行探查与翻修手术.结合上述病例分析翻修的适应证、术中处理方法.术后应用KT-2000、IKDC、Lysholm及Tegner评分系统对临床疗效进行评价.结果 本组患者术前膝关节明显不稳.2例因骨道骨质严重缺损行一期植骨术.其余10例一期行ACL翻修手术,重建移植物采用同侧腘绳肌腱(STG)4例,对侧STG 4例,同侧骨-髌腱-骨(B-PT-B)1例,髂胫束1例.ACL翻修术后KT-2000检查平均差值在膝关节屈曲90°位和30°位分别为1.6 mm和3.1 mm;术后IKDC、Lysholm及Tegner评分平均分别为72.8、78.3、4.9分,较术前有明显改善.结论 ACL翻修重建后患膝的主观功能和客观稳定性可获明显改善.     

关节镜下LARS人工韧带重建前交叉韧带

膝关节前交叉韧带（anterior cruciate ligament，ACL）损伤后自愈能力差，移植重建是目前治疗的主要手段。常用的移植物有很多种，其中最常用的是自体髌韧带和半腱肌腱，但供区并发症问题一直影响最终疗效。我院2006年6～12月采用法国产LARS（1igament advancement reinforcement system）人工韧带进行关节镜下ACL重建21例，效果满意，现报告如下。[第一段]     

同种异体胫前肌腱与自体腘绳肌腱重建前交叉韧带的病例对照研究

目的：对比异体胫前肌腱与自体胭绳肌腱重建前交叉韧带的临床疗效。方法：2005年9月至2007年5月,重建前交叉韧带100例,其中50例采用经深低温冷冻及v射线照射处理后的畀体胫前肌腱重建,50例采用自体胭绳肌腱重建。固定方式均为股骨端横杆悬挂固定（Rigidfix）和胫骨端中心固定（Intrafix）。术后通过对比两组症状体征、Lysholm评分来对比疗效。结果：两组均顺利完成手术,无感染及韧带再断裂发生。所有患者术后获随访,时间12-33个月（平均25．6个月）。异体组50例术膝轴移试验均阴性,前抽屉试验及Lachman试验为阴性或I度阳性;术后1年以上Lrrsholm总评分平均（89．3±6．3）分。自体组50例术膝体征检查结果与异体组类似,术后1年Lysholm总评分平均（90．5±4．5）分,两组对比差异无统计学意义（P〉0．05）。结论：同种异体胫前肌腱与自体胭绳肌腱重建前交叉韧带疗效相当,医生及患者可根据实际情况选择移植物。     

Preliminary clinical results of two techniques for addressing graft tunnel mismatch in endoscopic anterior cruciate ligament reconstruction

This study reports the initial clinical results of 540 degrees of graft rotation or free tibial bone block to address graft tunnel mismatch in endoscopic anterior cruciate ligament (ACL) reconstruction. The operative reports of patients who underwent endoscopic ACL reconstruction between 1999 and 2001 were reviewed. Nine of 11 patients treated with a free tibial bone block and 14 of 17 patients treated with 540 degrees of graft rotation were evaluated. Mean follow-up was 20 months (range: 13-40 months) for the bone block group and 34 months (range: 18-48 months) for the 540 degrees group. There were statistically significant improvements in physical examination test results postoperatively, and only one patient in the 540 degrees group had a grade one positive pivot shift test. KT-1000 arthrometer testing demonstrated a statistically significant decrease in manual maximum and side-to-side differences at final follow-up. Mean Lysholm and Noyes sports function scores were excellent or good for all patients. One patient required reoperation for flexion contracture, one patient required an arthroscopic irrigation and debridement for a minor infection, and one patient required arthroscopic subtotal medial meniscectomy for failed meniscal repair. No difference was noted between these results and previous results of patients undergoing conventional endoscopic ACL reconstruction. These results demonstrate graft rotation and free bone block techniques are effective in addressing graft tunnel mismatch in endoscopic ACL reconstruction.     

Revision anterior cruciate ligament reconstruction

Revision ACL surgery is indicated in patients who present with pathologic anterior laxity on clinical examination that reproduces their symptoms of instability during activities of daily living or athletic activities. The goals of the revision ACL surgery are to stabilize the knee, prevent further injury to the articular cartilage and menisci, and maximize the patient's function. Successful revision ACL surgery requires a thorough preoperative evaluation, including a detailed history, physical examination, and radiographic evaluation. Preoperative planning begins with a determination of the mechanisms of failure for the initial ACL reconstruction. Often a primary, as well as secondary cause, for failure can be identified. The determination of the cause of failure is the first step in a carefully-constructed treatment plan, which includes consideration of skin incisions to be used, method of graft removal, hardware removal, the need for a staged procedure or concomitant surgery, graft material selection, tunnel placement, graft fixation, and postoperative rehabilitation protocol. Despite the most meticulous planning, unanticipated findings may be encountered in the operating room, and the preoperative plan should have enough flexibility to accommodate these developments. Finally, it is crucial to counsel the patient preoperatively to limit his or her expectations regarding their surgical outcome. Given the complexity of revision ACL reconstruction, patient expectations must be adjusted to realistically match the potential for success. With proper planning, attention to detail, and appropriate patient expectations, revision ACL surgery can result in a beneficial and satisfying patient outcome.     

前交叉韧带损伤关节镜下重建治疗的临床研究进展

前交叉韧带（anterior cruciate ligament,ACL）是保持膝关节稳定的重要结构,断裂后可导致膝关节不稳,引起膝关节继发损害而严重影响膝关节功能。目前,ACL重建已成为治疗其损伤的有效方法。国内有关ACL的临床研究已较广泛和深入,但仍有许多新的课题有待研究。现结合本期刊登的几篇相关领域的论文予以评述,讨论有关ACL重建治疗中的热点问题。     

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。     

Second-look arthroscopic findings and clinical results after polyethylene terephthalate augmented anterior cruciate ligament reconstruction

Purpose

Based on the revival of artificial ligaments containing polyethylene terephthalate, this study aimed to evaluate objective intra-articular findings within scheduled second-look arthroscopy, patient-reported clinical outcome and stability after isolated augmented ACL reconstruction with polyethylene terephthalate (Trevira®) augmented patella-bone-tendon-bone graft.

Methods

In a retrospective analysis of our institutional database, we found 126 patients with polyethylene terephthalate (Trevira®) augmented ACL reconstruction. All these patients underwent standardised second-look arthroscopic evaluation when removal of the augmentation became necessary. These second-look arthroscopic analyses focused on graft integration and remodelling in line with the polyethylene terephthalate augmentation. Arthroscopic re-examination comprised a graft evaluation including a structural and functional classification according to the Marburger Arthroscopy Score (MAS). Additional clinical evaluation was performed via the IKDC score and the scores of Tegner and Lysholm. Instrumental anterior laxity testing was carried out with a KT–1000? arthrometer. Furthermore, a correlation analysis between the clinical parameters, the instrumental stability assessment and the corresponding arthroscopic graft condition was performed.

Results

The arthroscopic evaluation showed rupture of 87 (69 %) of 126 augmentation devices. In 27 (31 %) of these 87 cases, synovial reactions were found particularly in the anterior compartment. An intact synthetic augmentation with signs of graft integration with intact synovial coating was only found in 30 %. Evaluation according to the MAS showed good to excellent structural and functional characteristics in 88 % of patients. Presence of a type III graft (MAS) was found in an additional 11 %. A rudimentary (type IV) graft was only detected once. Eighty-five percent of patients were graded A or B according to IKDC score. The Lysholm score was 92.4?±?4.8. Correlation analysis demonstrated a significant relationship between clinical outcome according to the IKDC score (p?<?0.05), instrumental stability performance according to the KT-1000? assessment (p?<?0.05) and the corresponding arthroscopic graft evaluation according to the MAS.

Conclusion

Graft integration and remodelling has complex and multi-factorial origins, particularly with artificial augmentation. Correlation analysis showed a significant relation between clinical condition, instrumental stability performance and arthroscopic graft constitution. The release of polyethylene terephthalate fibres caused inflammation of synovial tissue of the knee. Characteristic sub-clinical graft changes of structural, morphological and functional qualities of the inserted graft appear on second-look arthroscopy despite good clinical results.