膝关节后纵隔与后交叉韧带下止点的解剖关系及临床意义

目的 探讨膝关节后纵隔与后交叉韧带(PCL)下止点的解剖关系及其在PCL重建中的临床价值. 方法 解剖22例新鲜冷冻膝关节,将PCL在屈膝90°下按纤维张力的不同分为前外束和后内束,解剖出它们在胫骨上的足迹,并用墨汁标记足迹的轮廓;使用带标尺的数码相机测量PCL前外束、后内束胫骨止点中心点与后纵隔的水平距离,并同时测量两束止点中心点与外侧胫骨平台后软骨缘上表面的垂直距离. 结果 膝关节存在一个从前至后的纵隔结构,其前方与脂肪垫、翼状皱襞或黏膜韧带相连,中间位于前、后交叉韧带之间,后方形成膝关节的后纵隔.在22个膝关节中,8个膝关节的后纵隔从PCL的外缘绕过以后止于后关节囊,占36.36%;14个膝关节的后纵隔在PCL前方分叉,包绕PCL后止于后关节囊,占63.64%.PCL前外束胫骨止点中心点距离后纵隔内侧的水平距离(0.90±2.40)mm,距离外侧胫骨平台后软骨缘上表面的垂直距离是(3.25±1.20)mm.后内束胫骨止点中心点距离后纵隔内侧的水平距离为(4.35±2.46)mm,距离外侧胫骨平台后软骨缘上表面的垂直距离为(6.91±1.57)mm. 结论 膝关节后纵隔与PCL下止点的解剖关系密切,后纵隔可以成为PCL单束重建和双束重建手术中胫骨止点定位的重要解剖标志之一.     

前交叉韧带重建股骨足迹精确定位的解剖与临床研究

目的　探讨前交叉韧带（ACL）个性化解剖重建术中韧带止点足迹精确定位的方法及效果。 方法　①15侧膝关节尸体标本,标记ACL股骨足迹,观察ACL足迹长轴与股骨干角度、前内束（AM）中心位点距后软骨缘距离、后外束（PL）中心位点距下软骨缘距离。②15例行ACL重建患者,术中采用三入路观察与导航定位方法明确ACL股骨足迹,测量AM与PL连线与股骨干夹角、AM距后软骨缘距离、PL距下软骨缘距离。 结果　15例膝关节尸体标本ACL股骨足迹长轴与股骨干角度为（18.5±　2.5）°、AM与股骨外髁内面后缘距离为（6.1±1.8）mm、PL距离下软骨缘距离为（6.2±2.2）mm,但每个标本均不相同。导航显示,ACL股骨足迹长轴与股骨干夹角为（19.3±3.1）°,AM与股骨外髁内面后缘为（5.8±1.2）mm、PL距离下软骨缘为（5.9±2.5）mm,各数据相差较大。 结论　①ACL股骨与胫骨解剖足迹变异较大,应根据每例ACL足迹不同进行精确的个性化解剖重建。②以同一个标准进行所有ACL重建难以达到真正的解剖重建。     

成人膝关节前外侧韧带的应用解剖学研究

目的 探究国人膝关节前外侧韧带(ALL)的解剖学特点,为临床膝关节ALL损伤的诊治及手术修复重建提供解剖学依据。方法 由山西医科大学解剖教研室提供的成人膝关节标本19具(膝周组织完好无破损、无畸形及手术外伤史),其中左膝关节9具、右膝关节10具。以膝前外侧为中心逐层解剖至关节囊层,寻找并观察ALL的起止点及走行等解剖学特点,测量并记录ALL的解剖数据,对ALL及其毗邻结构拍照记录,进行定性及定量描述。结果 19具膝关节标本中,17具发现ALL。ALL在中立0°位和屈曲60°并内旋5°位时的长度分别为(34.72±6.35)mm和(39.53±6.80)mm,在股骨侧止点、胫骨侧止点的宽度分别为(7.75±0.71)mm、(9.41±1.19)mm,在关节线处宽度为(6.79±1.01)mm。ALL整体是以宽扁样形态由后上向前下走行于膝关节前外侧缘,在关节线处的厚度为(1.21±0.20)mm;ALL在胫骨处以宽大的扇形结构止于外侧胫骨平台Gerdy结节与腓骨头连线中点偏上、距胫骨软骨缘的垂直距离为(11.62±1.32) mm,其胫骨侧止点距Gerdy结节的距离为(19.95±4.63) mm、距腓骨头的距离为(19.47±3.65) mm,Gerdy结节至腓骨头的距离是(33.82±4.69) mm。结论 ALL是一条位于膝关节前外侧关节囊外的独立非等长韧带结构,起于股骨外上髁的后上方,向前下走行,与外侧半月板体部相连,止于外侧胫骨平台前外部,对维持膝关节旋转稳定性发挥着一定的作用。     

四象限分区法用于前交叉韧带多纤维束动态受力分析

目的介绍四象限分区法在测量国人前交叉韧带(anterior cruciate ligament,ACL)多纤维束动态受力分析中的应用;并探讨了膝关节活动中ACL多纤维束动态力学特性。方法采集8侧正常国人膝关节标本,评估标本完整性后向ACL胫骨止点中心做斜行骨隧道,游离ACL胫骨侧止点,以四象限法平均分为4个区:1区,后内区;2区,后外区;3区,前外区;4区,前内区。将4个区的附着纤维束分别连接至自制"膝关节交叉韧带测力计"传感器上,连接系统后分别在膝关节屈曲90o位和伸直0o位将ACL各纤维束张力调零后测量膝关节4自由度(屈伸、内外翻、内外旋、前抽屉试验)内各纤维束的动态受力变化。结果2区和3区纤维束在由屈至伸的过程中所受张力逐渐增大,2区纤维束最大为22.52N±8.60N(30o),3区纤维束最大为13.98N±3.47N(0o);3区和4区纤维束在由伸至屈的过程中张力逐渐增大,4区纤维束最大为14.68N±5.29N(90o),3区纤维束最大为9.84N±5.06N(60o)。所有纤维束在外翻、内外旋、前抽屉试验中张力增加。内翻试验中所有纤维束张力增加不明显,1区纤维束在3个膝关节自由度内张力变化不明显。结论膝关节伸直过程中受力承担最大作用的纤维束主要分布在ACL胫骨止点后外分区内,屈曲位的主要承力纤维分布于前内分区,前外分区则有以上两种纤维束的附着,可能为ACL纤维束中动态受力连续变化的中转部分所在位置。四象限分区法测量ACL多纤维束动态受力有助于利用标准分区方法了解ACL多纤维束动态受力连续变化趋势,为进一步深入探讨ACL多纤维束连续动态受力提供了参考依据。     

膝关节前交叉韧带后外束股骨止点位置的解剖

目的 通过对膝关节前交叉韧带后外束股骨止点的解剖测量,找到确定前交叉韧带后外束股骨止点的简单可行的方法,为双束重建前交叉韧带手术中的骨道定位提供理论依据。方法 解剖20例新鲜膝关节标本（25~45岁）。在屈膝90°位,测量前交叉韧带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。结果前交叉韧带后外束股骨止点中心点距离股骨前方软骨缘(8.74±1.39)mm,距离后方软骨缘(8.69±1.57)mm（P =0.926）。后外束止点中心点距离股骨下方软骨缘(5.06±0.77)mm。结论膝关节屈膝90°位时,前交叉韧带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,距离前方和后方软骨缘的距离相等。在前交叉韧带双束重建的手术中,应用本研究的结果能够简单、快捷地确定前交叉韧带后外束股骨骨道位置。     

膝关节后交叉韧带前外侧束和后内侧束止点的解剖学研究

目的 探讨国人后交叉韧带的分束情况,对前外侧束和后内侧束的止点进行观测,掌握更为详细的解剖学资料,为临床双束重建后交叉韧带提供解剖学基础。 方法 30例膝关节标本,将后交叉韧带分为前外侧束和后内侧束,对双束股骨及胫骨端止点进行标记和解剖学观测。 结果 后交叉韧带的双束股骨止点中点至股骨内髁关节软骨前缘的距离分别为(8.52±1.81)mm和(11.63±1.81)mm,至股骨髁间窝顶的垂直距离分别为(4.67±0.55)mm和(10.32±1.23)mm;胫骨止点中点至胫骨关节面的垂直距离分别为(8.43±1.21)mm和(14.52±2.31)mm,至胫骨内侧软骨边缘的距离分别为(47.44±6.23)mm和(45.95±6.32)mm。双束股骨附丽区面积分别为(107.12±15.25)mm²和(65.35±10.27)mm²;胫骨附丽区面积分别为(50.07±11.33)mm²和(51.08±10.22)mm²。 结论 揭示了后交叉韧带双束止点的解剖学特点,为临床应用提供解剖学基础。     

单双束重建前交叉韧带的生物力学研究

目的比较前内束（AMB）重建、后外束（PLB）重建和双束重建前交叉韧带在关节稳定方面的差异。方法选用6具新鲜冷冻人膝关节标本在关节镜下双束重建前交叉韧带，在膝关节生物力学测定仪上分别测定前交叉韧带完整组、AMB重建组、双束重建组、PLB重建组和前交叉韧带断裂组膝关节生物力学特性的变化。结果（1）胫骨前移：双束重建组在接近伸直位时，与正常前交叉韧带组及PLB组差异不明显（P〉0．05），与其他组比较移位明显减小（P〈0．05）；在屈膝60°、90°位时，双束组与AMB组比较无显著性差异（P〉0．05），与PLB组比较移位明显减小（P〈0．05）；AMB组和PLB组比较，屈膝20°位时无统计学差异（P〉0．05），其他屈膝角度时AMB组明显移位小（P〈0．05）。（2）胫骨内、外旋：在20°、30°、60°、90°位时，双束组与AMB组及PLB组差异均显著（P〈0．05），双束重建明显好于ACL单束重建；AMB组与PLB组无显著性差异（P〉0．05）。（3）膝关节内、外翻：双束组、AMB组和PLB组各组之间膝关节内、外翻角度差异不明显。结论双束重建前交叉韧带在恢复膝关节前向稳定性及控制胫骨内、外旋方面均好于单束重建，接近正常。单独前内束重建能较好地恢复膝关节前向稳定性，单独后外束重建ACL不能很好地恢复膝关节前向稳定性，两者均有限制胫骨过度内、外旋转作用。     

后外侧角股骨止点与前交叉韧带解剖重建股骨隧道外口的关系

目的 测量后外侧角（PLC）股骨止点和前交叉韧带（ACL）解剖重建股骨隧道外口的位置,以获得详细的解剖学资料,并以此为ACL和PLC一期解剖重建提供解剖依据。 方法 采用30例新鲜成人尸体膝关节标本。屈膝120°关节镜下经前内辅助入路解剖重建ACL股骨隧道,并用克氏针标记。在膝关节股骨外髁分离出膝关节外侧副韧带（LCL）和腘肌腱(PT)股骨解剖止点。以股骨外上髁为原点,建立x、y垂直坐标轴,测量LCL、PT的股骨解剖中心点和ACL股骨隧道外口在坐标轴的坐标,并测量3点之间的距离。 结果 LCL附丽部中心点在股骨外上髁近端（1.27±3.35）mm,后方（2.99±1.29）mm。PT附丽部中心点在股骨外上髁远端（8.85±3.38）mm、后方（3.83±1.95）mm。ACL股骨隧道外口在股骨外上髁近端（16.12±5.34）mm,后方（6.84±4.17）mm。LCL附丽部中心点与PT附丽部中心点相距（9.67±3.92）mm,ACL股骨隧道外口与LCL附丽部中心点相距（13.07±4.93）mm,ACL股骨隧道外口与PT附丽部中心点相距（23.37±6.16）mm。 结论 揭示了LCL、PT的股骨解剖中心点和ACL股骨隧道外口位置的解剖学特点,为临床一期联合解剖重建提供解剖学依据。     

腘肌腱形态特点及其临床意义

目的 为临床腘肌腱损伤的诊断及关节镜下治疗提供解剖学基础.方法 对21个成人膝关节标本进行解剖,观察腘肌腱的形态及其与周围结构关系.结果 腘肌腱出现恒定,起始于腓侧副韧带股骨附着处前下方,穿过股二头肌腱和腓侧副韧带的深面在胫骨平台下与腘肌肌腹相连接.腘肌腱的长度为(40.12±0.91)mm,起点宽度为(6.19±0.27)mm,止点宽度为(6.46±0.35)mm,起点厚度为(3.38±0.24)mm,止点厚度为(3.62±0.25)mm.结论 腘肌腱是组成膝关节后外侧复合体的重要结构之一;深入了解其形态特点,对关节镜下腘肌腱损伤诊断、治疗及解剖重建有重要意义.     

前交叉韧带解剖重建股骨隧道与外侧副韧带解剖重建股骨隧道的关系

目的探讨前交叉韧带(ACL)单束解剖重建股骨隧道与外侧副韧带(LCL)重建股骨隧道的关系,以期为临床中ACL解剖重建提供解剖学数据,便于临床实际操作中避免2个股骨隧道相互干扰,为ACL和LCL一期解剖重建提供依据。方法采用30例成人尸体膝部标本,保留膝关节上下至少20cm,排除关节明显退变、畸形及关节损伤。男性16例,女性14例,年龄在23~66岁,平均年龄38.7岁。屈膝120°经前内辅助入路(AMP)钻取股骨隧道。在股骨外髁外侧面寻找后外侧角(PLC)结构,钝性分离LCL,并钻取LCL隧道。标本进行CT扫描,在CT片上观察隧道碰撞数,并计算两个隧道的最短距离。结果在LCL股骨隧道深度为25mm时,其与ACL股骨隧道最短距离为(3.9±2.4)mm;在LCL股骨隧道深度为30mm时,其与ACL股骨隧道最短距离为(2.7±1.9)mm。在ACL股骨隧道深度为25mm时,其与LCL股骨隧道的最短距离为(4.4±2.6)mm;在ACL股骨隧道深度为30mm时,其与LCL股骨隧道的最短距离为(3.2±2.1)mm。在30例标本中,共发现6例隧道碰撞,碰撞的几率高达20%。结论我们发现两者隧道发生碰撞的几率高,临床一期解剖重建时,术前应做个体化准备,规划好LCL重建所需股骨隧道的长度和隧道直径,从而规避与ACL股骨隧道的碰撞。     

Motion of the anterior cruciate ligament during internal and external rotation at the knee: A cadaveric study

Despite advances in our understanding of anterior cruciate ligament (ACL) anatomy and function, the change in position of the ACL during tibial rotation is not well understood. The purpose of this study was to quantify and compare the movements of the anteromedial (AM) and posterolateral (PL) bundles of the ACL during 15° of medial and lateral rotation (with & without a shear force). Cadaveric knees (12 male/12 female) were dissected and mounted at 90° of knee flexion. Anthropometric features of the ACL and distal femur were recorded, and each bundle was marked at: femoral attachment (FA), midpoint of ligament (MP), and tibial attachment (TA). Digital images of ACL motion in the frontal plane were taken as the tibia was rotated about a fixed femur. Using digitizing software, the change in position of the markers was quantified. Measurements suggested the ACL pattern of motion was consistent between sexes, regardless of shear force. The greatest amount of movement of both the AM and PM bundles occurred at the TA marker. The FA marker moved more during medial rotation, and the MP and TA markers moved more with lateral rotation. The 20 lb‐shear force affected medial rotation most. This study is the first to quantify movement of the ACL during medial and lateral tibial rotation. Data should assist surgeons to select a graft position that is capable of replicating the rotational movement of the native ACL, and help improve three‐dimensional stability of the ACL reconstructed knee. Clin. Anat. 30:861–867, 2017. © 2017 Wiley Periodicals, Inc.     

Fiber orientation of anterior cruciate ligament: An experimental morphological and functional study,part I

The anterior cruciate ligament (ACL) is divided morphologically as well as functionally into anteromedial and posterolateral bundles. The changes in distance between femoral and tibial attachment sites of both bundles were measured throughout the full range of motion in ten formalin-carbol preserved cadaveric knees. The femoro-tibial distance (and thus the length) of the anteromedial bundle remains nearly the same throughout the full range of motion. The femoro-tibial distance for the posterolateral bundle decreases with flexion; thus it becomes increasingly slack from 0° to 90° of flexion. For a truly functional replacement of the ACL, in which the roll-glide motion of the knee joint is regained, isometric reconstruction of the anteromedial bundle is necessary. By utilizing the described method of intraoperative measurement, isometric positioning of the graft may be achieved. © 1993 Wiley-Liss, Inc.     

Relationship between anterior cruciate ligament and anterolateral meniscal root bony attachment: High-resolution 3-T MRI analysis

BackgroundThe tibial bony attachments of the anterior cruciate ligament (ACL) and the anterolateral meniscal root (ALMR) are very close, and drilling the tibial tunnel in ACL reconstruction may damage the ALMR attachment. This study investigated the relationship between the tibial attachment of the ACL and ALMR using high-resolution 3-T magnetic resonance imaging (MRI).MethodsTwenty healthy subjects (35.8 ± 13.0 years) had 20 knees scanned using high resolution 3-T MRI. The tibial bony attachments of ACL, ALMR, and the tibia were segmented and three-dimensional models were created. The shape, area, and location of each attachment were evaluated using this model.ResultsThe ACL tibial attachment was elliptical in nine knees (45%), C-shaped in nine knees (45%) and triangle in two knees (10%). The mean values of the ACL vs ALMR tibial attachments were as follows: area, 106.2 ± 21.3 vs 56.2 ± 21.3 mm²; length, 16.8 ± 2.0 vs 11.0 ± 1.8 mm; and width, 6.9 ± 1.3 vs 6.6 ± 1.0 mm. The location of the ACL vs ALMR attachment centres was 46.5 ± 1.7% vs 56.5 ± 1.9% in the medial-lateral direction and 36.3 ± 3.6% vs 36.7 ± 3.5% in the anterior–posterior direction. The distance between the ACL and ALMR centres was 8.1 ± 1.3 mm.ConclusionsACL and ALMR tibial attachments were individually distinguished using high resolution 3-T MRI. The short distance between both centres of the attachments may suggest that ALMR can be damaged when the tibial tunnel is drilled in ACL reconstruction.     

The anterior cruciate ligament–lateral meniscus complex: A histological study

The anterior root of the lateral meniscus (LM) dives underneath the tibial attachment of the anterior cruciate ligament (ACL). Although the distinct role of meniscal attachments has been investigated, the relationship between the LM anterior insertion (LMAI) and ACL tibial insertion (ACLTI) remains unclear. This study histologically analyzed the LMAI and ACLTI. Samples were divided into four regions in an anterior-to-posterior direction. Histological measurements of these insertion sites were performed using safranin O-stained coronal sections. Distribution and signal densities of type I and II collagen were quantified. The ACLTI and LMAI formed the ACL–LM complex via fiber connections. The anterior part of the ACLTI had a widespread attachment composed of dense fibers. Attachment fibers of the LMAI became dense and wide gradually at the middle-to-posterior region. The ACL–LM transition zone (ALTZ) was observed between the LMAI and the lateral border of the ACLTI at the middle part of the ACL tibial footprint. Type II collagen density of the LMAI was higher than that of the ACLTI and ALTZ. Our results can help create an accurate tibial bone tunnel within the dense ACL attachment during ACL reconstruction surgery.     

Microstructure Variations in the Soft‐Hard Tissue Junction of the Human Anterior Cruciate Ligament

The role of the sub‐bundles in the anterior cruciate ligament (ACL) has been defined, such that the anterior‐medial bundle directly resists anterior tibial translation while the posterior lateral bundle is involved in rotational stability. With regards to this biomechanical function, much of the previous work on bundle‐specific morphology has been carried out on the macroscale, with much less attention given to the micro‐to‐ultrastructural scalar levels. This is especially true of the enthesis and its microstructure, a biomechanically significant region that has been largely neglected in the published literature dealing with ACL sub‐bundle anatomy. In this study, the human ACL tibial enthesis was investigated at multiple scalar levels using differential interference contrast and scanning electron microscopies with the aim of determining whether the sub‐bundle ligament structure, and its known macroscale function, is consistent with its micro‐architecture at the ligament–bone junction. The investigation found that different ligament insertion morphologies exist between the two bundles, where the AM bundle has more intense interdigitation with the bone matrix than that of the PL bundle. The results suggest that such structure–function relationships, especially across scalar‐levels, provide new insight into the significance of the sub‐bundle anatomy of the ACL. Anat Rec, 300:1547–1559, 2017. © 2017 Wiley Periodicals, Inc.     

Partial ACL tears augmented with distally inserted hamstring tendons and over-the-top fixation: an MRI evaluation

This study evaluated the mid-term MRI appearance of partial ACL tear augmentation with quadrupled distally inserted hamstrings, while preserving the intact ACL bundle. Twenty-eight patients with ACL partial tear underwent augmentation. After 15-40 months follow-up, patients were evaluated clinically and by MRI. The mean IKDC score at follow-up was 93.8. Twenty-five patients were rated as excellent, three as fair. The mean tibial tunnel section area decreased by 27%. A correlation was noted between the clinical and MRI results: the graft was not visible or continuous with high intensity areas and the mean decrease in the tunnel section area was 3% in the three cases rated as fair. The graft appeared continuous and low intensity and the reduction in tibial tunnel section area was 30% in the cases with excellent clinical results. The residual part of the ACL was still recognizable in 79% of cases. The tibial hamstring attachment appeared normal in 93% of cases. In conclusion, excellent results correlated with a decrease in tunnel size and normal graft appearances on MRI. The poor results showed that the graft was not visible or not continuous, with high intensity areas and intra-ligamentous cystic formation within the tunnel. MRI scanning is useful in evaluating hamstring ACL grafts after reconstruction.     

The restraining function of the cruciate ligaments on hyperextension and hyperflexion of the human knee joint

Each of the cruciate ligaments contains functionally different fiber groups; one fiber bundle is always taut; numerous others are taut in intermediate or extreme positions. The bulk of the fibers of the anterior cruciate ligament (ACL) is taut in maximal extension, while that of the posterior cruciate ligament (PCL) is taut in the intermediate positions and in maximal flexion. Fibers taut in extreme positions serve as restraints: during hyperextension, the ACL restrains forward migration of its tibial attachment, while the PCL interacts with other structures to prevent posterior opening of the joint. The inverse situation occurs in hyperflexion. Cruciate fibers are dissimilar in length and angular arrangement so that, when movements are restrained, they lengthen to different extents. To define this phenomenon in quantitative terms, the term isokolyons was coined for lines from which fibers showing identical elongation in percentage on exposure to a force take their origin.     

Computer investigation of ACL orientation during passive range of motion

No quantitative data are reported in the literature regarding the orientation of anterior cruciate ligament (ACL) fibers during passive range of motion. In this study we performed an original qualitative and quantitative analysis in eight cadaver knees, examining ACL elongation and 3D orientation. Computer elaboration of anatomical and kinematic data obtained by a six degrees-of-freedom electrogoniometer enabled a mathematical and statistical evaluation of the 3D behavior of the ACL. Our data confirmed the isometric behavior of ACL. The inclination of ACL with respect to the tibial plateau decreases with flexion from 56 degrees to 33 degrees. Orientation of ACL with respect to the femoral notch increases with flexion from 4 degrees to 58 degrees. The ACL orientation in a medio-lateral direction changes from 24 degrees to 52 degrees. The postero-lateral and the antero-medial bundle have different angular variations, mainly with respect to the tibial plateau and medio-lateral direction. This quantitative and qualitative information not only increases the anatomical knowledge of the ACL, but could also be important in developing or improving the surgical strategy for ACL reconstruction.