Changes in muscle torque following anterior cruciate ligament reconstruction: A comparison between hamstrings and patella tendon graft procedures on 45 patients

We designed a prospective study to examine the influence of graft type (hamstring or patella tendon) on thigh muscle torque recovery after anterior cruciate ligament reconstruction. 60 patients undergoing ACL reconstruction, using a hamstring or patella tendon graft, were studied and 45 were followed up to 1 year. Concentric and eccentric quadriceps and hamstring torque were recorded, using an isokinetic dynamometer preoperatively, 6 and 12 months after ACL reconstruction. We found an improvement in all muscle functions in both the operated and unoperated legs during the recovery period. Graft type had no effect on recovery. During the first 6 months, torque was restored to preoperative levels and continued to improve in all muscles and actions between 6 months and 1 year.     

关节镜下月国绳肌腱及生物界面螺钉重建前交叉韧带

目的探讨关节镜下胭绳肌腱及生物界面螺钉重建前交叉韧带的疗效。方法对2007年8月-2009年5月收治的27例前交叉韧带重建病例,采用胭绳肌腱及生物界面螺钉进行重建。男25例,女2例。年龄18±45岁,平均29．6岁。结果22例患者获随访3～24个月,平均8．7月。术后Lysholm评分为91．1±5．3,与术前65．8±5．9比较,差异有统计学意义（P〈0．01）。术后有1例患者发生隐神经损伤,1例出现膝关节化脓性感染,行移植物取出待二期翻修。除感染1例外,其余患者术后患膝活动均正常,不稳感消失。结论胭绳肌腱是修复前交叉韧带的良好移植物,关节镜下界面螺钉固定疗效满意。应避免隐神经损伤和感染等并发症的发生。     

Endoscopic anterior cruciate ligament reconstruction with patella tendon autograft

The patella tendon is the most commonly used graft source for ACL reconstruction because of its biomechanical strength and stiffness, the availability of bone-to-bone healing on either end, and the ability to firmly secure the graft within the tunnels. Consistently good results have been reported in the literature, with expectations to return to all activities at pre-injury levels of performance. We outline our technique for endoscopic ACL reconstruction using a patella tendon autograft. The technique is divided into the critical stages of pre-operative assessment, graft harvest, notch preparation, tunnel placement, graft passage, graft fixation, and rehabilitation. Methods for avoiding pitfalls and overcoming mishaps are described.     

Biomechanical comparisons of anterior cruciate ligament: reconstruction procedures with flexor tendon graft

An experimental study was conducted to compare the biomechanical characteristics of six currently available anterior cruciate ligament (ACL) reconstruction procedures with flexor digitorum profundus tendons. Forty porcine knees were divided into eight groups, of 5 knees each. In groups A, B, C, and D, the flexor tendon graft was fixed with sutures and an Endobutton, with 20-mm-wide polyester tapes and staples, with 10-mm-wide polyester tapes and an Endobutton, and with bone plugs and interference screws, respectively. In group E, the graft was fixed using a combined procedure of those in groups B and D. In group F, the graft was directly fixed with interference screws. In groups G and H, the bone-patellar tendon-bone graft was fixed with interference screws, and sutures, respectively. Each femur-graft-tibia complex specimen was tested with a tensile tester by anteriorly translating the tibia until failure. This study demonstrated that the biomechanical properties of the femur-graft-tibia complex reconstructed with the flexor tendon graft were significantly affected by synthetic fixation devices. Regarding the average maximal load of the groups with the flexor tendon graft, group B had the highest (893 N) and group C had the second highest (770 N). Groups E and A were in the third rank. Group F had the second lowest (312 N), and Group D had the lowest (230 N). The maximal load of group B was significantly greater (P < 0.01) than that of group G (656 N) with the bone-patellar tendon-bone grafts. As to clinical relevance, this study indicated that the flexor tendon graft can be an alternative substitute for the bone-patellar tendon-bone graft for ACL reconstruction, if we understand the biomechanical characteristics of each reconstruction procedure. Received: January 21, 2000 / Accepted: June 8, 2000     

Anatomic endoscopic anterior cruciate ligament reconstruction with patella tendon autograft

Current tibial endoscopic ACL reconstruction techniques provide functional stability, but fall short of the ultimate goal of ACL reconstruction, to restore normal knee kinematics. Vertical graft placement results in restoration of normal anteroposterior stability with a negative Lachman exam, but may not produce a stable knee in rotation, noted by a positive pivot shift. The Clancy anatomic endoscopic ACL reconstruction technique utilizes flexible reamers to achieve anatomic graft placement to more closely reproduce normal knee function. The overall results of arthroscopic anatomic endoscopic ACL reconstruction are essentially the same as we have reported using our previous open and rear-entry, two-incision techniques for anatomic graft placement. The long-term benefits of a more physiologic single incision endoscopic ACL reconstruction are not yet determined; however, short-term results are encouraging.     

A new technique for harvesting the patella tendon in patients undergoing anterior cruciate ligament reconstruction

A new technique for harvesting the patella tendon for anterior cruciate ligament reconstruction is described. A circular oscillating saw is used to harvest the bone plugs. We feel that this technique offers reproducibility that is difficult to obtain with more conventional methods of graft harvesting.     

骨骼肌对前交叉韧带重建腱性移植物关节内愈合效果的影响

目的探讨骨骼肌对前交叉韧带（ACL）重建腱性移植物关节内愈合效果的影响。方法取新西兰兔跟腱制备半腱半肌移植物（SSG）与全腱移植物（TTG）,切断其双侧ACL后,一侧采用SSG（SSG侧）、另一侧采用TTG（TTG侧）重建ACL,于术后2、4、8周将造模成功的30只新西兰兔处死（每个时相点10只）,于移植物关节内中央部取材制成5μm纵向切片,行苏木精—伊红（HE）染色和甲苯胺蓝（TB）染色,观察组织结构,高倍镜视野下对切片中央部进行细胞计数。结果术后2周,SSG骨骼肌占总面积的10%～40%,骨骼肌变性、萎缩,腱性组织胶原纤维排列规整,内部有少量成纤维细胞;TTG胶原纤维排列规整,内部偶见成纤维细胞。术后4周,SSG内已无大片骨骼肌残留,中央部为致密胶原纤维,排列不规整,可见大量新生成纤维细胞;TTG胶原纤维排列不规整,中央部仅见少量成纤维细胞。术后8周,SSG为致密结缔组织,胶原纤维排列较规整,中央部仍有较多成纤维细胞;TTG亦为致密结缔组织,胶原纤维排列较规整,移植物中央部细胞数较少。术后2、4、8周,SSG侧中央部成纤维细胞数均多于TTG侧,两侧比较,差异有统计学意义（t=6.194、16.738、9.613,P〈0.05）。2×3析因方差分析结果显示,不同种类的移植物中央部成纤维细胞计数存在显著差异（F=277.67,P〈0.05）;术后不同观察时相点,移植物中央部成纤维细胞计数存在显著差异（F=262.72,P〈0.05）;移植物处理方式与观察时相点之间存在显著交互作用（F=69.68,P〈0.05）。结论腱性移植物上残留骨骼肌有利于关节内段移植物内组织细胞的增生,有可能加快移植物的愈合与改建。     

Patellar tendon graft harvesting using horizontal incisions for anterior cruciate ligament reconstruction

Autograft endoscopic anterior cruciate ligament (ACL) reconstruction traditionally has been performed via standard arthroscopy portals and a single longitudinal anterior incision. This vertical incision is used for harvesting the central third of the patellar tendon with patellar and tibial bone blocks. From 1992 to 1995, more than 400 cases have been done with a new technique of graft procurement. This new method employs two transverse incisions that are more cosmetic and are less likely to become a source of pain or flexion limitation.     

异体肌腱重建前交叉韧带术后临床效果及关节镜下再探查分析

[目的]探讨采用异体肌腱重建膝关节前交叉韧带(anterior cruciate ligament,ACL)术后移植物的转归,为术后康复提供指导依据。[方法]2012年1月~2015年12月对行ACL重建术后1年以上的患者58例(58膝)进行随访,同时进行患膝关节镜下再探查(second-look);ACL重建手术时患者年龄18~52岁,平均(30.7±9.9)岁,均采用深冻异体肌腱作为重建移植物。比较手术前后膝关节功能恢复情况(Lysholm评分及International Knee Documentation Committee,IKDC评分)及膝关节前向稳定性(前抽屉试验、Lachman试验变化以及KT-1000侧侧差值);行二次关节镜检查,观察移植物连续性、移植物滑膜覆盖情况以及关节内是否有异生结构等。[结果]所有患者未发生感染、严重排异反应及其他严重并发症。ACL重建术后至末次随访时间为12~33个月,所有患者均行关节镜下再探查。末次随访时除1例患者出现约10°伸直受限,其余患者膝关节活动度基本正常。Lysholm评分由术前的(55.64±9.43)分提高至末次随访时的(86.40±4.78)分,IKDC评分由术前的(55.73±9.97)分提高至末次随访时的(85.75±4.97)分,差异有统计学意义(P<0.05);KT-1000侧侧差值由术前的(6.62±1.28)分提高至末次随访时的(1.57±0.98)分,差异有统计学意义(P<0.05)。关节镜下再探查结果:3例出现移植物完全吸收,连续性不佳;3例出现ACL移植物磨损;2例患者关节腔内可见Cyclops样结节。滑膜覆盖评价:移植物滑膜覆盖优22例,良24例,差12例;滑膜覆盖优良率为79.3%。滑膜覆盖优组和良组其Lysholm评分、IKDC评分、KT-1000侧-侧差值均优于滑膜覆盖差组,差异有统计学意义(P<0.05)。[结论]采用异体肌腱ACL重建术后移植物血管化、滑膜化进程慢,康复计划应相对缓慢;关节镜下再探查所见能够作为术后康复的良好依据。     

Recombined bone xenografts enhance tendon graft osteointegration of anterior cruciate ligament reconstruction

The objective of the study was to discover whether recombined bone xenograft (RBX), a porous solid material, could augment healing of the tendon-to-bone interface after anterior cruciate ligament (ACL) reconstruction. ACL reconstruction was performed bilaterally in 25 skeletally mature rabbits using long digital extensor tendon grafts. RBX was implanted into the treated knee, with the contralateral knee serving as control. Three rabbits were killed at postoperative weeks two, six and 12 for routine histology. The remaining 16 rabbits were killed at weeks six and 12, and their femur-graft-tibia complexes were harvested for mechanical testing. The treatment and control groups produced different histological findings at the interface between the tendon and bone. In the treatment group, large areas of chondrocyte-like cells were noted around the tendon-bone interface two weeks after the operation. At six weeks, more abundant bone formation was observed around the tendon. At 12 weeks, an immature neoenthesis structure was seen. In biomechanical evaluation six and 12 weeks after the operation, the ultimate strength of tendon in the bone tunnel was significantly higher in the treatment group than in the control group. RBX can augment the osteointegration of tendon to bone after ACL reconstruction.     

可吸收缝合线在移植韧带中降解性能的实验研究

目的 探讨可吸收缝合线在移植肌腱内的降解吸收机制及移植腱束之间的愈合情况。方法 15只成年新西兰大白兔，切取半腱肌，折叠成双股后，采用3个0快薇乔可吸收缝合线编织缝合，建立采用可吸收缝线编织缝合的前交叉韧带自体肌腱移植重建模型。术后观察实验动物一般情况，术后2、4、8周取材行大体及组织学观察。结果 术后动物肢体活动情况良好，大体观察实验动物前交叉韧带连续性完整，张力适中。组织学观察术后2周位于移植肌腱内部的缝合线无降解，少量炎性细胞浸润，而位于移植肌腱边缘的缝合线开始出现降解，移植腱束间通过纤维组织连接；术后4周移植肌腱内部缝合线部分降解，降解区未见新生组织长入；术后8周移植肌腱内部缝合线完全降解，形成一不规则无染色区。结论 可吸收缝合线在移植肌腱内部降解速度不变，但吸收周期明显延长。     

Patellar tendon graft position after anterior cruciate ligament reconstruction: Interobserver variability on lateral radiographs

We compared the reliability and validity of graft position measurements made by 4 orthopedic surgeons on intraoperative radiographs obtained using fluoroscopic control and postoperative radiographs obtained from the same 17 patients 6 weeks after ACL reconstruction. Measurements from postoperative radiographs varied significantly more than those from intraoperative radiographs. There was little agreement between the postoperative and intraoperative measurements of the tibial and femoral graft position. We conclude that postoperative radiographs are not a sufficient tool for assessing graft placement after ACL reconstruction using patellar tendon autografts. In order to consider graft position in follow-up studies and to compare results from various surgeons, we suggest intraoperative fluoroscopy to produce radiographs for accurate and reliable measurements.     

Two transverse versus single longitudinal incisions for patella tendon harvest in anterior cruciate ligament reconstruction

Background

The bone–patellar–bone autograft is the most commonly used graft in anterior cruciate ligament (ACL) reconstruction surgery. However, harvesting of the graft is associated with various local complications.

Hypothesis

Harvesting the graft via two transverse incisions rather than one longitudinal incision lowers the risk of injury to the infrapatellar branch of the saphenous nerve.

Study design

Retrospective review of prospectively collected data.

Methods

We compared the results of 38 consecutive patients who underwent arthroscopic ACL reconstruction between 12 and 20 months postoperatively. Group A (n = 16) consisted of patients in whom a single longitudinal incision had been used. Group B (n = 22) consisted of patients in whom harvest had been via two transverse incisions.

Results

The mean area of diminished sensation in Group A was 60.48 cm², range 0–195, and in Group B was 32.19 cm², range 0–132 (P = 0.028, t-test). The width and pigmentation of the scars were significantly less with the two transverse incisions technique. There was no significant difference between the two groups in any other tested parameter.

Conclusions

The use of two transverse incisions was associated with a reduced area of altered sensation and objective evidence of a more cosmetically acceptable scar. We advocate the routine use of the two transverse incisions technique for graft harvest in ACL reconstructive surgery.     

自体Hamstring腱重建前交叉韧带术后关节镜下再视观察

目的关节镜再视观察游离Hamstring腱重建前交叉韧带后在体内重塑与转归过程.方法关节镜下再视手术,观察关节镜下自体同侧游离Hamstring腱重建前交叉韧带33例.重建术至再视手术时间为2～36个月,平均11.9月.依据重建术至再视术的时间,替代腱按时段分组:1月～,4月～,7月～,10月～,13月～,18月～和25月～组.再视术重点观察评估了移植的Hamstring腱形状、色泽、张力、覆盖的滑漠组织和血管状况.结果再视关节镜下重建前交叉韧带的Hamstring腱随植入时间延长,其形态逐步向正常前交叉韧带重塑与转归;7月～组和此后各组的替代腱在关节镜视下表现为.一种几乎无滑膜和血管的灰白色粗壮的圆柱体,类似于正常的前交叉韧带组织,达到了在体内成熟的程度.结论自体游离多股Hamstring腱重建前交叉韧带术后具有良好早期存活,快速再血管化和重塑过程,其术后的重塑与成熟过程与自体髌腱的过程相似,但其在体内重塑与转归进程相对较快.     

Comparison of patella tendon versus patella tendon/kennedy ligament augmentation device for anterior cruciate ligament reconstruction: Study of results, morbidity, and complications

In a study designed to evaluate the efficacy of supplementing patellar tendon bone-tendon-bone intraarticular anterior cruciate ligament (ACL) reconstructions with the polypropylene braid ligament augmentation device (Kennedy LAD; 3M, Minneapolis, MN), 75 consecutive patients treated between July 1988 and January 1990 with isolated ACL disruptions in whom no associated ligament injury was present were offered the LAD as part of their preoperative consent. Interference screws at both bone plugs were used. Group I was composed of 25 patients (10 acute, 15 chronic) with ACL disruptions who had the LAD added to their reconstruction. Group II was composed of 50 patients (24 acute, 26 chronic) who underwent an identical surgical procedure except that the LAD was not used. Objective and subjective assessments were made throughout the postoperative course, with the longest follow-up an average of 24 months postoperatively. Statistical analysis of these findings failed to show any statistically significant differences between the groups. Complications that occurred among the augmented group included infection, synovitis, effusion, and recurrence of instability, intraarticular adhesions, hemarthrosis, and painful hardware. This study demonstrates that the LAD added to the morbidity and severity in this series. It does not seem to improve results and is therefore not recommended for use in this manner.     

关节镜下自体腘绳肌肌腱移植重建膝前交叉韧带的临床观察

目的探讨关节镜下自体腘绳肌肌腱移植重建膝前交叉韧带的临床疗效。方法自2006年12月-2010年1月,对215例膝关节前交叉韧带损伤患者采用关节镜下自体腘绳肌肌腱移植重建（包括单束和双束）。比较患者术前、术后Lysholm膝关节评分和膝关节稳定性改变。结果本组215例中210例获得随访,1例患者在术后6周出现膝关节内感染,予行关节镜下清理、抗感染等处理后治愈。术前和术后1个月、术后6个月、术后1年Lysholm膝关节评分分别比较差异均有统计学意义（P〈0.05）。术前215例患者物理检查均表现为膝关节不稳,术后所有患膝不稳定表现消失。结论关节镜下自体腘绳肌肌腱移植重建膝前交叉韧带疗效可靠,依据病人实际情况个性化合理选择单双束重建。