自体膕绳肌肌腱重建前交叉韧带的研究进展

前交叉韧带(ACL)损伤是膝关节的常见损伤。手术重建已成为治疗ACL损伤后膝关节不稳的首选方法。与传统的髌韧带重建方法相比,采用绳肌肌腱(HT)重建具有取材部位病损少、膝前疼痛和跪地疼痛发生率低等优点。本文就HT重建ACL的基础和临床研究进行综述。     

前交叉韧带损伤修复的研究现状

前交叉韧带（ anterior cruciate ligament ,ACL）损伤是膝关节常见损伤之一,严重影响膝关节稳定性和关节功能。目前,临床上通常采用韧带重建方法治疗ACL损伤。近年来,不少研究显示ACL重建手术的远期疗效仍不令人满意、不能有效预防关节退变发生,这可能与重建韧带不能有效恢复ACL的正常解剖和生理功能有关（如直接止点、本体感受器及纤维多向排列等）［1,2］。缝合修复治疗曾是ACL损伤治疗的重要方法之一。近年来随着研究深入人们对ACL损伤修复过程及相关机制有了进一步的认识,不少研究采用缝合、增强、微刺激及组织工程等方法治疗ACL损伤,有效地促进了ACL损伤的修复愈合［3］。在此,本文就ACL损伤修复治疗的研究现状作简要综述。     

前外侧韧带重建术治疗轴移试验Ⅱ级的前十字韧带损伤

目的:探讨膝关节前外侧韧带（anterolateral ligament,ALL）重建对轴移试验Ⅱ级的前十字韧带（anterior cruciate ligament,ACL）损伤重建术的作用。方法:2015年10月至2018年8月,由同一医生收治的轴移试验Ⅱ级的ACL损伤患者59例,采用ACL+ALL重建或单纯ACL...     

嵌压固定法解剖重建前交叉韧带单束损伤

随着运动伤和交通伤的增多，膝关节前交叉韧带（ACL）损伤呈上升的趋势。对ACL完全性断裂，关节镜下重建已经成为主流，但是对于ACL单束损伤是否进行重建？用什么材料和方法重建？目前尚无共识，我科采用嵌压固定法关节镜下重建前交叉韧带单束损伤取得了良好效果，现将结果报告如下。     

关节镜下半腱肌、股薄肌重建前交叉韧带

膝关节韧带损伤中，前交叉韧带（anterior cruiate ligament，ACL）损伤占据了较大比例，重建ACL对增加膝关节稳定性起到了积极作用。在微创技术日臻完善、成熟的条件下，我们自1999年11月至2003年11月，在关节镜下应用可吸收界面螺钉（Bio—interference Screw）固定半腱肌、股薄肌肌腱（ST—GT）重建ACL损伤22例，取得良好疗效。     

膝关节前交叉韧带胫骨止点的软组织解剖标记

背景：膝关节前交叉韧带（ACL）重建时,胫骨骨道定位不准会产生重建韧带与髁间窝的撞击或起不到维持膝关节稳定性的作用。因此,确定ACL胫骨止点的位置非常重要。目的：研究膝关节ACL胫骨止点前内束（AMB）和后外束（PLB）与软组织标记后交叉韧带（PCL）和外侧半月板前角的距离,从而明确ACL胫骨止点在胫骨平台的位置,为ACL损伤双束重建提供理论支持。方法：解剖18个膝关节尸体标本（左膝10个,右膝8个）,测量ACL中点、AMB中点、PLB中点与PCL和外侧半月板前角的距离,并分析左、右膝关节是否存在差异。结果：AMB中点与PCL和外侧半月板前角的距离分别为（15.00±3.97）mm和（19.78±4.10）mm;PLB中点与两者的距离分别为（10.17±5.56）mm和（19.50±4.40）mm;ACL中点与两者的距离分别为（12.67±4.52）mm和（19.61±3.87）mm。左右膝关节ACL中点、AMB中点、PLB中点与软组织解剖标记的距离无明显统计学差异。结论：膝关节ACL损伤行手术重建时,可采用PCL和外侧半月板前角作为定位标记。     

关节镜下同种异体肌腱双束法重建前交叉韧带

目的探讨同种异体肌腱移植重建关节内韧带，双束韧带即前内束（AM）、后外束（PL）重建前交叉韧带（ACL），完善韧带修补重建的条件，以期达到ACL重建后膝关节的生物力下曲率运动的均衡和对膝关节回旋稳定的调控。方法对67例ACL患者应用同种异体肌腱重建ACL。股骨髁侧椭圆形隧道，应用Arthrax公司提供的横钉固定肌腱法固定；胫骨侧建立ACL—AM和ACL—PL双隧道，挤压钉固定。结果67例均获随访，时间12—36（18．4±3．8）个月，Lysholm评分：术前（34．47±1．5）分，术后3个月（78．35±3．4）分，术后6个月（81．88±3．3）分，术后12个月（87．76±2．1）分，术后18个月（89．70±3．5）分。有关节软骨损伤者，影响术后Lysholm评分。结论同种异体肌腱可以满足韧带受区的要求，双束ACL重建符合膝关节韧带4连杆曲率生物运动模式，膝关节回旋稳定度高。手术操作简单，效果良好。     

前交叉韧带损伤关节镜下重建治疗的临床研究进展

前交叉韧带（anterior cruciate ligament,ACL）是保持膝关节稳定的重要结构,断裂后可导致膝关节不稳,引起膝关节继发损害而严重影响膝关节功能。目前,ACL重建已成为治疗其损伤的有效方法。国内有关ACL的临床研究已较广泛和深入,但仍有许多新的课题有待研究。现结合本期刊登的几篇相关领域的论文予以评述,讨论有关ACL重建治疗中的热点问题。     

前交叉韧带断裂和重建对膝关节软骨退变影响的实验研究

目的：研究前交叉韧带（ACL）断裂和不同时期重建对膝关节软骨继发损伤的影响。方法：以新西兰大白兔为实验对象,共14只。共分4组,每组7个膝关节,实验组Ⅰ：右膝前交叉韧带切断后随即重建,左膝的前交叉韧带切断后不予重建作为对照组Ⅰ;组Ⅱ：右膝前交叉韧带切断后3周重建,左膝行单纯关节切开术作为对照组Ⅱ。术后8周通过墨汁染色,常规组织学及扫描电镜方法观察各组膝关节软骨退变的情况。结果：（1）实验组Ⅰ关节软骨退变程度明显轻于对照组Ⅰ（Hc=5.9889,P=0.0144);(2)实验组Ⅱ关节软骨退变程度和对照组Ⅰ相比差异无显著性意义（Hc=0.7143,P=0.785)。结论：（1）ACL断裂后即刻重建可以有效阻止关节软骨继发损伤的发生;（2）ACL断裂后已继发关节软骨退变时再行重建,其对关节软骨退行性变的缓解作用不明显。ACL 裂后应进行早期重建,恢复膝关节稳定性,减少或延缓远期骨性关节炎的发性。     

关节镜下前交叉韧带重建手术配合

前交叉韧带（anterior cruciate ligament,ACL）是维持膝关节前向稳定的最重要结构,ACL断裂导致膝关节不稳和关节内其他结构的继发性损伤的几率非常高,因此,ACL断裂的病人多数应接受ACL重建手术[1],可重新稳定膝关节,改善关节功能。我们在配合膝关节镜下ACL重建手术时,取得了一定的经验,现将手术配合总结如下。     

Rekonstruktion des vorderen Kreuzbandes

The treatment of ruptures of the anterior cruciate ligament (ACL) plays an essential role for both clinicians and resident physicians. To date many questions regarding the outcome as well as ACL reconstruction techniques have not yet been conclusively clarified. Whether reconstruction of the ACL protects the knee from osteoarthritis is still unproven; however, it is well known that an unstable knee joint is more vulnerable to secondary injuries, such as meniscal tears. Thus, early ACL reconstruction is recommended to minimize the risk of these secondary injuries. Three alternative sources of material for autologous ACL reconstruction are commonly utilized. An accessory hamstring (i.e. semitendinosus tendon with or without the gracilis tendon), a central strip of the patellar tendon with bone blocks and a central strip of the quadriceps tendon with or without bone block are the most common donor tissues used in autografts. Besides selection of the type of graft, the tendon diameter also plays a crucial role. Some progress has recently been made with respect to tunnel placement. The aim is to find an anatomical tunnel position. Reconstruction of both the anteromedial and the posterolateral ACL bundles helps to rebuild the anatomy of the original ACL; however, scientifically this approach did not lead to any improvement in the results. For fixation techniques a differentiation is made between aperture, extracortical and implant-free fixation. Generally, re-ruptures are less common than revisions as a result of graft ruptures due to technical mistakes during surgery. The most common mistakes concern tunnel placement and graft fixation. Also overlooked instability can have a negative influence on the outcome of ACL reconstruction.     

Short-term recovery after anterior cruciate ligament reconstruction: a prospective comparison of three autografts

Sixty-four patients with three different autografts were prospectively evaluated following anterior cruciate ligament (ACL) reconstruction for motion return, thigh girth, quadriceps activity, assistive device usage, and duration of pain medication usage. The quadriceps tendon group achieved knee extension sooner than the patellar tendon group. The hamstring group used assistive devices for less time than the patellar tendon group. The quadriceps group required less pain medication than either of the groups. There are significant differences in short-term pain medication requirements and restoration of function among patients following ACL reconstruction using different autografts.     

无内固定物腘绳肌腱重建前交叉韧带临床探讨

目的探讨用无内固定物的绳肌腱重建前交叉韧带的临床运用和效果。方法自2002年12月～2004年6月对33例前交叉韧带损伤进行了无内固定物的绳肌腱重建前交叉韧带术,其中13例移植肌腱采用二股半腱肌腱和二股股薄肌腱,另20例仅为二股半腱肌腱,术前和术后进行Lachman试验评估膝关节的稳定性,用Lysholm评分方法评定膝关节功能。结果术前Lachman试验均为阳性,术后29例为阴性,4例为阳性。术前Lysholm评分为36～57分,术后Lysholm评分为71～96分。结论无内固定物的绳肌腱重建前交叉韧带为生物固定,固定可靠、费用少、短期效果好,中长期效果有待观察。     

Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts

The authors review the current knowledge on donor site–related problems after using different types of autografts for anterior cruciate ligament (ACL) reconstruction and make recommendations on minimizing late donor-site problems. Postoperative donor-site morbidity and anterior knee pain following ACL surgery may result in substantial impairment for patients. The selection of graft, surgical technique, and rehabilitation program can affect the severity of pain that patients experience. The loss or disturbance of anterior sensitivity caused by intraoperative injury to the infrapatellar nerve(s) in conjunction with patellar tendon harvest is correlated with donor-site discomfort and an inability to kneel and knee-walk. The patellar tendon at the donor site has significant clinical, radiographic, and histologic abnormalities 2 years after harvest of its central third. Donor-site discomfort correlates poorly with radiographic and histologic findings after the use of patellar tendon autografts. The use of hamstring tendon autografts appears to cause less postoperative donor-site morbidity and anterior knee problems than the use of patellar tendon autografts. There also appears to be a regrowth of the hamstring tendons within 2 years of the harvesting procedure. There is little known about the effect on the donor site of harvesting fascia lata and quadriceps tendon autografts. Efforts should be made to spare the infrapatellar nerve(s) during ACL reconstruction using patellar tendon autografts. Reharvesting the patellar tendon cannot be recommended due to significant clinical, radiographic, and histologic abnormalities 2 years after harvesting its central third. It is important to regain full range of motion and strength after the use of any type of autograft to avoid future anterior knee problems. If randomized controlled trials show that the long-term laxity measurements following ACL reconstruction using hamstring tendon autografts are equal to those of patellar tendon autografts, we recommend the use of hamstring tendon autografts because there are fewer donor-site problems.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 971–980     

Single Femoral Socket Double-Bundle Anterior Cruciate Ligament Reconstruction Using Tibialis Anterior Tendon: Description of a New Technique

The native anterior cruciate ligament (ACL) has been shown to consist of 2 functional bundles with independent behavior throughout range of knee motion. Conventional arthroscopic ACL reconstruction techniques selectively recreate the anteromedial bundle of the native ACL only. Numerous studies have reported the failure to restore normal knee kinematics in an ACL-deficient knee using a single-bundle reconstruction. It has been suggested that by reconstructing both the anteromedial and posterolateral bundles of the ACL, more normal knee kinematics may be achieved. Several authors have described surgical techniques to recreate the 2 functional bundles and they range from using 2 femoral tunnels to using a single femoral tunnel with the other bundle passed over the top. This article describes a new technique of recreating the 2 functional bundles of the ACL with tibialis anterior tendon allograft using a single femoral socket.     

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.     

自体及同种异体肌腱重建前交叉韧带术后本体感觉恢复的比较研究

目的比较自体及同种异体肌腱重建前交叉韧带(anterior cruciate ligament,ACL)术后本体感觉恢复情况,探讨两种移植物对本体感觉恢复的影响。方法分析2008年1月-2010年1月行ACL重建的40例患者临床资料,其中20例采用自体肌腱重建(自体组),20例采用同种异体肌腱重建(异体组)。两组患者性别、年龄、病程、膝关节活动度、国际膝关节文献委员会(IKDC)评分及Lysholm评分等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。术中均采用单束重建方法,ACL止点残迹保留在胫骨或股骨髁间窝残端。术后随访测量膝关节活动度,行IKDC评分及Lysholm评分评定膝关节功能,采用双膝关节被动角度再生试验评定本体感觉恢复情况。结果两组患者术后切口均Ⅰ期愈合,无感染及关节腔内积血等并发症发生。患者均获随访,随访时间12～18个月,平均13.5个月。术后12个月膝关节活动度、IKDC评分及Lysholm评分均较术前显著改善,差异有统计学意义(P<0.05)。术后3个月,自体组患侧膝关节在30、60、90°位时与健侧比较,差异均无统计学意义(P>0.05);异体组患侧膝关节在30°位时与健侧比较,差异无统计学意义(P>0.05),在60、90°位时比较差异有统计学意义(P<0.05)。术后12个月,两组患侧膝关节在30、60、90°位时与健侧比较,差异均无统计学意义(P>0.05)。术后3个月,两组患侧膝关节在30°位时比较,差异无统计学意义(P>0.05);60、90°位时比较差异有统计学意义(P<0.05)。术后12个月,两组患侧膝关节在30、60、90°位时比较,差异均无统计学意义(P>0.05)。结论自体肌腱重建ACL术后膝关节的本体感觉恢复早于同种异体肌腱。     

关节镜下横穿钉固定重建膝关节前交叉韧带的临床疗效分析

[目的]观察关节镜下股骨侧应用横穿钉(Transfix)固定,胫骨侧界面螺钉(Interference)结合门型钉固定自体腘绳肌腱或同种异体肌腱重建膝关节前交叉韧带的临床疗效。[方法]膝关节前交叉韧带重建患者117例,所有患者均应用股骨侧横穿钉(Transfix)固定,胫骨侧界面螺钉(Interference)结合门型钉固定行前交叉韧带单束重建,其中使用自体腘绳肌腱患者81例,使用同种异体肌腱患者36例,观察此固定方法的可靠性及近期疗效,使用Lysholm评分及IKDC 2000评价手术前后膝关节功能。[结果]103例患者获得随访,随访时间12～26个月(平均18个月),关节活动度正常。平均Lysholm评分由术前的(57.60±5.74)分提高到术后的(94.55±2.38)分(P0.05)。IKDC 2000评分96例正常,6例(5.8%)接近正常,1例(1%)异常。自体腘绳肌腱组和同种异体肌腱组患者的物理检查及功能评分无明显差异。[结论]股骨侧横穿钉固定,胫骨侧界面螺钉结合门型钉固定重建膝关节前交叉韧带的手术方式近期疗效肯定,移植物固定可靠,手术操作安全。应用自体及同种异体肌腱进行重建都具有良好的临床效果,可根据患者的病情及主观要求进行选择。     

Nonunited avulsion fractures of the intercondylar eminence of the tibia

Summary: We report 3 cases of nonunited avulsion fracture of the intercondylar eminence of the tibia. Characteristics of the clinical symptoms were limitation of knee extension, pain at knee extension, and a small amount of anterior instability. For the patient with a normal anterior cruciate ligament (ACL), the fragment was fixed by sutures with a button after curettage of the fibrous tissue. Two patients underwent endoscopic ACL reconstruction using quadrupled semitendinosus tendon because their ACLs had degenerated. Since the technique of ACL reconstruction under arthroscopic control has been well refined, endoscopic ACL reconstruction is considered to be 1 of the surgical options for nonunited avulsion fracture with symptomatic anterior instability if the ACL is degenerated.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 7 (October), 2000: pp 757–762