陈旧性前十字韧带损伤的诊断

目的评估前抽屉试验、Lachman试验、轴移试验和MRI在陈旧性前十字韧带损伤诊断中的意义。方法107例手术证实为陈旧性前十字韧带损伤患者,术前均行前抽屉试验、Lachman试验、轴移试验和MR检查。术后计算各项检查的敏感性,并分析产生假阴性的原因。结果前抽屉试验的阳性率为78.5%,Lachman试验为97.2%,轴移试验为91.6%,而MRI敏感性为93.5%。10例患者的关节镜检查显示前十字韧带近侧撕裂端再附着于后十字韧带。在此10例中,前抽屉试验的阳性率为60%,Lachman试验为80%,轴移试验为60%,而MRI敏感性为40%。本组9例轴移试验假阴性的患者中,有4例为撕裂的前十字韧带再附着于后十字韧带而替代了部分前十字韧带的功能,因此关节镜下显示胫骨外侧髁半脱位受限。2例Lachman试验假阴性的患者经关节镜证实为前十字韧带断端再附着伴有半月板桶柄样撕裂。在10例再附着患者中有3例MRI表现为韧带倾斜度变化。结论Lachman试验对诊断陈旧性前十字韧带损伤敏感性最高。MRI和轴移试验较敏感,但结果受MR检查技术和伴发损伤等诸多因素的影响。     

Partial rupture of the anterior cruciate ligament. Natural course

A prospective study was done of 29 patients with conservatively treated partial ruptures of the anterior cruciate ligament that were stable at the initial examination under anesthesia. The ruptures were reevaluated for stability and knee function from 12 to 60 months after injury. Many had developed signs of instability. The forward drawer sign (Lachman test) and the pivot shift tests were positive. There was also measurable sagittal instability (anterior drawer sign). In every case, knee function was almost completely restored.     

Clinical diagnosis of ruptures of the anterior cruciate ligament: a comparison between the Lachman test and the anterior drawer sign

A comparative study of the diagnostic accuracy between the Lachman test and the anterior drawer test was performed by examining 144 knees with ruptured anterior cruciate ligaments.

The diagnosis of anterior cruciate ligament rupture is often difficult to establish, especially in recent injuries with acute haemarthrosis.

The diagnostic accuracy of the Lachman test in recent ruptures when the patient is examined without general anaesthetic is superior to that of the anterior drawer test, while in chronic cases with third-degree instability the two tests are equally reliable.     

Stability tests in knee ligament injuries

For 182 knee joints with ligamentous injuries confirmed at surgery the records contained a complete and documented stability examination. In anterior cruciate ligament injuries the Lachman test and the anterior drawer sign were of similar value with regard to the frequency of false negatives - they missed half of the injuries - but their accuracy improved when they were repeated under anesthesia. The pivot shift was useful only under anesthesia. The medial collateral ligament injuries were usually detected because of valgus instability, also without anesthesia. The stability tests done with the patient under anesthesia are sufficiently reliable for making decisions about knee ligament surgery.     

陈旧性前交叉韧带损伤诊治分析

[目的]探讨临床检查和MRI诊断陈旧性前交叉韧带（anterior cruciate ligament，ACL）损伤的价值。[方法]回顾分析65例陈旧性ACL损伤患者的诊治经过，进行临床检查，其中8例行MRI检查，最后关节镜手术确诊。[结果]53例ACL完全损伤，前抽屉试验、Lachman试验和轴移试验的准确性分别为：79．2％、96．2％和92．5％；12例ACL部分损伤，前抽屉试验、Lachman试验和轴移试验的准确性分别为：16．7％、50．0％和33．3％。MRI诊断ACL损伤的准确性为100％。[结论]临床检查和MRI是诊断陈旧性ACL损伤的有效方法。     

Posterior instability of the knee near extension. A clinical and stress radiographic analysis of acute injuries of the posterior cruciate ligament

We evaluated the accuracy of six clinical tests for posterior instability in 24 knees with acute surgically-proven posterior cruciate ligament injuries and intact anterior cruciate ligaments. We also performed stress radiography under anaesthesia. The gravity sign and the posterior drawer test in near extension and its passive reduction were diagnostic in 20 of the 24 knees, and the active reduction of posterior subluxation was diagnostic in 18. The reversed pivot shift sign helped to diagnose severe posterior and posterolateral subluxations, but the external rotation recurvatum test was negative in all 24 knees. Stress radiography in near extension revealed a highly significant increase in posterior tibial subluxation in the injured knees.     

Anterior cruciate ligament suture in comparison with plasty

In this retrospective study we analyse the results of primary anterior cruciate ligament (ACL) sutures, primary ACL plastics and secondary ACL plastics 5 years after operation. All operations were performed with an additional PDS augmentation. Follow-ups of 100 of 130 patients could be done (80 male and 20 female). The average age at time of operation was 29.2 years. ACL rupture in 81 patients occurred due to a sport accident. In 26 patients a primary ACL suture was performed, in 59 patients a primary ACL plasty and in 15 patients an ACL plasty due to instability. There was no difference between the primary and secondary plasty groups, but there was between the suture and the plasty groups. In all, 92% of the suture group and 69% of the plasty group were satisfied with the surgical results. The pivot shift, Lachman and anterior drawer sign were less frequent in the ACL suture group, and the Lysholm score was higher. Primary suture combined with a PDS augmentation seems to represent an adequate treatment of acute proximal ACL ruptures.     

Stability tests in knee ligament injuries

Summary For 182 knee joints with ligamentous injuries confirmed at surgery the records contained a complete and documented stability examination. In anterior cruciate ligament injuries the Lachman test and the anterior drawer sign were of similar value with regard to the frequency of false negatives — they missed half of the injuries — but their accuracy improved when they were repeated under anesthesia. The pivot shift was useful only under anesthesia. The medial collateral ligament injuries were usually detected because of valgus instability, also without anesthesia. The stability tests done with the patient under anesthesia are sufficiently reliable for making decisions about knee ligament surgery.     

Relation of the fibular head sign to other signs of anterior cruciate ligament insufficiency. A follow-up letter to the editor.

The fibular head sign is a clinical finding that seems not to have been previously reported for the diagnosis of chronic anterior cruciate ligament insufficiency (ACLI) associated with lateral rotatory instability of the knee joint. The fibular head could be palpated as a prominent bony lump, felt subcutaneously in the posterior lateral corner of the popliteal fossa. In a prospective study of 20 patients with ACLI, the mean age of the patients (15 males, five females) at the time of assessment was 26 years (range, 18-57 years). The left knee was involved in 11 patients, the right knee in the remaining nine patients. All the patients sustained their knee ligament injury in sporting activities except one patient who was involved in a motor vehicular accident. The majority of the patients had instability-related symptoms for more than six months. After history taking, physical examination in the clinic, and examination under anesthesia, and arthroscopy in the operating room of all patients, it was determined that there were 13 ACL injuries, four posterior cruciate ligament (PCL) injuries, and three combined A/PCL injuries. All ACL injury patients had a prominent fibular head sign. Other associated signs included passive hyperextension of 10-20 degrees, and major anterolateral, and to a lesser degree a posterolateral, rotatory instability. The fibular head sign was negative in isolated posterior cruciate injuries and in combined A/PCL injuries.     

Anterior displacement. Its effects on instability and radiolucency in total knee replacements

One hundred sixty-nine posterior cruciate condylar knee arthroplasties were evaluated for investigation of the effect of anterior displacement on instability and interface radiolucency in total knee arthroplasty. All knees were followed for at least one year, and 37 knees were followed for at least three years. The status of the anterior cruciate ligament at surgery was first compared to the postoperative, six-month, one-year, and three-year anterior drawer sign. A correlation coefficient was computed to test for the existence of a relation between these two variables. A chi-square test for statistical significance was used to compare the overall anterior drawer results with time and the anterior drawer sign at each follow-up evaluation with pain and radiolucent zones between cement and bone. For further evaluation of the effect of anterior stability on radiolucent zones, the authors analyzed the records of all their posterior cruciate condylar total knee arthroplasties over a seven-year period (average follow-up period, 2.5 years). Anterior stability over time was independent of the status of the anterior cruciate at surgery, and the presence or absence of an anterior cruciate ligament at surgery did not affect anterior stability over time. Furthermore, cutting of the anterior cruciate did not change anterior stability over time. Anterior instability proved to be statistically less at six months than at surgery and did not become worse with time. Neither anterior instability nor the preoperative state of the anterior cruciate ligament affects pain and interface radiolucency between cement and bone.     

Stress Radiographical Measurements of Post-Traumatic Knee Instability: A Clinical Study

In a prospective, consecutive, clinical and stress radiographical study, comprising 153 traumatic knee injuries, the value of stress radiographical measurements, gonylaxometry, was studied. Clinical evaluation, gonylaxometry and preoperative evaluation under general anaesthesia were carried out in that order. Then the operative findings were recorded as drawings on standard diagrams. These were used as a basis for evaluation of the preoperative tests. of all the methods evaluated, gonylaxometry was found to provide the most accurate information regarding the knee injury. Very close to this result were the findings under general anaesthesia. Anterior drawer sign was measured gonyl-axometrically when damage to the anterior cruciate ligament was present; posterior drawer meant damage to the posterior cruciate ligament. Partial ruptures of cruciate ligaments did not allow antero-posterior displacements exceeding the critical levels of the test. Small positive medial instability was found with ruptures of profound medial structures, higher values with total rupture of the long superficial collateral band, and still higher values when cruciate ligament ruptures were also present. The predictive values of a positive radio-graphical test were 100 per cent as regards medial instability and 98 per cent for drawer looseness. The predictive values of a negative test were 96 per cent for drawer and 92 per cent for medial instability. These figures are based on the total material. 95 per cent confidence limits are given.     

Evaluation of knee instability in acute ligamentous injuries

The stability on clinical examination (CE) and examination under anaesthesia (EUA) was evaluated in 350 consecutive acute knee injuries. Valgus instability in knees with a medial collateral tear was observed on CE in 62 and on EUA in 67 cases (p less than 0.05). The anterior drawer sign was positive in 55 patients on CE and in 110 patients on EUA (p less than 0.0001), the corresponding figures for the Lachman test were 66 and 126 respectively (p less than 0.0001). The pivot shift-test was positive in 13 cases on CE and in 87 under anaesthesia (p less than 0.0001). Fresh total tears of the anterior cruciate ligament (confirmed at arthrotomy, n = 79) were detected by the Lachman test in 48 per cent on CE and in 96 per cent on EUA. Of the nine fresh, total tears of the posterior cruciate ligament three were disclosed by the posterior drawer test on CE and all nine on EUA. Anteromedial rotatory instability was observed on CE in 10 patients and on EUA in 47 (p less than 0.0001). In these patients 41 medial collateral tears, 23 posteromedial capsular tears, 21 medial meniscus and 40 anterior cruciate lesions were found. On CE only one anterolateral rotatory instability was found, whereas EUA disclosed 9 cases. Posteromedial rotatory instability was not confirmed on CE, though on EUA four cases were found. CE and EUA detected 2 and 3 posterolateral instabilities respectively. In conclusion, the use of EUA with an adequate mode of stability evaluation in acute knee injuries is strongly advocated. Clinical examination is considered highly unreliable with many false negative findings.     

Diagnosis of acute knee ligament injuries: the value of stress radiography compared with clinical examination, stability under anaesthesia and arthroscopic or operative findings

A consecutive series of 85 stress radiographic examinations was performed in order to evaluate the clinical reliability and use of stress radiography in disclosing acute knee ligament injuries. Eighty-three examinations were performed within one week of the injury. Sagittal stress examination discovered 27% of the 37 anterior cruciate ligament (ACL) tears and all four posterior cruciate tears. Valgus stress detected 56% of the medial collateral tears. The specificity of stress radiography was even reduced by the number of false positive stress results (n = 25) in posterior drawer or valgus-varus examinations. An ACL tear was, however, an isolated or major ligament injury in twenty (80%) of the false positive results. Clinical examination revealed all the medial collateral tears whereas only 40% of the anterior cruciate tears. The most reliable method for diagnosing acute knee injuries where clinical examination has failed in disclosing instability is examination under anaesthesia supplemented by acute arthroscopy.     

Diagnosis of anterior cruciate ligament injury of the knee joint]

From January, 1979 to May, 1989, 107 patients with problems related to anterior cruciate ligament (ACL) were treated in our hospital. 100 of the patients had anterior cruciate ligament injury confirmed by arthrotomy or arthroscopy. The remaining 7 patients were found to be normal either by arthroscopy or arthrotomy. 29 patients had fresh ACL injury and 71 old. All the patients had history of trauma of the knee joint. Swelling and pain in the affected knee joint took place in fresh cases and few of them complained of instability or deformity of the knee. On examination, floating patella test was positive in the majority of the fresh cases. It was shown that accurate diagnosis could be made by Lachman test rather than by conventional anterior drawer test in dealing with fresh injury, but with old ones, Lachman test didn't show the advantages. Examination under anesthesia or arthroscopy helped a lot in diagnosing fresh ACL injury. Anterior drawer test (ADT) was significant in determining the existence of ACL injury. When ADT was positive, ACL injury was found in the majority of the cases, however, injured ACL couldn't be ruled out by negative ADT only. Positive valgus stress test on 0 degrees position suggests possibility of ACL injury, even ADT was negative. Despite the negative anterior drawer test positive posterior drawer test on three directions indicated the injury of the posterior cruciate ligament and the anterior cruciate ligament. The positive rate of ADT was higher than that of pivot shift test in dealing with anterior cruciate ligament injury. Positive pivot shift test suggests ACL injury.     

关节镜下缝线“8”字打结空心钉固定治疗前交叉韧带胫骨止点撕脱性骨折

目的探讨关节镜下缝线“8”字打结、空心钉固定治疗前交叉韧带（ACL）胫骨止点撕脱性骨折的可行性及近期疗效。方法对15例ACL胫骨止点撕脱性骨折行关节镜下ACL胫骨止点缝合及空心钉固定术,采用在关节镜下结合常规关节镜人路和经髌腱人路进行骨折复位固定,术中使用双根5号Ethibond聚乙烯缝线,在韧带下方、骨块上方经前内侧人路从后往前拢住韧带,并打结呈“8”字形,经韧带两侧胫骨骨隧道拉到胫骨内下方。在骨隧道下方2cm处打入带垫圈的直径4．5mm空心钉,做后抽屉试验,同时拉紧固定线,复位骨块,将固定线固定于空心钉垫圈下,拧紧空心钉。结果手术时间40～60min,平均50min。15例随访6～18个月,平均12个月。术后6周,所有骨折均获愈合,未出现移位。术后3个月,1例有I度前抽屉试验阳性,其余患者均为阴性。所有患者屈伸膝活动度正常。术后半年Lysholm膝关节功能评分90～96分。结论关节镜下缝线“8”字打结空心钉固定治疗ACL胫骨止点撕脱性骨折,术中关节镜监控可靠,操作简便,效果满意,值得推广。     

Reinforced iliotibial tenodesis for chronic anterolateral instability of the knee: a 6-year follow-up

Reinforced iliotibial tenodesis is an extra-articular procedure to eliminate anterolateral instability of an anterior cruciate ligament-deficient knee. The procedure carries a low complication rate and offers an easy rehabilitation program. This study evaluated the use of reinforced iliotibial tenodesis in a select group of 52 patients with a mean age of 41 years (range: 38-50 years). Obese patients, professional athletes, and patients with more complex injuries (eg, concomitant posterior cruciate or medial collateral ligament injuries) were excluded. Results are encouraging after a mean follow-up of 6 years (range: 2-10 years). Although 24 patients had a positive anterior drawer or Lachman test, none had a positive pivot test. In addition, all patients reported giving way was eliminated after surgery.     

Diagnostic and incidence of the rupture of the posterior cruciate ligament

The purpose of this article is to evaluate the incidence and to give a general review of the examination of the posterior ligament complex. At least ca. 8–10 % of all severe ligament injuries concern the posterior cruciate ligament, which means, that an estimated 4000–5000 Germans suffer a PCL rupture every year. Motor-vehicle accidents are the most common cause of the injury, but sports-related traumas (football, skiing) have increased in recent years. The high number of high-energy mechanisms involved (up to 90 %), cause ligament ruptures often to be associated with other injuries, especially fractures of the femur and tibia head. In polytrauma patients PCL ruptures are frequently recognized very late, because the possibility of this kind of injury is often not considered during the clinical examination. The same holds for the diagnosis of monotrauma patients. The initial step in the evaluation is to obtain a thorough history (including the mechanism of injury) and to perform a physical examination. The instability after a PCL rupture may present as an ACL rupture, because the anterior drawer test seems to be positive. The anterior/posterior drawer test must be assessed with other evaluation procedures to distinguish between anterior und posterior instabilities. The posterior sag sign, the quadriceps active test or the reversed pivot-shift may indicate a PCL rupture. A correct roentgenogram can reveal an avulsion of the tibia and can prove posterior instability due to a posterior translation of the tibia. A quantitative examination (clinical or X-ray) of the instability and the indication of combined injury of the posterior cruciate ligament and the posterolateral complex are necessary for the therapeutic decision (operative/conservative). A rupture of the PCL may occur occasionally as a result of a luxation of the knee (reduced spontaneously) before the medical evaluation. A thorough neurovascular examination is essential. Magnetic resonance imaging can be important to the diagnosis of an acute injury, but it is not essential for the choice between operative and non-operative treatment. Arthroscopy has been found to have a high degree of accuracy in the diagnosis of ligament ruptures of the knee, but it is still an operative treatment, so that it can only be used if an operation of repair or reconstruction is planned anyway. Before operative treatment of chronic complex instability, potential osseous abnormalities (varus morphotype) must be revealed; in case of uncertainty, an X-ray control is necessary.     

Diagnostic and incidence of the rupture of the posterior cruciate ligament

Summary The purpose of this article is to evaluate the incidence and to give a general review of the examination of the posterior ligament complex. At least ca. 8–10 % of all severe ligament injuries concern the posterior cruciate ligament, which means, that an estimated 4000–5000 Germans suffer a PCL rupture every year. Motor-vehicle accidents are the most common cause of the injury, but sports-related traumas (football, skiing) have increased in recent years. The high number of high-energy mechanisms involved (up to 90 %), cause ligament ruptures often to be associated with other injuries, especially fractures of the femur and tibia head. In polytrauma patients PCL ruptures are frequently recognized very late, because the possibility of this kind of injury is often not considered during the clinical examination. The same holds for the diagnosis of monotrauma patients. The initial step in the evaluation is to obtain a thorough history (including the mechanism of injury) and to perform a physical examination. The instability after a PCL rupture may present as an ACL rupture, because the anterior drawer test seems to be positive. The anterior/posterior drawer test must be assessed with other evaluation procedures to distinguish between anterior und posterior instabilities. The posterior sag sign, the quadriceps active test or the reversed pivot-shift may indicate a PCL rupture. A correct roentgenogram can reveal an avulsion of the tibia and can prove posterior instability due to a posterior translation of the tibia. A quantitative examination (clinical or X-ray) of the instability and the indication of combined injury of the posterior cruciate ligament and the posterolateral complex are necessary for the therapeutic decision (operative/conservative). A rupture of the PCL may occur occasionally as a result of a luxation of the knee (reduced spontaneously) before the medical evaluation. A thorough neurovascular examination is essential. Magnetic resonance imaging can be important to the diagnosis of an acute injury, but it is not essential for the choice between operative and non-operative treatment. Arthroscopy has been found to have a high degree of accuracy in the diagnosis of ligament ruptures of the knee, but it is still an operative treatment, so that it can only be used if an operation of repair or reconstruction is planned anyway. Before operative treatment of chronic complex instability, potential osseous abnormalities (varus morphotype) must be revealed; in case of uncertainty, an X-ray control is necessary.      

Radiological sign of chronic anterior cruciate ligament deficiency

An early radiological sign of anterior cruciate ligament deficiency is described. A retrospective study of the radiographs of 38 patients with chronic anterior cruciate ligament deficiency was performed. In 36 patients from this group an osteophyte was present on the medial femoral condyle adjacent to the medial tibial spine. This was best seen on a 30 ° notch view and was the earliest radiographic sign of chronic anterior cruciate ligament deficiency.     

Operative treatment of combined anterior and posterior cruciate ligament injuries in complex knee trauma: can the cruciate ligaments be preserved?

A retrospective study was performed focusing on operative treatment after combined anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL) injuries. The operative treatment included the preservation of one or both cruciate ligaments. Twenty-eight patients, average age 30 years (range: 12-55 years), were evaluated 5.4 years (range: 1-14 years) postoperatively. Twenty-two operations were performed in patients with acute injuries (<30 days after trauma) and 6 operations in patients with chronic instabilities (>30 days after trauma). Both cruciate ligaments were preserved by suture or refixation in 16 patients. Suture of one and reconstruction of the other cruciate ligament with autologous tendon graft was performed in 12 cases. In addition, 61 procedures (meniscal suture/resection, medial/lateral reconstruction, tendon suture, and open reduction and internal fixation were performed. Postoperative treatment included continuous passive motion and protected weight bearing. Eleven (27% acute, 83% chronic) patients required revision (ACL/PCL reconstruction, osteotomy, and meniscal repair). At follow-up, 43% of the patients were very satisfied and 46% were satisfied. Seventy-one percent (89% preinjury) of the patients were able to maintain intensive and moderate International Knee Documentation Committee (IKDC) activity levels. The IKDC evaluation of the patients (acute %/chronic cases %) was graded for symptoms: A 39% (45/17), B 35% (27/67), C 15% (18/0), and D 11% (9/17); for range of motion: A 42% (36/67), B 42% (50/17), C 16% (14/17), and D 0%; and for ligaments: A 21% (18/17), B 33% (45/0), C 42% (32/83), and D 4% (5/0). Radiographic findings were A 18%, B 41%, and C 41%. Primary repair of acute injuries was superior to the delayed repair of chronic instabilities. Preservation of cruciate ligaments in acute combined ACL/PCL tears results in a satisfying knee function despite distinct residual ligament instability. Although suture of the cruciate ligaments in open technique is a therapeutic option in acute multiligamentous knee injuries, it is not recommended for the treatment of chronic instabilities.