Hamstring腱在体内重塑与转归的组织学研究

目的探讨游离Hamstring腱作为替代腱重建前十字韧带（anterior cruciate ligament，ACL）后在体内的重塑与转归过程，初步确定其术后在体内成熟的时间。方法33例关节镜下自体同侧游离4-5股Hamstring腱重建ACL的患者在行关节镜下再视手术时，于移植腱体中下段取活检组织进行组织学观察。重建术至再视手术的平均时间为11．9个月。替代腱依据重建术至再视手术的时段分为1月～、4月～、7月～、10月～、13月～、18月～和25月～组。将替代腱与正常ACL和半腱肌腱组织进行对比。结果重建ACL的Hamstring腱随植入时间延长，组织结构呈现其胶原纤维由不规则排列逐步向同向排列，排列不规则的菱形成纤维细胞逐步向较规则排列的椭圆形类纤维细胞转变，且细胞数目逐渐减少，血管腔数目也不断减少。上述的重塑变化主要发现在7月～组以前，其后各组重塑变化过程缓慢。结论自体游离Hamstring腱重建ACL术后具有良好的早期存活、加快再血管化和重塑过程的组织特性。其术后的重塑与成熟过程与自体髌腱相似，自体Hamstring腱在体成熟的时间为7-9个月。     

前交叉韧带重建后再血管化的影响因素

严重的前交叉韧带损伤通常需要重建来修复,重建的韧带在体内需经过不同时期的转归与重塑才能形成有功能的韧带,其中早期再血管化是重塑过程的关键。本文从韧带的来源、重建的方法、细胞因子对再血管化的影响三方面进行综述,发现自体来源较异体来源的韧带发生再血管化早;保留前交叉韧带残端和髌下脂肪垫能加速重建韧带再血管化的进程;VEGF、bFGF、PDGF等众多细胞因子也可促进重建韧带的再血管化并具有协同作用。     

前十字韧带重建术后自体Hamstring腱的超微结构研究

目的 观察自体Hamstring腱重建前十字韧带(anterior cruciate ligament,ACL)后在人体内超微结构的变化过程.方法 单侧关节镜下自体Hamstring腱重建ACL后再行关节镜手术患者18例,男10例,女8例;年龄21～43岁,平均27.3岁;其中16例因取内镶钉,2例因术后疼痛而行关节镜手术.取重建ACL术后Hamstring腱的部分组织块,以正常半腱肌腱和ACL作为对照组.取下的组织块依据重建术后时间分组:1～4个月组2例,4～7个月组4例,7～10个月组3例,10～13个月组3例,13～18个月组2例,18～25个月组2例和>25个月组2例.常规电镜技术制备组织块样品,透射电子显微镜下观察细胞和纤维;按纤维的直径分为细、中、粗三种,计算各纤维的平均数目(频率)和所占的相对面积.结果 显微镜下超微结构显示:植入体内早期(<7个月)细胞数多,主要为成纤维细胞,胶原纤维大小差异很大,以粗纤维为多;中期(7～13个月)细胞数目减少,类成纤维细胞居多,胶原纤维呈平行排列,纤维直径已趋均匀,中、细纤维占多数,且与正常ACL的中、细纤维接近,粗纤维罕见;后期(>13个月)细胞数少,主要为类纤维细胞,胶原纤维密集,聚集呈束状,纤维排列呈平行状,纤维直径不均匀,粗纤维增多,中纤维减少,细纤维占多数.结论 自体Hamstring腱组织重建ACL后在体内早期呈快速变化过程,中期组织以细、中纤维为主,已趋成熟,晚期以细纤维为主,且改建过程仍缓慢进行.     

膝关节多韧带损伤的临床研究

目的探讨膝关节多韧带损伤的诊断与治疗方法并评价其治疗效果。方法治疗51例单侧膝关节多韧带损伤,其损伤类型：21例前交叉韧带（ACL）＋内侧副韧带（MCL）,1例ACL＋后外侧复合体（PLC）,4例后交叉韧带（PCL）＋MCL,6例PCL＋PLC,6例ACL＋PCL＋MCL,3例ACL＋PCL＋PLC,8例ACL＋PCL,2例PCL＋髌腱。14例急性Ⅲ度MCL和3例急性Ⅲ度PLC损伤行切开手术,原位缝合,外固定制动3周,再行关节镜下其他韧带手术。2例Ⅲ度慢性MCL和3例Ⅲ度慢性PLC损伤行切开韧带重建术,并同期行关节镜下ACL或PCL重建术。在总共39条ACL损伤中,20条行关节镜下自体Hamstring腱ACL重建术,17条行关节镜下自体骨-髌腱-骨（BPB）重建ACL术,2条行同种异体肌腱重建ACL;在总共29条PCL损伤中,19条行关节镜下自体Hamstring腱PCL重建术,2条行同种异体肌腱重建PCL,另8条急性损伤经固定后由Ⅲ度变为〈Ⅱ度损伤,故未特别治疗。其中,17例ACL＋PCL损伤处理方法为：4例先行PCL重建,二期再行ACL的重建,7例同期自体Hamstring腱重建PCL、自体BPB重建ACL,2例为同种异体肌腱同期重建ACL和PCL,4例仅做ACL重建术。1例髌腱完全性断裂原位修复,另1例部分性髌腱损伤者未治疗。4例合并腓总神经损伤均未做特别治疗。结果平均随访2.4年（9个月～5年）。术后Lysholm评分平均为86.3（51～100）,Tegner活 动评分为5.2（2～8）,均较术前显著增加（P〈0.001）。1例外翻试验为2＋,2例Lachman试验或轴移试验≥2＋,6例应力后沉征或后抽屉试验2＋,4例内翻试验或反轴移试验2＋。其余的对应各种体格检查均为≤1＋。4例合并腓总神经损伤者,术后3例自行恢复,1例未恢复。结论在多韧带损伤中,≤Ⅱ度的MCL或者PLC损伤应采用保守治疗,Ⅲ度损伤者应尽早手术原位修复内侧副韧带及其关节囊或PLC,以利于后期进行其他重要韧带的治疗。交叉韧带或关节内重要组织可二期在?     

膝关节镜下采用挤压螺钉固定骨-髌腱-骨自体移植重建前交叉韧带

目的　探讨采用关节镜下微创手术的方法重建膝关节前交叉韧带。　方法　在膝关节镜下采用挤压螺钉固定骨 髌腱 (中 1/ 3) 骨复合体自体移植重建前交叉韧带 ,术后 1年以上者 2 0例 ,平均随访时间 1年 5个月。　结果　按关节功能评定标准 ,本组 2 0例中 ,优 13例 ,良 5例 ,可 2例 ,优良率 90 % ;9例术后关节镜观察重建前交叉韧带的形态结构 ,7例塑形改建良好。　结论　关节镜下重建前交叉韧带手术创伤小 ,骨道定位准确、固定牢固 ,可做到等长重建 ,有利于早期康复 ;由于利用了自体骨 髌腱 骨组织 ,重建的韧带经塑形改建后可获得牢固的生物学固定     

关节镜下解剖等长重建技术在LARS韧带重建前交叉韧带中的应用

目的 探讨前交叉韧带(ACL)解剖等长重建技术在关节镜下LARS韧带重建前交叉韧带术中应用的可行性及近期疗效.方法 用LARS人工韧带对8例前交叉韧带损伤行关节镜下ACL重建术.采用前交叉韧带解剖等长重建技术钻胫骨、股骨骨道,将LARS韧带拉入骨道,韧带游离部分位于关节腔内,拉紧后2枚界面螺钉固定韧带.结果 手术时间30～80 min,平均56 min.术后无滑膜炎、韧带断裂、活动明显受限等并发症.8例均随访2～6个月,平均4个月.根据Lysholm膝关节功能评分,术前评分为22～65分(40.25±17.07)分;术后评分为80～93分(88.75±4.06)分(t=8.083,P＜0.01).结论 前交叉韧带解剖等长重建技术在关节镜下LARS韧带重建前交叉韧带术中操作简便,效果可靠,值得推广.     

自体-异体混编肌腱重建前交叉韧带移植物腱骨愈合的实验研究

[目的]观察比较自体、异体及自体一异体混编肌腱重建前交叉韧带移植物腱骨愈合的组织学变化过程。[方法]取45只新西兰兔,随机平均分为自体组、异体组及混编组。切除兔右膝前交叉韧带,取其双侧趾长伸肌腱,两两随机合成双股自体、异体及混编待移植物后重建兔右膝前交叉韧带。采用HE染色、甲苯胺蓝染色,观察重建术后3、8及12周时移植物腱骨愈合的变化情况。[结果]重建术后3周时,各组移植物腱骨界面均表现为明显的组织坏死及炎性细胞浸润;8周时,3组腱骨界面均可见大量新生组织细胞,胶原纤维纵向无序排列:12周时,自体组腱骨界面间的胶原纤维排列较其他2组更有序,止点4层结构也更清晰;术后各期腱骨界面软骨细胞含量,自体组混编组异体组。[结论]前交叉韧带重建术后在相同的时间点,自体移植物腱骨愈合最优,而混编后的移植物介于自体和异体之间。     

关节镜下自体Hamstring腱重建前交叉韧带的应用

目的探讨关节镜下自体Hamstring腱重建前交叉韧带(Anterior Cruciate Ligament, ACL)的临床方法和疗效. 方法 22例ACL损伤,年龄17岁～50岁, 平均30.7岁,进行关节镜下自体Hamstring腱ACL重建术. 结果本组22例术后膝关节均获正常活动范围.术后Lachmen试验19例≤1+,2例2+,1例3+.轴移试验20例阴性或可疑,2例阳性.术后Lysholm评分为(87.7±9.6)分,较术前(54.4±12.1)分显著提高(t=2.33,p<0.05).术后Tegner活动评分为(5.1±1.3)分,较术前(2.8±0.8)分显著提高(t=4.36,p<0.01).19例X线内固定物的位置良好,3例内固定物的位置欠佳.3例胫部伤口早期感染,经伤口处理愈合.22例随访7月～25月,平均15.7月. 结论关节镜下自体Hamstring腱重建ACL是一种治疗急慢性ACL损伤的有前景的术式.     

前交叉韧带重建术中Hamstring腱的固定

替代腱的固定是前交叉韧带(anterior cruciate ligament,ACL)重建术的重要环节,也是最薄弱环节,是术后活动和康复项目开展的最主要的限制因素.当前康复锻炼的趋势是强调早期肌肉训练与负重行走,这就要求Hamstring腱的固定器材具有较高的生物力学强度.固定对ACL重建术的成功和术后活动有重要作用.     

前交叉韧带重建术替代腱固定技术新进展

前交叉韧带（anterior cruciate ligament，ACL）重建常用自体替代腱为骨-肌腱-骨（bone—patellar tendon—bone，BPTB）、股四头肌腱-髌骨（quadriceps tendon—patellar bone．QTPB）、Hamstring腱。替代腱的固定有各式各样的方法，BPTB和QTPB通常采用内镶螺钉和挤压钉固定，Hamstring腱的固定方法有：缝合、内扣器、垫环器、固定锚、U形钉、钉板器、腱内固定器、横钉和内镶钉。     

Editorial Commentary: How to Increase Hamstring Tendon Graft Size for Anterior Cruciate Ligament Reconstruction

The concept of a five-strand hamstring tendon autograft for anterior cruciate ligament reconstruction is not new. The concept of a five-strand hamstring tendon autograft was largely ignored until recent studies showed higher failure and revision rates for hamstring ACL reconstructions performed with graft diameters less than 8 mm. In the majority of patients in the United Arab Emirates, four-strand hamstring tendon autografts result in a graft diameter between 6.5-7.5 mm. As a result, since 2006, I have completely abandoned using four-strand hamstring tendon autografts in favor of five-and six-stranded hamstring tendon autografts for ACL reconstructions. The key to performing five-or six-strand hamstring tendon autografts lies in the ability to triple the semitendinosus tendon and in the case of six-strand hamstring tendon grafts, the gracilis tendon. Although, five-and six-strand hamstring tendon autografts can increase the diameter of hamstring tendon ACL grafts, the question of whether these grafts will reduce failure and revision rates remains unanswered.     

Small Size Autograft versus Large Size Allograft in Anterior Cruciate Ligament Reconstruction

BackgroundA small autograft diameter negatively affects functional outcomes, knee stability, and the risk of rerupture after anterior cruciate ligament (ACL) reconstruction, whereas the strength of allograft decreases over time. Therefore, it is not clear whether the use of smaller autografts or the use of larger allografts in ACL yields better results. The aim of this study was to compare the outcome of smaller autografts and larger allografts for ACL reconstruction.MethodsFifty-one patients who underwent ACL reconstruction with hamstring tendon autografts (size ≤ 8 mm) and 21 patients who underwent ACL reconstruction with allografts (size ≥ 10 mm) were included in our study. All patients underwent the same aggressive early postoperative rehabilitation program. There were no significant differences between the autograft and allograft groups regarding the preoperative patient age, sex, time from injury to surgery, and average follow-up time.ResultsThe mean diameter of the 4-stranded hamstring tendon grafts used as autografts was 7.48 ± 0.33 mm and the mean diameter of the allografts was 10.76 ± 0.67 mm. According to specific tests for the ACL (anterior drawer, Lachman, and pivot shift) and clinical evaluation tests (Lysholm knee scoring scale and International Knee Documentation Committee questionnaire), the final follow-up results were significantly better than the preoperative status in both autograft and allograft ACL reconstruction groups. Therefore, there were no significant differences between the autograft and allograft groups preoperatively and at the final follow-up.ConclusionsThe large size of the graft in ACL reconstruction has been reported to affect results positively. However, in our study, we could not find any significant differences between the smaller size autografts and larger size allografts in terms of inadequacy, rerupture, and final follow-up functional results. Although allografts were significantly larger than autografts, we did not have the positive effect of larger size grafts. Smaller size autografts were as effective as the larger size allografts.     

Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft

BACKGROUND: Surgical reconstruction of the anterior cruciate ligament (ACL) is indicated in the ACL-deficient knee with symptomatic instability and multiple ligaments injuries. Bone patellar tendon-bone and the hamstring tendon generally have been used. In the present study, we describe an alternative graft, the quadriceps tendon-patellar bone autograft, by using arthroscopic ACL reconstruction. METHODS: From March of 1996 through March of 1997, a quadriceps tendon-patellar bone autograft was used in 12 patients with ACL injuries. RESULTS: After 15 to 24 months of follow-up, the clinical outcome for those patients with this graft have been encouraging. Ten patients could return to the same or a higher level of preinjury sports activity. According to the International Knee Documentation Committee rating system, 10 of the 12 patients had normal or nearly normal ratings. Recovery of quadriceps muscle strength to 80% of the normal knee was achieved in 11 patients in 1 year. CONCLUSION: The advantages of the quadriceps tendon graft include the following: the graft is larger and stronger than the patellar tendon; morbidity of harvest technique and donor site is less than that of patellar tendon graft; there is little quadriceps inhibition after quadriceps harvest; there is quicker return to sports activities with aggressive rehabilitation. A quadriceps tendon-patellar autograft is a reasonable alternative to ACL reconstruction in patients who are not suitable for either a bone-patellar tendon-bone autograft or a hamstring tendon autograft.     

膝关节镜下自体腘绳肌腱移植重建前十字韧带部分束损伤

目的探讨关节镜下自体腘绳肌腱单束移植重建前十字韧带（anterior cruciate ligament,ACL）部分束损伤的临床效果。方法2007年1月至2010年5月关节镜下行自体腘绳肌单束重建ACL部分束损伤16例。术前Ly．sholm评分平均为55．4±6．7分。结果全部获得随访,随访时间为12～23个月,平均18±4．3个月。术后Lysholm评分增至平均89．3±3．3分,有统计学差异（P〈0．05）。所有患者主观症状均消失,全部恢复正常工作与体育锻炼。结论应用自体腘绳肌腱重建ACL部分束损伤明显改善膝关节功能。     

Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis

Background Current debate on treatment options for anterior cruciate ligament (ACL) reconstruction complicate the choice between hamstring and bone patellartendon bone autografts. We hypothesized a priori that cumulative meta-analysis (a form of sensitivity analysis) might show that the evidence for reduction of morbidity by hamstring grafts could have been reached at an earlier time. Furthermore, we hypothesized a priori that modern state-of-the-art hamstring graft fixation technique would give similar results regarding stability as bone-patellar tendon-bone autografts.

Methods We performed a cumulative meta-analysis and sensitivity analysis based on femoral graft fixation techniques to compare hamstring autograft and bonepatellar tendon-bone autografts in ACL reconstruction derived from a previously published meta-analysis.

Results Cumulatively, that hamstring autograft reduces anterior knee pain had already reached statistical significance in 2001 (relative risk 0.49 (95%CI: 0.32-0.76; p = 0.001, I2 = 0%)). The modern endobutton hamstring graft fixation technique (2 studies) yielded similar stability in the Lachman test as bone-patellar tendon-bone grafts, with a relative risk of 1.1 (95%CI: 0.82-1.5; p = 0.6, I2 = 0%). Exclusion of the endobutton group explains the increased laxity in the hamstring graft group.

Interpretation Cumulative meta-analysis strengthens the evidence for reduced morbidity using hamstring tendon autograft for anterior cruciate ligament reconstruction. Sensitivity analysis focusing on state-of-the-art hamstring graft fixation techniques further weakens the evidence that bone-patellar tendon-bone autografts provide better stability.     

双监视法解剖等长重建结合Rigidfix和Intrafix固定技术重建前交叉韧带

目的探讨双监视法解剖等长重建结合Rigidfix和Intrafix固定技术在腘绳肌腱重建前交叉韧带（ACL）中应用的可行性及近期疗效。方法对17例ACL损伤行关节镜下ACL重建术。采用双监视法解剖等长重建技术建立股骨胫骨隧道。股骨端用Rigidfix固定,胫骨端用Intrafix固定。结果17例均获随访,时间1218（14.18±2.19）个月。根据Lysholm膝关节功能评分,术前评分：25-66（46.76±14.79）分;术后1年评分：85-97（92.71±3.22）分（P〈0.01）。结论双监视法解剖等长重建结合Rigidfix和Intrafix固定技术应用在腘绳肌腱重建ACL中,具有定位准确、手术操作简便、固定牢固、疗效确切等优点。     

腘绳肌腱结合双固定技术重建前交叉韧带

目的探讨采用腘绳肌腱股骨端胫骨端双固定技术重建前交叉韧带(ACL)的可行性及近期疗效。方法对25例ACL损伤行关节镜下ACL重建术,采用笔者自行设计双监视法解剖等长重建技术建立股骨胫骨隧道。移植物股骨端用Endobutton钢板和Rigidfix固定,胫骨端用Bio-Intrafix和Stample门形加压钉固定。结果本组获随访12～18(13.76±1.61)个月,未发现滑膜炎、韧带断裂、活动度明显障碍等并发症。根据Lysholm膝关节功能评分,术前评分:20～48(31.32±8.71)分;术后1年评分:90～98(94.96±2.56)分(t=37.69,P<0.01)。结论在腘绳肌腱重建ACL中应用股骨端胫骨端双固定技术具有手术操作简便,固定牢固,效果可靠的优点,值得推广。     

双股腘绳肌腱重建解剖学形态的前交叉韧带

目的探讨经双股骨和3个胫骨隧道用双股腘绳肌腱移植,重建解剖学形态前交叉韧带的可行性和效果。方法使用关节镜技术准确的确立出前交叉韧带起止点位置,并钻取2个股骨和3个胫骨隧道,将双股腘绳肌腱分为3束重建解剖学形态的前交叉韧带。结果所有病例随访8~15个月,膝关节功能恢复满意。结论前交叉韧带重建技术更能发挥膝关节生物力学性能,具有广泛的应用前景。     

富血小板血浆与异体脱蛋白骨复合物颗粒促进前交叉韧带重建术后腱骨愈合的临床研究

目的观察富血小板血浆(PRP)与异体脱蛋白骨(DPB)复合物颗粒促进前交叉韧带(ACL)重建术后腱骨愈合的临床效果。方法将42例接受ACL重建术的患者随机分为实验组及对照组,对照组按常规方法行ACL重建术,实验组在两端骨隧道中填充入PRP+DPB复合物颗粒,术后6个月行CT检查,通过计算机图像分析软件测量出骨隧道扩大数值,并行Lysholm评分及IKDC评分。结果随访时间6～21个月,平均11.8个月。末次随访时,两组Lysholm评分及IKDC评分与术前比较,差异均有统计学意义(P<0.05);但两组间比较差异无统计学意义(P>0.05)。两组间术后CT测量的骨隧道直径扩大的数值差异具有统计学意义(P<0.05)。结论与对照组相比,PRP+DPB复合物颗粒可促进ACL重建术后骨腱愈合,减少骨隧道扩大,临床效果满意。