前交叉韧带重建中不同入路制备股骨骨道的对比研究

目的:比较改良经胫骨隧道(TT)入路和前内侧(AM)入路两种方法解剖位重建前交叉韧带(ACL)术后,股骨隧道的定位情况及临床疗效。方法:回顾性分析2016年1月～2017年12月我科收治的42例单侧前交叉韧带损伤患者的临床资料。其中24例采用改良TT入路技术重建ACL,18例采用AM入路技术重建ACL。术后1周内行膝关节CT平扫+三维重建评估股骨骨道位置,术后3个月时扫描MRI并测量JGS、JGC角;术前及术后12个月评估患者国际膝关节文献委员会(IKDC)评分、Lysholm评分、膝关节前方松弛度及轴移试验结果。结果:术前两组患者性别、年龄、病程、IKDC评分、Lysholm评分、膝关节前方松弛度、轴移试验阴性率,差异均无统计学意义(P>0.05)。末次随访时,两组患者IKDC评分、Lysholm评分,前方松弛度,轴移试验阴性率相较术前均显著改善,差异具有统计学意义(P<0.05);组间比较,差异无统计学意义(P>0.05)。CT三维重建分析显示,两组股骨骨道内口位置无明显差异(P>0.05),MRI测量JGS、JGC角,组间无明显差异(P>0.05)。结论:采用改良经胫骨隧道入路和前内侧入路重建ACL,均可获得良好的股骨解剖中心隧道定位,骨道位置无明显差异,术后早期疗效令人满意。     

单束重建前交叉韧带骨道位置对临床效果影响的研究

目的:探讨前交叉韧带重建术骨道位置对临床效果的影响。方法:2005年5月至12月于我所行自体腘绳肌腱单束重建前交叉韧带手术患者72例,采用其侧位X线平片测量骨道位置,结合膝关节功能评分、KT-2000测试结果进行分析。结果:患者的IKDC、Lysholm和Tegner评分以及KT-2000在134N下屈膝30度和90度位膝关节前后位移情况均较术前显著改善(P<0.01)。股骨骨道位于Blumensaat’s线的后23.87%,胫骨骨道位于胫骨平台全长的前38.25%。膝关节伸直受限患者胫骨骨道位于胫骨平台前34.19%,伸直正常患者胫骨骨道位于胫骨平台的前38.91%,二者相比具有显著性差异(P<0.05〉。KT-2000屈膝30度位膝关节前后位移值大于等于3mm患者的胫骨骨道位于胫骨平台的前44.78%,位移小于3mm患者胫骨骨道位于胫骨平台的37.39%,二者相比具有显著性差异(P<0.01)。结论:单束重建前交叉韧带手术使患者关节稳定性与功能均得到显著改善。X线测量可较客观、准确地反映骨道定位情况,骨道位置与临床效果相关;本次研究显示比较理想的骨道位置在X线侧位片上位于胫骨平台的前34~37%。     

3D打印导向器辅助关节镜下前交叉韧带重建术骨隧道准确性的对比研究

目的依据膝关节影像学定制前交叉韧带重建3D打印定位导向器(专利号:201620246858.0),研究3D打印定制前交叉韧带重建导向器辅助关节镜下行前交叉韧带重建的股骨、胫骨隧道定位可行性及准确性。方法 2015年1月—2017年6月,在陆军军医大学附属大坪医院骨科诊断急性前交叉韧带断裂的患者中,随机数字表法分成3D打印组与传统手术组,两组患者均50例。3D打印组男性38例,女性12例,平均年龄(28.8±7.3)岁,采用自行研制的3D打印前交叉韧带重建定位导向器,辅助关节镜下进行前交叉韧带重建术定位关节内股骨、胫骨隧道口位置;传统手术组男性40例,女性10例,平均年龄(30.0±7.8)岁,采用传统经胫骨隧道重建前交叉韧带方法关节镜下定位关节内股骨、胫骨隧道口位置,胫骨隧道端采用羟基磷灰石挤压螺钉固定,股骨隧道端微孔钢板(Endobutton)悬吊固定。术后常规照射膝关节正侧位X线片,采用Klos测量法评估胫骨隧道,Amis测量法评估股骨隧道,并对两组患者进行平均随访1年,最少随访时间6个月,记录术前及术后膝关节活动范围,术前与术后Lachman试验,评估术前及术后Lysholm评分、Tegner评分,并进行统计学分析。结果 3D打印组中Amis测量法评估股骨隧道位置测量平均值为(45.6±1.5)%,传统手术组测量平均值(41.4±1.4)%;Klos测量法对胫骨隧道位置测量评估,3D打印组测量平均值(62.7±3.3)%,传统手术组测量平均值(57%±2.6)%,差异均有统计学意义(P0.05);Lysholm评分3D打印组由术前(57.36±5.76)分提高至术后(96.42±1.39)分,传统手术组由术前(57.06±5.61)分提高至术后(96.12±1.39)分,Tegner评分3D打印组由术前(3.44±0.5)分提高至术后(5.96±0.8)分,传统手术组由术前(3.5±0.5)分提高至术后(6.1±0.78)分;膝关节活动范围3D打印组由(88.6±14.2)°提高至术后(117.3±5.7)°,传统手术组由(87.4±9.2)°提高至术后(119.3±5.3)°。结论基于CT和磁共振等影像学分析设计的3D打印前交叉韧带重建导向器辅助关节镜下进行前交叉韧带重建定位关节内股骨、胫骨隧道口位置比传统经胫骨隧道进行前交叉韧带重建的隧道内口更接近前交叉韧带止点解剖位置,但两组患者术后临床膝关节活动度及功能评分差异无统计学意义。     

关节镜下单骨道双束和单骨道单束重建前交叉韧带疗效的初步对比研究

目的:前瞻性对比研究单骨道双束和单骨道单束腘绳肌腱重建前交叉韧带的疗效差异。方法:2011年10月至2012年3月,共48例初次前交叉韧带断裂患者入选本研究,随机分为单骨道双束组(n=24)和单骨道单束组(n=24),分别采取关节镜下单骨道双束和单骨道单束重建前交叉韧带手术技术,移植物均使用自体腘绳肌腱。两组胫骨骨道均用Tibial Intrafix固定,单骨道双束组股骨骨道用Femoral Intrafix固定,而单骨道单束组股骨骨道用Endobutton固定。术后随访分别采用IKDC、Lysholm和Tegner评分进行主观膝关节功能评价,采用KT-2000测量客观评估稳定性。结果:48例患者均获随访,平均随访时间(14.71±1.69)个月。两组功能评分显示,术后IKDC、Lysholm和Tegner评分较术前均显著改善,但组间无显著性差异。两组术后客观稳定性评估较术前均显著提高,但组间无显著差异。在134N拉力下KT-2000测量侧侧差值:单骨道双束组屈膝30°时为(1.44±1.28)mm,屈膝90°为(1.15±1.30)mm;单骨道单束组屈膝30°时为(1.63±1.15)mm,屈膝90°为(1.31±1.26)mm。结论:单骨道双束腘绳肌腱重建前交叉韧带能够很好恢复膝关节前向稳定性,手术操作简便,固定牢固,近期疗效满意;但与单骨道单束重建前交叉韧带相比,膝关节主观功能评分和客观稳定性评估均无明显差别,需进一步研究。     

导航下前交叉韧带重建手术与关节镜下重建手术骨隧道位置的对比研究

目的:将计算机辅助手术技术(导航系统)应用于前交叉韧带重建手术,分组测量导航手术和同期进行的传统关节镜下手术中股骨和胫骨隧道位置,通过数据分析比较评估导航系统辅助前交叉韧带重建手术的精确性和可重复性。方法:自2005年12月至2006年5月,导航下完成47例关节镜下前交叉韧带重建手术。选取其中连续进行的40例导航手术作为研究组,再选取40例同期连续进行的传统关节镜手术作为对照组,对两组手术后的股骨和胫骨隧道关节内口位置进行比较测量。胫骨隧道位置的测量采用Klos推荐的方法进行测定,股骨隧道按照Amis法进行测量。结果:导航手术组胫骨隧道关节内出口位置平均值45.35%(标准差3.827%,范围37%～53%),传统关节镜手术组胫骨隧道关节内出口位置平均值41.05%(标准差6.008%,范围25%～54%),两组结果差异有显著性意义(P<0.05),导航手术组标准差小于关节镜手术组。导航手术组股骨隧道关节内入口位置平均值62.25%(标准差5.610%,范围52%～73%),传统关节镜手术组股骨隧道关节内入口位置平均值56.62%(标准差7.316%,范围46%～77%),两组结果差异有显著性意义(P<0.05),导航手术组标准差小于关节镜手术组。结论:导航系统应用于关节镜下前交叉韧带重建手术与传统关节镜下重建手术相比,股骨和胫骨的隧道位置均明显偏后,更接近前交叉韧带的解剖位置,导航手术组的可重复性明显高于传统手术组。     

腂绳肌腱结与骨栓嵌入固定法关节镜下重建后交叉韧带初探

目的探讨自体腂绳肌腱结与骨栓嵌入固定法关节镜下重建后交叉韧带(PCL)损伤的可行性.方法自2000年1月～2002年5月对10例PCL损伤,取自体半腱肌、股薄肌腱进行重建.根据移植肌腱的直径建立隧道,股骨隧道的下1/3和胫骨隧道的直径为5-7mm,股骨隧道近2/3段为11-12mm,股骨隧道呈倒置的酒瓶状.肌腱预张力后中间打结并嵌入12mm×6mm骨栓,将肌腱从股骨隧道经后关节腔牵入胫骨隧道,分2束在胫骨隧道穿出,交叉打结缝合固定在骨桥上.结果所有患者术后膝关节屈伸功能无受限,关节稳定性加强,抽屉试验阴性8例,Ⅰ°阳性2例.按照膝关节韧带损伤的功能评估标准,优6例,良3例,可1例.结论自体腂绳肌腱打结骨栓嵌入挤压固定重建PCL,方法可行,疗效可靠.生物固定有利于肌腱与骨的愈合,免用高值耗材,不影响MRI检查.     

腘绳肌腱结与骨栓嵌入固定法关节镜下重建后交叉韧带初探

目的 :探讨自体绳肌腱结与骨栓嵌入固定法关节镜下重建后交叉韧带 (PCL)损伤的可行性。方法 :自 2 0 0 0年 1月～ 2 0 0 2年 5月对 1 0例PCL损伤 ,取自体半腱肌、股薄肌腱进行重建。根据移植肌腱的直径建立隧道 ,股骨隧道的下 1 /3和胫骨隧道的直径为 5 -7mm ,股骨隧道近 2 /3段为 1 1 -1 2mm ,股骨隧道呈倒置的酒瓶状。肌腱预张力后中间打结并嵌入 1 2mm×6mm骨栓 ,将肌腱从股骨隧道经后关节腔牵入胫骨隧道 ,分 2束在胫骨隧道穿出 ,交叉打结缝合固定在骨桥上。结果 :所有患者术后膝关节屈伸功能无受限 ,关节稳定性加强 ,抽屉试验阴性 8例 ,Ⅰ°阳性 2例。按照膝关节韧带损伤的功能评估标准 ,优 6例 ,良 3例 ,可 1例。结论 :自体绳肌腱打结骨栓嵌入挤压固定重建PCL ,方法可行 ,疗效可靠。生物固定有利于肌腱与骨的愈合 ,免用高值耗材 ,不影响MRI检查。     

关节镜下膝关节腘肌腱重建的实验研究

目的:进一步研究膝关节后外复合体(posterolateral complex,PLC)与腘肌复合体的解剖特点,设计关节镜下重建腘肌腱的手术方法.方法:通过10例成人膝关节尸体标本进行两部分研究,每部分各取5例标本:第一部分进行大体解剖研究,对腘肌复合体(包括腘肌腱、肌腹、股骨附着点、肌腱-肌腹交界区)的解剖特点以及周围相邻解剖结构(包括胫骨平台、外侧半月板后角、后交叉韧带、胭腓韧带、血管)进行观察和测量.第二部分进行关节镜下手术重建技术的流程设计.设计显露腘肌腱的股骨附着点和肌腱-肌腹交界点的关节镜入路以及股骨和胫骨隧道的定位与制备方法,引入移植物并固定,完成腘肌腱的重建.结果:第一部分:腘肌腱的股骨附着点位于滑膜反折区,属滑膜外结构;止于股骨的腘肌腱沟的最近端,与关节软骨边缘紧邻,与外侧副韧带股骨附着点中心相距1.5～1.6cm.腘肌腱走行于腘肌腱浅沟内、肌腱-肌腹交界点位于胫骨后外侧平台的内、外中线与关节软骨面远侧1.0cm线的交点上,内侧距离后交叉韧带外侧边缘1.2～2.0cm、外侧与上胫腓关节的内侧缘紧邻.第二部分:进行膝关节镜下手术操作.采用前外入路及外侧辅助关节镜入路切除腘肌腱近端附着点周围滑膜反折,显露整个附着区,并利用克氏针确定中心点,自外向内制备股骨隧道.通过后外、后内及穿后间隔关节镜入路,沿腘肌腱走行局部切开与后关节囊的结合部,显露肌腱-肌腹交界点,并利用前交叉韧带重建胫骨导向器定位,自Gerdy结节向该交界点制备前后方向胫骨骨隧道.将移植物引入两隧道,并用挤压螺钉固定.5例标本手术均获成功,移植物可有效控制外旋稳定性.结论:根据解剖研究确定腘肌腱远近端的定位标志,通过关节镜技术进行显露及定位,在关节镜下完成腘肌腱的重建手术具有可行性.     

椭圆形骨道改良重建兔前交叉韧带动物模型的建立

目的:解剖研究兔前交叉韧带止点的大体形态,建立椭圆形骨道改良重建兔前交叉韧带动物模型。方法:18只新西兰大白兔(2.5~3 kg),8只用于前交叉韧带止点解剖研究,10只用于椭圆形骨道动物模型的建立。去除兔膝关节股骨内髁和前交叉韧带周围软组织,观察兔前交叉韧带股骨和胫骨止点形态,并使用游标卡尺对止点长短径进行测量。制作椭圆形骨道扩孔器(截面1.6 mm×2.5 mm),对10只新西兰大白兔右腿行椭圆形骨道重建前交叉韧带作为椭圆形骨道组,对其左腿用传统方法圆形骨道(截面直径2 mm)重建前交叉韧带作为圆形骨道组。取兔自体半腱肌放入骨道并固定,观察移植物与骨道的匹配程度。术后立即对兔双侧膝关节行三维CT扫描,对股骨和胫骨骨道的截面积、长径、短径、直径进行测量。结果:兔前交叉韧带止点的解剖形态为椭圆形。股骨止点的长径为5.28±0.83 mm,短径为2.61±0.33 mm。胫骨止点长径为5.33±0.40 mm,短径为2.68±0.11 mm。移植物肌腱与骨道匹配良好,未见明显空隙。椭圆形骨道组股骨骨道截面积为3.18±0.09 mm~2,胫骨骨道截面积为3.26±0.15 mm~2。圆形骨道组股骨骨道截面积为3.13±0.10 mm~2,胫骨骨道截面积为3.11±0.11 mm~2。椭圆形骨道组和圆形骨道组之间骨道截面积无显著差异。结论:兔前交叉韧带止点为椭圆形。使用自制椭圆形骨道扩孔器可成功构建与圆形骨道相对应的兔椭圆形骨道动物模型,并有很好的移植物与骨道匹配性,为下一步深入研究奠定了实验动物模型基础。     

半腱肌股薄肌腱打结骨栓嵌入固定镜下重建前交叉韧带的初步观察

目的　探讨自体半腱肌、股薄肌腱中间打结、骨栓嵌入挤压固定法在关节镜下重建前交叉韧带 (ACL)的可行性。　方法　 15例前ACL损伤 ,采用自体半腱肌、股薄肌腱中间打结 ,骨栓嵌入挤压固定法镜下重建ACL。半腱肌腱和股薄肌腱预张力后 ,肌腱中间打结嵌入 12mm×6mm骨栓。经ACL导向器打入导针 ,用环钻建立股骨和胫骨隧道。胫骨和股骨隧道下 1 3的直径为 5～ 7mm ,股骨隧道近 2 3为 11mm。将肌腱从股骨隧道的近端经关节腔牵入胫骨隧道 ,将肌腱拉紧、膝关节屈伸活动 2 0次 ,使肌腱结和骨栓完全嵌入瓶颈状股骨隧道内。将 4股肌腱从胫骨隧道和其下方 10mm处分别穿出 ,交叉打结并缝合固定在骨桥上。　结果　 15例患者得到随访 ,关节稳定 ,功能恢复正常。按膝关节疗效评定标准 ,优 11例 ,良 2例 ,可 2例 ,优良率 86.7%。　结论自体肌腱打结骨栓嵌入固定法重建ACL为生物固定 ,创伤小 ,固定可靠 ,费用低 ,有利于愈合 ;可免除金属内固定物 ,术后不影响MRI检查     

Comparison of tunnel positions in single-bundle anterior cruciate ligament reconstructions using computer navigation

Recurrent rotational instability has been identified as a potential source of failure of anterior cruciate ligament (ACL) reconstructions. The aim of the study was to assess whether knee kinematics in the horizontal configuration more closely resemble the intact knee when compared with other single-bundle configurations. Using the Praxim computer navigation system, ACL reconstructions were performed with tibialis anterior grafts in six fresh-frozen whole lower extremity cadaver specimens (12 knees). In each knee, all four reconstruction configurations: conventional (PL tibia to AM femur), anteromedial (AM), posterolateral (PL), and horizontal (AM tibia to PL femur) were performed. Standardized Lachman and pivot shift examinations were performed. For all graft positions during the pivot shift, decreases in the amount of ATT were observed compared with the ACL-deficient state. The knees with grafts placed in the anterior tibial footprint (AM and horizontal) had less ATT with the Lachman and pivot shift maneuvers than knees with grafts placed in the posterior tibial footprint (PL and conventional). A significant difference in depth of impingement was noted only between the AM position and the PL position. Single-bundle ACL reconstructions using graft placement within the anterior footprint on the tibia may reduce rotational instability when compared with more vertical configurations.     

自体骨-髌腱-骨和腘绳肌腱单束重建陈旧性断裂前交叉韧带后移植物愈合形态学和前向稳定性比较

目的:探讨陈旧性前交叉韧带(anterior cruciate ligament,ACL)断裂患者,采用自体骨-髌腱-骨(bone-patellar tendon-bone,B-PT-B)和自体腘绳肌腱(hamstring tendon,HT)单束重建后移植物愈合的形态学表现以及前向稳定性是否存在差异。方法:2000年12月～2003年8月,我所77例受伤病史>12个月的ACL断裂患者,分别采用自体B-PT-B和HT作为移植物,接受了膝关节镜下ACL单束重建,因去除金属内固定进行二次手术,并接受关节镜探查(术后10～32个月,平均14.7个月)。根据移植物种类将其分为B-PT-B组(n=27)和HT组(n=50)两组,比较关节镜下移植物愈合形态学表现,采用膝关节韧带位移测量仪(KT-2000),分别在屈膝30°和90°时测量前向松弛度。结果:B-PT-B组和HT组移植物愈合形态学表现分别为:①韧带完整的分别占96.3%(26/27)和98.0%(49/50),部分断裂占3.7%(1/27)和2.0%(1/50)(χ2=0.000,P=1.000);②滑膜完整的分别占77.8%(21/27)和82.0%(41/50)(χ2=0.119,P=0.655);③滑膜内有明显血管形成的分别占63.0%(17/27)和76.0%(38/50)(χ2=1.460,P=0.227);④有分股表现的分别占22.2%(6/27,此6例均无完整滑膜覆盖)和32.0%(16/50)。屈膝30°时,两组前向松弛度分别为1.5±1.8 mm和2.2±1.3 mm(t=1.949,P=0.055),90°时分别为1.1±1.4mm和1.4±0.9 mm(t=1.467,P=0.147)。结论:采用自体B-PT-B和HT单束重建陈旧性ACL断裂,术后短期肉眼观察移植物愈合形态学表现无显著性差异,前向稳定性均满意,且无显著性差异。     

Rotational and translational laxity after computer-navigated single- and double-bundle anterior cruciate ligament reconstruction

Based on biomechanical cadaver studies, anatomic double-bundle reconstruction of the anterior cruciate ligament (ACL) was introduced to achieve better stability in the knee, particularly in respect of rotatory loads. Previously, the success of ACL reconstruction was believed to be mainly dependent on correct positioning of the graft, irrespective of the number of reconstructed bundles for which computer-assisted surgery was developed to avoid malpositioning of the tunnel. The aim of the present study is to compare rotational and translational stability after computer-navigated standard single-bundle, and anatomic double-bundle ACL reconstruction. The authors investigated 55 consecutive patients who had undergone the single-bundle or double-bundle ACL reconstruction procedure with the use of autogenous hamstring tendon grafts and EndoButton^® fixation, and the patients had been followed for a minimum period of 24 months. Intraoperative, anteroposterior and rotational laxity was measured with the computer navigation system, and compared between groups. Both surgical procedures significantly reduced anteroposterior displacement (AP) and internal rotation (IR) of the tibia compared to the pre-operative ACL-deficient knee (P < 0.05). No significant differences were registered between groups with regard to anteroposterior displacement of the tibia. A significantly greater reduction in internal rotation was noted in the double-bundle group (15.6°) compared to the single-bundle group (7.1°). The IKDC and Lysholm score were significantly higher in the double-bundle group. However, the results were excellent in both groups. The use of a computer-assisted ACL reconstruction, which is a highly accurate method of graft placement, could be useful for inexperienced surgeons to avoid malposition. Whether double-bundle ACL reconstruction, which was associated with improved rotational laxity and significantly better IKDC and Lysholm scores compared to the standard single-bundle ACL reconstruction procedure, provide an influence in terms of avoiding osteoarthritis or meniscus degeneration, long-term results of at least 5 years are needed.     

The effect of femoral tunnel position on graft forces during inlay posterior cruciate ligament reconstruction

BACKGROUND: The femoral tunnel may be positioned centrally or eccentrically within the posterior cruciate ligament footprint during a single-bundle posterior cruciate ligament reconstruction. HYPOTHESIS: After reconstruction, graft forces are significantly different from those of the native posterior cruciate ligament and are affected by the position of the femoral tunnel. STUDY DESIGN: Controlled laboratory study. METHODS: The resultant force in the native posterior cruciate ligament was measured in nine cadaveric knees as the knee was flexed from -5 degrees to 120 degrees of flexion. Posterior cruciate ligament reconstruction was performed with the femoral side of the graft positioned centrally and then offset 5 mm eccentric to the central position. RESULTS: Mean graft forces were not significantly different between eccentric and central tunnel positions during passive knee extension between 120 degrees and 0 degrees of flexion; at 5 degrees of hyperextension, the eccentric position generated significantly lower graft forces. For both reconstruction techniques, mean graft forces were significantly higher than those for the native posterior cruciate ligament beyond approximately 90 degrees of flexion, for 5 N.m internal and external tibial torque; 5 N.m varus and valgus moment. CONCLUSIONS: Graft force reductions achieved with the eccentric femoral position appear to be relatively small compared with the forces expected during rehabilitation and activities of daily living. Clinical Relevance: After posterior cruciate ligament graft reconstruction, rehabilitation activities that load the knee at high degrees of flexion should be avoided to limit excessive forces on the maturing graft.     

Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes

Anterior cruciate ligament (ACL) reconstruction in double-bundle technique is advocated to more closely restore the anatomy and function of the native ligament than conventional single-bundle technique. But up to now there are only a few clinical investigations comparing both techniques in a prospective manner. We hypothesized that double-bundle ACL reconstruction reveals superior clinical and subjective results compared to single-bundle technique in a high-demand collective. A total of 50 male patients (mean age 29.4 years) were prospectively randomized consecutively into one of the two reconstruction techniques. Group 1 (SB) underwent a 4-stranded single-bundle reconstruction with a ST graft in femoral position at 10:00 and 02:00 o’clock, respectively. In group 2 (DB), reconstruction was performed by using a 2-stranded ST graft with double-bundle, four tunnel technique. Before surgery and at a 2 year follow-up (range 23–25 months) patients were evaluated by the same blinded observer. There was no significant difference in the side-to-side anterior laxity-measurement with the KT-1000 between both groups. As evaluated by the pivot shift, no significant correlation could be noted (Fisher exact test P = 0.098) between rotational stability and any of the both reconstruction techniques. However, the anterior and rotational stability improved significantly at 2-year follow-up compared to preoperatively (P = 0.003) in both groups. The statistical analysis showed a significant increase for the IKDC (subjective, objective) and the Lysholm Score at final follow-up among each single technique, while we found no significant difference between the two reconstruction methods. On the basis of our investigation, we conclude that reconstruction of the ACL by a double-bundle ST graft with an extracortical anchorage can achieve excellent clinical results. But in contrast to our initial hypothesis, we could not quote any significant advantages by creating two independent bundles. Reconstruction of the anterior cruciate ligament in conventional single-bundle technique with a more horizontal femoral tunnel placement obtains comparable clinical results in the present high-demand collective.     

The accuracy of bone tunnel position using fluoroscopic-based navigation system in anterior cruciate ligament reconstruction

Purpose

The first purpose of this study was to examine whether fluoroscopic-based navigation system contributes to the accuracy and reproducibility of the bone tunnel placements in single-bundle anterior cruciate ligament (ACL) reconstruction. The second purpose was to investigate the application of the navigation system for double-bundle ACL reconstruction.

Methods

A hospital-based case–control study was conducted, including a consecutive series of 55 patients. In 37 patients who received single-bundle ACL reconstruction, surgeries were performed with this system for 19 knees (group 1) and without this system for 18 knees (group 2). The positioning of the femoral and tibial tunnels was evaluated by plain sagittal radiographs. In 18 patients who received double-bundle ACL reconstruction using the navigation system (group 3), the bone tunnel positions were assessed by three-dimensional computed tomography (3D-CT). Clinical assessment of all patients was followed with the use of Lysholm Knees Score and IKDC.

Results

Taking 0% as the anterior and 100% as the posterior extent, the femoral tunnels were 74.9?±?3.0% in group 1 and 71.5?±?5.8% in group 2 along Blumensaat’s line, and the tibial tunnels were 42.3?±?1.4% in group 1 and 42.5?±?4.6% in group 2 along the tibia plateau. The bone tunnel positions in group 1 were located significantly closer to the position planned preoperatively and varied less in both femur and tibial side, compared with those without navigation (group 2). (Femur: P?P?Conclusion The fluoroscopic-based navigation system contributed to the more reproducible placement of the bone tunnel during single-bundle ACL reconstruction compared with conventional technique. Additionally, this device was also useful for double-bundle ACL reconstruction.

Level of evidence

Case–control study, Therapeutic study, Level III.     

Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement

BACKGROUND: Locations of femoral tunnels for anterior cruciate ligament replacement grafts remain a subject of debate. HYPOTHESIS: A lateral femoral tunnel placed at the insertion of the posterolateral bundle of the anterior cruciate ligament can restore knee function comparably to anatomical femoral tunnel placement. STUDY DESIGN: Controlled laboratory study. METHODS: Ten cadaveric knees were subjected to the following external loading conditions: (1) a 134-N anterior tibial load and (2) combined rotatory loads of 10-N.m valgus and 5-N.m internal tibial torques. Data on resulting knee kinematics and in situ force of the intact anterior cruciate ligament and anterior cruciate ligament graft were collected using a robotic/universal force-moment sensor testing system for (1) intact, (2) anterior cruciate ligament-deficient, (3) anatomical double-bundle reconstructed, and (4) laterally placed single-bundle reconstructed knees. RESULTS: In response to anterior tibial load, anterior tibial translation and in situ force in the graft were not significantly different between the 2 reconstructions except at high knee flexion. For example, at 90 degrees of knee flexion, anterior tibial translation was 6.1 +/- 2.3 mm for anatomical double-bundle reconstruction and 7.6 +/- 2.6 mm for laterally placed single-bundle reconstruction (P < .05). In response to rotatory loads, there were no significant differences between the 2 reconstruction procedures (4.8 +/- 2.4 mm vs 4.8 +/- 3.0 mm in anterior tibial translation at 15 degrees of knee flexion, P > .05). CONCLUSION: Lateral tunnel placement can restore rotatory and anterior knee stability similarly to an anatomical reconstruction when the knee is near extension. However, the same is not true when the knee is at high flexion angles. CLINICAL RELEVANCE: To reproduce the complex function of the anterior cruciate ligament, reproducing both bundles of the anterior cruciate ligament may be necessary.     

Calcium phosphate-hybridized tendon grafts reduce femoral bone tunnel enlargement in anatomic single-bundle ACL reconstruction

Purpose

This study aimed to clarify the effect of calcium phosphate (CaP)-hybridized tendon grafting versus unhybridized tendon grafting on the morphological changes to the bone tunnels at the aperture 1 year after anatomic single-bundle anterior cruciate ligament (ACL) reconstruction.

Methods

Seventy-three patients were randomized to undergo the CaP (n = 37) or the conventional method (n = 36). All patients underwent computed tomography (CT) evaluation 1 week and 1 year post-operatively. The femoral and tibial tunnels at the aperture were evaluated on reconstructed 3D CT images. Changes in the cross-sectional area (CSA) and diameters of the femur and the tibia, and the translation rate of the tunnel walls and the morphological changes of both tunnels were assessed.

Results

There was a significant reduction in the increase in the CSA and the anterior–posterior and proximal–distal tunnel diameters on the femoral side in the CaP group as compared with the conventional group. On the femoral side, the translation rate of the posterior wall was significantly larger in the CaP group than in the conventional group, whereas the translation rate of the distal wall was significantly smaller in the CaP group than in the conventional group.

Conclusions

As compared with the conventional method, the CaP-hybridized tendon graft reduced bone tunnel enlargement on the femoral side 1 year after anatomic single-bundle ACL reconstruction due to an anterior shift of the posterior wall and reduced distal shift in the femoral bone tunnel. Clinically, the CaP-hybridized tendon grafts can prevent femoral bone tunnel enlargement in anatomic single-bundle ACL reconstruction.

Level of evidence

I.

     

Importance of femoral tunnel placement in double-bundle posterior cruciate ligament reconstruction: biomechanical analysis using a robotic/universal force-moment sensor testing system

BACKGROUND: Previous studies have identified the femoral attachment of the posterior cruciate ligament fibers as one of the primary determinants of fiber tension behavior. In addition, a double-bundle posterior cruciate ligament reconstruction has been shown to restore the intact knee kinematics more closely than does a single-bundle reconstruction. HYPOTHESIS: An anterior tunnel position in double-bundle posterior cruciate ligament reconstruction restores the biomechanics of the normal knee more closely than does a posterior tunnel position. STUDY DESIGN: Controlled laboratory study. METHODS: Kinematics and in situ forces of human knees after double-bundle posterior cruciate ligament reconstruction with 2 different femoral tunnel positions (anterior vs posterior) were evaluated using a robotic/universal force-moment sensor testing system. Within the same specimen, the resulting knee kinematics and in situ forces were compared. For statistical analysis, 2-way analysis of variance repeated measures were performed. RESULTS: The femoral tunnel position of the double-bundle hamstring graft had significant effect on the resulting posterior tibial displacement and in situ forces of the hamstring grafts. The anterior femoral tunnel position provided significantly less posterior tibial translation than did the posterior tunnel position. There was a tendency toward higher in situ forces of grafts fixed in the anterior tunnel when compared to the posterior position, but this difference was statistically not significant. CONCLUSION: An anterior position of the bone tunnels in double-bundle posterior cruciate ligament reconstruction restores the normal knee kinematics more closely than does a posterior position of the tunnels. CLINICAL RELEVANCE: In double-bundle posterior cruciate ligament reconstruction, posterior placement of the tunnel should be avoided.