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.     

Knee laxity in cruciate ligament injury: Value of examination under anesthesia

Arthrometry was performed before and during anesthesia in 41 patients with acute or old anterior cruciate ligament injuries and only minor signs of valgus or varus instability. The uninjured contralateral knee served as a control. The influence of anesthesia on the anterior stability was distinct in acute knee injuries. There was also a small, but definite, increase in anterior laxity in uninjured knees. Knees with old injuries were more lax, and the injured-uninjured difference in anterior laxity was more pronounced. Stability examination under anesthesia is of great value for acutely injured knees.     

Knee laxity in cruciate ligament injury. Value of examination under anesthesia

Arthrometry was performed before and during anesthesia in 41 patients with acute or old anterior cruciate ligament injuries and only minor signs of valgus or varus instability. The uninjured contralateral knee served as a control. The influence of anesthesia on the anterior stability was distinct in acute knee injuries. There was also a small, but definite, increase in anterior laxity in uninjured knees. Knees with old injuries were more lax, and the injured-uninjured difference in anterior laxity was more pronounced. Stability examination under anesthesia is of great value for acutely injured knees.     

Diagnosis and treatment of the cruciate ligament injury of knee joint

During 1959 to 1986, 62 Cases with cruciate ligament injury of the knee joint were treated in our hospital. Thirty of these cases were anterior cruciate ligament injuries and 32 cases were posterior The diagnosis of the cruciate ligament injuries was made by stability tests of the cruciate ligament. When the knee was greatly swollen with multiple ligament injuries, a series of X-ray films should be taken to test the knee stability under local or nerve block anesthesia. Fresh tear of the cruciate ligament (33 cases) was treated with immediate surgical repair except in one. Old ligament injuries (28 cases) were treated by conservative method (10 cases) or surgical reconstruction (18 cases). All patients were followed for 2 to 18 years (mean 6 years). The results showed that the fresh tear of the cruciate ligament treated surgically had excellent and good rates in 87.9% (29/33). In the conservative treatment group, only 27.3% (3/11) obtained good result, and most of them were complicated with meniscal lesions and osteoarthritis. Eighteen cases treated by ligament reconstruction gave 34.5% (8/18) good result.     

分期修复重建膝关节多发韧带损伤的临床疗效

目的 :探讨关节镜下分期治疗膝关节多发韧带损伤的临床疗效。方法 :2006年3月至2012年6月,关节镜下分期治疗膝关节多发韧带损伤14例(14膝)。男8例,女6例;年龄20~49岁,平均(31.8±8.1)岁。患者均行X线、MR检查,提示10例前交叉韧带、后交叉韧带及内侧副韧带损伤,4例前交叉韧带、后交叉韧带及后外侧角损伤。合并内侧半月板损伤4例,外侧半月板损伤2例。Ⅰ期手术治疗内侧副韧带损伤、后交叉韧带及半月板,术后固定3周后开始主被动功能锻炼,3~6个月后膝关节活动范围正常且存在明显松弛时Ⅱ期重建前交叉韧带和(或)后交叉韧带。结果:术后切口均Ⅰ期愈合,无感染等手术相关并发症发生。患者均获随访,时间24~80个月,平均48.9个月。末次随访时膝关节Lysholm评分达87.1±2.8,优于术前19.6±0.9(t=12.3,P0.01)。国际膝关节评分委员会(International Knee Documentation Committee,IKDC)评级:9例接近正常,5例异常。结论 :关节镜下分期治疗膝关节多发韧带损伤能有效恢复膝关节稳定性和功能。     

Comparison of magnetic resonance imaging with operative findings in acute traumatic dislocations of the adult knee

OBJECTIVES: To compare magnetic resonance imaging (MRI) with examination under anesthesia and with surgical findings in evaluating soft tissue injuries in acute traumatic knee dislocations in adults. DESIGN: Retrospective analysis. SETTING: Level I trauma center. PATIENTS: For a single surgeon, all patients who underwent MRI before surgical treatment for knee dislocations (ten individuals). INTERVENTION: Incompetent ligaments were repaired or reconstructed. MAIN OUTCOME MEASUREMENTS: MRI of knee dislocations was compared with clinical examination under anesthesia and with intraoperative findings at arthrotomy in ten cases. Pertinent positive and negative findings were recorded, and accuracy, sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Two mid-grade sprains of the anterior cruciate ligament were erroneously read as complete tears. One rupture or avulsion of each the biceps tendon, the lateral collateral ligament, and the posterolateral and posteromedial corners were considered intact on MRI. The MRI studies erroneously identified tears of the lateral collateral ligament and medial meniscus in one case each. Otherwise, the study was highly accurate. CONCLUSIONS: MRI is useful for defining the presence of ligamentous injuries in knee dislocations; however, clinical examination under anesthesia is more accurate.     

膝关节脱位多韧带损伤Ⅰ期修复重建的临床观察

目的:探讨关节镜下Ⅰ期异体肌腱重建并结合关节外微创技术治疗膝关节脱位合并多发韧带损伤的临床疗效。方法:2008年1月至2012年1月共收治48例膝关节脱位患者,排除腘血管损伤,采用关节镜下Ⅰ期重建前后交叉韧带,并结合关节外微创技术修复膝关节韧带损伤。男38例,女10例;年龄20～59岁,平均35.6岁;左膝22例,右膝26例;伤后至手术时间2 d～2周。前交叉韧带(ACL)、后交叉韧带(PCL)、内侧副韧带(MCL)及后外侧复合体(PLC)损伤2例,ACL、PCL及MCL损伤36例,ACL、PCL及PLC损伤10例。合并腓总神经损伤4例。比较术前及末次随访时Lysholm 评分以评价膝关节功能。结果:所有患者获得随访,时间12～30个月,平均(18.2±6.3)个月,患者关节活动度和稳定性明显改善,Lysholm评分由术前40.3±4.1提高为随访时87. 0±6.4.结论:关节镜下应用同种异体肌腱Ⅰ期重建膝关节脱位并多韧带损伤,能较好地恢复关节稳定性,保留关节功能。术前训练指导及术后个体化康复是膝关节功能恢复的关键。     

Comparison of “catheter” and conventional arthroscopy in the diagnosis of knee derangements

The diagnostic efficiency of the Optical Catheter System (OCS), which uses a 1.7-mm arthroscope, was compared with that of conventional arthroscopy in 50 patients with various knee derangements in standard arthroscopic conditions. Correct diagnoses were obtained with the OCS in 98% of anterior cruciate ligament derangements—92%–98% of those involving the medial and lateral meniscus, respectively—and 96% of cartilage disorders. No false-positives were noted for anterior cruciate ligament and meniscus injuries. False-negatives were caused by abundant intraarticular bleeding (no tourniquet was applied) and peripheral meniscus tears and false-positives by synovial superposition resulting in a mistaken diagnosis of patellar chondromalacia.The OCS proved a good diagnostic tool. Its employment, especially in an outpatient setting, should be restricted to a small number of patients and entrusted to expert arthroscopists.     

膝关节多韧带损伤的手术治疗体会

目的 :介绍膝关节多韧带损伤的手术治疗方法和结果 ,总结治疗的经验与教训。方法 :随访自2008年至2013年经治的26例膝关节多韧带损伤患者,其中男17例,女9例;年龄29~55岁,平均40.7岁。所有患者在关节镜下采用自体或异体肌腱重建交叉韧带,并同时修补内侧副韧带、外侧副韧带及处理内外侧复合体损伤。9例分期手术,其余均采取Ⅰ期手术处理所有损伤。用Lysholm膝关节评分评价手术前后膝关节功能。结果:26例均获随访,时间为0.8~3.2年,平均1.6年,手术平均等待时间为1.2个月。术前膝关节Lysholm评分42.5±4.5(33~48分),终末随访时78.1±3.9(57~95分),随访时评分提高。术后关节活动度均超过90°,内外翻试验正常或接近正常,所有患者在屈70°时Lachman试验阴性。结论 :膝关节韧带多发损伤应首选关节镜下Ⅰ期重建;如无法Ⅰ期同时重建前后交叉韧带,则Ⅰ期先重建后交叉韧带,Ⅱ期重建前交叉韧带;后交叉韧带因多种原因易漏诊,避免因术前准备不充分而分期手术。     

Acute hemarthrosis of the knee: indications for diagnostic arthroscopy

The objective of this study was to define the role of early diagnostic knee arthroscopy for patients with an acute knee injury and hemarthrosis. Forty-five patients with an acute knee injury followed by a posttraumatic hemarthrosis during a 1-year period were prospectively reviewed. All patients were evaluated preoperatively followed by examination under anesthesia and arthroscopy of the knee. The majority of patients, 32 (71%), had an anterior cruciate ligament tear. Meniscal tears occurred in 21 patients (47%). Meniscal tears requiring surgery occurred in only 10 of 25 meniscal tears (40%). Seven patients (16%) had medial collateral ligament and/or posteromedial capsular sprain. Eight patients (18%) had an osteochondral fracture or patellar dislocation associated with an osteochondral fracture. The majority of knees with a torn meniscus or osteochondral fracture had an anterior cruciate ligament tear. Clinically, 18 of 21 knees (86%) with an acute complete anterior cruciate ligament tear were diagnosed preoperatively with the Lachman test. The Lachman test conducted with patients under anesthesia was positive for 19 of 21 knees (90%) with an acute complete anterior cruciate ligament tear. The preoperative examination correctly identified six of seven knees (86%) with a medial collateral ligament sprain. The preoperative Lachman test was positive in only two of five knees (40%) with a partial anterior cruciate ligament tear. The Lachman test with patients under anesthesia was positive for four of five knees (80%) with an acute partial anterior cruciate ligament tear. Preoperative examination yielded the correct diagnosis in only 9 of 21 knees (43%) with a meniscal tear and 1 of 6 knees (17%) with an osteochondral fracture.(ABSTRACT TRUNCATED AT 250 WORDS)     

急性完全性前交叉韧带损伤的膝关节镜下早期重建治疗

目的　探讨膝关节镜下对急性完全性前交叉韧带 (ACL)断裂的早期重建治疗 ,以尽早恢复膝关节稳定性。　方法　ACL急性断裂早期在关节镜下应用挤压螺钉固定骨 髌腱 (中 1/ 3) 骨复合体自体移植重建ACL ,止点重建或缝合修复治疗内侧副韧带断裂。　结果　 1998年 2月～ 1999年 3月共治疗急性完全性ACL断裂合并内侧副韧带断列患者 10例 ,术后平均随访 10个月 ,近期效果良好。　结论　急性ACL损伤早期可以在关节镜下完成重建 ,手术创伤小 ,治疗及时 ,可同时处理合并损伤 ,能早期恢复膝关节稳定性和运动功能。     

关节镜下前交叉韧带袖套状保残重建的临床效果

目的:观察袖套状保留残端的关节镜下前交叉韧带重建的临床效果。方法:收集2012年1月至2014年12月于骨科就诊的42例前交叉韧带损伤患者,其中男17例,女25例,平均年龄28.4岁,平均受伤时间5.5周(2~12周)。采用关节镜下重建前交叉韧带,同时保留胫骨侧韧带残端,通过滑膜袖套恢复残端张力。治疗前及治疗后2、6、12个月采用Lachman试验、前抽屉试验对稳定性进行评价,术后12个月采用Lysholm评分和Tegner运动分级评价膝关节功能。治疗前和治疗后12个月行膝关节MRI检查。结果:术后2、6、12个月Lachman试验、前抽屉试验均为阴性。术前Lysholm评分37.8±7.1,Tegner评分2.1±0.4;术后12个月的Lysholm评分96.8±6.1,Tegner评分6.2±0.9,均高于术前。术后12个月复查MRI显示前交叉韧带显影良好。结论:关节镜下前交叉韧带袖套状保残重建可以获得良好的临床效果。     

LARS人工韧带关节镜下重建膝前交叉韧带

目的 探讨关节镜下LARS人工韧带治疗膝关节前交叉韧带（ACL）完全性损伤的疗效。方法对12例ACL完全损伤患者实施关节镜下LARS人工韧带重建术。结果12例均获随访,时间3～11个月,膝关节前直向不稳症状均消失,前抽屉试验阴性,关节功能良好,未并发急性滑膜炎。患膝伸屈度0°～120°。根据Lysholm膝关节评分法,膝关节评分由术前（45．45±1．18）分提高到术后（84．77±2．26）分。结论LARS人工韧带组织相容性好,是理想的韧带移植材料。关节镜下LARS人工韧带重建ACL完全性损伤疗效好,创伤小,并发症少,患膝稳定性早期即可完全恢复,术后关节功能能达到正常运动要求。     

关节镜下Rigidfix交叉钉和Intrafix固定钉固定同种异体肌腱重建膝关节交叉韧带的病例对照研究

目的：探讨关节镜辅助下应用Rigidfix交叉钉和Intrafix固定钉固定同种异体肌腱,重建膝关节前交叉韧带（anterior cruciate ligament,ACL）和后交叉韧带（posterior cruciate ligament,PCL）的近期临床疗效.方法：2009年1月至2010年6月在关节镜下采用异体肌腱联合应用Rigidfix交叉钉与Intrafix固定钉治疗ACL或PCL损伤34例,分为两组：ACL重建组（A组）和PCL重建组（B组）.A组24例,男19例,女5例;平均年龄（31.83±9.57）岁;在关节镜下移植同种异体肌腱重建ACL,股骨侧用Rigidfix交叉钉固定,胫骨侧用Intrafix固定钉固定.B组10例,其中男8例,女2例;平均年龄（27.20±7.59）岁;在关节镜下移植同种异体肌腱重建PCL,股骨侧用Intrafix固定钉固定,胫骨侧用Rigidfix交叉钉固定.术后即行前后抽屉试验及Lachman试验检查膝关节稳定性,并随访患者18个月以上,采用膝关节Lysholm评分和Tegner评分进行疗效评估.结果：34例均获随访,时间18～26个月,平均（20.79±2.39）个月.所有患者术后疼痛症状消失,前、后抽屉试验及Lachman试验阴性.A组术前Lysholm评分43.04±7.57,术后6、12、18个月增加至85.41±4.68、92.50±3.05和93.45±2.57;术前Tegner评分2.62±0.92,术后6、12、18个月分别增加至7.45±1.14、8.58±0.77和8.95±0.55.B组术前Lysholm评分46.20±8.27,术后6、12、18个月分别增加至86.40±5.14、90.40±2.67和92.00±3.85;术前Tegner评分2.00-0.66,术后6、12、18个月分别增加至7.10±0.99、8.60±0.84和8.80±0.42.两组患者各时间点Lysholm和Tegner评分差异均无统计学意义.所有患者术前Lysholm评分43.97±7.79,术后6、12、18个月分别增加至85.70±4.76、91.88±3.06和93.02±3.01;术前Tegner评分2.44±0.89,术后6、12、18个月分别增加至7.35±1.09、8.58±0.78和8.91±0.51.随访期间无明显排异反应及严重并发症发生.结论：关节镜下采用Rigidfix交叉钉和Intrafix固定钉固定同种异体肌腱重建膝关节交叉韧带方法简?     

双极射频在前交叉韧带重建中的应用

目的:探讨关节镜下双极射频在前交叉韧带重建术中的应用。方法:在关节镜下应用双极射频对16例前交叉韧带重建术中的移植物进行皱缩,男12例,女4例;年龄18～46岁,平均31岁。单纯前交叉韧带损伤5例,合并半月板损伤10例,合并后交叉韧带损伤1例。术中和术后对所有病例观察随访,记录临床检查结果和Lysholm评分。结果:术中可见应用双极射频处理后的韧带逐渐收缩变短,韧带张力明显提高,麻醉状态下抽屉试验和Lachman试验均呈阴性。术后随访6～13个月,平均9.5个月,膝关节主观和客观稳定性均明显改善,Lysholm评分从术前(51.7±3.9)分提高到(86.2±3.5)分(P<0.01)。结论:关节镜下应用双极射频在前交叉韧带重建术中对移植物进行皱缩,可使重建韧带收缩变紧,提高关节的稳定性。     

Neuromuscular dynamic restraint in women with anterior cruciate ligament injuries

The purpose of this study was to identify neuromuscular characteristics related to dynamic restraint in the knee. Observing compensatory changes to these characteristics in women with anterior cruciate ligament injuries provides important information for understanding functional knee stability, injury prevention, and performance. Twelve female subjects with anterior cruciate ligament injuries and 17 female control subjects participated in this study to assess electromyographic activity during landing from a hop and knee perturbation; hamstring muscle stiffness and flexibility; and isokinetic strength. Females with anterior cruciate ligament deficiencies had significantly increased preparatory muscle activity in the lateral hamstring before landing, but no differences in reactive muscle activity during landing or reflex latency after joint perturbation. Females with anterior cruciate ligament deficiencies had significantly less hamstring muscle stiffness and flexibility, but also had greater peak torque and torque development for knee flexion. Lower Lysholm scores were observed in females with anterior cruciate ligament deficiencies but no difference was found in functional performance of the single leg hop test. These neuromuscular characteristics provide a foundation for future research investigating injury prevention and rehabilitation techniques that maximize dynamic restraint through stiffness regulation and the timing of specific muscle activation strategies.     

全关节镜下膝关节后外复合体重建

目的 介绍全关节镜下腘肌腱重建、腘肌腱联合腘腓韧带重建或膝关节后外复合体(posterolateral corner,PLC)解剖重建的手术技术,探讨全关节镜下PLC重建治疗膝关节后外不稳定的效果.方法 2008年8月至2010年4月,共完成全关节镜下后十字韧带(posterior cruciate ligament,PCL)+PLC重建手术34例.患者在接受手术时平均年龄34.1岁(15～52岁);男32例,女2例;从受伤到手术平均10.7个月.所有病例均为陈旧性损伤,且均为复合韧带损伤.所有PCL损伤的病例都存在PLC损伤.合并前十字韧带损伤6例(17.6%),合并前十字韧带、内侧副韧带损伤2例(5.9%),合并内侧副韧带损伤5例(14.7%).对膝关节PLC损伤进行分型,采用不同的重建技术进行治疗.对于A型旋转不稳定,采用全关节镜下腘肌腱重建、腘肌腱联合腘腓韧带重建;对于C型后外不稳定,采用全关节镜下PLC解剖重建.结果 14例患者获得随访并进行二次关节镜检查,平均随访18.5个月(13～25个月).终末随访包括:膝关节查体、KT-1000测量、膝关节应力像和胫骨外旋稳定性.使用膝关节应力像测量胫骨后移程度,胫骨后移由术前平均15.56mm减少为术后5.16mm,手术前后差异有统计学意义.使用屈膝30°位胫骨外旋试验评估膝关节后外旋转不稳定.对比患侧与健侧胫骨外旋的差值,由术前平均14.92°减小为术后-0.22°,手术前后差异有统计学意义.术后患者平均屈曲受限4.23°,无伸膝受限.结论 对于膝关节PLC损伤导致的不稳定,采用全关节镜下PLC重建的手术技术,能够有效恢复膝关节后外旋转不稳定.这种手术技术能够与PCL重建联合应用.

Abstract：

Objectiye To introduce the surgical technique of arthroscopy assisted anatomical posterolateral corner (PLC) reconstruction,including popliteal ligament,popliteofibular ligament and lateral collateral ligament,and evaluate the results of this technique.Methods From August 2008 to April 2010,34arthroscopic posterior cruciate ligament (PCL) and PLC reconstruction surgeries were performed.The average age of the patients was 34.1 (15-52) years.There were 32 males and 2 females.The average time period from injury to surgery was 10.7 months.All patients were chronic injuries and combined ligament injuries,including PCL and PLC injuries.Some cases had other ligament injury,including 6 patients of anterior cruciate ligament (ACL) injury (17.6%),2 of ACL combined medial cruciate ligament (MCL) injuries (5.9%),and 5 of MCL injuries (14.7%).According to Fanellis classification,for type A posterolateral rotation instability,we performed arthroscopic popliteal ligament reconstruction or popliteal ligament combined popliteofibular ligament reconstruction.For type C posterolateral instability,we performed arthroscopic PLC anatomical reconstruction.Results During the follow-up period,14 patients had undergone a second look arthroscopic examination and removal of hardware.The average follow-up time was 18.5 months (13-25 months).At the final follow-up,physical examination,stability evaluation with KT-1000 and Telos stress view,and dial test were performed.The posterior displacement of the knee had decreased from 15.56 mm preoperatively to 5.16mm postoperatively.The external rotation instability had decreased from 14.92° preoperatively to -0.22°postoperatively.The average limitation of knee flexion was 4.23° and no knee extension was limited.Conclusion With the surgical technique of arthroscopy assisted anatomical PLC reconstruction,we can restore the external rotation stability of knee.This technique can be performed combine with PCL reconstruction.     

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.     

Interface and biocompatibility of polyethylene terephthalate knee ligament prostheses A histological and ultrastructural device retrieval analysis in failed synthetic implants used for surgical repair of anterior cruciate ligaments

In a prospective clinical study of 54 patients with acute anterior cruciate ligament instability, 56 artificial ligaments made of polyethylene terephthalate (Trevira hochfest) were implanted to restore knee stability. The average follow-up of these artificial knee ligaments was 40.2 (12–79) months; five implants (10%) had to be explanted due to failure after an average of 17.8 (6–50) months. All explants were examined by histological and ultrastructural methods in a device retrieval analysis. With regard to short- and medium-term artificial ligament failure in the human knee joint, a non-isometric surgical implantation technique, inappropriate strain during rehabilitation and implant fatigue and wear were responsible for ligament failures.     

Editorial Commentary: The Measurement of Knee Laxity: Instrumented Measurement and Stress Radiography for Anterior Cruciate Ligament Injuries

The measurement of anterior knee laxity in anterior cruciate ligament injuries is an established method for both clinical practice and clinical studies in regard to anterior cruciate ligament surgery. Stress radiography was succeeded or paralleled by instrumented testing with the development of standardized devices starting in the 1980s. Because knee stability depends on the flexion angle test, conditions need to be comparable for both instrumented testing and stress radiography. The lack of a general consensus becomes even more evident for testing and measuring rotational instability. Knee laxity measurement in all dimensions, such as with robots in cadaver studies, has not found its general application in the clinical setting yet, but will be expected in the near future.