促进前交叉韧带重建术后腱-骨愈合的方法学进展

近年来,应用肌腱移植物（如腘绳肌腱）行前交叉韧带重建术越来越普遍。手术的远期疗效关键取决于肌腱移植物能否在骨隧道内获得可靠的腱-骨愈合,腱-骨界面开始仅通过一些Sharpey样纤维连接,其在力学上逊于正常的纤维软骨连接,之后肌腱移植物在骨隧道内需要相当长时间才能获得可靠的腱-骨愈合。因此,在没有获得可靠的腱-骨愈合前,腱-骨界面被认为是＂弱点＂,肌腱移植物容易产生滑移甚至从骨隧道内拔出,最终导致手术失败。因此,如何促进腱-骨愈合是目前研究的热点。本文对相关文献做一综述,重点关注应用于骨隧道局部的一些方法学进展。其中干细胞技术、生长因子的局部应用、基因转染技术以及炎症反应的生物调控技术等均已获得令人振奋的研究成果。生物活性骨水泥的应用以及物理治疗方法也取得可喜的成果。组织工程技术可能成为降低供区并发症的方法 ,尽管目前的研究成果令人鼓舞,但仅基于动物实验,应用于临床实践尚需进一步随机对照临床研究。     

自体腘绳肌肌腱重建交叉韧带腱-骨愈合研究进展

采用自体腘绳肌肌腱重建交叉韧带正得到越来越广泛的临床应用,如何促进肌腱与骨隧道及早、可靠的愈合,是近年研究的重点.该文就腘绳肌肌腱重建交叉韧带后腱-骨愈合的组织学及促进腱-骨愈合的生物学因素的研究进展作一综述.     

磷酸钙水泥对自体腘绳肌腱重建前交叉韧带后腱-骨愈合影响的生物力学研究

目的探讨骨形态发生蛋白结合型磷酸钙水泥(rhBMP-2-CPC)对自体腘绳肌腱重建前交叉韧带(ACL)后腱-骨愈合的影响。方法取54只成年新西兰大白兔,建立48只双膝关节ACL完全断裂的自身对照模型,24只用rhBMP-2-CPC充填移植腱-骨隧道界面(实验组),24只未用rhBMP-2-CPC(对照组),6只为生物力学试验的正常组。术后第2、4、8和12周取材进行生物力学检测。结果2、4、8和12周实验组肌腱移植物较对照组抗拉伸的最大载荷明显要大,差异有统计学意义(P<0.05)。结论实验组肌腱移植物的生物力学特性优于对照组;BMP-CPC能促进肌腱移植物在骨隧道内的早期腱-骨愈合。     

自体半腱肌复合骨形态发生蛋白和同种异体骨重建前交叉韧带后腱-骨愈合的生物力学研究

目的研究骨形态发生蛋白(BMP)复合同种异体骨(DPB)对自体半腱肌肌腱重建前交叉韧带后腱-骨愈合的影响。方法取64只成年新西兰大白兔,分成4组,建立左侧膝前交叉韧带(ACL)完全断裂模型。重建ACL时,于股骨隧道内分别植入BMP结合DPB、BMP、DPB。结果术后3、6、12及24周BMP结合DPB腱-骨愈合及移植物抗拉强度大于其他各治疗组,P<0.05。结论缓释载体DPB能延长BMP作用时间,提高移植物生物力学特性,拮抗骨吸收因子的负面效应,促进腱-骨愈合。     

前交叉韧带重建术后腱-骨界面愈合研究

前交叉韧带损伤后自身修复的能力极差,重建前交叉韧带主要依赖肌腱移植替代手术。肌腱与骨隧道内壁固定界面之间的愈合是修复重建的关键。腱-骨界面之间的固定方法对重建韧带止点的愈合速度和愈合方式均有影响,骨隧道内固定可增加移植肌腱固定的早期稳定性并减少术后骨隧道扩大,易于形成直接止点;骨隧道外固定容易引起骨隧道扩大,并倾向于形成间接止点。腱-骨界面间的微动和创伤后产生的炎性介质是引起骨隧道扩大的重要原因,一些细胞因子、生理刺激因素以及骨髓基质干细胞和骨膜的使用,可促进移植肌腱的腱-骨界面愈合。     

前交叉韧带重建术后骨隧道愈合研究进展

前交叉韧带重建术被广泛应用于前交叉韧带损伤治疗中,而骨隧道扩大是前交叉韧带重建术后主要的并发症。前交叉韧带重建后,骨隧道与韧带之间通过纤维软骨肌腱端进行愈合。在愈合前,由于纵向的"蹦极效应"和横向的"雨刷效应"等力学因素及关节滑液的侵蚀作用,会发生骨隧道扩大现象。为了应对骨隧道扩大,防治重建后前交叉韧带松弛,学者们就前交叉韧带手术过程中重建位点、固定方式及韧带选择等进行探究,通过改进手术方式来减少后期骨隧道扩大,并通过干细胞、生物因子、生物材料及生物制剂的治疗来促进骨隧道愈合。该文就前交叉韧带重建术后骨隧道愈合研究进展作一综述。     

前交叉韧带重建术后腱-骨愈合研究进展

<正>前交叉韧带损伤后修复能力差,完全断裂保守治疗效果不佳,临床治疗的主要方法是手术重建前交叉韧带,术后的腱-骨愈合的时间、愈合牢固程度等成为衡量手术质量的重要指标。手术中残端的保留、移植物初始的张力、骨隧道角度的选择等都会影响到腱-骨界面的愈合。目前从细胞因子、血小板血浆复合物等相关研究发现具有促进移植物的腱-骨界面愈合的作用,但随着移植物的选择、移植物固定方式、手术的方法、骨隧道定位等技术的更新,现有促进腱-骨愈合的研究是否     

自体-异体混编肌腱重建前交叉韧带移植物腱骨愈合的实验研究

[目的]观察比较自体、异体及自体一异体混编肌腱重建前交叉韧带移植物腱骨愈合的组织学变化过程。[方法]取45只新西兰兔,随机平均分为自体组、异体组及混编组。切除兔右膝前交叉韧带,取其双侧趾长伸肌腱,两两随机合成双股自体、异体及混编待移植物后重建兔右膝前交叉韧带。采用HE染色、甲苯胺蓝染色,观察重建术后3、8及12周时移植物腱骨愈合的变化情况。[结果]重建术后3周时,各组移植物腱骨界面均表现为明显的组织坏死及炎性细胞浸润;8周时,3组腱骨界面均可见大量新生组织细胞,胶原纤维纵向无序排列:12周时,自体组腱骨界面间的胶原纤维排列较其他2组更有序,止点4层结构也更清晰;术后各期腱骨界面软骨细胞含量,自体组混编组异体组。[结论]前交叉韧带重建术后在相同的时间点,自体移植物腱骨愈合最优,而混编后的移植物介于自体和异体之间。     

肌腱移植物在骨隧道愈合的研究进展

肌腱移植重建膝关节前交叉韧带时,腱、骨之间可以间接或直接愈合。移植肌腱在骨隧道内的愈合受诸多因素的影响,实验和临床研究的结果各有异同,出现了一些包括基因工程在内的促进腱 骨愈合的方法,但在进入临床应用之前,还需进一步深入研究。     

脱蛋白骨复合骨形态发生蛋白对前交叉韧带重建术后腱-骨愈合的影响

目的 探讨兔异体脱蛋白松质骨(DPB)复合骨形态发生蛋白(BMP)对前交叉韧带(ACL)重建术后腱-骨愈合的影响. 方法取96只成年新西兰大白兔,分为四组,每组24只:DPB+BMP组、DPB组、BMP组及空白对照组,分别用自体半腱肌腱进行膝关节ACL重建,DPB+BMP组在股骨隧道内植入DPB-BMP复合体,DPB组和BMP组分别在股骨隧道内植入DPB、BMP,空白对照组的骨隧道内不植入其他材料.于术后2、4、6、8周时分别处死各组中的6只动物,切取骨隧道内标本,通过大体观察及组织学观察分析腱-骨愈合进程. 结果术后2周时BMP+DBP组的骨隧道内新骨生成活跃,肌腱周围出现较多纤维软骨组织;4周时骨隧道内出现钙化的纤维软骨,肌腱末端与钙化软骨融合为一体,并见Sharpey's纤维形成;6周时隧道内出现了更多的钙化软骨,肌腱与骨的结合区出现潮线,具有正常ACL止点的结构特点;8周时肌腱与骨的连接更加成熟,钙化软骨增多.其他三组的腱-骨愈合过程均迟于DPB+BMP组.结论 DPB复合BMP能促进ACL重建术后的腱-骨愈合.     

Editorial Commentary: Reduce the Failure Risk: A Challenge to Reduce the Risk of Using Hybrid Graft in Anterior Cruciate Ligament Reconstruction

Hybrid grafting (augmentation of small hamstring autografts with allograft tissue) is preferred by many surgeons for anterior cruciate ligament (ACL) reconstruction. Although a recent, well-conducted, systematic review reported no significant differences in failure risk between hybrid graft and autograft ACL reconstruction, a trend toward a greater failure risk using the hybrid graft existed in many of the included studies. Three potential causes of hybrid graft ACL reconstruction failure that are absent in autograft ACL reconstruction are different levels of graft revascularization and ligamentization, differences in the tendon-bone healing capacity between the allograft and autograft portions in the bone tunnel, and processing of the graft. Research advances in these areas will further reduce the failure risk of hybrid graft ACL reconstruction.     

膝关节持续被动活动对兔重建前交叉韧带腱骨愈合的影响

目的 通过兔半腱肌腱腱后固定方法重建前交叉韧带(ACL)实验动物模型,研究持续被动活动(CPM)对移植物隧道内腱骨界面的组织学转归影响.方法 对12只雄性新西兰大白兔右侧后肢膝关节行自体双股半腱肌腱移植重建ACL.术后随机分为两组:CPM组(n=6)术后第2天开始早期CPM康复6周;自由活动组(n=6)笼养.分别于术后第6、12、24周取材,采用HE和甲苯胺蓝染色观察腱骨愈合过程.结果 前侧腱骨界面纤维组织较多且较后侧腱骨界面宽;后侧腱骨界面的成骨细胞和类软骨细胞较多,新骨沉积较多.在骨道内口(关节腔入口),破骨细胞较多.与自由活动组比较,CPM组界面组织改建塑形更成熟、胶原排列更有序,潮线结构出现较早,类软骨细胞、成骨细胞和类似潮线的结构较多.结论 腱骨界面前侧张力较大,纤维较多;腱骨界面后侧压力较大,软骨较多.半腱肌腱重建ACL术后早期CPM加快移植物止点潮线结构恢复,增强移植物与骨组织之间整合.     

富血小板血浆与异体脱蛋白骨复合物颗粒促进前交叉韧带重建术后腱骨愈合的临床研究

目的观察富血小板血浆(PRP)与异体脱蛋白骨(DPB)复合物颗粒促进前交叉韧带(ACL)重建术后腱骨愈合的临床效果。方法将42例接受ACL重建术的患者随机分为实验组及对照组,对照组按常规方法行ACL重建术,实验组在两端骨隧道中填充入PRP+DPB复合物颗粒,术后6个月行CT检查,通过计算机图像分析软件测量出骨隧道扩大数值,并行Lysholm评分及IKDC评分。结果随访时间6～21个月,平均11.8个月。末次随访时,两组Lysholm评分及IKDC评分与术前比较,差异均有统计学意义(P<0.05);但两组间比较差异无统计学意义(P>0.05)。两组间术后CT测量的骨隧道直径扩大的数值差异具有统计学意义(P<0.05)。结论与对照组相比,PRP+DPB复合物颗粒可促进ACL重建术后骨腱愈合,减少骨隧道扩大,临床效果满意。     

Histological findings of tendon-bone healing following anterior cruciate ligament reconstruction with hamstring grafts

BACKGROUND: The purpose of the study was the histological examination of tendon-bone healing of hamstring grafts after anterior cruciate ligament (ACL) reconstruction. METHODS: During five arthroscopies done 6-14 months after ACL reconstructions, biopsies of the wall of the former drilled femoral canal were obtained. Four patients were primarily operated on using a suspending device (Endobutton, Acufex Microsurgical, Mansfield, MA, USA, and Transfix, Arthrex, Naples, FL, USA) for femoral fixation, one patient was reconstructed with a biodegradable interference screw directly inserted between the tendon and the wall of the canal. Biopsies were obtained using a tube harvester during re-arthroscopy. Three grafts were stable, two grafts were unstable, and revision of the ACL was performed. RESULTS: Histologically, in the four cases of reconstruction with a button or a rectangular pin, biopsies resembled granulation tissue without insertion of fibers between the tendon tissue and the bony wall. A wide area of woven bone was noted adjacent to the pre-existing lamellar bone. In contrast, the tendon-bone junction in the knee reconstructed with a biodegradable interference screw resembled a zone of metaplastic fibrous cartilage between the tendon graft and the lamellar bone. Collagen fibers connecting the tendon-bone interface occurred under polarized light microscopy. CONCLUSION: We conclude that the use of hamstring grafts for ACL reconstruction can lead to different histological pattern of tendon-bone healing. Micromotion of the hamstring graft inside the drilled canal can be play a role in tendon-bone healing.     

Editorial Commentary: Revision Anterior Cruciate Ligament Using Soft Tissue Autograft Quadriceps Is Effective but Not Recommended for All Comers

The average revision rate is between 3.2% and 11.1%following primary anterior cruciate ligament (ACL) reconstructions,¹ and an objective failure rate of 13.7% has been reported for revision ACLR.² Prior implants, positioning of tunnels, and muscle weakness from the prior reconstruction present challenges. Additionally, graft choice for the revision reconstruction is restricted, depending on the primary reconstruction. Revision ACL reconstruction with the all-soft tissue quadriceps tendon autograft is a viable option with 83.3% of the patients surpassing the minimally clinically significant difference for International Knee Documentation Committee (IKDC) scores, which is similar to outcomes for revision ACL reconstruction (ACLR) using bone-patella-bone and hamstring tendon autografts. Furthermore, objective strength data suggest that it is possible to achieve equal limb symmetry index strength ratios even in the setting of prior bone-patella tendon-bone autograft. However, although I am cautiously optimistic regarding soft tissue quadriceps autograft in revision ACLR, I would be hesitant to recommend it for all comers. In my experience, young high school/collegiate female athletes with primary reconstruction using BPTB autograft may not be able to tolerate a secondary insult to the extensor mechanism via quadriceps tendon (QT) autograft harvest, where hematoma and arthrofibrosis could be concerns. Furthermore, increased posterior tibial slope may require evaluation and treatment, and the addition of a lateral extra-articular tenodesis may reduce residual rotatory laxity in ACL revision patients.     

Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft

BACKGROUND: Surgical reconstruction of the anterior cruciate ligament (ACL) is indicated in the ACL-deficient knee with symptomatic instability and multiple ligaments injuries. Bone patellar tendon-bone and the hamstring tendon generally have been used. In the present study, we describe an alternative graft, the quadriceps tendon-patellar bone autograft, by using arthroscopic ACL reconstruction. METHODS: From March of 1996 through March of 1997, a quadriceps tendon-patellar bone autograft was used in 12 patients with ACL injuries. RESULTS: After 15 to 24 months of follow-up, the clinical outcome for those patients with this graft have been encouraging. Ten patients could return to the same or a higher level of preinjury sports activity. According to the International Knee Documentation Committee rating system, 10 of the 12 patients had normal or nearly normal ratings. Recovery of quadriceps muscle strength to 80% of the normal knee was achieved in 11 patients in 1 year. CONCLUSION: The advantages of the quadriceps tendon graft include the following: the graft is larger and stronger than the patellar tendon; morbidity of harvest technique and donor site is less than that of patellar tendon graft; there is little quadriceps inhibition after quadriceps harvest; there is quicker return to sports activities with aggressive rehabilitation. A quadriceps tendon-patellar autograft is a reasonable alternative to ACL reconstruction in patients who are not suitable for either a bone-patellar tendon-bone autograft or a hamstring tendon autograft.     

Acceleration of tendon-bone healing in anterior cruciate ligament reconstruction using an enamel matrix derivative in a rat model

We examined whether enamel matrix derivative (EMD) could improve healing of the tendon-bone interface following reconstruction of the anterior cruciate ligament (ACL) using a hamstring tendon in a rat model. ACL reconstruction was performed in both knees of 30 Sprague-Dawley rats using the flexor digitorum tendon. The effect of commercially available EMD (EMDOGAIN), a preparation of matrix proteins from developing porcine teeth, was evaluated. In the left knee joint the space around the tendon-bone interface was filled with 40 μl of EMD mixed with propylene glycol alginate (PGA). In the right knee joint PGA alone was used. The ligament reconstructions were evaluated histologically and biomechanically at four, eight and 12 weeks (n = 5 at each time point). At eight weeks, EMD had induced a significant increase in collagen fibres connecting to bone at the tendon-bone interface (p = 0.047), whereas the control group had few fibres and the tendon-bone interface was composed of cellular and vascular fibrous tissues. At both eight and 12 weeks, the mean load to failure in the treated specimens was higher than in the controls (p = 0.009). EMD improved histological tendon-bone healing at eight weeks and biomechanical healing at both eight and 12 weeks. EMD might therefore have a human application to enhance tendon-bone repair in ACL reconstruction.     

Evaluation of bone incorporation of patellar tendon autografts and allografts for ACL reconstruction using CT

Anterior cruciate ligament (ACL) reconstruction is a relatively common orthopedic procedure, with patellar tendon frequently a graft source. However, controversy exists regarding the decision to use autograft or allograft patellar tendon tissue. This experimental study used computed tomography (CT) to compare the percentage of bone graft incorporation following ACL reconstruction using autografts and allografts. Fifty consecutive patients undergoing ACL reconstruction were included in the study. The tibial bone plug was imaged with CT 1 week, 2 months, and 5 months postoperatively. Four images from each completed scan were analyzed for percentage of incorporation of the bone graft. The results of autograft and allograft incorporation for each of the time intervals were compared. No statistically significant difference was found in the amount of bone incorporation at the tibial bone plug 1 week, 2 months, and 5 months. Clinical concerns regarding slower or less complete healing of allograft bone tissue compared to autograft are not supported with regard to the grafts studied.     

金葡素促进兔前交叉韧带重建后腱骨愈合的实验研究

目的 :探讨兔膝关节前交叉韧带(ACL)重建后,金黄色葡萄球菌滤液制剂(金葡素)对移植肌腱与骨隧道愈合的作用。方法:将3月龄新西兰大白兔24只(体重平均2.56 kg,雌雄不限)随机分为实验组和空白对照组,每组12只。采用兔自体趾长伸肌腱建立膝前交叉韧带重建后的腱骨愈合模型。实验组分别于术中及术后第2天向胫骨端腱骨界面处缓慢均匀注射金葡素0.1 ml,对照组以相同时间和方法注射等量0.9%Na Cl注射液。术后双膝不予制动,以青霉素注射液80万U/d连续肌肉注射3 d。分别于术后4、8和12周各处死动物8只,完整获取腱骨愈合标本并分别进行组织学分析,肉眼观察判断ACL重建大体情况,苏木精-伊红染色进行Yamakado腱骨界面组织形态分型评价,苦味酸-天狼猩红染色观察腱骨界面胶原纤维情况,血管内皮生长因子免疫组化染色定量评价腱骨界面再血管化情况,甲苯胺蓝染色定量评价腱骨界面新骨生成情况。结果:大体观察显示全部动物术后伤口Ⅰ期愈合,关节功能恢复良好,未见感染、死亡及金葡素注射不良反应。腱骨界面形态学分型结果显示术后各时间点实验组腱骨界面愈合质量均优于对照组(P0.05))。苦味酸-天狼猩红染色显示实验组胶原纤维术后4周生成少,8周大量生成,12周Sharpey纤维有序排列,集结成束,各时间点胶原纤维生成情况均优于对照组。基于血管内皮生长因子免疫组化染色和甲苯胺蓝染色的定量分析显示实验组术后4、8和12周腱骨界面新生血管面积和新骨生成面积均高于对照组(P0.05)。结论:金葡素能够在葡萄球菌肠毒素C等多种明确成分的协同作用下,通过局部启动无菌性炎症反应,加快腱骨界面血管生成和血液供应,激活骨细胞和纤维细胞大量增殖,有效促进兔ACL重建后腱骨愈合,有望成为促进ACL重建后腱骨愈合的新的临床方法。     

Bone graft procurement for patellar defect grafting in anterior cruciate ligament reconstruction

Bone grafting of the patellar defect from harvest of the central third bone-patellar tendon-bone autograft in anterior cruciate ligament (ACL) reconstruction has been advocated by some authors to decrease the risk of patellar fracture from the existing stress riser as well as decrease postoperative donor site pain. We present a method of harvesting bone reamings during ACL reconstruction that is simple, efficient, and maximizes the amount of bone that can be collected.Arthroscopy 1998 Jul-Aug;14(5):543-5