后交叉韧带损伤

后交叉韧带损伤谢利民近年来,随着对后交叉韧带（ＰＣＬ）的解剖、生理功能和生物力学研究的不断深入,特别是对其损伤后自然转归的深入了解,后交叉韧带损伤正日益受到重视,治疗方法的研究也正在不断深入。一、ＰＣＬ的功能、解剖与生物力学ＰＣＬ起于股骨内髁的外面,...     

后交叉韧带损伤的手术治疗

后交叉韧带（posterior cruciate ligament，PCL）损伤的发病率比前交叉韧带低，约占所有膝关节韧带损伤的3．4％～20．0％。单纯PCL部分损伤或完全损伤常采取保守治疗，短期效果满意而长期效果则存在争议。如果PCL完全撕裂合并膝关节后外侧损伤，则非手术治疗的效果不可靠，渐进性骨关节炎和膝关节功能受限的发生率高，目前多主张手术重建。     

儿童后交叉韧带损伤1例

患儿女 ,10岁 ,因“右足、左小腿外伤后疼痛、活动受限 1ｈ”入院。入院时拍片示“右足舟骨骨折、左膝及左胫腓骨无异常”。入院后由于患儿不合作 ,查体困难 ,故以“右足舟骨骨折”给予石膏外固定等对症治疗。一周后 ,患儿仍诉左膝部疼痛不适 ,仔细检查患儿的左膝后 ,发现后抽屉实验阳性 ,考虑为“左膝后交叉韧带损伤”。故在静脉复合麻醉下行左膝关节探查、后交叉韧带修补术。术中见后交叉韧带断裂 ,断裂距止点约 2ｍｍ ,故用 10号丝线缝合 ,近端“8”字交叉缝合后线从断端引出 ,再从断端残留处进针 ,缝于胫骨后缘软骨上。术后屈膝 30°石…     

后交叉韧带损伤的诊断治疗

目的通过对收治的４８例后交叉韧带损伤患者的病历分析,探讨有关后交叉韧带损伤的诊断和治疗的问题。方法对所有患者,经物理检查、影像学检查,并结合病史确诊后,分别予以石膏托外固定、起止点重建、原位缝合修补、髂胫束移植重建,半腱肌移植重建、髌韧带中１／３的骨－韧带－骨移植重建、股薄肌移植重建,并配合康复治疗。结果所有病例有效随访４个月～２０年,平均６年８个月,方法不同,疗效不同,优良率５２．１％,有效率７９．２％。结论（１）提高早期的诊断率,可以提高后交叉韧带损伤的疗效。（２）非手术治疗的疗效,远低于手术治疗的疗效,而手术治疗的方法较多,其中以带骨块的起止点修复重建术和髌韧带中１／３的骨－韧带－骨自体移植重建疗效最佳。（３）早期手术治疗和及时、正确的修复并发的复合伤,是提高治疗效果,减少膝关节功能的丢失,降低和推迟晚期并发症发生的重要前提。     

后交叉韧带损伤膝关节功能康复分析

我们对1990年6月至2000年6月收治的32例后交叉韧带损伤患者,针对不同类型,分别采取了不同的治疗方法,现将功能康复结果报告如下.     

关节镜下人工韧带治疗膝后交叉韧带损伤

通过对１１例膝后交叉韧带（ＰＣＬ）,对断裂患者在关节镜下行Ｇｏｒｅ－Ｔｅｘ人工韧带重建ＰＣＬ,对近期随访结果进行分析,随访９￣２１个月,平均１７个月。术后所有患膝不稳定症状消失。Ｌａｃｈｍａｎ试验阴性,后抽屉试验阴性骨折关节功能良好。根据Ｌｙｓｈｏｌｍ膝关节评分法,平均积分由术前的５４分提高到术后的８９分。认为关节镜下代 韧带治疗后交叉韧带损伤手术反应小,恢复快,近期疗效肯定,过 铲尚待日后更深入     

不同后交叉韧带指数测量方法对前交叉韧带损伤的诊断价值

目的:比较6种不同测量方法下的后交叉韧带(posterior cruciate ligament,PCL)指数(Index),分析验证其在前交叉韧带(anterior cruciate ligament,ACL)损伤中的临床诊断价值。方法:回顾性分析2018年5月至2022年3月收治的225例患者的膝关节MRI资料,年龄18～60岁,中位数32岁。根据ACL是否损伤,分为ACL正常组和ACL损伤组。在114例ACL损伤和111例ACL完整受试者的膝关节MRI矢状位图像上,测量MRI矢状位PCL在股骨附着点和胫骨附着点之间的直线距离(A)和该直线到矢状位图像上PCL弧形标记点之间的最大垂直距离(B),计算PCL Index并评估其对ACL损伤的诊断价值。结果:ACL正常组和ACL损伤组PCL Index1、2、3、6比较差异无统计学意义(P>0.05);两组PCL Index4、5比较,差异有统计学意义(P<0.001)。ACL正常组的PCL Index2、6与患者年龄呈负相关性(相关系数=-0.213,-0.189;P<0.05),ACL损伤组的PCL Index5与...     

The posterior cruciate ligament and rotatory knee instability

Summary The importance of the posterior cruciate ligament in relation to valgus-varus and axial rotatory stability in the knee joint was investigated. Mobility patterns were drawn from 20 osteoligamentous preparations after successive transection of the posterior cruciate ligament (PCL), the medial and lateral collateral ligaments, and the posterior joint capsule. The knee joint remained grossly stable after isolated transection of the PCL, and further cutting of either one of the collateral ligaments or of the posterior capsule yielded no greater instability than one should expect from isolated cutting of each of these structures. The posterior cruciate ligament was the stabilizing factor in flexion and external rotation after injury to the lateral collateral ligament and the posterolateral capsule, and it restricted internal rotation after cutting of the medial cruciate ligament and the posteromedial capsule. Valgus instability was markedly increased during the whole range of movement when PCL was included in injury to the medial compartment ligaments, and when included in a lateral compartment injury a further varus instability was found, though only in the flexed or semiflexed knee. No hyperextension could be demonstrated after these injuries

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Zusammenfassung Der Einfluß des hinteren Kreuzbandes (PCL) in bezug auf Valgus-Varus- und axialer Rotationsinstabilität wurde untersucht. Anhand von osteoligamentären Präparaten wurden Bewegungsabläufe nach schrittweiser Durchtrennung des PCL, des MCL, des LCL und der posterioren Gelenkkapsel aufgezeichnet. Nach isolierter Durchtrennung des PCL blieb das Kniegelenk im großen und ganzen stabil, auch eine kombinierte Durchtrennung eines Kollateralligamentes oder der posterioren Kapsel erzeugte keine Instabilität, die sich von der nach isolierter Durchtrennung der erwähnten Strukturen unterscheiden ließ. Nach der Durchtrennung des LCL und der lateralen posterioren Kapsel zeigte sich das PCL als stabilisierender Faktor bei Flexion und Außenrotation, und bei Innenrotation nach Durchtrennung des MCL und der medialen posterioren Kapsel. Valgus-Instabilität wurde wesentlich verstärkt während des vollen Bewegungsausschlages, wenn das PCL bei Verletzung des medialen Bandapparates mitbetroffen war. Varus-Instabilität nahm von der semiflektierten Stellung an zu, wenn das PCL bei Verletzung des lateralen Bandapparates mitbetroffen war. Nach isolierter oder kombinierter Verletzung des PCL trat in keinem Fall eine Hyperextension auf.

     

The posterior cruciate ligament in total knee arthroplasty

The purpose of this study was to answer 2 questions: Does the posterior cruciate ligament (PCL) produce femoral rollback in a single-design, cruciate-sparing total knee arthroplasty (TKA)? Does the PCL prevent posterior tibial displacement when it is retained after a single-design, cruciate-sparing TKA? Knee kinematics and limits of motion were measured with the knees in the following states: (1) intact knee, (2) anterior cruciate-deficient knee, (3) PCL-retaining total knee of a single design (TKA), (4) PCL-retaining TKA with PCL cut, and (5) PCL-substituting TKA. Femoral rollback was then calculated from the above data. The results showed that the PCL was able to prevent posterior translation and maintain femoral rollback when it was preserved during TKA. Therefore, the PCL can be functional after TKA, in a single-design, cruciate-sparing TKA. When the PCL was cut, significant changes in knee kinematics were observed.     

The posterior cruciate ligament during flexion of the normal knee

The posterior cruciate ligament (PCL) was imaged by MRI throughout flexion in neutral tibial rotation in six cadaver knees, which were also dissected, and in 20 unloaded and 13 loaded living (squatting) knees. The appearance of the ligament was the same in all three groups. In extension the ligament is curved concave-forwards. It is straight, fully out-to-length and approaching vertical from 60 degrees to 120 degrees, and curves convex-forwards over the roof of the intercondylar notch in full flexion. Throughout flexion the length of the ligament does not change, but the separations of its attachments do. We conclude that the PCL is not loaded in the unloaded cadaver knee and therefore, since its appearance in all three groups is the same, that it is also unloaded in the living knee during flexion. The posterior fibres may be an exception in hyperextension, probably being loaded either because of posterior femoral lift-off or because of the forward curvature of the PCL. These conclusions relate only to everyday life: none may be drawn with regard to more strenuous activities such as sport or in trauma.     

The role of the posterior cruciate ligament in total knee replacement

We randomised 129 knees which were to be replaced using a standard posterior-cruciate-ligament (PCL)-retaining cemented total knee replacement into two groups. In one the PCL was retained in the normal way and in the other it was resected. They were well matched, with a predominance of women, and a mean age of 67 years. There was no statistically significant difference in the Hospital for Special Surgery scores at a mean of 57 months (56 to 60) between the two groups although 21 patients (24 knees) were lost to follow-up. Relief from pain, correction of deformity, range of movement, stability and strength were comparable in both. Radiological assessment showed femoral rollback in approximately 20% of knees with a slightly higher incidence in the PCL-resected group. There was no significant loosening detected in either group at review at two years. At five years, one knee in the PCL-retained group had been revised because of infection and one patient in each group was awaiting revision for loosening. Our findings have shown no significant difference in the five-year results for a PCL-retaining total knee replacement if the PCL is excised or preserved. This suggests two important points. First, the PCL is not functional in most patients with a total knee replacement even when retained. Secondly, patients with an excised PCL show a good result with a PCL-retaining implant, thereby questioning the need for a posterior stabilised design in such a situation.     

异体前十字韧带移植重建兔后十字韧带的生物力学研究

目的探讨以兔异体前十字韧带为移植物解剖重建后十字韧带的生物力学变化。方法在研究正常兔前、后十字韧带解剖学和生物力学特性的基础上,用异体前十字韧带移植物解剖重建后十字韧带。应用无菌取材、新鲜冰冻技术制备异体骨-前十字韧带-骨移植物,-80℃保存14d以上待用。24只成年新西兰大白兔,随机选取其一侧后腿作为实验组,重建后十字韧带,对侧为对照组。分别于术后6、12、26、52周取材,测定股骨-移植物-胫骨的几何学特点、断裂部位、结构力学特性和材料力学特性。结果移植物平均长度在52周时为对照组正常后十字韧带的101%(P=0.90),平均横截面积为142%;强度在术后52周时为对照组正常后十字韧带的83%,最大拉长量为72%,刚度为92%;最大应力在术后52周时为对照组正常后十字韧带的58%,最大应变为72%,弹性模量为65%。断裂部位均位于移植物体部。移植物的几何学特点、结构力学特性和材料力学特性均有逐渐接近对照组正常后十字韧带的趋势。结论相同材料力学特性的移植物重建后十字韧带后生物力学特性转归良好,移植物的相同材料力学特性是影响后十字韧带重建效果的重要因素。     

钢丝牵拉修复重建治疗后交叉韧带损伤

目的:采用钢丝通过钻孔牵拉修复后交叉韧带胫骨附着区新鲜撕脱损伤,评价其疗效。方法:43例胫骨附着区撕脱、膝后交叉韧带断裂患者,男31例,女12例,年龄20～46岁。采用膝关节后侧入路,在膝关节后方作1个“S”形切口,显露PCL胫骨附着区撕脱骨折处,复位满意后,予克氏针钻孔于胫骨结节,通过钢丝牵拉复位,钢丝结扎,纽扣固定于胫前皮肤外,检查膝关节的活动情况满意后清洗并关闭切口。术后应用抗生素3～5d,并以石膏外固定进行保护,按照恢复时间进行有规律的功能锻炼。结果:术后随访4～24个月,平均14个月,患者Lachman试验阴性,后抽屉试验阴性,关节功能良好。采用Lysholm膝关节评分法评估,术前(58.23±7.40)分,术后(89.39±7.20)分,术前后比较t=19.845,P<0.01,差异有统计学意义。结论:PCL断裂并发关节不稳用钢丝牵拉修复重建治疗手术操作方便,并可促进骨折愈合,但长期疗效尚待研究。