Low-velocity knee disclocation associated with sports injury

A knee dislocation usually involves injury to both the anterior cruciate ligament and posterior cruciate ligament,and to either the medial collateral ligament or the lateral structures of the knee. Acute surgical repair of all structures has led to a high rate of arthrofibrosis. We describe a treatment algorithm for treatment based on the healing potential of each structure. The medial collateral ligament can heal with a short duration of serial casting. The posterior cruciate ligament can heal without treatment, and patients with laxity of 2+ have similar outcomes to patients with less laxity. The anterior cruciate usually does not heal, but ACL reconstruction can be performed on an elective basis when the acute inflammatory response has subsided.     

关节镜下横杆悬挂法重建膝前交叉韧带临床研究

目的:介绍关节镜下横杆悬挂固定法(ArthrexTransFixⅡ法)固定移植的半腱肌腱、股薄肌腱重建膝关节前交叉韧带的方法,并对其中期临床疗效进行了分析。方法:从2003年6月至2005年9月,采用横杆悬挂固定法固定移植的半腱肌、股薄肌腱重建膝关节前交叉韧带123例。其中,男性100例,女性23例。年龄16～57岁,平均年龄28.5岁。左膝60例,右膝63例。平均病程12.3个月。取患膝半腱肌腱、股薄肌腱并修整、编织缝合后植入骨道,股骨骨道的移植物行横杆悬挂法固定,胫骨端用生物可吸收挤压钉加门形钉固定。结果:123例患者中,112例获得随访,随访时间6～27个月,平均18.5个月。随访病例术前Lysholm评分为53.2±3.2分,随访时Lysholm评分为93.4±2.3分,两者相比有显著性差异(P<0.05)。结论:关节镜下横杆悬挂法绳肌移植重建膝前交叉韧带是一种微创、疗效确切的方法。     

关节镜下重建膝关节新鲜与陈旧前交叉韧带训练伤疗效对比分析

目的比较部队官兵体能训练所致膝关节前交叉韧带(ACL)损伤手术时机对疗效的影响。方法关节镜下对平均病程(5±0.8)周27例新鲜组和平均病程(76±10.5)周19例陈旧组ACL损伤,均以半腱肌和股薄肌为替代物进行手术重建。结果按Lysholm评分,新鲜组和陈旧组ACL损伤的优良率分别为92.5%和78.9%,两组比较差异有显著统计学意义(P<0.01)。结论体能训练所致膝关节交叉韧带损伤早期关节镜手术重建的疗效优于晚期重建。     

Fluoroscopic validation of electrogoniometrically measured femorotibial translation in healthy and ACL deficient subjects

Equipment which measure femorotibial motions indirectly by using a patellar pad are reported to have errors caused by deformation of soft tissues and slippage of the device. For the purpose of validation, the tibial translation in relation to the femur per degree of knee extension was estimated from the slope coefficients of the flexion-displacement curve, obtained by both fluoroscopic and electrogoniometric tests, in the knee of the dominant limb in healthy subjects and in both knees of patients with unilateral anterior cruciate ligament (ACL) deficiency. In addition, the anterior and posterior static knee laxity limits and the tibial resting position were evaluated. Within all knee groups, the tibia moved posteriorly in relation to the femur during extension. The measured movement was similar both with the electrogoniometer and with fluoroscopy thereby indicating that sagittal plane knee translation measurements with the CA-4000 electrogoniometer are reliable and in good agreement with the X-ray measurements, even though the measurements were made separately. The ACL injured knees showed approximately 20% smaller posterior movement of tibia in relation to femur per degree change of knee extension than the non-injured or control knees (p < 0.05) and a more anterior resting position of the tibia relative to femur as compared to the contralateral healthy knee during knee laxity testing (p = 0.002).     

Isolated ACL versus multiple knee ligament injury: associations with patient characteristics,cartilage status,and meniscal tears identified during ACL reconstruction

Objectives: The objectives of this study were to determine (1) if patients undergoing reconstruction of an isolated anterior cruciate ligament (ACL) tear had different characteristics (age, gender, body mass index [BMI]) than patients undergoing ACL reconstruction (ACLR) with multiple knee ligament (MKL) tears and (2) whether there was a difference in prevalence of articular cartilage injury and meniscus tears between these two groups.

Methods: Patients undergoing primary ACLR between February 2005 and June 2013 were identified through an ACLR registry. Patients were grouped by whether they had an isolated ACL tear or an ACL tear associated with another knee ligament tear. The study cohort was analyzed to identify differences in patient characteristics and cartilage/meniscus injury patterns between the groups.

Results: Of the 21,377 ACLR cases enrolled in the registry during the study period, 2.5% (n = 549) had MKL tears. The MKL group had more males (73.2% vs. 62.8%, p < 0.001) than the isolated ACL group. The MKL group also had a higher percentage of patients with a BMI greater than 30 (31.1% vs. 22.7%, p = 0.0002). When adjusting for these variables, any articular cartilage injury was equal in the two groups (OR = 1.01, CI 0.82–1.25, p = 0.922), while medial femoral condyle injury was less common in the MKL group (OR = 0.73, CI = 0.56–0.07, p = 0.28). The likelihood of any meniscus tear was lower in the MKL group (OR = 0.56, CI = 0.47–0.67, p < 0.001) as was the likelihood of medial meniscus tears (OR = 0.53, CI = 0.44–0.65, p < 0.001).

Conclusions: When comparing patients with MKL tears versus isolated ACL tears at ACLR, there was a higher percentage of males and patients with BMI over 30 in the MKL group. Medial femoral condyle articular cartilage injury, any meniscus tear, and medial meniscus tears were less common in patients with MKL injury compared to patients with isolated ACL tears.     

The drill wobble effect: oversizing the femoral tunnel during ACL reconstruction

Objectives: In ACL reconstruction, autologous tendon graft can be attached to the femur, within a boney tunnel, using an Endobutton device. The ultimate aim being to achieve biological fixation and incorporation into the bone. Accurate bone tunnel diameter to match the tendon graft is vital to biologic incorporation and strength. The common technique of in sequence passing a guide wire, a cannulated 4.5 mm Endobutton drill, then a cannulated femoral socket drill causes the guidewire to lose cortical fixation and stability before the femoral socket drill is passed.

The Objective of this study is to analyze this common technique of femoral socket creation and determine if it results in unintentionally oversizing the femoral socket due to femoral socket drill-wobble over a destabilised guide wire.

Methods: 12 cadaveric femoral pairs equally divided between two groups underwent femoral socket creation in one of the two following sequences.

Group 1: Guidewire, 4.5 mm endobutton drill, 8 mm femoral socket drill. Group 2: Guidewire, 8 mm femoral socket drill, 4.5 mm endobutton drill. The created femoral tunnels apertures and calibres were measured and then compared for accuracy between the two groups.

Results: Passing the 4.5 mm drill before the 8 mm socket drill results in oversized tunnel apertures and calibres when compared to passing an 8 mm socket drill after the 4.5 mm drill has been passed (p<0.0001).

Conclusion: To most precisely create an 8 mm femoral socket in ACL reconstruction, the 8 mm femoral socket reamer followed by the 4.5 mm should be passed over the guide wire to prevent guide wire destabilization and drill-wobble.     

MRI of knee ligament injury and reconstruction

Knee ligament instability may lead to meniscal and chondral damage, resulting in early osteoarthritis. Due to its superior soft tissue contrast and avoidance of harmful ionizing radiation, MRI has become the most important imaging modality for early recognition of structural defects of the knee joint. This review aims to the understanding of MRI appearances of knee ligament structures associated with knee instability, and to review the common patterns of altered knee mechanics that lead to ligament failure. Normal anatomy of the knee ligaments, pathologic conditions, and postsurgical appearances of the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, and posterolateral corner are described. J. Magn. Reson. Imaging 2013;38:757–773 . © 2013 Wiley Periodicals, Inc .     

Graft selection in surgicalreconstruction of the multiple-ligament-injured knee

Knowledge of the various graft options available for reconstruction of the knee with multiple ligamentous injuriesis necessary for the surgeon and patient to make an informed decision. Allograft is frequently used for such reconstructions, because multiple grafts are often necessary. Allograft avoids the morbidity associated with autograft harvest, allows smaller incisions, and saves operative time. A concern with the use of allograft, however, is the small but serious risk of disease transmission, including viral and bacterial infections. Allograft is also expensive and its availability may be limited. Some patients may prefer reconstruction with autograft tissue. Bone-patellar tendon-bone autograft is strong, stiff, and allows bony fixation at both ends. Harvest complications, primarily anterior knee pain, are drawbacks to using this source. Hamstring tendon autograft harvest results in less donor-site morbidity and comparable strength to bone-patellar tendon-bone autograft when bundled. Quadriceps tendon autograft also has been used in knee reconstruction, offering a strong graft with less morbidity than bone-patellar tendon-bone autograft harvest. Quadriceps tendon harvest is technically challenging, however. Achilles tendon and anterior tibialis allografts, as well as both autograft/allograft patellar tendon, quadriceps tendon, and hamstring tendon can all be used to reconstruct the anterior cruciate ligament, posterior cruciate ligament, or collateral ligament complexes. Ultimately, the choice of graft is dependent on surgeon and patient preference, availability of graft sources, and the number of ligaments requiring reconstruction or augmentation.     

ACL/PCL reconstruction: the role of double-bundle PCL reconstruction

Our approach to combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries depends on the timing of the injury and concomitant ligament and bony pathology. In the acute setting (within 3 weeks), we prefer to perform single-bundle ACL and PCL reconstruction because we have seen consistently good results. However, chronic combined injuries do not fare as well because single-bundle PCL reconstruction in these injuries has not consistently corrected posterior laxity. Because of this clinical data, we now utilize a double-bundle PCL technique for knees with chronic, combined ligament deficiency with instability. This particular patient population has significant anterior, posterior, and, in many cases, posterior lateral laxity. Once the decision has been made to proceed with this procedure, attention to the technical details is critical to achieving good results. In this article, we will outline important general and specific technical details that will facilitate the procedure and optimize the clinical outcome.     

Anterior cruciate ligament (ACL)-deficient knee with degenerative arthrosis: treatment with an isolated autogenous patellar tendon ACL reconstruction

We evaluated 58 patients (mean age 30.4 years) who had undergone an isolated anterior cruciate ligament (ACL) reconstruction for chronic instability (mean time from injury to surgery, 8.2 ± 5.2 years) and showed radiographic evidence of degenerative arthrosis. Objective evaluation at a mean of 4.1 years postoperatively included KT-1000 arthrometer stability, range of motion, and quadriceps muscle strength testing. Subjective analysis at a mean of 5.5 years postoperatively included rating of pain, stability, activity level, and a total score both preoperative and postoperative. Patients were divided into two groups: group 1 (n = 28) with a follow-up ≤ 5 years (mean 3.3 years); group 2 (n = 30) with a follow-up > 5 years (mean 7.2 years). Results were analyzed by length of follow-up and by the grade and compartment of arthrosis. All patients enjoyed a full range of motion preoperatively and postoperatively. The mean KT-1000 arthrometer manual maximum difference improved from a mean of 8.2 mm preoperatively to 2.4 mm postoperatively. All subjective scores showed statistically significant improvement over the preoperative values. Patients with medial compartment arthrosis reported a better subjective total score (mean 87) than patients with lateral compartment (mean 73) or bicompartmental (mean 79) arthrosis, but there was not a statistically significant difference. There was no correlation between pain, stability, or total scores and time after surgery. Patients in groups 1 and 2 had equal objective stability and similar subjective scores, but group 2 reported a lower activity level. An isolated ACL reconstruction can provide long-term stability and symptomatic pain relief in patients with chronic instability and arthrosis. The procedure has low morbidity and does not compromise future tibial osteotomy or total knee replacement. Received: 16 September 1996 Accepted: 1 March 1997     

Relative contribution of the ACL, MCL, and bony contact to the anterior stability of the knee

Ligaments and other soft tissues, as well as bony contact, all contribute to anterior stability of the knee joint. This study was designed to measure the in situ force in the medial collateral ligament (MCL), anterior cruciate ligament (ACL), posterolateral structures (PLS), and posterior cruciate ligament (PCL) in response to 110 N anterior tibial loading. The changes in knee kinematics associated with ACL deficiency and combined MCL+ACL deficiency were also evaluated. Utilizing a robotic/universal force-moment sensor system, ten human cadaveric knee joints were tested between 0° and 90° of knee flexion. This unique testing system is designed to determine the in situ forces in structures of interest without making mechanical contact with the tissue. More importantly, data for individual structures can be obtained from the same knee specimen since the robotic manipulator can reproduce the motion of the intact knee. The in situ forces in the ACL under anterior tibial loading to 110 N were highest at 15° flexion, 103 ± 14 N (mean ± SD), decreasing to 59.2 ± 30 N at 90° flexion. For the MCL, these forces were 8.0 ± 3.5 N and 38.1 ± 25 N, respectively. Forces due to bony contact were as high as 34.1 ± 23 N at 30° flexion, while those in the PLS were relatively small at all flexion angles. Combined MCL+ACL deficiency was found to significantly increase anterior tibial translation relative to the ACL-deficient knee only above 60° of knee flexion. These findings confirm the hypothesis that there is significant load sharing between various ligaments and bony contact during anterior tibial loading of the knee. For this reason, the MCL and osteochondral surfaces may also be at significant risk during ACL injury. Received: 29 December 1997 Accepted: 16 July 1998     

High risk of new knee injury in elite footballers with previous anterior cruciate ligament injury

Background

Anterior cruciate ligament (ACL) injury is a severe event for a footballer, but it is unclear if the knee injury rate is higher on returning to football after ACL injury.

Objective

To study the risk of knee injury in elite footballers with a history of ACL injury compared with those without.

Method

The Swedish male professional league (310 players) was studied during 2001. Players with a history of ACL injury at the study start were identified. Exposure to football and all time loss injuries during the season were recorded prospectively.

Results

Twenty four players (8%) had a history of 28 ACL injuries in 27 knees (one rerupture). These players had a higher incidence of new knee injury of any type than the players without ACL injury (mean (SD) 4.2 (3.7) v 1.0 (0.7) injuries per 1000 hours, p  =  0.02). The risk of suffering a knee overuse injury was significantly higher regardless of whether the player (relative risk 4.8, 95% confidence interval 2.0 to 11.2) or the knee (relative risk 7.9, 95% confidence interval 3.4 to 18.5) was used as the unit of analysis. No interactive effects of age or any other anthropometric data were seen.

Conclusion

The risk of new knee injury, especially overuse injury, was significantly increased on return to elite football after ACL injury regardless of whether the player or the knee was used as the unit of analysis.     

高频超声膝关节前交叉韧带损伤分级诊断与关节镜对比研究

目的:探讨高频超声对膝关节前交叉韧带(ACL)损伤分级诊断的临床价值。方法:对85例临床拟诊为ACL损伤的患者行高频超声与关节镜检查,将2种检查结果进行对比,并对ACL损伤进行分级。结果:根据ACL损伤的程度及表现,将其分为3级,高频超声诊断符合率91.76%(78/85),假阴性率4.71%(4/85),假阳性率3.53%(3/85)。结论:高频超声分级诊断ACL损伤具有较高的准确性,可作为膝关节ACL损伤的常规检查方法。     

前交叉韧带部分断裂的诊治

目的 :探讨前交叉韧带 (anteriorcruciateligament,ACL)部分断裂的诊断方法和治疗方式。方法 :2 0 0 0年 3月～ 2 0 0 2年 6月收治ACL部分断裂患者 2 4例 ,其中 7例以前内束断裂为主 ,17例以后外束断裂为主。所有病例均经关节镜检查确诊 ,其中行关节镜下ACL重建者 16例。结合症状、体征和MRI进行诊断 ,并比较前内束断裂和后外束断裂临床表现的差异。术后随访 9～ 13个月 ,平均 11个月。对手术前后膝关节Lysholm评分结果进行统计分析。结果 :本组病例出现关节不稳的 ,ACL前内束断裂者占 2 8 6 % ,后外束断裂者占 98 2 % ;体检前抽屉试验 (ADT)、Lachman试验和轴移试验 (PST)阳性率 ,前内束断裂者分别为 71 4 %、14 3%和 0 ;后外束断裂者分别为 17 6 %、98 2 %和 76 5 %。ACL重建术后Lysholm评分平均为 93 4 7± 2 6 2 ,较术前 (6 3 5 3± 8 11)明显提高(P <0 0 1)。结论 :ACL部分断裂根据损伤部位的不同临床表现也存在差异。后外束断裂者出现关节不稳较前内束常见 ,前内束断裂主要表现为前抽屉试验阳性 ,而后外束断裂常表现为Lachman试验和轴移试验阳性。对于伴有关节不稳的 ,手术重建ACL效果良好。     

Study on three-dimensional kinematics and electromyography of ACL deficient knee participants wearing a functional knee brace during running

This investigation examined the muscular activity and 3D knee joint kinematic changes of anterior cruciate ligament-deficient (ACLD) participants in the involved leg under bracing condition during running. Different adaptation strategies have been found between patients who can cope with the injury and patients who cannot. One of the expected changes can be the muscle activation characteristic of the injured knee during strenuous activity with and without a functional knee brace. Three-dimensional kinematic and electromyographical (EMG) data were collected from 11 participants for 10 consecutive gait cycles during running on a treadmill under both braced and unbraced conditions. Participants were administered the “Knee Outcome Survey Activities of Daily Living Scale” to distinguish functional and non-functional candidates. No significant differences on 3D kinematics and EMG data were noted between functional and non-functional participants, thus data analysis focused on comparisons of bracing conditions for one combined group. Bracing significantly reduced total range of motion in the frontal and transverse planes (P<0.05). Muscle activity at heel-strike showed a consistent trend to increase for the hamstrings and decrease for the quadriceps under the braced condition when compared to the unbraced condition. Our findings indicate that bracing the ACLD knee alters the kinematics of the injured leg while running. Tendencies toward reductions in quadriceps and increases in hamstrings activity at heel-strike indicate that bracing might have resulted in added stability of the injured knee. The adaptations to bracing found in this preliminary study further support the potential mechanical and proprioceptive contributions of the functional knee brace to protect the ACLD knee.     

前交叉韧带损伤的MRI诊断与临床诊断比较研究

目的:探讨核磁共振(MRI)和临床检查对急性前交叉韧带(anterior cruciate ligament,ACL)损伤诊断的价值.方法:自2000年9月～2003年12月,对76例急性创伤性膝关节血肿病例进行前抽屉试验、Lachman试验两项临床检查和MRI检查,后进行关节镜手术检查.所有病例平均年龄28.0±7.9岁,关节镜手术距受伤时间平均为5.0±1.4天,其中男性58例,女性18例;左膝损伤25例,右膝损伤51例,运动损伤32例,交通伤25例,滑倒扭伤、摔伤19例.所有病例伤后8小时内均出现膝关节肿胀、疼痛、活动受限.以关节镜检查结果为标准,对临床检查和MRI检查诊断ACL损伤的结果进行比较.结果:关节镜检查发现ACL损伤52例,正常24例.前抽屉试验、Lachman试验两项临床检查共诊断出ACL损伤31例,正常45例;MRI检查共诊断出ACL损伤51例,正常25例.以关节镜检查为标准,临床检查诊断结果:真阳性数28例,真阴性数24例,假阳性数3例,假阴性数21例,准确度、敏感度、特异度分别为68.4%、57.1%、88.9%;MRI诊断结果:真阳性数49例,真阴性数22例,假阳性数2例,假阴性数3例,准确度、敏感度、特异度分别为93.4%、94.2%、91.7%.MRI诊断急性ACL损伤的准确度显著高于临床检查(P＜0.01).结论:临床检查诊断急性前交叉韧带损伤的假阴性率较高,MRI是早期诊断急性前交叉韧带损伤的有效方法.     

反复冻融同种异体跟腱重建兔前交叉韧带后移植物生物力学研究

目的:研究反复冻融对同种异体跟腱重建兔前交叉韧带(ACL)后移植物的生物力学特性是否有影响。方法:取成年雄性新西兰白兔异体跟腱,经密封包装和Co60照射灭菌后,-80℃和室温20℃反复冻融。选用36只体重2.0～2.5kg成年雄性新西兰白兔行ACL重建手术,其中18只左、右膝分别用冻融1次(对照组)、2次的移植物,另外18只左、右膝分别用冻融3次、10次的移植物。术后6周、12周分批宰杀取材。每一时段各组随机取4条重建ACL行生物力学拉伸试验(各组剩下5个膝关节用于形态学研究),检测重建前交叉韧带最大载荷、刚度、最大载荷能量、最大应力、最大应变、弹性模量和能量密度。结果:6周时冻融10次组最大载荷(26.38±4.71N)及最大载荷能量(0.52±0.07N·m)明显高于其他三组(P<0.05),其余指标各组间无显著性差异(P>0.05)。12周时各组间的所有力学指标均无显著性差异(P>0.05)。结论:虽然术后6周反复冻融10次同种异体跟腱重建的兔膝ACL的抗拉强度高于冻融次数少组,但术后12周不同反复冻融次数对重建ACL生物力学的影响无明显差异。     

Postoperative rehabilitation of the multiple-ligament reconstructed knee

Rehabilitation following multiple-ligament reconstruction continues to evolve although basic scientific principles continue to form the foundation for all current protocols. The protocols presented have been implemented following anterior cruciate ligament (ACL)/posterior cruciate ligament (PCL), ACL/PCL/posterolateral complex (PLC), ACL/PCL/medial cruciate ligament (MCL), and ACL/PLC reconstructive procedures. They are designed to allow for optimal healing during the maximum and moderate protection phases, and to restore mobility and function during the final stage. These protocols should serve as guidelines only, and modifications may be necessary based on graft selection, presence of articular cartilage involvement, and surgeon preference.     

关节镜下异体骨-髌腱-骨纤维束重建治疗前交叉韧带部分损伤

目的 探讨异体骨-髌腱-骨纤维束（B-PT-B）重建前交叉韧带（ACL）全部纤维束和部分纤维束的早期疗效。方法在187例采用B-PT-B术式重建ACL的患者中，获得随访的ACL部分束损者共25例，其中采用全部纤维束重建的患者6例，部分纤维束重建19例。术后行X线和KT-1000检查，并按照IKDC、Lysholm、Irgang、Larson评分进行疗效评价。结果 所有患者随访时移植物位置良好，KT-1000检查双侧膝关节前向松弛度差值〈3mm。部分束重建组与全部束重建组各评分系统和分项评分系统无显著性差异。结论 异体B-PT-B重建治疗ACL部分损伤可以取得良好的临床疗效，与ACL全部束重建术相比综合评定无明显差异。