Hybrid Anterior Cruciate Ligament Reconstruction: Introduction of a New Technique for Anatomic Anterior Cruciate Ligament Reconstruction

Recently, anatomic or double-bundle reconstruction of the anterior cruciate ligament (ACL) has been presented in an effort to more accurately restore the native anatomy. These techniques create 2 tunnels in both the femur and tibia to reproduce the bundles of the ACL. However, the increased number of tunnels, particularly on the femoral side, has raised some concerns among authors and surgeons. We describe a technique to reconstruct the 2 distinct bundles of the ACL by using a single femoral tunnel and 2 tibial tunnels, the “hybrid” ACL reconstruction. The femoral tunnel is drilled through an anteromedial arthroscopy portal, which allows placement in a more anatomic position. Fixation in the femur is achieved with a novel device that separates a soft-tissue graft into 2 independently functioning bundles. Once fixed in the femur, the anteromedial and posterolateral bundles of the graft are passed through respective tunnels at the anatomic footprint on the tibia. These bundles are independently tensioned, which creates a reconconstruction that is similar to the native ACL. The technique presented provides surgeons with an alternative to other double-bundle techniques involving 4 tunnels.     

Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction With Anatomic Aimers

Graft positioning is a key issue in anterior cruciate ligament (ACL) reconstruction and even more sensitive in double-bundle reconstruction, where 2 tunnels have to be drilled within the ACL footprints at both the femoral and tibial insertion sites. Specific ancillary instruments have been developed to facilitate the positioning of the 4 sockets necessary when performing anatomic double-bundle ACL reconstruction. This technical note describes the rationale and the step-by-step method of using the specific aimers developed for this purpose. However, a prerequisite for successful double-bundle ACL reconstruction is a good knowledge of ACL footprint anatomy.     

关节镜下膝关节后交叉韧带重的临床体会

目的：总结17例关节镜下后交叉韧带重的体会。方法：关节镜下移植中1／3骨－髋韧带－骨或半腱＋股薄肌腱组织建重膝关节后交叉韧带,用于治疗后交叉韧带损伤后关节不稳定。结果：所有患平均随访时间为13．1个月。Larson评分由术前61例提高到93分。Lysholm评分由术前55分提高到91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,1例Lachman弱阳性,所有患主观评价膝关节功能明显增进,对治疗效果满意。结论：在关节镜直视下,能准确确定位后交叉韧带解剖止点,钻制骨遂道,植入移植组织,该技术具有不切开关节囊,损伤小、关节粘连率低的优点。     

关节镜下前交叉韧带重建术后膝关节皮温变化的研究

目的探讨关节镜下前交叉韧带(anterior cruciate ligament,ACL)重建术后膝关节皮温变化的特点。方法2015年7月~2016年10月我院63例ACL重建,检测术前和术后3、6、12周(23例)双侧膝关节及周围皮肤温度,观察术后膝关节肿胀情况。结果健侧膝关节术前膝前方皮温低于膝内侧、膝外侧、髌骨上缘上方10 cm处大腿以及髌骨下缘下方10 cm处小腿皮温(P<0.05)。患侧术前、术后3和6周膝前与膝内侧温差差异有显著性(χ^2=41.608,P=0.000),术后3周患侧膝前和膝内侧温度接近,温差明显小于术前(P=0.000),术后6周温差与术前差异无显著性(P=0.069)。不同时间(术前、术后3和6周)膝前、膝内和外侧和大腿患侧皮温明显高于健侧(P<0.05),小腿患侧和健侧差异无显著性(P>0.05)。术后12周仅39.1%(9/23)的患者双侧膝前温度差>1℃。术后3、6周膝关节肿胀患者较不肿患者膝前温差明显升高(Z=-3.821,P=0.000;t=-5.181,P=0.000)。结论正常膝关节膝前方皮温较低,关节镜下ACL重建术后3、6周时皮温高于健侧,12周时接近正常。     

关节镜下应用EndoPearl和Intrafix固定腘绳肌肌腱重建前交叉韧带

目的 关节镜下采用腘绳肌肌腱和EndoPearl与Intrafix重建前交叉韧带.方法 31例前交叉韧带断裂患者在关节镜下采用四股腘绳肌肌腱重建前交叉韧带,股骨端应用EndoPearl和可吸收界面螺钉固定,胫骨端应用Intrafix固定,术后系统康复.结果 全部获随访,平均15.5个月(12～20个月).术前Lysholm评分平均为(54.2±5.4)分,术后为(98.4±0.2)分.与术前相比差异有显著性意义(P＜0.05).结论 关节镜下采用腘绳肌肌腱和EndoPearl与Intrafix重建前交叉韧带操作简单,固定可靠,疗效肯定.     

Factors Affecting the Femoral Cartilage Thickness After Anterior Cruciate Ligament Reconstruction

BackgroundThis study aimed to evaluate the changes in the distal femoral cartilage thickness in patients that underwent anterior cruciate ligament reconstruction (ACLR) and to analyze their association with concomitant meniscal surgery, knee muscle strength, kinesophobia, and physical activity level.MethodsThe demographic characteristics and surgical data of 47 male patients that underwent unilateral ACLR (mean, 27.55 ± 5.63; range, 18–40 years) were evaluated. The patients were assessed in three groups depending on surgery: isolated ACLR (n = 15), ACLR + partial medial meniscus resection (ACLR&M) (n = 16), and ACLR + medial meniscus repair (ACLR&MR) (n = 16). The medial (MCCT), intercondylar (ICCT), and lateral (LCCT) femoral cartilage thicknesses on both limbs were measured using ultrasonography. The extensor and flexor muscles strength of the knees was assessed using an isokinetic dynamometer at 60°/s. The physical activity level was evaluated by the International Physical Activity Questionnaire (IPAQ) short form and Tegner Activity Scale (TAS). The fear of movement was assessed by the Tampa Scale for Kinesiophobia Questionnaire (TSKQ).ResultsThe postoperative mean follow-up duration was 32.24 ± 9.17 months. MCCT and LCCT were significantly decreased in the ACLR&M group (p < 0.001 and p = 0.019, respectively). MCCT, ICCT and LCCT were significantly decreased in the ACLR&MR group (p = 0.017, p = 0.011, and p = 0.004, respectively). No significant change was found in the ACLR group. Cartilage thickness changes were not significantly correlated with the knee muscle strength, IPAQ, TAS and TSKQ scores in all groups (p > 0.05).ConclusionThe results showed partial meniscectomy and meniscus repair at the time of ACLR as important risk factors for decreased chondral thickness.     

关节镜下应用EndoPearl与Intrafix固定双侧绳肌肌腱一期重建膝关节前后交叉韧带

目的探讨关节镜下应用EndoPearl与Intrafix固定双侧腘绳肌肌腱同时重建膝关节前后交叉韧带的近期临床效果。方法对2004年6月~2005年3月收治的10例膝关节前后交叉韧带同时断裂的患者,切取双侧腘绳肌腱,2条半腱肌腱和2条股薄肌腱分别对折成四束,折端固定同直径EndoPearl。关节镜下利用两组移植物同时分别重建膝前后交叉韧带。股骨端应用可吸收界面螺钉顶压固定EndoPearl与移植肌腱,胫骨端应用Intrafix固定四束肌腱。结果10例均获得随访,平均7.5个月(6~15个月),切口Ⅰ期愈合,无感染。其中新鲜损伤4例,陈旧性损伤6例,合并后外侧复合体损伤3例,均予同期修复,合并内侧副韧损伤6例,未予特殊处理,5例曾急诊修复腘动静脉。术后3个月膝关节活动范围均超过120°,无伸膝受限,后抽屉试验Ⅰ度阳性2例,其余为阴性;Lyshlom评分(92.6±3.2)分。结论关节镜下应用EndoPearl与Intrafix固定双侧腘绳肌肌腱同时重建膝关节前后交叉韧带方法确切,可有效恢复膝关节功能。     

Twenty-Year Experience of a Double-Bundle Anterior Cruciate Ligament Reconstruction

Double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using a four-strand semitendinosus tendon was started in our department in July 1994. The motivation for starting the procedure was that the EndoButton with an inside-out procedure instrument became available in Japan. A review article of our DB ACL reconstruction procedure was summarized for the twentieth anniversary of the surgical procedure. Initial tension setting of the two grafts was changed in the first 8 years to achieve better stability during DB ACL reconstruction. A randomized clinical trial (RCT) was started in July 2002 to clarify superiority of the DB procedure to single-bundle (SB) reconstruction under the concept of anatomic reconstruction. Several anatomic studies were performed to describe normal ACL anatomy, which is essential for realizing anatomic reconstruction. A remnant-preserving technique would be an additional option for our DB procedure to improve reconstruction outcomes. Thus, a new remnant-preserving DB procedure was started in 2012. The reproducibility of the new procedure was investigated using three-dimensional computed tomography images. More complex procedures were performed using a transtibial technique and EndoButtons. Initial tension balancing between the two grafts was important for a better outcome. Superiority of knee stability after the DB compared to that after the SB procedure was clarified by the RCT. However, no patient consensus has been reached on any subjective advantage to the DB procedure. Studies of normal ACL anatomy have left questions unresolved regarding where the two tunnels should be created for direct and indirect insertions based on normal anatomy. A new remnant-preserving DB ACL procedure has been practiced. The procedure was more reproducible with respect to creating the femoral tunnel. DB ACL reconstruction using a semitendinosus tendon is an attractive option when pursuing a better outcome for patients.     

Anterior Cruciate Ligament Double-Bundle Reconstruction With Hamstring Tendon Autografts

The anterior cruciate ligament (ACL) surgical technique via a 5-strand hamstring tendon autograft is designed with a conventional single-bundle reconstruction that has shown favorable results and an additional posterolateral (PL) bundle reconstruction. The conventional single-tunnel technique is performed for the tibial tunnel, and the double-tunnel technique is performed for the femoral tunnel. The anteromedial (AM) femoral tunnel is prepared with 1 mm of the posterior femoral cortex being left over the top at the 11- to 1-o’clock position. The PL femoral tunnel is prepared with the outside-in technique by use of a 4.5-mm cannulated reamer. The AM bundle is fixed with a rigid fixation system on the femoral side, and the PL bundle is fixed to tie with the miniplate from the outside femur. A double-bundle reconstruction with 5-strand hamstring autografts, in conjunction with a conventional AM bundle and an additional PL bundle, seems to be a very effective method for the treatment of ACL instabilities. Although the long-term clinical outcome of the procedure is yet to be determined, complications including graft impingement, limitation in range of motion, and residual instability have not been observed to date in the first 38 patients who have undergone our technique.     

改良关节镜下前交叉韧带重建术的安全性研究

目的探讨关节镜下经前内侧入路（anteromedial,AM）建立股骨隧道的膝关节前交叉韧带（anterior cruciateligament,ACL）移植重建手术的改良方法的安全性。方法 2010年1～10月采用改良AM方法完成ACL重建20例（实验组）,2009年1～12月采用传统AM方法完成ACL重建20例（对照组）,比较2组股骨隧道的长度,股骨隧道斜度,股骨外髁后壁爆裂和后外侧管神经损伤的情况。结果实验组术中股骨隧道长度为（41.8±4.1）mm,显著长于对照组（37.2±4.4）mm（t=3.421,P=0.002）。实验组股骨隧道冠状角度为51.9°±7.7°,显著大于对照组39.1°±5.8°（t=5.938,P=0.000）。对照组1例出现股骨隧道后壁爆裂,2组其余患者未发现后壁爆裂和后外侧血管神经损伤。结论改良AM方法可以增加ACL重建手术的安全性。     

Injury to the Anterior Tibial Artery during Bicortical Tibial Drilling in Anterior Cruciate Ligament Reconstruction

Many complications have been reported during or after anterior cruciate ligament (ACL) reconstruction, including infection, bleeding, tibial tunnel widening, arthrofibrosis, and graft failure. However, arterial injury has been rarely reported. This paper reports a case of an anterior tibial arterial injury during bicortical tibial drilling in arthroscopic ACL reconstruction, associated with an asymptomatic occlusion of the popliteal artery. The patient had a vague pain which led to delayed diagnosis of compartment syndrome and delayed treatment with fasciotomy. All surgeons should be aware of these rare but critical complications because the results may be disastrous like muscle necrosis as in this case.     

早期康复训练对膝关节前交叉韧带重建术后疗效的Meta分析

目的：基于已发表的随机对照试验,采用Meta分析关节镜下前交叉韧带(ACL)术后早期康复训练的疗效。方法：计算机检索PubMed、Embase和CENTAL数据库等,收集ACL术后早期康复的随机对照试验(RCT),检索时间不限,语种仅英语。两名研究人员按照纳入与排除标准独立对文献进行筛选,提取有关数据资料,并采用Cochrane Collaboration工具表对文献质量进行评价。采用Revman5.3软件进行Meta分析,比较研究组（ACL术后早期康复训练）与对照组（ACL术后常规康复训练）的Lysholm膝关节评分、Tegner膝关节评分、KT-1000或K-2000关节活动度测量仪测量值,评价康复疗效。结果：共纳入12篇RCT,共544例研究对象。两组Lysholm膝关节评分差异有统计学意义,Tegner膝关节评分、KT-1000/KT-2000测量值、单腿跳跃试验方面差异均无统计学意义。结论：前交叉韧带术后早期康复对膝关节恢复可能存在优势,临床上应制定个体化的康复方案,使患者膝关节得到最大程度的恢复。