前交叉韧带断裂后股骨髁间窝变化的影像学研究

目的探讨前交叉韧带（ACL）断裂后会否引起患侧股骨髁间窝增生致狭窄。方法收集2008年10月～2008年12月进行关节镜下治疗单侧膝关节ACL断裂患者共216例,对其中35例健侧膝关节X线检查无退变的患者进行研究。术前记录患膝ACL断裂的病程,拍摄双侧膝关节髁间窝位X线片,测量其宽度,并对患侧膝关节进行IKDC、Lvsholm及Tegner评分。结果本组患者的髁间窝宽度差值（健侧－患侧）为（2．62±1．38）ml／1,患膝ACL断裂病程为（24．71±15．20）个月,两者呈正相关,并有统计学意义：患侧膝关节的IKDC、Lysholm及Tegner评分分别为（69．31±5．17）、（72．34±6．17）及（4．66±0．54）,此三者与髁问窝宽度差值问的相关性无统计学意义。结论影像学测量观察表明,ACL断裂后可继发患侧膝关节股骨髁间窝狭窄,其狭窄程度随病程的延长进一步加重。     

Association between intercondylar notch narrowing and bilateral anterior cruciate ligament injuries in athletes

Background  

Intercondylar notch narrowing is a risk factor for anterior cruciate ligament (ACL) injuries, but it is unclear whether a narrow intercondylar notch correlates with bilateral ACL injuries.     

The relationship of intercondylar notch size and content to notchplasty requirement in anterior cruciate ligament surgery

A stenotic intercondylar notch is an indication for a notchplasty at the time of ACL reconstructive surgery. However, the absence of a stenotic notch does not ensure that impingement of the ligament upon the intercondylar notch will not occur. An excessively large ligament, even in the presence of a normal intercondylar notch, will result in abrasion of the ligament on the notch. This can result in the premature failure of the reconstructed ACL. Therefore, both the notch size and notch content are important determinants in assessing whether a notchplasty is required as part of the ACL reconstructive procedure.     

Distal femoral intercondylar notch dimensions and their relationship to composition and metabolism of the canine anterior cruciate ligament

OBJECTIVE: To determine the relationship between the dimensions of the distal femoral intercondylar notch (ICN) and the composition and metabolism of the anterior cruciate ligament (ACL) in three dog breeds with different relevant risks to ligament rupture and subsequent osteoarthritis (OA). DESIGN: ICN measurements were obtained from the femurs of Golden Retrievers (high risk), Labrador Retrievers (high risk) and Greyhounds (low risk). Femoral condyle width and height, ICN height and width indices, and notch shape index were measured using Vernier callipers in all dogs. Intact ACLs were obtained from the same dog breeds for a study of the impinged areas and were analysed for collagen content, collagen cross-links, and sulphated glycosaminoglycan (GAG) content, matrix metalloproteinase (MMP)-2 and the tissue inhibitors of metalloproteinases (TIMPs)-1 and -2. RESULTS: Femoral condyle width and height and ICN width indices were significantly greater in the low risk compared to the high risk breeds (P<0.01 for all parameters). In contrast, the pro (P=0.003) and active (P=0.007) forms of MMP-2 and sulphated GAGs (P=0.0002) were significantly greater in the impinged areas of the ACLs of the rupture predisposed breeds. CONCLUSIONS: Impingement by the ICN on the ACLs of the high risk breeds may result in increased collagen remodelling and increased sulphated GAG deposition, causing reduced structural integrity of the ligament. Altered ACL composition may predispose the ligament to increased laxity leading to joint degeneration and OA. This may have a comparative implication for pathogenesis of ACL rupture in humans.     

The influence of the tibial slope and the size of the intercondylar notch on rupture of the anterior cruciate ligament

It has been suggested that an increased posterior tibial slope (PTS) and a narrow notch width index (NWI) increase the risk of anterior cruciate ligament (ACL) injury. The aim of this study was to establish why there are conflicting reports on their significance. A total of fifty patients with a ruptured ACL and 50 patients with an intact ACL were included in the study. The group with ACL rupture had a statistically significantly increased PTS (p < 0.001) and a smaller NWI (p < 0.001) than the control group. When a high PTS and/or a narrow NWI were defined as risk factors for an ACL rupture, 80% of patients had at least one risk factor present; only 24% had both factors present. In both groups the PTS was negatively correlated to the NWI (correlation coefficient = -0.28, p = 0.0052). Using a univariate model, PTS and NWI appear to be correlated to rupture of the ACL. Using a logistic regression model, the PTS (p = 0.006) and the NWI (p < 0.0001) remain significant risk factors. From these results, either a steep PTS or a narrow NWI predisposes an individual to ACL injury. Future studies should consider these factors in combination rather than in isolation.     

Abnormal lateral notch in knees with anterior cruciate ligament injury

We reviewed plain radiograms of anterior cruciate ligament injuries to determine the frequency of an abnormal lateral notch found in the lateral femoral condyle, and we investigated a possible mechanism for its occurrence by determining the relationship with associated injuries. We analyzed data for 216 patients who underwent ACL reconstruction between 1993 and 1996, whose radiographic images of the contralateral knee were available. The numbers of male and female patients were 122 and 94, respectively, and their ages ranged from 14 to 47 years (average, 25 years). The abnormal notch visualized by lateral radiograph was found in 66 of 216 knees (30.6%) and was classified into three types. The type of abnormal notch seen most frequently (73%) was located at the same site as the notch on the contralateral side, but appeared deeper than normal. Knees with abnormal notches showed lateral meniscal injuries more frequently than those without such notches (P < 0.005). The abnormal notch was assumed to have formed at the time of injuries, after impingement of the lateral femoral condyle on the lateral tibial condyle. Cartilage damage at the abnormal notch should be carefully observed in the future. Received for publication on Aug. 14, 1998; accepted on Aug. 27, 1999     

关节镜下治疗前交叉韧带胫骨髁间嵴撕脱骨折

目的探讨关节镜下对前交叉韧带胫骨髁间嵴撕脱骨折应用缝合线加钢缆进行复位和内固定的疗效。方法 56例前交叉韧带胫骨髁间嵴撕脱骨折患者(Ⅱ型13例,ⅢA型15例,ⅢB型13例,Ⅳ型15例),关节镜下应用Ethibond X519缝合线加钢缆对胫骨髁间嵴撕脱骨折区进行缝合捆绑,通过胫骨髁前置双隧道牵引复位、固定。结果术后X线片显示胫骨嵴撕脱骨折完全复位。56例均获随访,时间18～21个月。末次随访时骨折完全愈合。Lachmen试验(-)56例;前抽屉试验(-)55例,1例弱阳性。IKDC评定:术前C级30例,D级26例;术后A级55例,B级1例。Lysholm评分:术前37～52(42.7±0.34)分;术后91～96(95.7±0.56)分,平均提高53.0分±0.43分,术前、术后比较差异有统计学意义(P<0.01)。结论关节镜下应用缝合线加钢缆内固定治疗膝关节前交叉韧带胫骨髁间嵴撕脱骨折,可以对移位的撕脱骨折很好地复位,最大限度地加大单位面积上的压力,增加刚性稳定。并可早期功能锻炼。     

A study of the synovial and ligamentous structure of the anterior cruciate ligament

Summary The synovial and ligamentous structure of 16 human anterior cruciate ligaments (ACL), removed at autopsy, were examined by light microscopy with special regard to their topographical relationships. The soft tissue support of the ACL consists of fibrous, areolar and areolo-adipose synovial tissue. The subsynovial layer comprises a tight fibrous peripheral part and an element of loose connective tissue containing some tight connective tissue strands, vessels and nerves. The collagenous ligamentous part of the ACL is the proper functional tissue and contains approximately 1500 fascicles measuring an average of 250 m in diameter. These fascicles are composed of bundles of collagen fibres, fibrocytes and deposits of proteoglycans. The synovial and ligamentous structures are attached by the second part of the subsynovial layer, which radiates into the ligamentous tissue and envelops the fascicles like a sheath. By this means the biological connection between these two structures is guaranteed.The relevance of these findings to operative reconstruction of recent ligamentous injuries is discussed.

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Résumé Etude microscopique de 16 ligaments croisés antérieurs (L. C. A.) prélevés post-mortem en conservant la continuité topographique de leur structure synoviale et ligamentaire. Le revêtement synovial du L. C. A. se compose de trois types différents de tissu: fibreux, aréolaire et aréolo-adipeux. La synoviale elle-même est constituée de deux couches dont la seconde partie, la sous-synoviale, se différencie en une partie périphérique, fibreuse et dense et une partie faite de tissu conjonctif lâche, porteur des structures vasculaires et nerveuses. Le tissu collagène du L. C. A., le vrai tissu fonctionnel, contient environ 1500 fascicules d'un diamètre moyen de 250 m. Ces fascicules sont constitués de faisceaux de fibres collagènes, de fibrocytes et de protéoglycans. Les structures synoviales et ligamentaires sont reliées entre elles par l'intermédiaire de la couche sous-synoviale qui irradie dans le tissu ligamentaire dont elle engaîne les fascicules. Ainsi est établie une connexion biologique entre ces deux structures.Les conséquences de cette étude sur la réparation chirurgicale des ruptures récentes du L. C. A. sont discutées.

     

Intercondylar notch measurements with special reference to anterior cruciate ligament surgery

The femoral intercondylar notch width was measured in 93 patients with chronic anterior cruciate ligament (ACL) insufficiency (Group 1), in 62 patients with an acute tear of the ACL (Group 2), and in 38 fresh anatomic specimen knees (Group 3). In six of the specimen knees, further anatomic studies of the intercondylar notch were performed after tissue removal. The average intercondylar distance was 16.1 mm in Group 1, 18.1 mm in Group 2, and 20.4 mm in Group 3. All differences were highly significant. The intercondylar notch was wider in the posterior part and had no crossing bony ridges but had generally concave walls, which provided a functional shelf for the ACL to insert on the lateral side. Significant osteophyte formation and stenosis of the anterior outlet of the intercondylar notch occur early in the ACL-deficient knee. A narrow anterior outlet of the intercondylar notch without osteophytes was also found in knees with an acute ACL rupture. At reconstruction of the ACL, notchplasty should be performed concomitantly.     

前交叉韧带早期重建术后股骨外侧髁压迹远期转归的相关研究

目的:探讨前交叉韧带(anterior cruciate ligament,ACL)早期重建术后股骨外侧髁压迹(lateral femoral notch,LFN)的转归并评估术后膝关节功能恢复情况。方法:对2015年12月至2019年12月间接受早期前交叉韧带重建的32例的临床资料进行回顾性分析,其中男18例,女14例,年龄16～54(25.39±2.82)岁;身体质量指数(body mass index,BMI)为20～30(26.15±3.09) kg/m²;交通伤6例,运动损伤19例,重物压伤7例。膝关节MRI显示所有患者损伤后LFN深度>1.5 mm,且术中对于LFN未进行干预。通过MRI资料观察患者手术前后的LFN缺损深度、面积及体积,对患者手术前后的国际软骨修复学会(International Cartilage Repair Society,ICRS)评分、Lysholm评分、Tegner活动水平、膝关节损伤和骨关节炎结局评分(knee injury and osteoarthritis outcome score,KOOS)进行分析。结果:...     

Imaging the anterior cruciate ligament

MR imaging has surpassed all other imaging modalities to become the "gold standard" for imaging evaluation of ACL injury. The accuracy and sensitivity of MR imaging for evaluation of ACL tears is excellent when correlated with clinical tests and arthroscopic findings, and is improved in equivocal cases with assessment of secondary signs for ACL tear. The MR imaging assessment of partial and chronic ACL tears is less accurate but is clinically useful. MR imaging provides information about associated injuries prior to surgery. Radiologic diagnostic methods for the assessment of ACL tears on MR images are well established; recent techniques such as dedicated cartilage imaging offer new information of use to clinicians about the sequelae of ACL injuries.     

The anterior cruciate ligament

Our knowledge of the anterior cruciate ligament has expanded rapidly over the last decade. Recent advances in arthroscopic techniques, the development and release of synthetic stents and prostheses, increasing laboratory and clinical data involving allograft implantation, and biomechanical research in knee rehabilitation have led to a bewildering array of choices for treatment of anterior cruciate ligament deficiency. As new information and techniques are presented, and new synthetic and biological materials become available, orthopedic surgeons must judge their value and modify treatment recommendations accordingly. A thorough knowledge of the basic science and clinical information is necessary to appropriately evaluate these new advances. A review of our current knowledge of the anterior cruciate ligament is presented to facilitate this evaluation process.     

Arthroscopic technique for replacing the anterior cruciate ligament using a free patellar tendon transplant]

The replacement of the anterior cruciate ligament (ACL) by a free patellar tendon graft is a well-known procedure. The disadvantage is that the necessary arthrotomy destroys the nerve supply of the joint capsule. Therefore, we developed a procedure of ACL replacement that can be done by arthroscopy without opening the joint except for a small incision needed for the arthroscopy and working canal. The surgical technique is described.     

Anterior cruciate ligament and intercondylar notch in the coronal oblique plane: anatomy complemented by magnetic resonance imaging in cruciate ligament-intact knees.

We assessed the anatomy of the anterior cruciate ligament (ACL) and femoral intercondylar notch on cryosections from one cadaveric knee specimen in the coronal oblique plane oriented parallel to the intercondylar roof. We determined the course of the ACL, the widths of the cruciate ligaments at intersection, and the intercondylar notch configuration on coronal oblique plane magnetic resonance images in 51 adult cruciate ligament-intact knees (25 women, 26 men; age range, 16 to 47 years). The intercondylar notch widths were measured at the notch entrance, at the intersection of the ACL and posterior cruciate ligament (PCL), and at the notch outlet. In the coronal oblique plane, the ACL exhibited a diagonal course from the central and medial part of the anterior intercondylar area of the tibia distally, across the lateral third of the intercondylar notch, to the intercondylar surface of the lateral femoral condyle proximally. At the cruciate ligament intersection, the absolute widths of the ACLs measured on average 6.1+/-1.1 mm in men and 5.2+/-1.0 mm in women representing 31.9% and 31.1% of the ACL/central intercondylar notch width ratios. The absolute widths of the PCLs measured on average 9.6+/-1.3 mm in men and 8.5+/-1.3 mm in women representing 50.4% and 51.4% of PCL/central intercondylar notch width ratios. On average for both groups, men and women, the absolute widths of the PCLs were significantly larger than the absolute widths of the ACLs. However, the relative widths of the cruciate ligaments with respect to corresponding intercondylar notch widths were not significantly different. In the coronal oblique plane, the intercondylar notch widths showed on average a significant decrease from posterior to intersection and from intersection to anterior. At notch outlet, the mean notch width measured 21.4 mm in men and 18.5 mm in women. At intersection, the mean notch width measured 19.1 mm in men and 16.6 mm in women. At notch entrance, the notch width measured 14.6+/-1.8 mm in men and 12.7+/-2.1 mm in women. We recommend magnetic resonance tomography of the knee in the coronal oblique plane oriented parallel to the intercondylar roof as the imaging modality of choice to visualize accurately the anatomic diagonal course of the ACL and its relation to the intercondylar notch and posterior cruciate ligament complex.