膝关节交叉韧带和侧副韧带的断面解剖学研究及其意义

目的研究膝关节交叉韧带和侧副韧带的断面形态特征和变化规律,为诊断膝部韧带病变提供更为详尽的形态学资料。方法利用27例正常成人膝关节标本制作连续断面,其中矢状断面9例,冠状断面12例,横断面6例。通过横、矢、冠状断面标本,观测膝关节韧带的断面形态特征及定量测量。结果矢状面上测量前、后交叉韧带长度分别为(29.66±4.21)mm、(40.26±6.81)mm,厚度分别为(10.03±1.97)mm、(11.24±3.50)mm。冠状面上前、后交叉韧带长径分别为(15.18±3.25)mm、(18.79±3.35)mm,短径分别为(6.37±1.32)mm、(8.03±1.46)mm;胫、腓侧副韧带长度分别为(102.85±19.64)mm、(45.52±14.91)mm,厚度分别为(2.63±0.72)mm、(3.43±1.04)mm。髁间隆起的横断面上胫、腓侧副韧带长径分别为(21.98±11.95)mm、(5.25±1.93)mm,短径分别为(2.03±0.59)mm、(2.87±0.64)mm。结论 (1)观测交叉韧带最好的断面是膝关节正中矢状面,其次是正中旁开1个矢状断面。除厚度外,在矢状面上前后交叉韧带长度、股、胫骨附着区宽度均有明显差异。(2)胫、腓侧副韧带在连续的冠状断面及横断面上均可显示,以冠状断面配合横断面相对为佳。     

Vascular volume determination of articular tissues in normal and anterior cruciate ligament-deficient rabbit knees

The vasculature of diarthroidal joints has been well documented; however, the volume of vessels supplying different articular tissues is unknown. Angiogenesis, the formation of new vessels from preexisting ones, is difficult to quantify in joints due to the unavailability of a suitable technique. Although angiogenesis is known to occur in rheumatoid arthritis, the development of new vessels following joint injury has not been ascertained. A vascular casting technique was developed using carmine red dye to measure the vascular volume of the medial collateral ligament (MCL), lateral collateral ligament (LCL), menisci, medial capsule, and infrapatellar fat pad of the rabbit knee joint. Vascular volume determinations were repeated at 4 weeks in a group of anterior cruciate ligament (ACL)-transected animals and in a sham-operated control group. The volume of vessels supplying the MCL was estimated to be 0.22 ± 0.07 μl (mean ± S.E.M.), the LCL volume was 0.25 ± 0.05 μl, the medial meniscus volume was 0.19 ± 0.03 μl, the lateral meniscus volume was 0.40 ± 0.08 μl, the medial capsule volume was 0.14 ± 0.05 μl, and the infrapatellar fat pad volume was 1.90 ± 0.62 μl. Following ACL transection, angiogenesis was found to occur in the MCL only. All other tissue vascularities were not significantly different from sham-operated controls. A quantifiable method for measuring vascular volume of knee joint tissues has been described. Joint instability stimulates angiogenesis in the ipsilateral MCL; however, the absence of angiogenic activity in other articular tissues might help explain the lack of posttraumatic healing associated with these joints. Anat. Rec. 251:207–213, 1998. © 1998 Wiley-Liss, Inc.     

膝关节矢状断层影像解剖学

目的 为膝关节疾患的影像学诊断提供矢状断层解剖学基础。方法 用成年男尸右膝部标本5例(新鲜3，福尔马林固定2)，按解剖骨性标志画线，其中1例标本先行矢状位MRI扫描，所有标本冻硬后，切制矢状断层解剖标本，每例切5个断层，皆观察其内侧面。结果 观察了构成膝关节的主要结构，交叉韧带、半月板及其周围软组织的形态特征、位置、毗邻及其在连续断层的变化规律，并匹配同一断层之MRI。测量股骨内、外侧髁关节软骨厚为2．3mm和2．4mm，胫骨内、外侧髁关节软骨厚为2．5mm和2．6mm，髌骨关节软骨厚为5．3mm，前交叉韧带长36．1mm，前、后交叉韧带中部矢状径为6．32mm和6．51mm，内、外侧半月板矢状径为42．4mm和33．2mm，内侧半月板前、后部厚度为5．1mm和5．8mm，外侧半月板为6．5mm和7．1mm。结论 膝关节的矢状断层解剖各结构形态、位置及变化规律，对骨科及影像学诊断和治疗有重要的价值。     

膝降动脉作为游离股前外侧皮瓣受区血管的临床应用

目的　探讨胫前或胫后血管均无法利用的情况下将膝降动脉作为游离股前外侧皮瓣移植修复膝关节周围创面受区血管的临床可行性应用。 方法　2015年1月至2017年5月,应用于膝降动脉和大隐静脉吻合的游离股前外侧皮瓣移植修复7例膝关节周围大面积皮肤软组织缺损合并肌腱、骨外露的患者,其中男4例,女3例,皮瓣面积为38 cm×8 cm~18 cm×8 cm。 结果　随访6~14个月,平均8.9个月,2例面积较大皮瓣远端分别坏死约6 cm、4 cm,经切除后与残留创面二期植皮愈合,剩余5例皮瓣完全成活,受区残留创面二期植皮愈合。 结论　术前经彩色多普勒超声精确定位并测量膝降动脉口径、血流,术中采用显微外科技术扩大膝降动脉口径,可将膝降动脉作为游离股前外侧皮瓣受区血管修复膝关节周围软组织缺损创面,并取得满意的临床疗效。     

膝降血管髌下支蒂股骨内侧髁骨膜瓣逆行转位术的应用解剖

目的　为膝降血管髌下支蒂股骨内侧髁骨膜瓣修复膝关节面缺损提供解剖学基础。 方法　在30侧动脉内灌注红色乳胶的成人下肢标本上,以收肌结节、股骨内侧髁为观测点解剖观测膝降动脉关节支的走行、分支与分布。另在1侧新鲜标本上进行摹拟手术。 结果　膝降血管关节支在距股骨内侧髁下缘上(5.9±1.2) cm处发出两大分支：①骨膜支起始外径（1.3±0.2）mm,在股骨内侧髁面上走行距离为(4.8±1.1) cm;②髌下支起始外径为(1.3±0.2) mm,向下走行距离为(6.6±1.5)cm。 结论　可形成膝降血管髌下支-骨膜支蒂股骨内侧髁骨膜瓣逆行转位修复膝关节面缺损。     

膝关节的横断层影像解剖学

目的：为给膝关节伤病的横断层影像学诊断提供解剖学基础。方法：用成年男尸右膝部标本6具(新鲜4、经福尔马林固定2)，先作膝关节横断层CT及MR扫描，冰冻后切制成11个横断层解剖标本。结果：观察了每一断层内各结构的形态特征、位置毗邻及其在连续断层的变化规律，并匹配同一断层的CT及MRI。①髌股关节显示于第5～8断层，其关节软骨均匀一致，表面平整光滑，但关节腔形态不尽相同，分别呈磨合紧密狭窄凸向后的弧形，前后径短的横位“X”字形及前小后大相通的“工”字形。②髌韧带显现于第9～11断层，其横断面最宽处为24．6mm，最厚处为4．85mm。③前、后交叉韧带显示于第8～11断层，其横断面之长、短径值，前交叉韧带为7．45mm与6．55mm，后交叉韧带为6．25mm与4．12mm。④第10断层可视为膝关节的代表断面，各主要辅助结构均可见，其中内侧半月板呈大的“C”字形。而外侧半月板呈曲度较大的小的反“C”字形，二者的前后角处，分别有前、后交叉韧带。结论：膝关节各横断层的解剖形态、结构对医学影像学诊断有很重要的临床意义。     

Origin of the anterior cruciate ligament and the surrounding osseous landmarks of the femur

The aims of this study were to evaluate the discernibility of the LIR (lateral intercondylar ridge) and the LBR (lateral bifurcate ridge) and show their reliability in femoral tunnel placement in ACL (anterior cruciate ligament) reconstruction. Additionally, their position to the femoral axis, their course, and the ACL footprint were analyzed. For this study, 235 human femora were evaluated. Of these, 166 specimens originated from the Museum of Natural History (group A), and 69 were obtained from fixed cadavers at the Anatomic Institute (group B). The femoral footprint and the osseous landmarks were identified macroscopically and labeled in the photographs. A coordinate system was outlined, and the dimensions, position, and orientation of the femoral footprint of the ACL were measured. The LBR was found in 24.7% of the specimens in group A and in only 13.2% of the specimens in group B. The LIR was found in 97.9% and 85.3% of the specimens in groups A and B, respectively. The area of the ACL footprint was 127.21 ± 32.54 mm² in group A and 119.58 ± 34.84 mm² in group B. The shapes and angles of the osseous landmarks near the line of Blumensaat were highly variable. The LBR is an unreliable intraoperative landmark for arthroscopic ACL reconstruction due to its low incidence. Other anatomical structures, such as the LIR or the osteochondral border, may be more helpful and reliable landmarks to guide proper tunnel placement. Clin. Anat. 27:1103–1110, 2014. © 2014 Wiley Periodicals, Inc.     

Vascular anatomy of the spleen: The basis for organ-preserving surgery

The increased susceptibility to infection following splenectomy calls for a partial organ-preserving operative procedure. The basis for this conservative surgery depends on a thorough knowledge of the vascular anatomy of the organ. With this in mind 32 spleens were studied by angiographies and corrosion casts. The organs were classified into four groups according to their vascular pattern with special emphasis on the blood supply of the polar segments. Two, three, and four segments were found in 3.1%, 15.6%, and 81.3%, respectively. A bifurcation of the splenic artery was noted in 93.8%, and a trifurcation in 6.2%. A Y-type of branching of the hilar vessels with easier access for surgical procedures was noticed in 84.4%, and a T-type in 9.4%; in 6.2% a classification was not possible. Intersegmentary anastomoses, as a potential hazard for operations on the spleen, were present in 15.6%. Arteries and veins coincided. The exact diagnosis of the specific individual vascular anatomy and segmental organization of the spleen are necessary presuppositions for a successful partial spleen-preserving technique. © 1993 Wiley-Liss, Inc.     

Variations in the normal anatomy of the collateral ligaments of the human elbow joint

The variations which occur in the medial and lateral ligament complexes of the elbow were investigated. These occurred frequently with the standard appearances occurring in no more than half the specimens on the medial side and one quarter of those on the lateral side. Surgeons who regularly perform elbow arthroplasty must be aware of these considerations, especially with the introduction of unconstrained prostheses which rely upon the ligament complex for their postoperative stability.     

Computational modeling of a forward lunge: towards a better understanding of the function of the cruciate ligaments

This study investigated the function of the cruciate ligaments during a forward lunge movement. The mechanical roles of the anterior and posterior cruciate ligament (ACL, PCL) during sagittal plane movements, such as forward lunging, are unclear. A forward lunge movement contains a knee joint flexion and extension that is controlled by the quadriceps muscle. The contraction of the quadriceps can cause anterior tibial translation, which may strain the ACL at knee joint positions close to full extension. However, recent findings suggest that it is the PCL rather than the ACL which is strained during forward lunging. Thus, the purpose of the present study was to establish a musculoskeletal model of the forward lunge to computationally investigate the complete mechanical force equilibrium of the tibia during the movement to examine the loading pattern of the cruciate ligaments. A healthy female was selected from a group of healthy subjects who all performed a forward lunge on a force platform, targeting a knee flexion angle of 90°. Skin-markers were placed on anatomical landmarks on the subject and the movement was recorded by five video cameras. The three-dimensional kinematic data describing the forward lunge movement were extracted and used to develop a biomechanical model of the lunge movement. The model comprised two legs including femur, crus, rigid foot segments and the pelvis. Each leg had 35 independent muscle units, which were recruited according to a minimum fatigue criterion. This approach allowed a full understanding of the mechanical equilibrium of the knee joint, which revealed that the PCL had an important stabilizing role in the forward lunge movement. In contrast, the ACL did not have any significant mechanical function during the lunge movement. Furthermore, the results showed that m. gluteus maximus may play a role as a knee stabilizer in addition to the hamstring muscles.     

腓骨长肌腱转移重建膝交叉韧带的应用解剖

在30例成年下肢标本,观测了腓骨长肌形态、血管和神经.肌腱平均长13.5cm,肌腱与交叉韧带横经相近.自入肌的最低神经与血管分支处,将肌腹和肌腱逆转向上,可超出膝关节间隙14.7cm.采用腓骨长肌腱转位重建膝关节交叉韧带是可行的,肌腱游离度大,可作单条或多条韧带损伤重建.     

Anatomic and radioanatomic study of the lateral genicular arteries: application to prevention of postoperative hemarthrosis after arthroscopic lateral retinacular release

Summary Arthroscopic lateral retinacular release can be complicated by hemarthrosis in 10 to 18% of cases. The vascular structures involved are the lateral vascular pedicles of the knee. This study examines the topography of these pedicles. Anatomic and radioanatomic studies carried out in 50 specimens defined the route of the vascular pedicles at the lateral aspect of the knee. From the measurements carried out, we noted the relative homogeneity of the routes taken by the different proximo-lateral vascular pedicles, which are highly vulnerable, and the variability of the disto-lateral arterial routes. A tracing-paper study identified two distinct routes for the disto-lateral vascular pedicle and evaluated the risk of injury to it in surgical approaches to the lateral aspect of the knee. Finally, the topographic data of the study suggest the possibility of preventive hemostasis of the proximo-lateral pedicle via a minimal approach close to the patella. Furthermore, it seems possible to avoid cutting the disto-lateral pedicle if it is localised by cutaneous trans-illumination at the beginning of the operation.

---

Etude anatomique et radio-anatomique des artères latérales du genou. Application à la prévention de l'hémarthrose post-opératoire après section du rétinaculum patellaire latéral par voie d'abord arthroscopique

Résumé La section du rétinaculum patellaire latéral (aileron rotulien externe) par voie arthroscopique peut dans 10 à 18 % des cas se compliquer d'hémarthrose. Les structures vasculaires impliquées sont les pédicules vasculaires latéraux du genou. Ce travail étudie la topographie de ces pédicules. L'étude anatomique et radio-anatomique portant sur cinquante pièces précise le trajet des pédicules vasculaires de la face latérale du genou. Les mesures réalisées permettent d'affirmer la relative homogénéité des trajets des différents pédicules vasculaires proximo-latéraux, très vulnérables, et une variabilité de trajet des artères disto-latérales. La réalisation de calques permet d'identifier deux types de trajets distincts pour le pédicule vasculaire disto-latéral et d'apprécier le risque de le léser lors d'un abord de la face latérale du genou. Enfin, les données topographiques de l'étude permettent de discuter de l'opportunité d'une hémostase préventive du pédicule proximo-latéral par un abord minime à proximité de la patella. II semble possible, en outre, d'éviter de sectionner le pédicule disto-latéral grâce à sa localisation par trans-illumination cutanée en début d'intenvention.

     

髌韧带与膝交叉韧带的血供及其在交叉韧带损伤重建中的意义

目的　探讨髌韧带和膝交叉韧带的血供特点,为临床韧带重建提供形态学依据。 方法　通过成人和胎儿股动脉红色乳胶灌注并解剖剥离、胎儿墨汁灌注组织透明和组织切片等方法,观察髌韧带和膝交叉韧带的动脉分布特点并测量胎儿韧带内微血管密度。 结果　髌韧带的动脉来自膝下外动脉、胫前返动脉、膝降动脉和膝下内动脉的分支;胎儿髌韧带不同区域微血管密度不同,且以韧带中心部为最低。前、后交叉韧带的动脉分别来源于膝中动脉、髌下脂肪垫以及膝下外动脉的分支。多数韧带内血管沿长轴走行,同时也有横向交通的小血管,血管网呈梯状或平行的丛状。近侧端和远侧端较密而中间部相对稀疏。 结论　①髌韧带和膝交叉韧带均存在中心部乏血管区;②韧带两端血供最丰富,且近侧段好于远侧段;③髌韧带血供优于膝交叉韧带,髌韧带重建交叉韧带具有血供基础。     

寰枕关节周围韧带的显微断层解剖

目的：揭示寰枕区的显微断层解剖结构,为临床手术提供准确的解剖学数据。方法：选取8具尸体头颅标本制作颅底组织块,并将这些组织块进行塑化,然后切成连续的切片。染色后在光学显微镜下观察。结果：齿突尖主要为骨密质,齿突中下部主要为骨松质。齿突尖韧带是连接齿突尖与枕骨大孔前缘的细小索状纤维束。覆膜是坚韧的薄膜,从枕骨斜坡下降,在十字韧带的上下纵束之后,与枢椎联系紧密。硬脊膜前方为覆膜,后方为蛛网膜。硬脊膜从斜坡开始与覆膜汇合,并向下移行至枕骨大孔前缘最下方的位置分开然后各自继续向下走行,在齿突的位置和覆膜再次汇合,向下走行至枢椎椎体后分离。在齿突尖水平的位置覆膜与前方的后纵韧带汇合。结论：Barkow韧带可能并不存在,临床手术中不能将其作为识别标志。     

半月板和交叉韧带矢状断层研究

目的　观察膝关节矢状断层的半月板和交叉韧带的形态、可出现的层面情况并测量有关数据 ,为影像学诊断提供解剖学依据。方法　 11例 (2 2侧 )经福尔马林液防腐的膝关节标本按MRI检查姿势标线 ,冷冻后用断层带锯作厚 5mm的矢状断层 ,获得 314断层 (观察 5 84层面 ) ,对各断层面的半月板和交叉韧带进行观察 ,并用电子游标卡尺进行测量。结果　半月板后角高度明显高于前角 (P <0 0 1) ,内侧半月板后角宽度约是前角的 2倍 ,而外侧半月板宽度前、后角基本一致 ,外侧半月板体部宽于内侧且更靠近中轴 ,盘状半月板主要发生于外侧 ;正中矢状面显示交叉韧带全长的出现率为 82 % ,其全长的最好层面为正中矢状面和正中旁 1cm层面 ;前交叉韧带与矢状面的夹角较后交叉韧带小 ;前、后交叉韧带在股骨和胫骨的附着点宽约 12mm ,各附着点宽差异无显著性 (P >0 0 5 )。结论　膝关节矢状断层形态学研究提示半月板的后角容易损伤 ;外侧半月板后角明显较内侧窄而高 ,此为临床所见外侧半月板较内侧半月板更易损伤的形态学基础。     

The ultrastructure of sensory nerve endings in human anterior cruciate ligament

Summary The sensory innervation of the anterior cruciate ligament (ligamentum cruciatum anterius) of the human knee joint was studied by light-and electron microscopy. The connective tissue between the synovial membrane and the cruciate ligament contains small Ruffini corpuscles and lamellar corpuscles with several inner cores. The connective tissue septa between the individual fascicles of the cruciate ligament contain Ruffini corpuscles and free nerve endings. The free nerve endings are innervated by C-fibres and myelinated A-delta fibres. The afferent axons of Ruffini corpuscles are myelinated and measure 4–6 m in diameter, those of the lamellar corpuscles with several inner cores measure about 6 m in diameter.It is discussed, whether these receptors of the anterior cruciate ligament may influence the muscle tone via polysynaptic reflexes.Supported by Verein zur Förderung der Erforschung und Bekämpfung rheumatischer Krankheiten e.V., Bad Bramstedt and DFG (Ha 1194/3-1).     

膝降血管髌下支蒂胫骨骨膜瓣移位修复膝关节面的应用解剖

目的：为用膝降血管髌下支蒂胫骨骨膜瓣移位修复膝关节面病损提供解剖学依据。方法：用30侧经动脉红色乳胶灌注的成人下肢标本,解剖观测膝降动脉髌直支起始、位置、运载胫骨内侧面的分支、分布和吻合。结果：膝降动脉髌下支沿大收肌腱板和收肌结节前面下行,至膝关节间隙水平向前横行于关节囊表面,由此向下发2-5支胫骨骨膜支。这些骨膜支与膝下内侧动脉和稳动脉等动脉的胫骨骨膜支相互吻合,分支分布于胫骨内侧面。结论：以膝降血这髌下支为蒂的胫骨骨膜瓣移位可用于治疗膝关节面病损。     

膝关节后交叉韧带解剖研究及临床意义

目的:对后交叉韧带的解剖结构进行观察研究,为临床诊治提供解剖学基础。方法:对42例人膝关节标本PCL进行观察,测量其长度、宽度和厚度以及附着区的形态;应用显微外科技术对14具新鲜冷冻标本进行解剖;对PCL行组织学观察,掌握其微观结构。结果:PCL长(33.8±1.3)mm(31.0～37.0mm),两端粗大,最窄处位于中间。PCL是不可分割的完整韧带,由许多纤维组成并发生扭转,纤维束相互穿插融合。组织切片示PCL近端和远端纤维分布松散,中段紧密。结论:PCL是完整的韧带,各束之间有交叉纤维联结。     

膝内侧稳定结构的解剖特征与软组织平衡的关系

目的:观测国人膝内侧结构解剖学特点,为膝关节置换术中内侧结构软组织平衡的松解策略选择提供形态学依据.方法:80例固定及20例新鲜成人膝关节标本,解剖观察内侧结构的组成及其位置与形态学特点.结果:膝关节内侧面支持结构包括内侧副韧带复合体和半膜肌复合体等结构,可分为3层.内侧副韧带复合体包括内侧副韧带(medial collateral ligament,MCL)深、浅两层,可分为前纵部和后斜部两部分.MCL前纵部以间接止点形式融入胫骨平台关节面下50～60 mm,鹅足深方的胫骨内侧骨面骨膜,长约92mm,中部宽约15mm后斜部纤维以腱板起于股骨内卜髁后侧,下止点弥散;在关节间隙处,后斜部纤维与其深方第3层(内侧关节囊)愈着,被半月板、冠状韧带固定.MCL深层实际上为膝内侧关节囊增厚,自股骨内上髁下半周缘骨面垂直向下走行,连接内侧半月板,止于胫骨平台内侧缘中点关节面下0.8～1.5cm骨面,并与半膜肌腱横臂融合.膝关节后内侧区域为半膜肌腱鞘和半膜肌腱的9处附丽所加强,维持膝关节后内侧角稳定.结论:基于膝关节内侧结构解剖特点,膝关节置换术中软组织平衡可以做到微创化、选择性的松解.尽量保护其结构和功能的完整对术后功能有重要意义.