膝关节后交叉韧带合并后外侧角损伤

[目的]探索膝关节后交叉韧带(PCL)合并后外侧角(PLC)损伤的临床特征,评估同期关节镜下四股腘绳肌腱单束重建膝PCL和后1/2股二头肌腱重建PLC的技术和效果。[方法]自2001年12月～2004年12月,14例病人(14膝)重度膝关节不稳入住本科,均表现为3+后抽屉试验阳性,内翻试验阳性,外旋试验患膝较健侧>10°,关节镜检查证实为PCL断裂,膝后外侧间隙张开,外侧半月板抬高,腘肌腱断裂。2例伴腓总神经损伤。均于关节镜下行自体四股腘绳肌腱单束PCL重建术,后侧1/2股二头肌腱PLC重建术。[结果]本组术后早期均未发生严重并发症。14例均获得随访,随访时间12～33个月,平均(21.14±7.26)个月。膝关节后侧稳定性有非常明显进步。膝关节伸直位、屈曲30°位内翻试验均为阴性。膝关节屈曲30°、90°位外旋试验双侧差均<10°。Lysholm膝关节功能评分为70～95分,平均(86.79±7.23)分,较术前(40～60)分,平均(47.14±8.25)分)明显改进(P<0.01)。IKDC综合评定正常(A级)4膝、接近正常(B级)9膝、异常(C级)1膝,较术前[异常(C级)3膝、显著异常(D级)11膝]有非常明显的改进(Z=3.296,P<0.001)。14例患者中,12例恢复伤前运动水平,2例运动水平较伤前减低。[结论]PCL损伤常合并PLC损伤,表现为重度后侧不稳和后外侧旋转不稳。关节镜下单束重建膝PCL,同期后侧1/2股二头肌腱重建PLC,手术损伤小、术后膝关节功能恢复满意。     

膝关节后外侧角损伤对前交叉韧带重建的影响

[目的]评估后外侧角损伤对前交叉韧带重建的影响。[方法]2004年3月～2008年12月,作者复习了59例接受前交叉韧带重建的患者资料。39例患者接受单纯ACL重建(A组),20名患者接受ACL和后外侧角联合重建(B组)。通过术前到术后3年的随访资料来评价疗效。[结果]术后采用KT 2000测量仪测得的在胫前移位平均差值,A组(2.1±0.9 mm)>B组(1.5±0.8 mm)(P=0.032)。A组6膝(15.4%)、B组2膝(10%)有Ⅰ级前移。A组和B组Lysholm评分平均分别为92.9分和90.0分(P=0.387)。根据IKDC评分,A组32膝(82.1%)和B组20膝(85.0%)得分相同或基本相同(P=0.853)。[结论]前交叉韧带联合后外侧角重建比单纯交叉韧带重建使膝关节更稳定,然而两组在术后功能上并没有表现出显著差异。     

Accuracy of nonorthogonal magnetic resonance imaging in acute disruption of the anterior cruciate ligament

A controlled, prospective study of 30 patients with suspected acute internal derangement of the knee was undertaken to evaluate the sensitivity, specificity, predictive value, and accuracy of nonorthogonal (oblique) sagittal magnetic resonance imaging (MRI) in the assessment of anterior cruciate ligament (ACL) injuries. Thirty patients with acute hemarthroses underwent MRI within 12 days of injury, followed by arthroscopy within 24 h of the MRI. A control population of 30 chondromalacia patients underwent similar evaluation. In the acute hemarthrosis patient population, the incidence at arthroscopy of acute complete ACL tears was 60% (18/30); of partial ACL tears, 13.3% (4/30); and of chronic tears, 10% (3/30). A normal ACL was found in 16.6% (5/30) of patients. In the MRI evaluation of patients with suspected ACL injury the following results were obtained for both acute and chronic complete disruption on orthogonal (sagittal) and nonorthogonal (oblique sagittal) imaging, respectively: sensitivity, 61 (16/26) versus 100%; specificity, 70 (21/34) versus 100%; positive predictive value, 61 (16/26) versus 100%; negative predictive value 70 (24/34) versus 100%; and accuracy, 66 (40/60) versus 100%. In the evaluation of partial ACL injury, four partial tears were correctly diagnosed on nonorthogonal MRI, with one false-positive diagnosis. Orthogonal imaging failed to correctly identify any of the partial ACL injuries. Two patients in the control population demonstrated evidence of chronic ACL tears. We believe that we have demonstrated the superiority of T2-weighted nonorthogonal sagittal over conventional orthogonal sagittal ACL MRI in the evaluation of ACL injury.     

Combined anterior cruciate ligament and medial collateral ligament injuries in adolescents

Although literature supports bracing of most medial collateral ligament (MCL) injuries followed by arthroscopic repair of anterior cruciate ligament (ACL) tears in adults with combined ACL-MCL injuries, little is published regarding the treatment of these injuries in the pediatric population. The purpose of this study was to present our outcomes after treatment of combined ACL-MCL injuries in a series of adolescents. All 180 patients who underwent ACL reconstruction at our children's hospital from January 1997 to January 2003 were reviewed to identify those patients with concomitant grade II or III MCL injuries. Clinical data were obtained from chart review. All patients were treated with a hinged brace for their MCL injury followed by delayed arthroscopic reconstruction of their ACL using a transphyseal technique with Achilles tendon soft tissue allograft. Patients were contacted by phone to complete Lysholm knee questionnaires and assess return to athletic competition. Data were compared with a control cohort of patients who underwent isolated ACL reconstruction using the same technique. Twelve (6.7%) of 180 patients had combined ACL-MCL injuries. There were 6 boys and 6 girls; the mean age was 15.6 years (range, 14-17 years). Follow-up averaged 5.3 years (range, 2.6-8.2 years), and no patients were lost to follow-up. At last examination, all patients had a stable knee on both Lachman and valgus stress tests; the mean Lysholm knee score was 96 (range, 94-100). All patients were able to return to their preinjury level of athletics. One patient required manipulation for arthrofibrosis. When compared with the control group of 19 isolated ACL reconstructions, there was no significant difference with regards to Lysholm scores or return to athletics.Bracing of grade 2 or 3 MCL injuries followed by ACL reconstruction was an effective means of treating combined ACL-MCL injuries in this small series of adolescent patients.     

Comparison of sagittal obliquity of the reconstructed anterior cruciate ligament with native anterior cruciate ligament using magnetic resonance imaging

Purpose: This study was conducted to compare the obliquity of asymptomatic anterior cruciate ligament (ACL) grafts with normal controls using sagittal magnetic resonance imaging (MRI). Type of Study: Case control study. Methods: Sagittal MRIs from 30 patients with a reconstructed ACL graft and from 30 individuals with an intact ACL were reviewed. Reconstructed patients were operated on with a 2-incision technique using a patellar tendon autograft. These selected patients had a normal or nearly normal IKDC score with a 3 mm or less anterior posterior translation on KT-1000 arthrometer testing compared with the intact knee. MRI showed a continuous and homogeneous graft without evidence of roof impingement. Obliquity of the grafted ACL was determined on each lateral MRI by measuring the intersection of the graft line with the tibial plateau plane. These figures were compared with data similarly obtained from 30 individuals with a stable knee and an intact ACL determined by history and physical examination. Results: Graft obliquity in reconstructed patients averaged 67° with a range between 55° and 81°. In normal controls, intact ACL obliquity averaged 51° with a range between 45° and 55°. The difference between the two groups was statistically significant (P <.0001). Conclusions: MRIs of patients with an appropriate tibial tunnel placement in order to avoid notch impingement showed a continuous and homogeneous graft similar to the native ACL, but with a more vertical graft that does not recreate the normal sagittal obliquity. However, according to arthrometer testing, these more vertical grafts can control anterior posterior knee displacement.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 3 (March), 2003: pp 257–261     

The diagnostic accuracy of anterior cruciate ligament rupture using magnetic resonance imaging: a meta-analysis

This study evaluates the diagnostic accuracy of anterior cruciate ligament (ACL) rupture using magnetic resonance imaging in the management of patients with symptomatic tibiofemoral instability. Published and unpublished databases including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED and CINAHL, as well as unpublished studies registers were searched for studies that compared the diagnostic findings of MRI to arthroscopic surgery for patients with a suspected ACL rupture in September 2010. For each study, sensitivity and specificity of complete ACL rupture were analysed as bivariate data to account for a possible negative correlation within studies, and pooled meta-analysis was performed. Fifty-three studies compared the diagnostic accuracy of MRI to arthroscopic findings for a total of 4,673 patients, 4,683 knees. Overall, the pooled sensitivity of MRI for detecting complete ACL rupture was 94.5% (95% confidence interval 0.92–0.96) and specificity of 95.3% (0.93–0.97). MRI has high accuracy for patients with complete ACL rupture. Due to the higher economic costs and increased complication risks of diagnostic arthroscopy, MRI is therefore recommended as the principal investigation following clinical examination, to diagnose ACL rupture.     

Magnetic resonance imaging of anterior cruciate ligament rupture

Background  

Magnetic resonance (MR) imaging is a useful diagnostic tool for the assessment of knee joint injury. Anterior cruciate ligament repair is a commonly performed orthopaedic procedure. This paper examines the concordance between MR imaging and arthroscopic findings.     

Combined injuries of the medial collateral ligament and the anterior cruciate ligament

Aim of this retrospective study is to evaluate the effect of acute and late anterior cruciate ligament (ACL) reconstruction in patients with a combined injury of the ACL and the medial collateral ligament (MCL). All MCL injuries were treated non-operatively. In 27 patients (group I) we performed early ACL reconstruction (within the first 3 weeks after injury). The postoperative rehabilitation protocol included brace treatment for all patients over a period of 6 weeks. In 37 patients we performed late ACL reconstruction (after a minimum of 10 weeks). In this group initial non-operative MCL treatment (6 weeks brace treatment) was followed by a period of accelerated rehabilitation. Patients with late ACL reconstruction had a lower rate of loss of motion after finishing the postoperative rehabilitation programme and a lower rate of re-arthroscopies for a loss of extension (group I: 4 patients, group II: 1 patient). The difference in the mean quadriceps muscle strength (group I: 83.3%, group II: 86.3%) was not statistically significant. After a mean interval of 22 months, we saw no difference in the frequency of anterior or medial instabilities or in the loss of motion. The Lysholm score was significantly better in the group with late ACL reconstruction (group I: 85.3, group II: 89.9). The position on the Tegner activity scale decreased in both groups, to 5.5 in group I (preoperatively: 6.0) and to 5.6 in group II (preoperatively: 5.9). With regard to the lower rate of motion complications in the early postoperative period, the lower rate of re-arthroscopies, and the significantly better results in the Lysholm score, we prefer late ACL reconstruction in the treatment of combined injuries of the ACL and the MCL.     

Magnetic resonance imaging of reconstructed anterior cruciate ligament.

After anterior cruciate ligament reconstruction with autologous patellar tendon, 23 patients who had clinically stable knees were studied prospectively with sequential magnetic resonance imaging 1, 2, 3, 6, and 12 months after surgery. The images of the anterior cruciate ligament were obtained with a 1.5 tesla magnetic resonance scanner in the oblique sagittal, coronal, and oblique axial planes. The cross-sectional area and signal intensity on the reconstructed anterior cruciate ligament were measured in an oblique axial image. The usefulness of the oblique axial image in evaluating the integrity of the reconstructed anterior cruciate ligament was seen. The result showed that the diameter of the graft increased by 70% of its initial size and the signal intensity of the reconstructed graft also showed a tendency to increase. In three patients, there was discontinuity in the graft direction on the oblique sagittal image, but on the oblique axial image there was no evidence of reconstructed anterior cruciate ligament rupture in the sequential images. This shows the value of the oblique axial image in evaluating the integrity of the reconstructed anterior cruciate ligament. Also, sufficient notchplasty in anterior cruciate ligament reconstruction may be needed to prevent graft impingement.     

前交叉韧带损伤合并后外角损伤的治疗

膝关节多发韧带伤较常见的类型有前交义韧带(anterior cruciate ligament,ACL)合并内侧剐韧带损伤,后交义韧带合并后外们损伤,ACL、后交叉韧带合并内外侧剐韧带损伤等,这些损伤的诊断及治疗均有大量文献报道.     

Occult osseous lesions documented by magnetic resonance imaging associated with anterior cruciate ligament ruptures

Magnetic resonance images (MRI) were performed within three weeks of anterior cruciate ligament (ACL) rupture on 75 skeletally mature patients. Occult bony lesions were documented in 64 (85%) of the patients. Of the 64 patients with bone injuries, 83% had lesions of the lateral compartment. The lateral femoral condyle was involved in 50%, and the lateral tibial plateau was injured in 50% of the patients with changes. Nineteen of the 64 patients had more than one area of bony injury. Although the majority of bony lesions resolve, permanent alterations remained in some cases. This study has implications that may affect rehabilitation and the long-term prognosis in those patients with extensive bony and associated articular cartilage injuries.     

Evaluation of anatomic risk factors using magnetic resonance imaging in non-contact anterior cruciate ligament injury

BackgroundThe purpose of our study was to compare the significance of the tibio-femoral morphological variables (notch width index, notch shape index, intercondylar notch angle, medial and lateral tibial slopes) in predicting non-contact ACL (anterior cruciate ligament) injuries and to compare these factors between genders in South Asian population. The author hopes to provide a comprehensive analysis on the risk factors which would help in betterment of the patients at danger for anterior cruciate ligament injury.Materials and methodsA total of 110 MRI knees of patients with 55 subjects of noncontact ACL injury and 55 age and sex matched controls were included in a retrospective study. Notch width index, notch shape index, intercondylar notch angle were assessed in axial and coronal MR imaging along with medial and lateral posterior tibial slopes. Morphology of the notch was also assessed.ResultsACL injured group were found to have a statistically significant narrow notch width index and decreased intercondylar notch angle with increased lateral posterior tibial slope. Type-A notches were found to have increased risk of having ACL injuries. Gender comparative results showed no statistically significant differences.ConclusionACL tears are associated with decreased notch width index, intercondylar notch angle and increased lateral posterior tibial slope. Type-A notches are seen to have increased risk for ACL injuries.     

Segond fracture with anterior cruciate ligament tear in an adolescent

The authors report a case of acute knee injury in a 14-year-old teenager. The X-ray showed a so-called Segond’s fracture: a small avulsed bone fragment, elliptical in shape, lying immediately below the external tibial plateau, a few millimeters from the lateral tibial cortex. The fracture site was in the portion of the tibial condyle which is linked to the middle third of the lateral capsule by meniscal tibial fibers. Clinical examination under anesthesia and subsequent arthroscopy revealed a total intrasubstance ACL (anterior cruciate ligament) tear close to the proximal insertion. The authors confirm Segond’s report of a possible association of this avulsion fracture with ACL injuries, even in adolescence.     

Magnetic resonance imaging of posterior cruciate ligament injuries: assessment of healing

This study evaluated posterior cruciate ligament (PCL) healing using magnetic resonance imaging (MRI). Forty knees with acute PCL injuries underwent acute and follow-up (>6 months) MRI examinations. Twenty-three knees had isolated injuries, and 17 knees had associated ligament damage. The initial MRI scans showed 22 high-grade injuries with complete disruption, 14 with midgrade injuries with extensive edema on T2 images with some bridging fibers present, and 4 patients had low-grade injuries. At a mean time of 3.2+/-1.3 years after the initial MRI, the follow-up MRIs revealed the PCL healed with continuity in all of the low-grade and mid-grade injuries, and in 19 of 22 high-grade injuries. Of the 19 high-grade PCL tears that healed, 4 healed with normal contour and 15 were continuous with altered morphology at follow-up. Of 11 high-grade PCL-injured knees with associated ligament damage, only 1 PCL failed to regain continuity. The 3 PCLs that did not regain continuity were in 2 patients with isolated injuries and 1 patient with associated anterior cruciate and medial collateral ligament injuries. These results demonstrate that most nonoperatively treated PCL injuries, even in association with other knee ligament damage, can heal with continuity.     

Hamstring spasm in anterior cruciate ligament injuries

The accurate diagnosis of an anterior cruciate ligament (ACL) injury continues to be a challenge to clinicians, and often requires magnetic resonance imaging or arthroscopy for confirmation. We present a literature review of the currently known physical signs of ACL injury, followed by three case reports that describe a sign we believe may be helpful in the diagnosis of acute/semiacute ACL injury: involuntary hamstring spasm.     

Medial collateral knee ligament healing: Combined medial collateral and anterior cruciate ligament injuries studied in rabbits

We examined the histological appearance and biochemical properties of the healing medial collateral ligament (MCL) of a rabbit knee after combined MCL and anterior cruciate ligament (ACL) injury treated with ACL reconstruction and with or without MCL repair. By so doing, we hoped to understand better our previous biomechanical observations (Ohno et al. 1995) and possibly learn where to focus future investigation into improving the quality of the healing MCL.

Ligaments were examined at 6 and 12 weeks of healing. We found healing of all ligaments with hypercellularity and fibroblast elongation along the axis of loading, as expected. Unexpected, however, was the finding of multiple osteophytes in both the repaired and nonrepaired specimens at the medial borders of the joint and at the MCL insertions. These were felt to affect possibly the biomechanics of the MCL by causing stress risers at the point where they undermine the ligament. Biochemically, we demonstrated a correlation between collagen content and hydroxypyridinium crosslinks and modulus of elasticity. While this implies that the modulus is dependent on collagen content and hydroxypyridinium crosslink density, modulus is also probably dependent on other factors such as collagen organization, type and internal structure. Overall, the detailed characterization and correlation between the histological, biochemical, and biomechanical properties of the healing MCL in the severe knee injury model provide insight into the functional behavior of the healing MCL.     

Comparison of anatomical risk factors for noncontact anterior cruciate ligament injury using magnetic resonance imaging

PurposeTo compare the significance of the tibio-femoral geometrical indices (notch width index, medial and lateral tibial slopes) and patellar tendon- tibial shaft angle in predicting non-contact ACL injuries and to compare these factors between genders.MethodsRetrospective case control study evaluating 66 MRI knee of patients of age group of 18–60 years with 33 cases of noncontact ACL injury and 33 age matched controls. Notch width index, medial and lateral tibial slopes and patellar tendon tibial shaft angles were calculated and compared for statistical significance and was also compared between the genders. ROC curve was for plotted for the significant factors.ResultsStatistically significant difference was seen in notch width index and patellar tendon tibial shaft angles with cases showing a narrow notch width index and an increased patellar tendon tibial shaft angle. Gender comparative results showed no statistically significant differences. ROC curve plotted for NWI showed an optimal cut off value of 0.263 with a sensitivity of 88% and a specificity of 52%. ROC curve plotted for PTTS angle showed a cut off value of 26.7 degrees with a sensitivity of 67% and a specificity of 49%.ConclusionNarrow Notch width index and increased Patellar tendon tibial shaft angle are predictors of ACL injury. PTTS angle which has been studied as a function of knee flexion angle, can itself be an independent predictor of ACL injury (at a constant knee flexion angle).     

Magnetic resonance imaging after anterior cruciate ligament reconstruction:A practical guide

Anterior cruciate ligament(ACL) reconstruction is one of the most common orthopedic procedures performed worldwide. In this regard, magnetic resonance imaging(MRI) represents a useful pre-operative tool to confirm a disruption of the ACL and to assess for potential associated injuries. However, MRI is also valuable postoperatively, as it is able to identify, in a non-invasive way, a number of aspects and situations that could suggest potential problems to clinicians. Graft signal and integrity, correct tunnel placement, tunnel widening, and problems with fixation devices or the donor site could all compromise the surgical outcomes and potentially predict the failure of the ACL reconstruction. Furthermore, several anatomical features of the knee could be associated to worst outcomes or higher risk of failure. This review provides a practical guide for the clinician to evaluate the post-surgical ACL through MRI, and to analyze all the parameters and features directly or indirectly related to ACL reconstruction, in order to assess for normal or pathologic conditions.     

Knee evaluation in two systems and magnetic resonance imaging after operative treatment of posterior cruciate ligament injuries

We reviewed 30 patients operated on because of acute (n = 14) or chronic (n = 16) rupture of the posterior cruciate ligament (PCL) with an average follow-up time of 6.9 years. The clinical outcome was expressed using the OAK and the International Knee Documentation Committee (IKDC) evaluation forms. All patients had undergone posterior stress X-radiography, 14 patients had additionally undergone magnetic resonance imaging (MRI). OAK score showed good or excellent results in 93% of the acute and 38% of the chronic cases. The IKDC form, however, revealed nearly normal results in only 29% of the acute and 6% of the chronic cases. The length and thickness of the operated PCL on MRI correlated with the clinical result.