关节镜下双股半腱肌重建前交叉韧带

前交叉韧带（ＡＣＬ）损伤是常见膝部损伤，有关诊断、关节镜下修复重建的问题已引起临床界的重视〔１、２〕。采用我科自行研制的配套器械行双股半腱肌关节镜下重建ＡＣＬ手术，临床治疗５０例前交叉韧带损伤患者，随访资料完整３９例，取得满意的临床效果。１资料与方法...     

应用半腱肌、股薄肌和髌韧带在关节镜下重建前交叉韧带65例

目的 探讨应用髌韧带（bone-patellar tendon-bone,BTB)和半腱肌、股薄肌（bone-ham-string-bone,BHB)在关节镜下修复前交叉韧带（anterior cruciate ligament,ACL)损伤的临床疗效。手术要点及关节功能改善情况。方法 在膝关节镜直视下,选用自体BTB和BHB行ACL竽建手术65例,其中BTB重建30例,BHB重建31例,股四头肌腱重建4例,结果 随访时间1个月-3年,手术前Lachman和Piveot shift试验从阳性转为阴性,按日本骨科学会膝关节疗效评定标准,优48例,良7例,可10例,本组病人2个月后均恢复原来日常活动,半年后恢复体育活动,结论 应用BTB、BHB在关节镜下修复ACL损伤,术中等长点的选择是手术关键,坚强固定是早期康复训练的前提。     

关节镜下钮扣钢板固定四股半腱肌重建膝关节前交叉韧带

目的 探讨关节镜下钮扣钢板固定四股半腱肌重建膝关节前交叉韧带的治疗效果。方法 关节镜下四股半腱肌重建膝关节前交叉韧带20例。术前MRI证实膝关节前交叉韧带断裂,术中关节镜下均证实膝关节前交叉韧带断裂,四股半腱肌重建者用钮扣钢板固定。结果 平均随访7个月,无1例打软腿,假交锁症状消失,关节痛消失。X线见内固定物与术后一致,无移位。Lysholm膝关节功能评分：术前平均54.5,随访评分95.6。结论 关节镜下四股半腱肌重建膝关节前交叉韧带临床效果好,并发症少,手术时间短。     

关节镜下双股半腱肌腱重建后交叉韧带

目的探讨关节镜下双股半腱肌腱转移重建后交叉韧带(PCL)术的临床疗效。方法采用开口螺旋肌腱剥离器剥离半腱肌腱,保留肌腱远侧附着点,在近侧腱肌交界处切断,对折成两股编织,转移到关节镜下重建PCL。隧道内口侧使用可吸收挤压螺钉固定,股骨隧道外口加强固定。结果手术16例,平均随访23.5个月。Larson评分由术前58分提高到93分,Lysholm评分由术前54分提高到90分,所有患膝术前后抽屉试验及Lachman试验均阳性,术后仅2例抽屉试验弱阳性,l例Lachman试验弱阳性。结论(1)关节镜下使用双股半腱肌腱转移重建PCL较B-PT-B通过隧道时柔顺通畅。(2)隧道内口可吸收螺钉挤压固定,愈合后内口消失,可避免韧带撞击内口使之逐渐扩大引起重建韧带松弛。(3)隧道内外口的坚强固定,使重建后交叉韧带有足够刚强度。     

膝关节镜下半腱肌及股薄肌肌腱重建前交叉韧带的临床观察

目的探讨膝关节镜下前交叉韧带重建的方法和效果。方法回顾分析26例膝关节镜下应用自体半腱肌及股薄肌腱以界面挤压螺钉及Endobutton固定重建前交叉韧带的临床资料,对患膝关节功能进行评估。结果术后随访12-18个月,根据Lysholm膝关节评分标准,由术前（54．7±9．13）分提高到术后（86．6±6．97）分。结论膝关节镜下采用自半腱肌及股薄肌肌腱重建前交叉韧带的方法可行,疗效满意,可作为重建前交叉韧带的方法广泛应用。     

应用半腱肌腱重建前交叉韧带末端形成的特点

目的 :观察应用半腱肌腱重建前交叉韧带末端形成的过程。方法 :应用家兔为实验对象 ,将前交叉韧带切除 ,然后应用半腱肌腱进行前交叉韧带的重建 ,术后 4、8、12和 16周取材 ,进行组织学和组织化学染色 ,观察末端形成的过程。结果 :在骨隧道内的肌腱转归与在关节腔内的肌腱不同 ,未发现组织坏死和新生组织长入替代的过程。末端形成时 ,在骨与肌腱接触面先发生骨髓腔开放 ,细胞由骨髓腔向肌腱内长入 ,肌腱逐渐由软骨化转为骨化 ,末端形成是先有骨的推进过程 ,最后在肌腱刚入骨的部位形成末端。此过程需要 12周以上才能完善。结论 :与应用髌腱重建时的骨-腱 -骨的重建方式不同 ,应用半腱肌腱重建前交叉韧带时末端的形成过程是形成一个新的末端。末端形成时主要是骨性部分向肌腱推进的过程 ,而不是肌腱内胶原纤维向骨长入的过程。     

关节镜下自体髌腱重建前交叉韧带

目的探讨关节镜下自体髌腱中1/3重建前交叉韧带(ACL)术效果的影响因素。方法对15例前交叉韧带损伤患者,在关节镜下行自体骨-髌腱-骨(B-PT-B)中1/3重建ACL。其中同时行侧副韧带修复1例,半月板损伤部分切除3例,半月板结合部缝合1例。结果按照日本骨科学会制定的膝关节疗效评定标准,优6例,良7例,中2例,优良率为86.7%。结论术中选择等长点,测量关节内重建韧带的长度,获取标准的髌腱两端骨块及胫骨、股骨隧道,并正确使用挤压螺钉固定两骨块于隧道中是减少并发症、提高手术效果的关键。该手术创伤小,对关节内环境影响小,可同时进行关节内其他手术,术后恢复快,是ACL重建的优良方法     

半腱肌解剖重建治疗膝关节内侧副韧带Ⅲ度损伤

对37例膝关节内侧副韧带Ⅲ度损伤患者进行手术治疗,采用游离半腱肌、保留鹅足止点、切断近端、通过骨隧道可吸收界面钉固定的方法解剖重建膝关节内侧副韧带浅层及后斜韧带.采用Lysholm评分法评估患者手术前后的功能,术前平均42.19分,术后平均95.30分.     

军队人员关节镜下重建前交叉韧带

目的 探讨军人前交叉韧带损伤患者采用自体四股半腱肌腱 股薄肌腱重建前交叉韧带的手术方法及远期疗效.方法 关节镜下以自体四股半腱肌腱 股薄肌腱为前交叉韧带重建替代物,保留少许前交叉韧带残端作为定位标志物,对35例前交叉韧带损伤军人行重建术.结果 术后35例膝关节活动度均恢复至正常范围,无韧带撞击现象,前抽屉试验全部阴性,Lachman试验全部小于Ⅰ度.Lysholm评分由术前的平均52.3分提高到术后的平均88.5分,差异有显著性意义(P＜0.01).大多数患者获得满意治疗效果,可继续从事日常工作.结论 关节镜下自体四股半腱肌腱 股薄肌腱重建前交叉韧带是恢复膝关节稳定性较好的方法.关节镜下重建前交叉韧带是前交叉韧带损伤军人较为理想的手术方式,其创伤较小、卧床时间短、远期疗效较好.     

关节镜下4股半腱肌腱单束重建前交叉韧带部分损伤

目的 介绍关节镜下单束蕈建增强治疗前交叉韧带(anterior cruciate ligament,ACL)后外侧束部分损伤方法 ,探讨其临床效果. 方法 对26例单纯ACL后外侧柬部分损伤患者,在关节镜下采用自体半腱肌腱进行单束解剖重建.按照国际膝关节评分委员会(internationalknee documentation committee,IKDC)和Lysholm膝关节功能评分表对患膝功能进行评估,通过KT-1000检查比较膝关节的前向松弛度. 结果 术后无活动受限,屈膝活动度130°～150°,平均142°.术后随访12～18个月,最后随访时IKDC评分为A级25例(96%),B级1例(4%);IKDC评分从术前的(71.4±3.7)分提高到随访结束时的(95.8±3.4)分(t=9.836,P<0.01).屈膝25°位KT-1000检查,双侧膝关节胫骨结节前移差异从术前的(5.1±1.2)mm减少到终末随访的(2.1±1.3)mm(t=10.48,P<0.01).患者术前Lysholm膝关节功能评分为(76.7±3.2)分,终末随访时为(95.7±2.4)分(t=7.356,P<0.01). 结论 在关节镜下采用自体半腱肌腱单束解剖重建增强治疗ACL后外侧束部分损伤,能取得良好效果.     

Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons

Numerous surgical procedures have been developed and used for anterior cruciate ligament (ACL) reconstruction. Patellar tendon is probably the most common graft used, but gracilis and semitendinous tendons present some interesting advantages: small incision, large graft when doubled, characteristics close to ACL, rapid harvest. We describe a combined intra- and extra-articular arthroscopic ACL reconstruction using hamstring tendons which includes some original steps. The tendons are harvested, leaving the distal insertion intact, and sutured together. After drilling of the tibial tunnel, an over-the-top arrangement is formed, creating a groove in the posterolateral aspect of the femur. The tendons are then fixed with double staples in the groove, and their remaining part is fixed distally to Gerdy’s tubercle passing under the fascia, but over the lateral collateral ligament (LCL). This technique ensures sufficient strength in the graft and permits correction of any associated instability, because of the presence of the extra-articular portion of the tendons. Furthermore, the over-the-top arrangement reduces trauma and possible pitfalls related to tunnel construction and permits isometry of the extra-articular portion to be established. Forty patients involved in sports activity were prospectively selected and evaluated at a minimum 2 years’ follow-up. IKDC score and Lysholm score were used for clinical evaluation, and the KT-2000 was used for instrumental laxity measurements. Resumption of sport and time to that point were recorded as well as Tegner activity score. We had 92.5% normal and fairly normal knees according to IKDC score and only 7.5% abnormal knees. Mean Lysholm score was 95. Mean Tegner score was 7.2. KT-2000 showed a mean injured/uninjured difference of 2.1 mm. In all, 90% of patients resumed sports at the same level, 67.5% in 3–4 months and 27.5% in 4–6 months. The highly satisfactory results of this series with no major complications confirm the reliability of this techinque and the possibility of guaranteeing functional behaviour in the knee. Received: 5 April 1997 Accepted: 25 July 1997     

关节镜下运用4股腘绳肌腱同期重建前后交叉韧带损伤

目的 关节镜下运用Intrafix和可吸收界面螺钉固定自体4股腘绳肌腱，同期重建前交叉韧带（anterior cruciate ligament，ACL）、后交叉韧带（posterior cruciate ligament，PCL），评估其疗效。方法 ACL、PCL同时损伤的患者16例，关节镜下以自体4股胭绳肌腱作为重建移植物，应用可吸收界面螺钉固定移植物股骨端，Intrafix钉鞘和可吸收锥形钉固定胫骨端，同期行ACL和PCL损伤重建术。7例行内侧副韧带修补，4例行外侧副韧带复合结构修复，2例行内外侧同时修复。所有患者按照国际膝关节评分委员会（International Knee Documentation Committee，IKDC）评分标准进行术前评估，均为D级。术前Lysholm评分为（36．5±3．7）分。结果 随访时间为12～18个月，平均14．6个月。终末随访时，IKDC总体评价：A级6例（38％），B级9例（56％），C级1例（6％），无D级患者。Lachman试验0～2mm8例；3～5mm6例；6～10mm2例（P〈0．05）。屈70°前后总位移0～2mm10例；3～5mm5例；6～10mm1例（P〈0．05）。屈70°后位移0～2mm12例；3～5mm4例（P〈0．05）。术后2个月Lysholm功能评分为（90．4±2．9）分，终末随访时为（93．4±3．5）分，与术前相比差异均有统计学意义（P〈0．05）。结论 关节镜下以自体4股胭绳肌腱作为移植物，应用可吸收界面螺钉、Intrafix钉鞘和可吸收锥形钉固定股骨胫骨端同期重建ACL和PCL损伤，有利于早期积极的功能康复，膝关节功能恢复满意。     

Arthroscopic anterior cruciate ligament reconstruction

Our understanding of the structure and function of the anterior cruciate ligament has progressed rapidly over the past decade. Arthroscope-assisted anterior cruciate ligament replacement is a new procedure that allows isometric placement of the anterior cruciate ligament graft. Postoperative rehabilitation is enhanced by preservation of the extensor mechanism.     

关节镜下自体半腱及股薄肌腱重建膝前交叉韧带

 目的 探讨关节镜下以自体半腱肌、股薄肌腱重建膝前交叉韧带(ACL)的手术方法及疗效.方法 自2006年3月～2007年12月,关节镜下绳肌腱修复膝前交叉韧带损伤39例.膝前小切口取半腱肌腱、股薄肌腱修整、对折后成四股,分别建立胫骨隧道及股骨隧道,用Endobutton和生物可吸收挤压螺钉固定肌腱,重建ACL的解剖结构和生理功能.术后即行功能锻练.结果 术后患者伤口均Ⅰ期愈合,8～10周膝关节屈伸功能恢复正常.随访时间3～15个月,平均8个月.抽屉试验和Lachman试验阳性者2例,可疑阳性者6例;余患者均为阴性.根据敖英芳临床判断标准,本组优23例,良11例,中3例,差2例.Lysholm评分术后(87.6±4.6),与术前(45.3±4.2)比较,差异显著(P<0.01).结论 绳肌腱具有良好的抗拉强度和刚度,在关节镜下用四股绳肌腱重建膝前交叉韧带是一种疗效可靠的治疗方式.     

关节镜下半腱肌腱股薄肌腱单端固定法重建交叉韧带24例分析

目的总结膝关节镜下同侧半腱肌腱、股薄肌腱单端固定法重建后交叉韧带的方法及疗效,分析其优缺点。方法应用同侧半腱肌腱、股薄肌腱单端固定,重建后交叉韧带损伤24例。结果术后随访6～36个月,平均18个月。按lysholm膝关节评分标准,由术前43分提高到术后93分。结论同侧半腱肌腱、股薄肌腱单端固定法重建后交义韧带创伤小、操作简便,是重建后交叉韧带的理想方法之一。     

Arthroscopic partial meniscectomy in the anterior cruciate deficient knee

One hundred ACL insufficient knees were followed for an average of 3.5 years after arthroscopic partial meniscectomy had been performed. Fifty-two percent of the patients obtained a satisfactory result and 41% were able to participate in strenuous sports activities. The arthroscopic partial meniscectomy reduced pain and swelling in a high proportion of cases, but stability was only marginally improved. Negative prognostic factors were: sex (female), generalized laxity, contralateral recurvatum of more than 10 degrees, complete as opposed to partial ACL lesions, Grade III tibiofemoral or patellar chondromalacia, associated peripheral ligamentous laxity, pivot shift of Grade II or greater, and anterior tibial displacement of more than 5 mm as measured with the KT-1000 knee arthrometer.     

Double semitendinosus anterior cruciate ligament reconstruction: 10-year results

In a series of 30 consecutive patients who suffered from chronic instability of the knee joint, reconstruction of the torn anterior cruciate ligament was performed with a looped semitendinosus tendon, reinforced by an extra-articular anterolateral procedure. Of these 30, 27 could be followed up 9–11 years after the operation. The evaluation included the International Knee Documentation Committee (IKDC) questionnaire and was completed by testing with a Kneelax arthrometer at 132 N and by anteroposterior standing X-ray, in order to evaluate the degenerative changes. At the time of the check-up: 96% of the study group considered that they had normal or nearly normal knees, and 81% had recovered to the same sports activity level as before their injury. The degenerative changes noted at the index operation did not progress notably, except in two cases. Laxities of 7 knees were normal, with a side-to-side difference of less than 2 mm; 15 were nearly normal, with a mean difference of 3.45 mm; and 5 were abnormal, with a mean difference of 6.2 mm. The study shows that the procedure is efficient in restoring a satisfactory stability for most patients and stabilises the evolution of the degenerative lesions as shown by standing X-ray. Received: 30 December 1996 Accepted: 25 July 1997     

Arthroscopic anterior cruciate ligament reconstruction with periosteum-enveloping hamstring tendon graft

Tendon–bone incorporation of a tendon graft within the bone tunnel is of priority concern when using for anterior cruciate ligament (ACL) reconstruction. Superior healing process and stronger healing strength can be achieved when periosteum is sutured on the tendon inserted into a bone tunnel. We applied this idea to ACL reconstruction for enhancing tendon graft–bone tunnel healing. This is a prospective clinical outcome study with this surgical technique at minimal 2 years follow-up. Periosteum-enveloping hamstring tendon graft has been used in 68 patients. Data from 62 patients who had been followed up completely were analyzed. All patients suffered from a grade 3 or higher grade of Lachman and anterior drawer test with a positive pivot-shift test. Clinical assessments included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, KT-1000 instrumented testing, thigh muscle assessment, and radiographic evaluation. The median Lysholm knee score was 59 (40–70) and 94 (60–100) points (P<0.01) before and after surgery. After reconstruction, 81% of patients were able to return to moderate or strenuous activity. Four (6%) patients were found to exhibit grade 2 or more ligament laxity. Complete range of motion could be achieved in 86% of patients. Three patients (5%) had positive pivot shift. Finally, 92% of patients were assessed as normal or nearly normal rating by IKDC guideline. Bone tunnels enlargement of more than 1 mm was identified in 5% of femoral tunnels and 6% of tibial tunnels. The study shows that a satisfactory result can be achieved with the periosteum-enveloping hamstring tendon graft in ACL reconstruction. Periosteum can be easily harvested at the proximal tibia from a routine incision for hamstring tendon harvesting. Besides the potential for improving tendon–bone healing, enveloped periosteum may help to seal the intra-articular tunnel opening in the early postoperative period, and thus avoid synovial fluid reflux into the tunnel. Bone tunnel enlargement could be reduced.