前交叉韧带重建中电磁导航系统辅助骨隧道定位的准确性

文题释义：电磁导航系统：由台车、磁场发生器、配套机械臂及附件组成。采用电磁技术结合计算机辅助系统,可在遮挡的情况下进行精确实时的空间三维定位,可在具有医用级别金属的环境中工作。根据术前规划结合合适的配准方式,系统可预先校准,快速设置,立即使用,实时导航。适用于骨外科、神经外科、耳鼻喉外科、腹腔镜疗法、内窥镜治疗等领域。骨隧道定位：前交叉韧带重建中建立的骨隧道是固定移植物和发挥移植物功能的关键,良好的骨隧道位置能极大提高患膝功能,尽管关节镜技术已取得极大的进展,但仍有患者出现因骨隧道定位不当发生的移植物病理性松弛和膝关节不稳定等不良结果。因个体差异,使用传统的关节镜技术形成一个解剖上正确的骨隧道仍有一定的困难。术前手术计划和导航系统在准确性和可重复性方面为定位骨隧道位置和方向提供了良好的辅助作用。背景：前交叉韧带重建中骨隧道定位的准确性和可重复性一直是难点,电磁导航系统作为一种新型导航技术在应用中可以实现三维空间内定位,希望可以弥补外科医生在手动完成骨隧道时产生的失误。目的：验证一种新型电磁导航系统在前交叉韧带重建中骨隧道解剖定位的可行性及准确度。方法：新鲜冰冻膝关节标本30例,切断前交叉韧带制备前交叉韧带断裂膝关节标本。随机分成2组,分别采用电磁导航结合关节镜(导航组)及传统关节镜(对照组)定位骨隧道。术后行膝关节侧位片检查,观察2组标本骨隧道的出口位置,测量胫骨隧道中点在胫骨平台前后径上的位置,测量Blumensaat线与胫骨隧道中轴线之间的角度(α角),测量股骨隧道在Blumensaat线上的位置。结果与结论：①在导航组中,膝关节伸直位时的侧位X射线片显示所有胫骨隧道的前缘位于Blumensaat线延长线与胫骨胫骨平台交点的略后方,避免了髁间碰撞;对照组有2例胫骨隧道前缘位于Blumensaat线略前方;②导航组Blumensaat线的延长线与胫骨平台水平交点处至胫骨隧道前边缘之间的距离(a)、a与胫骨平台前后径宽度(c)的比值以及α角均较对照组更小(P < 0.05),这增加了胫骨隧道定位的准确性;③2组胫骨隧道位置差异无显著性意义(P=0.323);但导航组胫骨隧道中心位置变化范围(38.1%-53.8%)略低于对照组(30.4%-56.4%);同时导航组a距离(0.1-3.2 mm)的变化范围较对照组(-2.1-5.7 mm)小,骨髓道定位更严格,胫骨隧道定位的可重复性增加;④分析股骨隧道位置,所有导航组均在在后上象限(4/4)的位置,对于对照组有13例。与对照组相比导航组股骨隧道位置更靠后(P=0.001),导航组相对偏后的股骨隧道可以更加保证膝关节的稳定性;⑤说明在尸体膝关节实验中,电磁导航技术可以用于辅助前交叉韧带重建过程中骨隧道的定位,增加了骨隧道的精确性和可重复性,但存在人为和电磁导航系统误差,在临床应用中仍需改进。ORCID: 0000-0003-1765-3457(贾国庆)中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

ACL断裂单束解剖重建及胫骨隧道扩大的临床研究

目的　探讨前交叉韧带单束解剖重建术后胫骨隧道扩大对临床效果的影响。 方法　回顾性分析我科在2011年5月至2012年12月行关节镜下前交叉韧带单束解剖重建术的40例（40膝）患者资料,通过膝关节X线片、CT及三维重建测量胫骨隧道宽度后,对骨隧道扩大进行分级及定义。采用膝关节活动度（range of motion, ROM）、前抽屉试验（anterior drawer test ADT）、Lachman试验、轴移试验（pivot shift test, PST）、Lysholm评分表、IKDC2000评分表评定临床疗效。 结果　术后随访未发现关节屈伸活动障碍者。术后患侧活动度与健侧活动度,两者间差异无统计学意义（t =-1.844,P =0.069）。骨隧道扩大组与非扩大组间ADT、Lachman和PST差异无统计学意义（χ2 =1.314、0.011、0.005,P =0.33、1.0、1.0）。40例患者术前Lysholm评分与术后Lysholm评分、两者差异有统计学意义（t =-45.50,P <0.001）;术前IKDC2000评分与术后IKDC2000评分两者差异有统计学意义（t =-25.18,P <0.001）。骨隧道扩大各级别间Lysholm评分差异无统计学意义（F =1.274,P =0.292）,各级别两两间差异无统计学意义。 结论　膝关节镜下单束解剖前交叉韧带重建术后胫骨隧道扩大对患者中期临床疗效没有明显影响。     

Instrumentation to avoid impingement lesions in anterior cruciate ligament reconstruction

During anterior cruciate ligament reconstruction most experienced knee surgeons site the tibial tunnel by reference to tibial landmarks alone, without any reference to the apex and roof of the intercondylar notch. Clearly in most instances, a satisfactory siting of this tunnel will be produced which will avoid implant impingement. However, even in the hands of the experienced knee surgeon using a subjective method of positioning, the tibial tunnel may be placed too anteriorly, resulting in impingement of the graft. This article describes a new jig which addresses the problem of anterior tibial tunnel placement with its attendant problems of impingement by objectively siting the tibial tunnel in a position that is related to the femoral side of the knee joint.     

Biomechanical testing of hybrid hamstring graft tibial fixation in anterior cruciate ligament reconstruction

Hamstring tendon using quadrupled semitendinosus and gracilis autografts is a well-established technique for ACL reconstruction. However, several methods have been used for tibial fixation of the tendon graft. The purpose of this study was to compare the biomechanical characteristics of quadrupled hamstring graft tibial fixation using three different fixation methods. Nine matched pairs (18 specimens) of cadaver tibias were divided into three groups of six specimens. The first group was fixed with only a tapered 30-mm bioabsorbable screw (BIS), the second group was fixed first with a BIS and then the remaining tendon portion was additionally fixed with a titanium cortical screw and spike washer, and the third group was fixed with only a cortical screw and spike washer. A custom-made probe hook was mounted on a load cell (Interface, MFG, Scottsdale, AZ) to measure the ACL tension before and after the final tibial fixation. Group 2 displayed greater mean maximum load at failure than both groups 1 and 3 (p < 0.05). The stiffness of the graft nearly doubled in group 2 compared to groups 1 and 3 (p < 0.05). All specimens failed by slippage and pullout. Biomechanical testing with cadavers showed that a BIS and additional cortical screw and spike washer fixation to the distal hamstring tendon resulted in higher load at failure and stiffness compared to either BIS or cortical screw and spike washer fixation alone.     

前交叉韧带胫骨附着处临床解剖学研究

目的 研究前交叉韧带(ACL)胫骨附着处的解剖形态学特点,并探讨ACL胫骨附着处测量值埘选择ACL重建方式的意义.方法 对10例福尔马林处理的成人膝关节标本进行解剖.在屈伸膝关节时根据ACL纤维张力区分前内束和后外束,然后从胫骨附着处切断韧带,用Photoshop软件测量附着处的相关数据.结果 ACL存在着两个不同的功能束,即前内束和后外束;胫骨附着处的形状不规则,可分为倒三角形、椭1形及四边形三种;ACL胫骨附着处的前后径与横径分别为(17.89±2.44)mm、(13.85±1.79)mm;前内束和后外束胫骨附着处的面积分别为(101.18±32.28)m㎡、(77.61±19.86)m㎡;两束中心点连线的距离为(8.03±1.51)mm.结论 本研究改进的数字图像测量方法是一种既实用又廉价的测量方法;ACL胫骨附着处测量值可作为选择ACL重建方式的参考.     

Comparison of anterior cruciate ligament volume after anatomic double-bundle anterior cruciate ligament reconstruction

Backgroud

To determine whether anatomic double-bundle anterior cruciate ligament reconstruction (DB-ACLR) can restore the native ACL volume, and whether the volume change after reconstruction affects clinical outcomes and re-rupture rates following the contemporary techniques.

Complications following anterior cruciate ligament reconstruction in the English NHS

Unlike the English National Joint Registry (NJR) for arthroplasty, no surgeon driven national database currently exists for ligament surgery in England. Therefore information on outcome and adverse events following anterior cruciate ligament (ACL) surgery is limited to case series. This restricts the ability to make formal recommendations upon surgical care. Prospectively collected data, which is routinely collected on every NHS patient admitted to hospital in England, was analysed to determine national rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE) rate, 30-day wound infection and readmission rates following primary ACL reconstruction between March 2008 and February 2010 (13,941 operations, annual incidence 13.5 per 100,000 English population). 90-day DVT and PTE rates were 0.30% (42) and 0.18% (25) respectively. There were no in-hospital deaths. 0.75% (104) of the consecutive patient cohort had a wound complication recorded. 0.25% (35) underwent a further procedure to wash out the infected knee joint and 1.36% (190) were readmitted to an orthopaedic ward within 30 days. This is the first national comprehensive study of the incidence of significant complications following ACL surgery in England. This should allow meaningful interpretation of future baseline data supporting the development of a national ligament registry.     

Marrow adipose tissue accumulation and dysgenesis of the trabecular bone after anterior cruciate ligament transection and reconstruction in the rat proximal tibial epiphysis

The accumulation of marrow adipose tissue (MAT) is frequently associated with bone loss. Although anterior cruciate ligament (ACL) injury induces bone loss, MAT accumulation after ACL injury has not been evaluated. In addition, no information about changes in MAT after ACL reconstruction is available. In this study, we aimed to examine (1) the effects of ACL transection on the amounts of trabecular bone and MAT present, and (2) whether ACL reconstruction inhibits the changes in the trabecular bone and MAT that are induced by ACL transection. ACL transection alone or with immediate reconstruction was performed on the right knees of rats. Untreated left knees were used as controls. Histomorphological changes in the trabecular bone and MAT in the proximal tibial epiphysis were examined prior to surgery and at one, four, and 12 weeks postsurgery. The trabecular bone area on the untreated side increased in a time-dependent manner. However, after ACL transection, the trabecular bone area did not increase during the experimental period, indicating dysgenesis of the bone (bone loss). Dysgenesis of the trabecular bone after ACL transection was attenuated by ACL reconstruction. MAT accumulation due to adipocyte hyperplasia and hypertrophy had been induced by ACL transection by four weeks postsurgery. This ACL transection-induced MAT accumulation was not prevented by ACL reconstruction. Based on these results, we conclude that (1) dysgenesis of the bone in the proximal tibia following ACL transection is accompanied by MAT accumulation, and (2) ACL reconstruction attenuates dysgenesis of the trabecular bone but cannot prevent MAT accumulation.     

3D打印胫骨隧道导航模块辅助前交叉韧带重建的临床研究

目的　探讨3D打印胫骨隧道导航模块辅助前交叉韧带重建的可行性及疗效评价。 方法　选取2015年1月至2016年5月就诊于莆田学院附属医院骨科,符合标准,行前交叉韧带重建的56例患者,随机分为两组：3D打印组和对照组,评估两组手术时间、术中定位的次数、术后6、9个月IKDC膝关节功能评分、术后6、9个月Lysholm评分以及术后9个月膝关节活动度。计数资料采用卡方检验分析,计量资料采用两独立样本t检验分析。 结果　最终52例患者进入统计学分析,对照组27例,3D打印组25例。对照组和3D打印组的手术时间及胫骨隧道的定位次数差异有统计学意义（t=4.186,P<0.05;t=3.069,P<0.05）。术后3个月、术后9个月IKDC膝关节功能评分、Lysholm评分以及术后9个月的膝关节活动度,两组比较差异均无统计学意义（P>0.05）。 结论　3D打印胫骨隧道导航模块辅助前交叉韧带重建存在可行性。     

关节镜下保留残端与非保残重建前交叉韧带的疗效比较

目的　比较关节镜下保留及非保留残端重建前交叉韧带 (anterior cruciate ligament, ACL) 的疗效。 方法　选择我院2014.03~2015.05收治的64例有韧带残端残留的ACL断裂患者64例为研究对象,采用关节镜下四股自体腘绳肌腱单束重建技术,随机分为两组,即保留残端组和非保留残端组,每组32例,非保残组给予切除残端行常规关节镜手术重建ACL,保残组在保留残端的基础上行关节镜下ACL重建术。记录比较两组术前、术后关节稳定性及功能评分进行对比,术后1年测本体感觉,部分患者二次手术时探查重建韧带。 结果　64 例均获随访,随访时间 12~27个月。术后1年Lysholm评分,非保残组平均91.9分,保残平均93.2分;IKDC 评分功能在A、B级非保残组29例,保残组30例;抽屉试验阴性非保残组29例保残组31例,Lachman 试验阴性两组均为30例,比较差异均无统计学意义( P＞0.05);两组的本体感觉重复试验无差异,患者自述关节稳定性及位置觉以观察组稍优,术后共有9例患者二次行关节镜手术,对照组4例,观察组5例,镜下见对照滑膜覆盖率及韧带表面光滑度较观察组稍差,因例数太少,未行统计学分析。 结论　关节镜下保留残端与非保留残端单束重建术重建 ACL ,均能获得满意的临床效果,但关节镜下保留残端患者有更好的自我感觉,可能和保留残端有利于移植物的再血管化及本体感受器的恢复有关,需要更多的数据来进行统计学分析。     

The natural history of anterior cruciate ligament reconstruction using patellar tendon autograft

The purpose of this study was to review the results of ACL reconstruction using a patellar tendon graft placed ‘over the top’ plus a Macintosh lateral tenodesis, examining changes in knee laxity and functional status with increasing time. There were 74 patients operated on over an 11 year period, and divided into four groups for analysis according to postoperative time. There was a significant and progressive increase in side-to-side laxity difference with time, although functional status did not change significantly, indicating a lack of correlation between objective clinical tests and subjective findings. The highest Lysholm, Tegner and IKDC scores were at 4–5 years after operation, when 60% of patients were at their pre-injury level of sports activity. However, there was always a very significant difference between actual and desired Tegner activity levels for the group as a whole. While there was a significant correlation between degenerative changes and the time between injury and reconstruction, there was no correlation with postoperative time: this provides evidence that ACL reconstruction can protect the knee from later degeneration.     

Factors affecting knee laxity following anterior cruciate ligament reconstruction using a hamstring tendon

Background

The aim of the present study was to investigate the correlation between the pre-operative and intraoperative factors that predict postoperative knee laxity following anterior cruciate ligament (ACL) reconstruction using a hamstring tendon.

High variability in anterior cruciate ligament femoral footprint: Implications for anatomical anterior cruciate ligament reconstruction

BackgroundThe study aimed to (1) investigate the variability of the femoral ACL center in ACL-ruptured patients, (2) identify whether the currently available over-the-top femoral ACL guides could allow for anatomical reconstruction of the native ACL footprint.Material and methodsMagnetic resonance images of 95 knees with an ACL rupture were used to create three-dimensional models of the femur. The femoral ACL footprint area was outlined on each model, and the location of the femoral ACL center was reported using an anatomical coordinate system. The distance of the femoral ACL center from the over-the-top position was measured.ResultsThe femoral ACL center demonstrated a high intersubject variability ranging from 1.8 mm (9%) to 12.3 mm (60%) posterior and from 7.7 mm (37%) distal to 4.8 mm (23%) proximal using the posterior condyle circle reference. The average distance of the femoral ACL center from the over-the-top position was 1.9 ± 1.5 mm posterior and 13.8 ± 2.7 mm distal, respectively. The contemporary over-the-top femoral ACL aimers could restore the femoral ACL center in only 6.5% of the patients.ConclusionsThe femoral ACL center demonstrated a high variation on its location, which resulted in a high intersubject variability from the over-the-top position. The contemporary over-the-top femoral tunnel guides do not provide sufficient offset to allow for an anatomical ACL reconstruction. Anteromedial-portal specific femoral ACL guides with a femoral offset ranging from 10 to 18 mm in the proximal/distal direction are required to restore the native ACL footprint.     

The negative impact of anterior cruciate ligament reconstruction in professional male footballers

Background

Soccer is one of the most common international sports in which ACL injuries occur, with previous studies reporting high return-to-play rates following ACL reconstruction (ACLR). Return-to-play analysis fails to take into consideration how effective a player remains once returning to competition. The aims of this study are to provide a large-scale international analysis of return-to-play and player performance statistics among professional soccer athletes following ACLR.

One-stage revision anterior cruciate ligament reconstruction in cases with excessive tunnel osteolysis. Results of a new technique using impaction bone grafting

Background

This level IV study describes a new one-stage procedure for revision ACL reconstruction in cases with extreme tunnel widening.

Influence of anterolateral ligament injuries on stability and second-look arthroscopic findings after allograft transtibial anterior cruciate ligament reconstruction

Background

The purpose of this study was to evaluate the influence of anterolateral ligament (ALL) injuries on stability and second-look arthroscopic findings after anterior cruciate ligament (ACL) reconstruction.

关节镜下空心螺钉固定ACL胫骨止点撕脱骨折

目的观察关节镜下空心螺钉固定ACL胫骨止点撕脱骨折的临床效果。方法 2010年2月~2011年3月,关节镜下空心螺钉固定ACL胫骨止点撕脱骨折13例,在关节镜下复位骨折块,空心螺钉固定骨折块。通过1年以上随访行疗效评定。患者膝关节功能以Lysholm评分系统评分。结果全部病例获完整随访,平均随访16m(12~25m)。Lysholm膝关节功能评分:术前23~65分,平均(48.45±5.23)分;术后83~96分,平均(91.34±6.53)分。优11例,良1例,中1例,优良率92.3%。结论关节镜下空心螺钉固定ACL胫骨止点撕脱骨折创伤小、恢复快,是一种可行的方法。     

Range of motion and complications following primary repair versus reconstruction of the anterior cruciate ligament

Introduction

Recently, there has been a resurgence of interest in primary anterior cruciate ligament (ACL) repair. The procedure is less invasive than ACL reconstruction, yet studies assessing early postoperative course are lacking. Goal therefore was to assess postoperative range of motion (ROM), complications and operative times following primary repair and compare this to the gold standard of reconstruction.

Gender differences in the restoration of knee joint biomechanics during gait after anterior cruciate ligament reconstruction

Background

The aim of our study was to evaluate the effects of gender on recovery of knee joint biomechanics over the stance phase of gait after reconstruction of the anterior cruciate ligament (ACL).

前交叉韧带损伤重建术后及随访的弥散张量成像观测

目的　为前交叉韧带重建术后的预后评估提供影像数据。 方法　选取新乡医学院附属医院膝关节弥散张量成像正常者100例和前交叉韧带Ⅲ、Ⅳ级损伤重建61例及随访57例,划分前交叉韧带损伤、重建处及正常组相应部位的感兴趣区,测量各向异性分数（fractional anisotropy,FA）、表观弥散系数（apparent diffusion coefficient,ADC）,生成纤维示踪图像。 结果　前交叉韧带术前和术后1周、3个月的FA值和ADC值为（0.395±0.047）、（0.541±0.056）、（0.542±0.058）和（2.791±0.336）×10-3 mm2 / s、（2.263±0.224）×10-3 mm2 / s、（2.028±0.341）×10-3 mm2 / s,术后1周与3个月FA值差异无统计学意义,其他组间FA、ADC值差异有统计学意义。前交叉韧带损伤重建术后随访3个月、6个月、1年和正常组的FA值、ADC值为（0.542±0.058）、（0.595±0.056）、（0.684±0.059）、（0.577±0.064）和（2.028±0.341）×10-3 mm2 / s、（1.699±0.175）×10-3 mm2 / s、（1.375±0.151）×10-3 mm2 / s、（1.324±0.160）×10-3 mm2 / s,随访6个月与正常组FA值和随访1年与正常组ADC值差异无统计学意义,其他组间FA、ADC值差异有统计学意义。 结论　弥散张量成像能客观反映前交叉韧带重建术后的微观结构变化,在预后评估中有重要的诊断价值。