Location of the tibial tunnel aperture affects extrusion of the lateral meniscus following reconstruction of the anterior cruciate ligament

The anterior root of the lateral meniscus provides functional stability to the meniscus. In this study, we evaluated the relationship between the position of the tibial tunnel and extrusion of the lateral meniscus after anterior cruciate ligament reconstruction, where extrusion provides a proxy measure of injury to the anterior root. The relationship between extrusion and tibial tunnel location was retrospectively evaluated from computed tomography and magnetic resonance images of 26 reconstructed knees, contributed by 25 patients aged 17–31 years. A measurement grid was used to localize the position of the tibial tunnel based on anatomical landmarks identified from the three‐dimensional reconstruction of axial computed tomography images of the tibial plateaus. The reference point‐to‐tibial tunnel distance (mm) was defined as the distance from the midpoint of the lateral edge of the grid to the posterolateral aspect of the tunnel aperture. The optimal cutoff of this distance to minimize post‐operative extrusion was identified using receiver operating curve analysis. Extrusion of the lateral meniscus was positively correlated to the reference point‐to‐tibial tunnel distance (r ² = 0.64; p < 0.001), with a cutoff distance of 5 mm having a sensitivity to extrusion of 83% and specificity of 93%. The mean extrusion for a distance >5 mm was 0.40 ± 0.43 mm, compared to 1.40 ± 0.51 mm for a distance ≤5 mm (p < 0.001). Therefore, a posterolateral location of the tibial tunnel aperture within the footprint of the anterior cruciate ligament decreases the reference point‐to‐tibial tunnel distance and increases extrusion of the lateral meniscus post‐reconstruction. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1625–1633, 2017.

     

Abnormal lateral notch in knees with anterior cruciate ligament injury

We reviewed plain radiograms of anterior cruciate ligament injuries to determine the frequency of an abnormal lateral notch found in the lateral femoral condyle, and we investigated a possible mechanism for its occurrence by determining the relationship with associated injuries. We analyzed data for 216 patients who underwent ACL reconstruction between 1993 and 1996, whose radiographic images of the contralateral knee were available. The numbers of male and female patients were 122 and 94, respectively, and their ages ranged from 14 to 47 years (average, 25 years). The abnormal notch visualized by lateral radiograph was found in 66 of 216 knees (30.6%) and was classified into three types. The type of abnormal notch seen most frequently (73%) was located at the same site as the notch on the contralateral side, but appeared deeper than normal. Knees with abnormal notches showed lateral meniscal injuries more frequently than those without such notches (P < 0.005). The abnormal notch was assumed to have formed at the time of injuries, after impingement of the lateral femoral condyle on the lateral tibial condyle. Cartilage damage at the abnormal notch should be carefully observed in the future. Received for publication on Aug. 14, 1998; accepted on Aug. 27, 1999     

Pseudoaneurysm of the medial inferior genicular artery following anterior cruciate ligament reconstruction

Pseudoaneurysm is a rare complication of surgery or trauma around the knee. A 30-year-old man presented 10 days following anterior cruciate ligament repair with a 2 cm pulsatile swelling on the medial side of the knee. Angiography demonstrated a pseudoaneurysm of the medial inferior genicular artery. Surgical exploration and ligation of the feeding vessel to the aneurysm was performed and the patient made a full recovery. Vascular injury must be suspected in patients presenting with a haemarthrosis or pulsatile swelling following surgery on the knee.     

Knee function following suture of fresh tear of the anterior cruciate ligament

A retrospective consecutive series of 60 patients treated with primary suture of knee ligament injuries is presented. All patients had an anterior ligament (ACL) tear. In 54 patients this injury was combined with a medial compartment tear. Four patients had isolated tears of the ACL. At follow-up after 4 years, 11 patients complained of instability, and in eight of these an anterolateral rotatory instability was demonstrated by the Slocum test. In contrast, only five of 49 patients with subjectively stable knees had positive Slocum tests. Thirty of 47 patients with negative Slocum tests had excellent function, compared with four of 13 patients with positive tests.     

膝上外侧动脉穿支髂胫束皮瓣的解剖特点与临床应用

目的 探讨膝上外侧动脉穿支髂胫束皮瓣的解剖学基础与临床应用效果.方法 自1999年9月至2009年7月,在40侧经动脉灌注红色乳胶的成人下肢标本上,解剖、观测膝上外侧动脉的起源、走行、分支、分布、吻合以及髂胫束的血供来源,临床应用吻合膝上外侧动脉穿支髂胫束瓣移植5例、髂胫束皮瓣4例.结果 80%(35侧)膝上外侧动脉单独起自腘动脉,起始外径(1.8±0.4)mm.该动脉向外蜿蜒上行分为升、降支,从股外侧肌与股二头肌短头肌之间的股外侧肌间隔穿出形成肌间隙(隔)筋膜皮肤穿支,或与膝上最外侧动脉在股外侧肌内吻合后发出肌皮穿支,供养大腿中下段髂胫束和前外侧皮肤,其中较粗大穿支起始外径(1.0±0.2)mm,并在深筋膜浅层或深层于近端与旋股外侧动脉降支吻合,远端与膝关节网吻合.临床应用9例,其中修复单纯跟腱缺损5例,跟腱伴皮肤缺损2例;修复小腿、足软组织缺损各1例.随访6个月～7年8个月,带血供髂胫束修复跟腱缺损功能恢复良好,4例髂胫束皮瓣全部成活.结论 吻合膝上外侧动脉穿支髂胫束皮瓣是一种新型、简便、实用的复合(软组织)缺损修复方法,适于临床推广应用.     

人工韧带用于前交叉韧带修复重建：目前产品与经验

人工韧带产品自20世纪70年代开始用于临床重建前交叉韧带(anterior cruciate ligament,ACL),经历了较为坎坷的发展历程。早期人工韧带产品重建ACL疗效欠佳,大多以失败告终。近20年来随着新人工韧带产品的出现,临床应用其重建ACL逐渐增多,常用人工韧带包括Leeds-Keio TM、LARSTM(Ligament Advanced Reinforcement System)、Trevira HochfestTM,其中LARSTM应用较多。上述人工韧带具有优越的力学性能,累积失败和并发症发生率较早期产品有显著改善,但也有各自不足之处。     

Collagen-platelet rich plasma hydrogel enhances primary repair of the porcine anterior cruciate ligament.

The anterior cruciate ligament (ACL) fails to heal after suture repair. One hypothesis for this failure is the premature loss of the fibrin clot, or provisional scaffolding, between the two ligament ends in the joint environment. To test this hypothesis, a substitute provisional scaffold of collagen-platelet rich plasma (PRP) hydrogel was used to fill the ACL wound site at the time of suture repair and the structural properties of the healing ACLs evaluated 4 weeks after surgery. Bilateral ACL transections were performed in five 30-kg Yorkshire pigs and treated with suture repair. In each animal, one of the repairs was augmented with placement of a collagen-PRP hydrogel at the ACL transection site, while the contralateral knee had suture repair alone. In addition, six control knees with intact ACLs from three additional animals were used as a control group. No postoperative immobilization was used. After 4 weeks the animals underwent in vivo magnetic resonance imaging to assess the size of the healing ACL, followed by biomechanical testing to determine tensile properties. The supplementation of suture repair with a collagen-PRP hydrogel resulted in significant improvements in load at yield, maximum load, and linear stiffness at 4 weeks. We conclude that use of a stabilized provisional scaffold, such as a collagen-PRP hydrogel, to supplement primary repair of the ACL can result in improved biomechanical properties at an early time point. Further studies to determine the long-term effect of primary repair enhancement are needed.     

Biology of anterior cruciate ligament injury and repair: Kappa delta ann doner vaughn award paper 2013

Anterior cruciate ligament (ACL) injuries are currently treated by removing the injured ligament and replacing it with a tendon graft. Recent studies have examined alternative treatment methods, including repair and regeneration of the injured ligament. In order to make such an approach feasible, a basic understanding of ACL biology and its response to injury is needed. Identification of obstacles to native ACL healing can then be identified and potentially resolved using tissue engineering strategies—first, with in vitro screening assays, and then with in vivo models of efficacy and safety. This Perspectives paper outlines this path of discovery for optimizing ACL healing using a bio‐enhanced repair technique. This journey required constructing indices of the functional tissue response, pioneering physiologically based methods of biomechanical testing, developing, and validating clinically relevant animal models, and creating and optimizing translationally feasible scaffolds, surgical techniques, and biologic additives. Using this systematic translational approach, “bio‐enhanced” ACL repair has been advanced to the point where it may become an option for future treatment of acute ACL injuries and the prevention of subsequent post‐traumatic osteoarthritis associated with this injury. © 2013 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 31:1501–1506, 2013     

髂胫束转位修复膝关节前交叉韧带损伤

目的探讨自体髂胫束修复外伤性前交叉韧带(ACL)断裂疗效。方法用设计术式,将同侧髂胫束转位修复外伤性ACL断裂。结果16例患者,随访时间平均6年,优8例,良5例,可2例,差1例。结论髂胫束修复ACL,设计术式合理,有完全的韧带转化功能,有取材广泛的优点。     

Arthroscopic anterior cruciate ligament repair: preliminary results and instrumented testing for anterior stability

The authors present their preliminary results of arthroscopic primary repair of anterior cruciate ligament tears performed on five patients, with a mean follow-up time of 9.2 months. All patients were re-evaluated by subjective questionnaire and clinical examination, and tested for anterior drawer at 20 degrees flexion using the KT-1000 Knee Ligament Arthrometer and the UCLA Instrumented Clinical Knee Testing Apparatus. Subjectively, four patients were rated as fair and one as good. The Lachman test was negative in two and trace or mildly positive in three patients. Pivot shift test was negative in all. Instrumented testing demonstrated three patients with increased anterior laxities outside the normal range, and two of these patients also showed reduced anterior stiffnesses which were beyond the normal range. Based on these results, the authors question the feasibility of arthroscopic repair of anterior cruciate ligament tears and suggest a more objective evaluation of this procedure.     

Enhanced histologic repair in a central wound in the anterior cruciate ligament with a collagen-platelet-rich plasma scaffold.

The anterior cruciate ligament (ACL) of the knee is an intra-articular ligament that fails to heal after primary repair. The medial collateral ligament (MCL) of the knee is an extra-articular ligament that heals uneventfully in the majority of cases. Why these two ligaments have such different responses to injury remains unclear. In this article, we address two hypotheses: first, that the histologic response to injury is different in intra-articular and extra-articular ligaments, and second, that the response of the intra-articular ligaments can be altered by placing a collagen-platelet-rich plasma (collagen-PRP) hydrogel in the wound site. Wounds were created in extra-articular ligaments (MCL and/or patellar ligament) and an intra-articular ligament (ACL) in canine knees, and the histologic response to injury evaluated at 3 days (n = 3), 7 days (n = 4), 3 weeks (n = 5), and 6 weeks (n = 5). In the 3-week (n = 5) and 6-week (n = 5) animals, bilateral central wounds were made in the ACLs and the wounds in one knee of each animal treated with a collagen-PRP hydrogel while the contralateral side was untreated. Extra-articular ligament wounds had greater filling of the wound site and increased presence in the wound site of fibrinogen, fibronectin, PDGF-A, TGF-beta1, FGF-2, and von Willebrand's factor when compared to intra-articular ligament wounds. Treatment of the intra-articular wound with a collagen-PRP hydrogel resulted in increased filling of the wound site with repair tissue that had similar profiles of growth factor and protein expression to the extra-articular ligament wounds. The use of a collagen-PRP scaffold can ameliorate histologic differences noted between healing extra-articular ligamentous wounds and nonhealing intra-articular ligamentous wounds. This study supports the hypothesis that premature scaffold failure may play a key role in the normally expected failure of the ACL to heal after injury.     

Evaluation of the clinical signs of anterior cruciate ligament and meniscal injuries

Background:

The diagnostic accuracy of anterior drawer (AD) sign, Lachman test and the pivot shift test for anterior cruciate ligament injury and McMurray test for medial and lateral meniscus is varied with sensitivity and specificity ranging from 2 to 100%. Generally, it is accepted that the pivot shift test is the most specific test to diagnose anterior cruciate ligament (ACL) tears and that the Lachman test is more sensitive than AD sign. This study was undertaken to calculate the sensitivity, specificity, positive predictive value, negative predictive value, and efficiency for the above-mentioned diagnostic tests.

Materials and Methods:

Twenty-eight male patients with clinical ACL injury were examined in the outpatient department and under anaesthesia, the findings were compared with arthroscopy.

Result:

The sensitivity and specificity for the Lachman test, AD sign and pivot shift test performed in the outpatient setting are 78.6 and 100%, 89.3 and 100%, and 75 and 100%, respectively. The sensitivity and specificity for the Lachman test, AD sign, and pivot shift test performed under anesthesia are 92.9 and 100%, 92.9 and 100%, and 100 and 100%, respectively. The sensitivity and specificity of the McMurray test for medial and lateral meniscus were 35.7 and 85.7% and 22.2 and 100%, respectively.

Conclusion:

The Lachman test, AD sign and pivot shift test are highly specific tests to diagnose ACL laxity in a non-acute setting; pivot shift test under anesthesia is the most sensitive and specific test for diagnosing ACL laxity in a non-acute setting and the McMurray test is not a sensitive test to diagnose meniscal injury in the presence of ACL injury.     

Image-guided reconstruction of the anterior cruciate ligament

The replacement of the ruptured Anterior Cruciate Ligament (ACL) of the knee is a biomechanically difficult task. The correct placement of the graft, especially the isometry of the tibial and femoral insertion points, is critically to the success of the procedure. However, during arthroscopy, the planning of the insertion points and accurate execution of the plan is difficult. This paper reports an X-ray based system for navigation of the ACL graft implant. The system integrates arthroscopy and intra-operative X-ray imaging to identify the correct insertion points of the graft. Furthermore, it allows testing the isometry of these points before drilling of the femoral and tibial tunnel, and guides the drilling itself.     

前交叉韧带的解剖结构及其与重建技术的研究现状

前交叉韧带(ACL)是膝关节内非常重要的韧带之一,同时,前交叉韧带损伤也是比较常见的一种运动损伤。目前,前交叉韧带重建技术(ACLR)是治疗前交叉韧带损伤比较传统的方式,术后能较好地维持膝关节稳定性,但对于ACL的解剖及ACLR的手术方式、骨道形状等存在多种选择,本文目的是对ACL解剖研究的新进展及其对ACLR技术的影响进行总结。     

Complete tear of the lateral meniscus posterior root is associated with meniscal extrusion in anterior cruciate ligament deficient knees

This study aimed to evaluate the relationship between preoperative lateral meniscal extrusion (LME) and arthroscopic findings of lateral meniscus posterior root tear (LMPRT) in knees with anterior cruciate ligament (ACL) tear. Thirty‐five knees that had LMPRTs with concomitant ACL tears on arthroscopy were evaluated. Patients were divided into two groups, partial and complete root tears, via arthroscopic findings at the time of ACL reconstruction. For comparison, we added two groups, using the same database; 20 normal knees (normal group) and 20 ACL‐injured knees without LM injury (intact LM group). We retrospectively measured preoperative LMEs using magnetic resonance imaging (MRI). Twenty‐three knees had partial LMPRTs. Complete LMPRTs were observed in 12 knees. The average LME was ?0.1 ± 0.4 mm in the normal group, 0.2 ± 0.5 mm in the intact LM group, 0.4 ± 0.8 mm in the partial LMPRT group, and 2.0 ± 0.6 mm in the complete LMPRT group. A significant difference in preoperative LMEs was observed between the complete LMPRT group and the other groups (p < 0.001). The receiver operating curve analysis, which distinguishes a partial tear from a complete tear, identified an optimal cut‐off point of 1.1 mm for preoperative LME. This LME cut‐off had a sensitivity of 100% and specificity of 83% for complete LMPRT. We found that preoperative LMEs were larger in complete LMPRTs associated with ACL injuries than in partial LMPRTs. Our results suggest that preoperative MRI‐detected LME may be a useful indicator for estimating LMPRT severity in ACL‐injured knees. Level of evidence: Retrospective comparative study level IV. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1894–1900, 2018.

     

关节镜下保留残端手术与常规手术重建前交叉韧带疗效比较

目的比较关节镜下保留残端手术与常规手术重建前交叉韧带(ACL)的疗效。方法采用关节镜下自体腘绳肌腱单束重建治疗66例膝关节ACL断裂患者,其中采用常规手术方法重建治疗37例,保留残端手术方法重建治疗29例。结果 66例均获随访,时间12~28个月。常规手术组及保留残端手术组术后前抽屉试验和Lachman试验比较差异均无统计学意义(P0.05);采用Lysholm、IKDC评分评价膝关节功能:两组术后比较差异均有统计学意义(P0.05),保留残端组优于常规手术组。结论关节镜下保留残端手术与常规手术行自体腘绳肌腱单束重建治疗膝关节ACL损伤都能获得满意的临床疗效,但关节镜下保留残端手术有利于移植物的再血管化及本体感受器的恢复。     

Effect of hyaluronan on the healing of partially ruptured anterior cruciate ligament of rabbits

The midportion of the anterior cruciate ligament (ACL) of rabbits was partially transected, and the effect of hyaluronan (HA) on its healing was determined. A 1% solution of HA (HA group) or physiological phosphate-buffered saline (control group) was administered intraarticularly, at 0.1 ml/kg body weight, once a week from 1 week after the operation. Two, 4, and 6 weeks after the initiation of HA administration, the ACLs were examined grossly, histologically and immunohistochemically. At 2 weeks, the lacerated portions were completely covered with scar-like tissue in both groups. These tissue areas were smaller in the HA group than in the control group. Histologically in the HA group, the regularity of collagen fibers (indicating the maturity of regenerated collagen fibers) had increased compared to findings in the control group, and the number of fibroblastic cells decreased gradually at a significantly faster rate. The number of inflammatory cells and blood vessels decreased gradually in both groups, with these values being lower in the HA group at each time point but not significantly so. Immunohistochemical examination of the repaired tissue revealed strong staining with anti-chondroitin sulfate proteoglycan antibody in the HA group 2 weeks after the first HA administration. The staining gradually became reduced, with the rate of reduction being faster in the HA group than in the control group. The stimulation of chondroitin sulfate proteoglycan production and the faster reduction of it in the HA group suggests that HA facilitated tissue repair and inhibited the formation of scar tissue.