前交叉韧带解剖重建股骨隧道的应用解剖学研究

目的:测量膝关节前交叉韧带解剖重建股骨隧道的解剖学数据,为临床前交叉韧带解剖重建提供解剖学基础。方法:采用30例成人尸体膝部标本。屈膝120°关节镜下经前内辅助入路(AMP)解剖重建前交叉韧带股骨隧道,并用克氏针标记。去除标本的软组织,正中劈开股骨髁。测量股骨隧道长度;测量隧道内口至股骨后髁皮质边缘的距离与股骨髁间窝顶的垂直距离,记录隧道内口分位点位于髁间窝的钟点位置;测量隧道外口与股骨外髁的相对位置。结果:股骨隧道长度平均(36.35±3.14)mm(30.65~42.35 mm);隧道内口至股骨后髁皮质边缘的距离(17.84±3.35)mm(14.02~23.49 mm),至股骨髁间窝顶的垂直距离(14.05±2.32)mm(9.17~20.08 mm)。根据表盘法,隧道内口位于左膝02∶30±00∶10(01∶50~02∶50),右膝09∶30±0∶15(08∶30~10∶40);股骨隧道外口位于股骨外上髁近端(3.16±2.51)mm(1.61~6.30 mm),后方(4.25±2.16)mm(1.73~8.52 mm)。结论:本研究揭示了前交叉韧带解剖重建股骨隧道的解剖学特点,为临床应用提供了解剖学基础。     

膝关节前交叉韧带前内束和后外束股骨止点位置的解剖研究

目的探讨膝关节前交叉韧带（ACL）前内束及后外束股骨止点的解剖位置,找到确定ACL前内束和后外束股骨止点的简单可行的方法,为双束重建ACL手术中的股骨骨道定位提供理论支持。方法解剖18个新鲜膝关节标本（25～45岁）的股骨端前内束和后外束的足迹,以标定前内束和后外束股骨止点中心点的位置。在屈膝90°位,测量ACL前内束及后外束股骨止点中心点距股骨髁间窝外侧壁前方、后方和下方软骨缘的距离。再对测量数据进行评估和对比。结果 ACL后外束股骨止点中心点距离股骨前方软骨缘（8.55±1.33）mm,距离股骨后方软骨缘（8.65±1.54）mm,二者间无统计学差异（t=-0.191,P〉0.05）;而ACL后外束股骨止点中心点距离股骨下方软骨缘（5.11±0.79）mm。ACL前内束股骨止点中心点距离股骨前方软骨缘（14.95±2.06）mm,距离股骨后方软骨缘（6.08±0.88）mm,二者间有统计学差异（t=16.633,P〈0.01）;而ACL前内束股骨止点中心点距离股骨下方软骨缘（9.10±1.55）mm。结论膝关节屈膝90°时,ACL后外束的股骨止点中心点位于股骨髁间窝外侧壁距离下方软骨缘5mm的高度,并处在与前方和后方软骨缘几乎等距的位置。而ACL前内束的股骨止点中心点位于股骨髁间窝外侧壁距离下方软骨缘9mm的高度,并处在前后连线大约后1/3的位置。在ACL双束重建的手术中,应用本研究的结果能够简单、快捷地确定ACL前内束和后外束股骨骨道位置。     

Anatomical reconstruction of the anterior cruciate ligament in goats

A surgical procedure was developed for the implantation of an anatomical, two-banded anterior cruciate ligament (ACL) prosthesis. Prostheses were fabricated of braided long-chain polyethylene fibers. The left ACL of adult male goats was surgically excised and replaced with either an anatomical reconstruction (5 goats) or a conventional reconstruction (5 goats). The anatomical reconstruction required drilling four bone tunnels, two each in the femur and tibia. Each band of the prosthesis was placed through one tunnel in the femur and the corresponding tunnel in the tibia, recreating the anteromedial and posterolateral bands. The two bands were tensioned independently and stapled in place. In the conventional procedure, the prosthesis was doubled and placed through two larger tunnels, one in the femur and one in the tibia, tensioned and stapled together. All animals were terminated 3 months after surgery. Clinical evaluation of passive range of motion, antero-posterior laxity and the appearance of the joint space showed little or no difference between the reconstruction methods. The ultimate failure load for the natural (unoperated) ACL was 1691 +/- 210 N, while the anatomical and conventional reconstruction groups had mean ultimate failure loads of 1233 +/- 732 and 1012 +/- 220 N, respectively. The elongation to failure of all groups was similar: the natural ACL group = 7.1 +/- 2.8 mm, the anatomical group = 7.2 +/- 2.9 mm, and the conventional group = 7.7 +/- 3.9 mm. The slope of the load-deformation curve, or stiffness, was significantly higher for the natural ACL (4.53 +/- 1.24 x 10(5) N/m) than for either of the reconstruction methods (2.75 +/- 1.59 x 10(5) N/m for the anatomical and 2.34 +/- 0.60 x 10(5) N/m for the conventional). The energy to failure, or area under the load-deformation curve, showed no significant difference between groups. In conclusion, both types of reconstructions were less strong, stiff, and tough than the natural ACL. There was no significant difference observed between the anatomical and conventional reconstruction methods over the 3-month implantation time in either clinical evaluation or mechanical testing. Therefore, at 3 months postsurgery, the anatomical reconstruction technique was considered no better and no worse than the conventional reconstruction technique.     

Radiographic analysis of femoral tunnel position in anterior cruciate ligament reconstruction

Successful reconstruction of the anterior cruciate ligament (ACL) depends on anatomic placement of a graft ligament substitute. This study examined the accuracy of a plain radiograph in determining femoral tunnel position during ACL reconstruction. Nine cadaveric distal femurs had six separate tunnels made in each specimen: 12:00 (high position), 1:30 (anatomic position), and 3:00 (low position) in the left femora and 12:00 (high), 10:30 (anatomic), and 9:00 (low) in the right femora. At each position on the clock face, two 9-mm tunnels were drilled, leaving 2 mm (correct) and 12 mm (incorrect) of posterior wall intact. With a radiopaque tunnel dilator in each tunnel, a true lateral radiograph, a 10 degree externally rotated lateral radiograph, and a 10 degree internally rotated lateral radiograph were obtained. All radiographs were analyzed for femoral tunnel placement in the anteroposterior plane with the four-quadrant method described by Harner et al and the ratio method described by Aglietti et al. Statistically significant differences could only be distinguished between anatomic (10:30), anterior (12-mm rim), and posterior (2-mm rim) positions. There were no statistically significant differences for any of the other positions when comparing true laterals to true laterals, true laterals to internal or external oblique views, or when comparing internal and external oblique views. A malpositioned anterior tunnel (12-mm rim posterior), which was "low" at 9:00 or "high" at 12:00 in the notch (malplaced), could not be distinguished reliably from an anatomically correct placed tunnel with a single-plane lateral radiograph.     

Positioning of the tibial tunnel for anterior cruciate ligament reconstruction

Two mechanisms of unintentioanl anterior tibial tunnel axis shift can occur despite accurate placement of the guide wire within the proximal tibia. The first results from using a short-block reamer head joined to a shaft of smaller diameter. If the tibial tunnel is drilled obliquely, it is possible for the reamer head to displace anteriorly in the knee joint before completion of the posterior portion of the tibial tunnel. The second mechanism of anterior shift involves using two sequential drills to create the tibial tunnel. To delineate the causes of this unwanted shift, cadaveric studies and special roentgenographic studies were undertaken. Results demonstrated that the shift is related directly to the presence of high-density bone in the tibial plateau. In an effort to minimize this effect, various drill designs were tested, and it was determined that a drill-head length of 25 mm was most effective at reducing the shift without sacrificing the freedom of movement necessary to obtain precise endosteal placement of the femoral tunnel. Along with these experimental studies, a retrospective 7-year review of anterior cruciate ligament (ACL) reconstruction failures was performed to assess the clinical significance of inadvertent anterior positioning of the tibial tunnel.     

前交叉韧带损伤与胫骨平台后侧骨损伤的相关性分析

目的探讨前交叉韧带(anterior cruciate ligament,ACL)损伤与胫骨平台后侧骨损伤的相关性。方法纳入我院2010年10月至2017年10月行膝关节MRI的门诊或住院病人581例,年龄为(45.72±11.38)岁(20~79岁);男362例,女219例。分析所有病人的膝关节MRI影像学资料,记录病人ACL损伤程度(轻度损伤/断裂/撕脱骨折)、胫骨平台后侧骨损伤程度(骨挫伤/骨折),以及股骨损伤、半月板和侧副韧带损伤情况,并分析其致伤原因。采用Spearman秩相关分析病人ACL损伤与胫骨平台骨损伤之间的关系,并分析可能的损伤机制。结果581例病人中,ACL轻度损伤440例(75.73%),ACL断裂122例(21.00%),ACL撕脱骨折19例(3.27%)。202例出现胫骨平台后侧骨挫伤,47例出现胫骨平台后侧骨折;152例(61.04%)发生在外侧平台,59例(23.69%)发生在内侧平台,38例(15.26%)发生在双侧平台。Spearman秩相关分析结果显示ACL损伤程度与胫骨平台后侧骨损伤程度呈正相关(r=0.344,P<0.0001)。结论随着ACL损伤程度增加,胫骨平台后侧骨损伤越重,且以胫骨平台后外侧骨损伤为主。     

Tourniquet-induced tibial nerve palsy complicating anterior cruciate ligament reconstruction

In this case report, an unremarkable anterior cruciate ligament reconstruction is complicated by a tourniquet-induced tibial nerve palsy. The case underscores the necessity of being aware of the potential for complications associated with tourniquets, despite following recommended guidelines of tourniquet time and pressure.     

Measurement of changes in distance between the femoral and the tibial drill holes for the anterior cruciate ligament reconstruction

We have developed an experimental system in which a new Gallium-Indium containing transducer can continuously measure the changes of separation distances between the femoral and tibial points. The measurements provides information for the attachment location in the anterior cruciate ligament (ACL) reconstruction and used for various combinations of extra-articular and intra-articular methods. At the first experiment, the distance between each pair of points at the level of the capsule for fifteen combinations during simple flexion-extension knee motion were measured on six cadaveric knees. At the next experiment, in an ACL-deficient knee the distances of ten combinations in the intra-articular method were measured. These results indicated that for an isometric placement the combination of the center of tibial insertion and the postero-proximal of the femoral origin of the ACL appeared to furnish a better location for intraarticular reconstruction. No combination was recommended for extraarticular reconstruction.     

3D CT evaluation of femoral and tibial tunnels in anatomic double bundle anterior cruciate ligament reconstruction

BackgroundAn anatomical double bundle ACL reconstruction replicates the anatomy of native ACL as the tunnels are made to simulate the anatomy of ACL with AM and PL bundle foot prints. The goal of anatomic ACL reconstruction is to tailor the procedure to each patient’s anatomic, biomechanical and functional demands to provide the best possible outcome. The shift from single bundle to double bundle technique and also from transtibial to transportal method has been to provide near anatomic tunnel positions.PurposeTo determine the position of femoral and tibial tunnels prepared by double bundle ACL reconstruction using three dimensional Computed tomography.Study designA prospective case series involving forty patients with ACL tear who underwent transportal double bundle ACL reconstruction.MethodComputed tomography scans were performed on forty knees that had undergone double bundle anterior cruciate ligament reconstruction. Three-dimensional computed tomography reconstruction models of the knee joint were prepared and aligned into an anatomical coordinate axis system for femur and tibia respectively. Tibial tunnel centres were measured in the anterior-to-posterior and medial-to-lateral directions on the top view of tibial plateau and femoral tunnel centres were measured in posterior to anterior and proximal-to-distal directions with anatomic coordinate axis method. These measurements were compared with published reference data.ResultsAnalysing the Femoral tunnel, the mean posterior-to-anterior distances for anteromedial and posterolateral tunnel centre position were 46.8% ± 7.4% and 34.5% ± 5.0% of the posterior-to-anterior height of the medial wall and the mean proximal-to-distal distances for the anteromedial and posterolateral tunnel centre position were 24.1% ± 7.1% and 61.6% ± 4.8%. On the tibial side, the mean anterior-to-posterior distances for the anteromedial and posterolateral tunnel centre position were 28.8% ± 4.3% and 46.2% ± 3.6% of the anterior-to posterior depth of the tibia measured from the anterior border and the mean medial-to-lateral distances for the anteromedial and posterolateral tunnel centre position were 46.5% ± 2.9% and 50.6% ± 2.8% of the medial-to-lateral width of the tibia measured from the medial border. There is high Inter-observer and Intra-observer reliability (Intra-class correlation coefficient).Discussion and conclusionFemoral AM tunnel was positioned significantly anterior and nearly proximal whereas the femoral PL tunnel was positioned significantly anterior and nearly distal with respect to the anatomic site. Location of tibial AM tunnel was nearly posterior and nearly medial whereas the location of tibial PL tunnel was very similar to the anatomic site Evaluation of location of tunnels through the anatomic co-ordinate axes method on 3D CT models is a reliable and reproducible method. This method would help the surgeons to aim for anatomic placement of the tunnels. It also shows that there is scope for improvement of femoral tunnel in double bundle ACL reconstruction through transportal technique.     

膝关节前交叉韧带胫骨止点的软组织解剖标记

背景：膝关节前交叉韧带（ACL）重建时,胫骨骨道定位不准会产生重建韧带与髁间窝的撞击或起不到维持膝关节稳定性的作用。因此,确定ACL胫骨止点的位置非常重要。目的：研究膝关节ACL胫骨止点前内束（AMB）和后外束（PLB）与软组织标记后交叉韧带（PCL）和外侧半月板前角的距离,从而明确ACL胫骨止点在胫骨平台的位置,为ACL损伤双束重建提供理论支持。方法：解剖18个膝关节尸体标本（左膝10个,右膝8个）,测量ACL中点、AMB中点、PLB中点与PCL和外侧半月板前角的距离,并分析左、右膝关节是否存在差异。结果：AMB中点与PCL和外侧半月板前角的距离分别为（15.00±3.97）mm和（19.78±4.10）mm;PLB中点与两者的距离分别为（10.17±5.56）mm和（19.50±4.40）mm;ACL中点与两者的距离分别为（12.67±4.52）mm和（19.61±3.87）mm。左右膝关节ACL中点、AMB中点、PLB中点与软组织解剖标记的距离无明显统计学差异。结论：膝关节ACL损伤行手术重建时,可采用PCL和外侧半月板前角作为定位标记。     

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。     

Hybrid hamstring graft tibial fixation in anterior cruciate ligament reconstruction

Tibial fixation of the anterior cruciate ligament hamstring tendon graft is commonly considered more problematic than femoral fixation. When interference screws are used for tibial hamstring tendon graft fixation, graft sometimes looses its tension, so a hybrid fixation (more than one method of fixation) must be applied. Biomechanical studies show that an implementation of interference screws combined with different indirect distal hamstring tendon fixation techniques can withstand much higher tearing forces when compared with one type of fixation. We made a technique of hybrid tibial fixation of the hamstring graft using round interference screws and an additional bi-cortical 4.5-mm diameter screw with a modified head that allows control over the initial tension of the graft.     

股骨外髁形态与前交叉韧带股骨足迹关系的初步研究

目的探讨正常人股骨外髁形态特点与前交叉韧带（ACL）股骨足迹形态变化之间的关系,以及术中ACL个性化解剖双束重建的设计策略。方法60例成年膝关节标本,常规解剖膝关节测量股骨ACL纵轴长度,观察股骨外髁内侧面的形状,测量ACL股骨足迹中轴长度与股骨干之间的夹角。结果（1）人类股骨外髁内面大致分为三角形、梯形、过度形三种形态;（2）ACL股骨足迹纵轴长度以三角形最短,过渡型次之,梯形最长;（3）ACL中轴与股骨干夹角有分别为：三角形：（28．6°±2．2°）;过度型：（19．8°±1．9°）;梯形：（5．3°±1．3°）,三者间比较有统计学差异（F=2．367,P〈0．01）。结论股骨外髁形态决定了ACL足迹轴线角度,对临床个体化ACL双束重建的设计有重要意义。     

Ideal tibial tunnel length for endoscopic anterior cruciate ligament reconstruction

A successful single-incision endoscopic anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft requires attention to many technical details. The emphasis of placing the femoral bone plug flush with the opening of the femoral tunnel results in distal shift of the graft. Longer tibial tunnels are required to prevent excessive graft extrusion. The purpose of this study is to compare four direct and indirect measurement methods of tibial tunnel preparation to determine which method can be used to create consistently reproducible tibial tunnels that prevent excessive extrusion or recession of the graft within the tunnel. Tunnels placed at the empiric angles of 40 degrees, 50 degrees, and 60 degrees to the tibial plateau resulted in the incidence of acceptable tibial tunnel lengths of 44%, 83%, and 39%, respectively. Tunnels placed at an angle determined by the formula "N + 7" where 7 degrees is added to the patellar tendon length (N) resulted in acceptable tunnels 89% of the time. Direct measurement methods using the formulas "graft - 50 mm" and "N + 2 mm" resulted in acceptable tibial tunnels of 44% and 100%, respectively. We recommend using the "N + 7" in conjunction with the "N + 2 mm" formula to obtain the advantages of both indirect and direct measurement methods.Arthroscopy 1998 Jan-Feb;14(1):9-14     

Fracture of the femoral tunnel after an anterior cruciate ligament reconstruction

Fractures after anterior cruciate ligament (ACL) reconstructive surgery are rare. Patella fractures can occur as a complication after bone-patellar tendon-bone autografts, and few case reports of tibia fractures have been published. Although reports of femur fractures have been published, the causes are attributed to stress risers other than the femoral tunnel. To our knowledge, this is the first case report of a femoral tunnel serving as a stress riser after an ACL reconstruction with bone-patellar tendon-bone autograft. The patient’s fracture resulted from minimal trauma and required surgical fixation.