LARS韧带与自体腱重建髌韧带治疗急性髌韧带近止点断裂

[目的]比较LARS人工韧带与自体半腱肌移植重建髌韧带治疗急性髌韧带近止点断裂的疗效。[方法]2008年7月～2018年6月本院共收治髌韧带断裂患者41例,近止点部断裂21例纳入本研究,采用LARS人工韧带10例,自体半腱肌移植重建11例。记录围手术期资料,测量髌上10cm大腿周径、膝关节活动度,利用Lysholm及Kujala评分对膝关节进行功能评价,行影像检查,测量Caton指数。[结果]所有患者均顺利手术,无严重并发症。LARS韧带组手术时间、术中失血量、术后3d VAS评分显著优于自体肌腱组(P0.05);但LARS韧带组手术费用显著高于自体韧带组(P0.05)。两组患者随访7～36个月。末次随访两组术后各项指标均较术前明显改善(P0.05),两组患者间末次随访时膝关节活动度、髌上10 cm大腿周径、Lysholm评分和Kujala评分的差异均无统计学意义(P0.05)。所有患者均未出现膝关节功能受限,优良率100%。[结论]LARS人工韧带与自体半腱肌移植重建髌韧带治疗急性髌韧带近止点断裂均能够有效修复伸膝装置及恢复膝关节功能,具有相同的手术效果。     

Effect of suture size on locking and grasping flexor tendon repair techniques

An experimental study was performed using human cadaver flexor tendons to investigate the effect of locking and grasping loop techniques on the tensile properties of repaired flexor tendons, which closely resemble the clinical model. Statistically significant improvement was observed only with the locking loop technique for ultimate and gap strength values using 2-0 core suture and ultimate strength values using 3-0 core suture. There was no statistically significant increase in tensile strength values using 4-0 core suture material. A heavier core suture used with the locking loop technique provided greater ultimate and gap strength of a repaired tendon than when used with the grasping loop technique.     

Patellar tendon autograft versus hamstring tendon autograft in arthroscopic anterior cruciate ligament reconstruction: appraisal of the evidence

Arthroscopy–assisted reconstruction of a torn anterior cruciate ligament (ACL) is a commonly performed surgical procedure. The type of graft used for ACL reconstruction has traditionally been an autograft; the more commonly used grafts are the bonepatellar tendon–bone (BPTP) and hamstring tendons, namely the gracilis and semitendinosus tendons (GST). We surveyed the evidence concerning the outcome of patients treated by arthroscopic reconstruction of the ACL with either BPTP or GST. On basis of several welldesigned studes, specifically 5 meta–analyses and one systematic review, we critically discuss the best evidence available today regarding ACL reconstruction. This evidence suggests that BPTP may be considered for patients performing high–demand activities not involving repetitive kneeling.     

股四头肌与骨-髌腱-骨自体移植对前交叉韧带重建的Meta分析

目的:通过Meta分析比较股四头肌与骨-髌腱-骨自体移植对前交叉韧带重建手术疗效的影响。方法:计算机检索建库至2019年5月PubMed、EMbase、Cochrane图书馆、万方数据库和中国知网发表的比较股四头肌、骨-髌腱-骨自体移植物的病例对照研究文献,根据纳入与排除标准进行文献筛选、质量评价及数据提取,采用Review Manager 5.3统计学软件对患膝与健膝前向移位差值、Lachman试验、轴移试验、Lysholm评分、IKDC (International Knee Documentation Committee)客观等级、膝前疼痛和移植失败率进行Meta分析。结果:共纳入6篇文献,915例患者,其中股四头肌自体移植495例,骨-髌腱-骨自体移植420例。Meta分析结果显示:股四头肌自体移植与骨-髌腱-骨自体移植在胫骨向前移位差值>3 mm[OR=1.53,95%CI(0.68,3.44),P=0.31],3～5 mm[OR=0.64,95%CI(0.31,1.35),P=0.24],>5 mm[OR=1.18,95%CI(0.33,4.22),P=0.80...     

自体髌腱与四股腘绳肌腱移植重建前交叉韧带安全性的Meta分析

Objective To compare clinical outcomes of patellar tendon and 4-strand hamstring autografts in single-bundle endoscopic reconstruction of anterior cruciate ligament(ACL). Methods The digital databases(PubMed,Embase,Cochrane Central Register of Controlled Trials,CBM)were searched for randomized controlled trials (RCTs)comparing patellar tendon with hamstring autografts for reconstruction of ACL.In addition.the reference lists from related original studies and review articles were hand-searched.The Cochrane Collaboration's tool for assessing risk of bias and Cochrane collaboration's RevMan 5.0 software were used for assessing trial methodological quality and data analyses. Results Fourteen RCTs were included.There were 1232 participants who met inclusion criteria in all studies.Meta-analyses showed that no statisticallv significant differences were found in graft failure rate after single-bundle reconstruction of the ACL at mean follow-ups of 2 to 3 years (RR=0.69,95%C/0.34 to 1.38,P=0.29,of 5 years (RR=0.37,95%CI 0.09 to 1.55,P=0.18),of 10 years(P=0.94)or when 3 subgroups combined(RR=0.71,95%CI 0.39 t0 1.31.P=0.28).The diffe-rence in≥5°extensor deficit was not statistically significant between the 2 groups(RR=1.63.95%CI 0.85 to 3.16,P=0.14).Anterior knee pain and kneeling pain or discomfort showed significantlv differences between the 2 groups at a mean follow-up of 2 years(P<0.05),but did not at follow-ups of 5 years and 10 years(P>0.05). Conclusions In single-bundle endoscopic ACL reconstruction.patellar tendon and 4-strand hamstring autografts have similar rates of graft failure and knee motion deficits.The patellar tendon autograft may have higher rates of anterior knee pain and kneeling pain or discomfort at an early stage after operation than the 4-strand hamstring autografi,but there may be no such differences on a long-term basis.     

自体髌腱与四股腘绳肌腱移植重建前交叉韧带安全性的Meta分析

目的 评价自体髌腱与4股腘绳肌腱移植关节镜下单束重建前交叉韧带(ACL)的安全性.方法 计算机检索CENTRAL、PubMed、EMBASE、中国生物医学文献数据库等,获取自体髌腱与4股腘绳肌腱移植重建ACL的随机对照试验(RCT),根据Cochrane图书馆推荐的RCT偏倚评估标准对纳入研究的方法学质量进行评估,并使用RevMan 5.0统计学软件对结果进行Meta分析,比较自体髌腱与4股腘绳肌腱移植重建ACL的移植失败率、伸膝缺失度、膝前痛等的差异.结果共纳入14篇文献,包括1232例患者.自体髌腱组与自体4股腘绳肌腱组的移植失败率在平均随访2～3年(RR=0.69,95%CI 0.34～1.38,P=0.29)、5年(RR=0.37,95%CI0.09～1.55,P=0.18)、10年(P=0.94)及合并后(RR=0.71,95%CI 0.39～1.31,P=0.28)差异均无统计学意义.两组伸膝缺失度≥5°的例数比较差异无统计学意义(RR=1.63,95%CI0.85～3.16,P=0.14).两组膝前痛随访2年差异有统计学意义(RR=2.04,95%CI 1.34～3.09,P=0.0008),而随访5年(RR=3.00,95%CI 0.92～9.79,P=0.07)及随访10年(P=0.737)差异均无统计学意义.两组膝跪痛或不适随访2年差异有统计学意义(RR=1.97,95%CI 1.01～3.85,P=0.05),随访5年(RR=1.51,95%CI 0.95～2.39,P=0.08)及随访10年(P=0.342)差异无统计学意义.结论自体髌腱与4股腘绳肌腱移植失败率及膝关节被动伸直缺失的发生率相似.自体髌腱移植随访早期(平均随访2～3年)膝前痛、膝跪痛或不适的发生率较高,但随着时间的延长(5～10年),两者趋于一致.

Abstract：

Objective To compare clinical outcomes of patellar tendon and 4-strand hamstring autografts in single-bundle endoscopic reconstruction of anterior cruciate ligament(ACL). Methods The digital databases(PubMed,Embase,Cochrane Central Register of Controlled Trials,CBM)were searched for randomized controlled trials (RCTs)comparing patellar tendon with hamstring autografts for reconstruction of ACL.In addition.the reference lists from related original studies and review articles were hand-searched.The Cochrane Collaboration's tool for assessing risk of bias and Cochrane collaboration's RevMan 5.0 software were used for assessing trial methodological quality and data analyses. Results Fourteen RCTs were included.There were 1232 participants who met inclusion criteria in all studies.Meta-analyses showed that no statisticallv significant differences were found in graft failure rate after single-bundle reconstruction of the ACL at mean follow-ups of 2 to 3 years (RR=0.69,95%C/0.34 to 1.38,P=0.29,of 5 years (RR=0.37,95%CI 0.09 to 1.55,P=0.18),of 10 years(P=0.94)or when 3 subgroups combined(RR=0.71,95%CI 0.39 t0 1.31.P=0.28).The diffe-rence in≥5°extensor deficit was not statistically significant between the 2 groups(RR=1.63.95%CI 0.85 to 3.16,P=0.14).Anterior knee pain and kneeling pain or discomfort showed significantlv differences between the 2 groups at a mean follow-up of 2 years(P<0.05),but did not at follow-ups of 5 years and 10 years(P>0.05). Conclusions In single-bundle endoscopic ACL reconstruction.patellar tendon and 4-strand hamstring autografts have similar rates of graft failure and knee motion deficits.The patellar tendon autograft may have higher rates of anterior knee pain and kneeling pain or discomfort at an early stage after operation than the 4-strand hamstring autografi,but there may be no such differences on a long-term basis.     

Four-strand hamstring tendon autograft versus LARS artificial ligament for anterior cruciate ligament reconstruction

This retrospective study compared the results after anterior cruciate ligament (ACL) reconstruction using a four-strand hamstring tendon graft (4SHG) versus Ligament Advanced Reinforcement System (LARS) artificial ligament in 60 patients between January 2003 and July 2004 with a minimum four-year follow-up. The KT-1000 examination, the International Knee Documentation Committee (IKDC) scoring systems and Lysholm knee scoring scale were used to evaluate the clinical results. The mean side-to-side difference was 2.4 ± 0.5 mm and 1.2 ± 0.3 mm in the 4SHG group and LARS group, respectively (P = 0.013). Although other results of ACL reconstruction, measured by IKDC evaluation, Lysholm scores and Tegner scores, showed using a LARS graft clinically tended to be superior to using a 4SHG, there were no significant differences calculated. Our results suggest that four years after ACL reconstruction using a LARS ligament or 4SHG dramatically improves the function outcome, while the patients in the LARS group displayed a higher knee stability than those in the 4SHG group.     

Biomechanical comparison of double grasping repair versus cross-locked cruciate flexor tendon repair

Purpose

This study was conducted to compare the in vitro biomechanical properties of tensile strength and gap resistance of a double grasping loop (DGL) flexor tendon repair with the established four-strand cross-locked cruciate (CLC) flexor tendon repair, both with an interlocking horizontal mattress (IHM) epitendinous suture. The hypothesis is that the DGL-IHM method which utilizes two looped core sutures, grasping and locking loops, and a single intralesional knot will have greater strength and increased gap resistance than the CLC-IHM method.

Methods

Forty porcine tendons were evenly assigned to either the DGL-IHM or CLC-IHM group. The tendon repair strength, 2-mm gap force and load to failure, was measured under a constant rate of distraction. The stiffness of tendon repair was calculated and the method of repair failure was analyzed.

Results

The CLC-IHM group exhibited a statistically significant greater resistance to gapping, a statistically significant higher load to 2-mm gapping (62.0 N), and load to failure (99.7 N) than the DGL-IHM group (37.1 N and 75.1 N, respectively). Ninety percent of CLC-IHM failures were a result of knot failure whereas 30 % of the DGL-IHM group exhibited knot failure.

Conclusions

This study demonstrates that the CLC-IHM flexor tendon repair method better resists gapping and has a greater tensile strength compared to the experimental DGL-IHM method. The authors believe that while the DGL-IHM provides double the number of sutures at the repair site per needle pass, this configuration does not adequately secure the loop suture to the tendon, resulting in a high percentage of suture pullout and inability to tolerate loads as high as those of the CLC-IHM group.     

Distal biceps tendon repair: anchor versus transosseous suture fixation

Suture anchor fixation and transosseous suture fixation were compared in 12 fresh-frozen cadaveric radii using either No. 2 braided polyester suture or single Mainstay 3.5-mm threaded anchors (made at the time by Howmedica, Rutherford, NJ) with No. 2 suture. Suture fixation failed at a mean strength of 162 N (range, 129-179 N), anchor fixation at 136 N (range, 121-150 N). Neither technique is strong enough to safely allow immediate biceps activity. Nevertheless, suture anchor fixation to the radial tuberosity offers a lower but clinically comparable strength to transosseous suture fixation while limiting postoperative risks.     

Comparison of pullout button versus suture anchor for zone I flexor tendon repair

PURPOSE: To evaluate the clinical outcome after repair of zone I flexor tendon injuries using either the pullout button technique or suture anchors placed in the distal phalanx. METHODS: Between 1998 and 2002 we treated 26 consecutive zone I flexor tendon injuries. Thirteen patients had repairs from 1998 to 2000 using a modified pullout button technique (group A) and 13 patients had repair using suture anchors placed in the distal phalanx (group B). Patient characteristics were similar for both groups. The same postoperative flexor tendon rehabilitation protocol and follow-up schedule were used for both groups. Evaluation included range of motion, sensibility and grip strength, failure, complications, and return to work. The Student t test was used to determine significant differences. RESULTS: All patients completed 1 year of follow-up evaluation. There were 2 infections in group A that resolved with oral antibiotics and no infections in group B. There were no tendon repair failures and no repeat surgeries in either group. At final follow-up evaluation there were no statistically significant differences for the following end points: sensibility (Semmes-Weinstein monofilament testing and 2-point discrimination), active range of motion (at the proximal interphalangeal joint, distal interphalangeal joint, or their combined motion), flexion contracture (at the proximal interphalangeal joint, distal interphalangeal joint, or their combined contracture), and grip strength (injured tendon as a percent of the contralateral uninjured tendon). The suture anchor group had a statistically significant improvement for time to return to work. CONCLUSIONS: There was no significant difference in the clinical outcome after flexor tendon repair using either suture anchors or the pullout button technique. A significant improvement was found for time to return to work for repairs using the suture anchor technique. Flexor tendon repair can be achieved using suture anchors placed in the distal phalanx, thereby avoiding the potential morbidity associated with the pullout button technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

双津下套圈缝合法与跟腱龙技术治疗急性跟腱断裂的比较

[目的]为比较两种微创手术治疗急性跟腱断裂的临床结果。[方法]共计140例患者纳入本研究,其中101例采用津下技术,39例采用跟腱龙技术修复跟腱。记录手术时间、住院天数、并发症等情况,并采用AOFAS踝-后足疗效评价及ATRS跟腱断裂评分评定术后疗效。[结果]津下组手术时间及住院天数短于跟腱龙组,差异有统计学意义(P0.05)。津下组患者总体并发症发生率为1%,仅有1例再断裂,无感染、腓肠神经损伤、皮肤粘连等并发症。跟腱龙组术后总体并发症发生率为10%,其中,腓肠神经损伤1例,切口感染1例,跟腱粘连1例,1例术后1个半月因肺栓塞去世。138例患者获得随访,随访时间6个月～3年。两组患者ATRS和AOFAS评分均随时间延长而增高,并且不同时间点差异有统计学意义(P0.05)。术后6月和术后1年时,津下组评分较跟腱龙组评分高(P0.05),术后3年时,津下组评分与跟腱龙组评分差异无统计学意义(P0.05)。[结论]小切口双津下缝合法和跟腱龙手术均为微创手术,具有切口小、愈合快、并发症少等优点。与跟腱龙手术相比,小切口双津下套圈缝合法术后早期效果更好。     

LARS韧带与自体肌腱重建前交叉韧带疗效比较的Meta分析

[目的]运用Meta分析对LARS韧带与自体肌腱重建前交叉韧带的疗效进行对比,为临床治疗方案的选择提供参考依据。[方法]运用计算机检索Pub Med,Springer Link,EMBASE,the Cochrane Library,Medline,Science Direct,中国知识资源总库、万方数据库、维普数据库等电子数据库,检索时限定为:1980年1月~2015年11月,收集关于手术与非手术治疗肱骨近端骨折疗效对比的临床试验,依照确定的纳入与排除标准筛选出合格的文献并对其质量进行评价,然后运用Rev Man 5.2软件整合各个研究的临床观察指标进行统计学分析。[结果]共纳入8篇文献,390例患者,LARS组患者181例,自体肌腱组患者209例。Meta分析显示,在Lysholm评分、Tegner评分以及膝关节稳定性方面,两组之间的差异具有统计学意义,LARS组优于自体肌腱组(P0.05);在IKDC评分方面,两组之间的差异无统计学意义(P0.05)。在术后并发症发生率方面,LARS组较自体肌腱组低(P0.05)。[结论]与自体肌腱重建前交叉韧带相比,LARS韧带能给患者带来更好的临床功能以及关节稳定性,同时也减少了术后并发症的发生。由于样本量的局限,本研究的结论仍需更多高质量的临床对照研究来进行验证。     

经皮与开放缝合治疗急性闭合性跟腱断裂的临床研究

[目的]比较经皮闭合缝合与开放缝合治疗急性闭合性跟腱断裂的疗效,为临床医生选择治疗方法提供依据。[方法]共40例患者纳入研究,随机分成两组,经皮组及开放组各20例,记录两组手术时间、住院时间、切口愈合情况、腓肠神经支配区感觉情况;3、6个月时单足提踵结果;6个月时测量小腿最大周径与跟腱断裂平面小腿周径,并计算与健侧的差值,有无跟腱黏连及再断裂,应用ATRS评分进行功能评价。[结果]两组病例均获得随访,且开放组(平均16个月)与经皮组(平均15个月)随访时间差异无统计学意义。经皮组住院时间(中位数7 d)、手术时间(中位数30 min)、总并发症发生率(5%)均低于开放组,开放组分别为12 d、60 min和40%,经皮组跟腱断裂平面小腿周径健侧与患侧差值(9.0±2.0)mm,大于开放组(7.1±1.7)mm,且上述差异有统计学意义。开放组切口并发症发生率(20%)、再断裂率(10%)、跟腱黏连发生率(10%)、3个月时单足提踵试验阳性率(40%)均高于经皮组,经皮组分别为0、0、0和35%,经皮组腓肠神经损伤率(5%)、ATRS评分(88.6±4.8)分、小腿最大周径健侧与患侧差值(8.1±2.3)mm,均大于开放组,开放组分别为0、(86.0±7.0)分、(7.5±2.2)mm,但上述差异无统计学意义。按3个月时单足提踵试验结果分组,阳性15例,ATRS评分为(86±7)分;阴性25例,ATRS评分为(90.9±3.2)分,阴性组ATRS评分更高,且差异有统计学意义。[结论]经皮闭合缝合治疗急性跟腱断裂与传统开放手术相比,可以获得同样的功能结果,且能明显缩短住院时间、手术时间及降低总并发症发生率。跟腱修复术后3个月时,单足提踵试验阴性比阳性者功能结果更好。     

Cross stitch peripheral tendon repair: a mechanical comparison with core stitch techniques

The purpose of this experimental study was to compare certain mechanical properties of a true epitendineal cross stitch suture with simple and double locking core tendon repairs. Using tensile strength and tendon lengthening until gap formation as measurement parameters, these three types of repair were tested in human flexor and extensor tendons from fresh cadavers. The peripheral cross stitch and the locked core repairs were found to have a greater lengthening capacity than the simple core suture, whereas the latter significantly better withstood axial load. Our findings established that, at least when used as a true epitendinous suture, the cross stitch technique alone was not suited for the repair of severed tendons. However, its design is particularly useful in preventing the suture site from potentially restrictive bulking.     

Late reconstruction of chronic distal biceps tendon ruptures using fascia lata autograft and suture anchor fixation

Distal biceps tendon ruptures are a rare injury, and surgical reconstruction is typically recommended for chronic ruptures. There is no consensus regarding the most appropriate reconstruction technique. We present our experience with reconstruction of chronic distal biceps tendon ruptures with fascia lata autograft, secured to the bicipital tuberosity with suture anchors. A single anterior incision is used for all patients. Tension is set with the elbow in 50 degrees of flexion. Ninety-two percent of our patients reported improvement in elbow flexion and supination and were pleased with the surgery. Range of motion and isokinetic flexion and supination strength after this procedure was comparable with other distal biceps tendon reconstruction options using tendon grafts and suture anchor fixation from a single anterior approach. Furthermore, common complications associated with distal biceps tendon repair and reconstruction can be avoided with this technique. We therefore feel that this technique is a viable surgical treatment alternative with good subjective and objective outcomes.Level of Evidence: Level IV.     

Endoscopic reconstruction for chronic Achilles tendon ruptures using a hamstring tendon autograft

BackgroundTo determine the safety and efficacy of endoscopic reconstruction of chronic Achilles tendon ruptures using a hamstring tendon autograft at mid-term follow-up.MethodsWe reviewed the medical records of patients with chronic Achilles tendon rupture treated surgically by endoscopic reconstruction using a hamstring tendon autograft at our institution between March 2010 and October 2015. Radiologic outcomes were assessed using pre- and postoperative magnetic resonance imaging (MRI). Functional outcomes were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot Scale, the Plantar Flexion Strength (PFS), the Victorian Institute of Sport Assessment-Achilles (VISA-A) scale, the Visual Analogue Scale (VAS) pain score, and the Arner-Lindholm standard. All patients achieved primary healing with no lengthening of the Achilles tendon, skin necrosis, infection, deep vein thrombosis or other complications.ResultsMean follow-up period was 15 ± 3 months (range, 12–18 months). There was no Achilles tendon re-rupture. MRI examination revealed that Achilles tendon continuity was restored. Patients’ mean AOFAS, PFS, and VISA-A scores were significantly higher and mean VAS pain score was significantly lower after surgery compared to before (P < 0.05). According to Arner-Lindholm standards, there were twenty (76.9%) excellent, six (23.1%) good, and zero bad outcomes.ConclusionEndoscopic reconstruction utilizing a hamstring tendon autograft is a safe and efficacious option for repair of chronic Achilles tendon ruptures. Studies with larger sample sizes and a longer follow-up are required to confirm the advantage of this technique compared to open surgery.     

关节镜下同种异体胫前肌腱与自体腘绳肌腱重建前交叉韧带远期效果的比较

目的:对比同种异体胫前肌腱(tibialis anterior allograft,TAA)与自体腘绳肌腱(hamstring tendon autograft,HTA)重建前交叉韧带(anterior cruciate ligament,ACL)的10年随访临床疗效.方法:回顾分析2007年3月至2010年3月单束重...     

带线锚钉锁边缝合桥接修复急性闭合性跟腱远端断裂的临床疗效

目的：探讨带线锚钉微创治疗急性闭合性跟腱远端断裂的临床疗效。方法：自2019年7月至2021年3月,采用微创带线锚钉锁边缝合桥接修复技术治疗20例急性闭合性跟腱远端断裂患者,其中男18例,女2例;年龄19~52(40.0±9.0)岁。观察其并发症情况,并于术前和术后1年采用美国足踝外科协会踝与后足功能评分系统(American Orthopaedic Foot&Ankle Society,AOFAS)评价踝关节功能恢复情况。结果：所有患者获得随访,时间6~18(12.0±3.2)个月。所有患者切口Ⅰ期愈合,无感染及皮肤坏死发生,未出现腓肠神经损伤及下肢深静脉血栓形成,无足跟疼痛和跟腱再断裂发生,踝关节屈伸活动良好。AOFAS评分由术前的(59.0±4.3)分提高至术后1年的(95.1±2.6)分。结论：带线锚钉锁边缝合桥接修复急性闭合性跟腱远端断裂疗效确切,可降低跟腱再断裂、神经损伤、皮肤坏死等并发症,具有手术创伤小、吻合方法可靠、功能恢复好等优点,是治疗急性闭合性跟腱远端断裂的理想方法。