关节镜下单束重建前交叉韧带前内侧束断裂

目的探讨关节镜下前交叉韧带(ACL)前内侧束断裂的重建方法及疗效。 方法 2004年5月至2010年5月采用关节镜技术重建293例ACL损伤患者,其中40例(13.7％)患者术中关节镜下诊断为ACL前内侧束断裂,男34例,女6例;年龄18～39岁,平均30.1岁。受伤至手术时间平均为4.2个月（7 d至8个月）。术中保留ACL后外侧束,使用自体4股腘绳肌腱重建前内侧束。术前及术后随访评估包括临床查体和Lysholm评分,本体感觉功能采用被动活动察觉阈值进行评估。 结果 40例患者术后获平均33个月（7～56个月）随访。膝关节Lysholm评分术前平均为(56.7±8.6)分,末次随访时平均为(92.0±5.0)分,差异有统计学意义(t=27. 750,P=0.000)。末次随访时按Lysholm评分评定疗效：优19例,良16例,可5例,优良率为87.5％。Lachman试验阴性34例,弱阳性4例,阳性2例。末次随访时患膝被动活动察觉阈值平均为2.12°±0.15°,健膝被动活动察觉阈值平均为2.09°±0. 16°,差异无统计学意义（t=0. 657,P=0.515）。术后所有患者均恢复日常工作,关节稳定性明显改善。结论关节镜下单束重建ACL前内侧束,术中保留了后外侧束,有利于隧道的精确定位和移植物固定机械强度的增加,并能加速移植肌腱的血管化和再神经支配,促进膝关节功能尽快恢复。     

Arthroscopic reduction and fixation of avulsion fracture of the tibial attachment of the anterior cruciate ligament

In treating avulsion fracture of the tibial attachment of the anterior cruciate ligament, surgical reduction and fixation of fractured bone is necessary for patients who have a wide displacement of bone fragment (i.e., types III and IV in the Meyers classification). Our arthroscopic technique allows the creation of bone tunnels on the medial and lateral sides of the bone fragment from the medial side of the tibial tubercle without using special equipment. At surgery, fixation wire is prepared into a loop, pulled into the joint space, and the loop is opened within the joint. This makes intra-articular manipulation easy, and the bone can be reduced more accurately. This arthroscopic technique decreases surgical invasion of the joint, allows good postoperative range of motion without problems, and is useful in preventing extension limitation due to dislocation of the anterior portion of the fragment.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 1003–1006     

前交叉韧带胫骨附丽处撕脱骨折髌下微创治疗

目的:介绍一种对前交叉韧带(ACL)胫骨附丽处撕脱骨折的微创治疗途径。方法:ACL胫骨附丽处撕脱骨折患者81例,男64例,女17例;年龄10～58岁,平均37.8岁;交通伤57例,坠落伤15例,运动伤6例,其他伤3例。按Zaricznyj分类:Ⅰ型3例,Ⅱ型16例,ⅢA型21例,ⅢB型25例,Ⅳ型16例。利用经髌下纵切口插入膝关节腔内的食指导引,予ACL胫骨附丽处撕脱骨折复位后,经皮空心钉内固定;骨折块小、Ⅳ型骨折或骨骺未闭合时,钢丝固定。结果:对81例患者进行6～24个月随访,平均18个月,术后3个月膝关节活动度与健侧相比无明显区别,骨折全部愈合,Lysholm膝关节功能评分为(91.6±3.2);术后6个月评分为(95.7±3.6)。结论:ACL胫骨附丽处撕脱骨折髌下微创治疗,操作简便、微创,效果可靠。     

Arthroscopic physeal sparing all inside repair of the tibial avulsion fracture in the anterior cruciate ligament: technical note

We describe a new and effective arthroscopic physeal sparing repair of the tibial eminence avulsion fracture using all an inside repair technique. The treatment of ACL avulsion is controversial, especially in skeletally immature patients, with concerns about physeal damage, and a more reliable way of fixation is still being pursued for small or comminuted fragments. Screw fixation and suture cerclage has some limitations, especially in the small fragment or skeletally immature patients. We fixed avulsion fragment using all inside repair between the distal portion of the ACL and transverse ligament and periosteum. A crescent suture hook loaded with NO. 0 PDS is introduced and the suture hook pierces the transverse intermeniscal ligament and periosteum. The half length of the PDS is now advanced out through the hook and the end is brought out to the anterolateral portal. With the suture hook located intra-articularly and loaded with half the length of the original PDS, the suture hook repierces the transverse intermeniscal ligament at 5 mm on the side and the remaining half length of PDS is now advanced out through the hook and the end is brought out to the anterolateral portal. After that procedure, the suture hook loaded with NO. 0 absorbable Maxon is introduced through the anteromedial portal for the role of shuttle relay. The suture hook pierces the ACL just above the superior border of the avulsion fragment, the Maxon is now advanced out through the hook and the end is brought out to the anterolateral portal. Subsequently, the suture hook is removed and a suture retriever is introduced through the anterolateral portal. PDS and Maxon are held together and retrieved out of the anterolateral portal by the suture retriever at the same time. Our technique has advantages in small comminuted fractures and skeletally immature patients.     

前交叉韧带胫骨棘止点撕脱骨折不同内固定疗效分析

[目的]明确前交叉韧带胫骨棘止点撕脱骨折不同内固定对膝关节稳定性和运动功能的影响。[方法]对45例前交叉韧带胫骨棘止点撕脱骨折患者分别进行关节镜下钢丝、丝线、螺钉复位内固定,术后定期随访,按Ly-sholm膝关节功能评分和IKDC膝关节功能评分对术后膝关节功能进行评估,判断患肢整体功能恢复情况。[结果]关节镜下复位内固定取得了较好的膝关节稳定性和运动功能,膝关节活动范围正常,关节功能良好;关节镜复位内固定术后6个月Lysholm膝关节功能评分为(92.2±2.4)分,术后1 a Lysholm膝关节功能评分(95.1±2.7)分;钢丝组、丝线组、螺钉组等内固定之间的Lysholm膝关节功能评分无显著性差异(P>0.05)。[结论]关节镜下钢丝、丝线、螺钉复位内固定是前交叉韧带胫骨棘止点撕脱骨折的重要治疗手段,术后可获得良好的膝关节功能和稳定性。     

Outcome of double bundle anterior cruciate ligament reconstruction using crosspin and aperture fixation

Background:

Double bundle anterior cruciate ligament (DBACL) reconstruction is said to reproduce the native anterior cruciate ligament (ACL) anatomy better than single bundle anterior cruciate ligament, whether it leads to better functional results is debatable. Different fixation methods have been used for DBACL reconstruction, the most common being aperture fixation on tibial side and cortical suspensory fixation on the femoral side. We present the results of DBACL reconstruction technique, wherein on the femoral side anteromedial (AM) bundle is fixed with a crosspin and aperture fixation was done for the posterolateral (PL) bundle.

Materials and Methods:

Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing.

Methods:

Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing.

Results:

The KT-1000 results were evaluated using paired t test with the P value set at 0.001. At the end of 1 year, the anteroposterior side to side translation difference (KT-1000 manual maximum) showed mean improvement from 5.1 mm ± 1.5 preoperatively to 1.6 mm ± 1.2 (P < 0.001) postoperatively. The Lysholm score too showed statistically significant (P < 0.001) improvement from 52.4 ± 15.2 (range: 32-76) preoperatively to a postoperative score of 89.1 ± 3.2 (range 67-100). According to the IKDC score 90% patients had normal results (Category A and B). The AM femoral tunnel initial posterior blow out was seen in 4 patients and confluence in the intraarticular part of the femoral tunnels was seen in 6 patients intraoperatively. The quadriceps strength on isokinetic testing had an average deficit of 10.3% while the hamstrings had a 5.2% deficit at the end of 1 year as compared with the normal side.

Conclusion:

Our study revealed that the DBACL reconstruction using crosspin fixation for AM bundle and aperture fixation for PL bundle on the femoral side resulted in significant improvement in KT 1000, Lysholm and IKDC scores.     

半月板缝合针引导钢丝关节镜下内固定治疗前交叉韧带胫骨嵴撕脱骨折

目的 探讨关节镜下半月板缝合针引导钢丝内固定治疗前交叉韧带（anterior cruciate ligament,ACL）胫骨嵴撕脱骨折的疗效。方法 1999年12月～2005年8月关节镜下应用半月板缝合针引导钢丝内固定治疗ACL胫骨嵴撕脱骨折15例。采用膝关节Lysholm评分对关节镜手术前、后关节功能进行评价,术后定期复查膝关节正侧位X线片。结果 手术操作均在30min以内完成,无关节感染、意外损伤、关节粘连、骨折不愈合并发症发生。15例随访6～54个月,（20.9±15.0）月,复查X线片显示15例骨折愈合良好。术前Lysholm评分10～56分,（19.1±15.2）分,手术后提高至91～100分,（97.5±3.7）分（t=18.483,P=0.000）。2例术后8、14个月出现内固定钢丝断裂,但骨折愈合良好。结论 关节镜下半月板缝合针引导钢丝固定治疗ACL胫骨嵴撕脱骨折,方法简便、适用范围广、创伤小、术后功能恢复满意。     

前交叉韧带胫骨止点撕脱骨折的关节镜治疗

目的：探索前交叉韧带胫骨止点撕脱骨折错位在关节镜下复位及钢丝内固定的新途径。方法：关节镜下骨折块复位及钢丝内固定前交叉韧带胫骨止点撕脱骨折14例。结果：术后14例骨折块位置满意。所有病例均获正常活动范围。结论：本术式为治疗前交叉韧带胫骨止点撕脱骨折错位提供了一种新的术式。关节镜下治疗前交叉韧带胫骨止点撕脱骨折是简便易行和便于推广应用的治疗。     

″Silent” transverse patellar fracture following anterior cruciate ligament reconstruction

Patellar fracture is a rare but specific complication of anterior cruciate ligament reconstruction using bone–patellar tendon–bone autograft. When this complication occurs, early internal fixation is recommended and need not compromise the outcome. We report 2 cases of displaced transverse patellar fracture occurring after reconstruction but which were not diagnosed and presented with late sequelae.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: pp 997–999     

经胫骨隧道入路与前内入路重建前交叉韧带比较

目的创新性地以临床功能和膝关节稳定性结合股骨隧道位置和长度作为评估标准,以此评价前内入路和经胫骨隧道入路,哪一种手术方法更具优越性。 方法从2010年8月至2013年7月,烟台毓璜顶医院连续104位重建前交叉韧带的病人被纳入研究。纳入标准：随访至少1年,正常的对侧膝关节,无严重的术后并发症,获得术后CT三维重建影像资料的病人。排除标准：伴有后交叉韧带损伤、伴有侧副韧带损伤、伴有骨关节炎的病人、翻修手术。病人随机分为两组,其中经前内入路组为56人,包括男性46人,女性10人,平均年龄(30±12)岁;经胫骨隧道入路组是48人,包括男性40人,女性8人,平均年龄(32±11)岁。所有病人均前瞻性地于术前和最后1次随访时行Lysholm膝关节评分、国际膝关节文献委员会评分(IKDC评分)、Tegner膝关节运动水平评分。于最后1次随访时行屈膝30°前抽屉试验(Lachman试验)、轴移试验(Pivot-shift试验)、KT-1000评估。于术后1周行基于CT的三维重建,以此评估股骨隧道位置,并于术中测量股骨隧道长度。对于Lysholm评分,IKDC评分,Tegner评分,隧道长度,KT-1000和隧道位置均行两独立样本的t检验。Lachman试验和Pivot-shift试验结果行Mann-Whitney秩和检验(两独立样本的非参数检验)。 结果前内入路组平均随访时间(26±7)月,经胫骨隧道入路组平均随访时间(25±6)月。术前和最后1次随访时,两组间Lysholm评分(术前t＝0.347,P >0.05;末次随访t＝1.557,P>0.05),IKDC评分(术前t＝－0.383,P>0.05;末次随访t＝1.102,P>0.05)和Tegner评分(术前t＝0.283,P>0.05;末次随访t＝1.763,P>0.05)相比,差异均无统计学意义。最后1次随访时,两组间Lachman试验(Z＝－0.482,P>0.05)、Pivot-shift试验(Z＝－1.455,P>0.05)和KT-1000(t＝－0.750,P >0.05)相比,差异均无统计学意义。然而,前内入路组平均股骨隧道长度明显短于经胫骨隧道组,差异有统计学意义(t＝－5.554,P<0.01);前内入路组隧道位置明显比经胫骨隧道组更深(t＝－4.508,P<0.01)、更低(t＝8.865,P<0.01),差异有统计学意义。 结论前内入路与经胫骨隧道入路的临床功能和膝关节稳定性没差别,但是前内入路股骨隧道长度明显短于经胫骨隧道,且位置更深、更低,更容易定位于前交叉韧带股骨端解剖足印区。     

A novel arthroscopic procedure for fixation of avulsion fracture of tibial attachment of anterior cruciate ligament guided by meniscal stitching needle

Objective： To introduce a novel technique in which meniscal stitching needle is used as a puller to induct steel wire to secure the tibial eminence avulsion under arthroscopic visualization, and evaluate the cfinical results.
Methods： From 1999 to 2005, fifteen cases of tibial eminence avulsion were treated with this new technique. Lysholm scoring scale system was used to assess knee function before and after surgery. Regular plain anteroposterior and lateral X-ray flms were undertaken to detect the bony healing of avulsed fragment.
Results： The operating time could be controlled within 30 minutes. No complications such as intraarticular infection, iatrogenic injury, fibroarthritis or nonunion of fracture occurred in this group. X-ray film revealed that bony healing in all 15 cases was achieved from 6 weeks to 12 weeks postoperatively. Lysholm score was improved from 19.1 ± 15.2 （ ranging from 10 to 56 ） preoperatively to 97.5 ± 3.7 （ranging from 91 to 100） postoperatively on average in 12-54 months follow up （mean 23 months）. The statistically significant difference was shown in Student＇s t test （t = 18. 483, P =3. 100×10^-11, P 〈 0. 01）. Wire breakage was found in two patients whose wires were removed 8 months and 14 months after initial operation, respectively.
Conclusion： This technique has many advantages, such as simplicity, wide indications from type Ⅱ to type Ⅳ fractures, minimal invasion, short operating time and predictable satisfactory results.     

Trantibial anterior cruciate ligament double bundle reconstruction technique: two tibial bundle in one tibial tunnel

The anterior cruciate ligament (ACL) consists of two functional bundles that behave independently throughout the range of knee motion. Many two-bundle reconstruction techniques have been introduced to restore the function of the two bundles of the ACL. Generally, two femoral and two tibial tunnels are made during the surgery for a two-bundle ACL reconstruction. However, the procedure is technically demanding and time consuming. This paper describes one-tibial-two-femoral ACL double bundle reconstruction technique with a sextuple-stranded hamstring autograft. The anteromedial femoral tunnel is made using transtibial drilling technique and posterolateral femoral tunnel is made using outside-in technique. The two bundles in a single tibial tunnel are separated using biodegradable interference screw. Stable and adequate femoral fixation of the two bundles with a transtibial fixation and bioabsorbable screw can be obtained. This technique is relatively simple, and replicates the anatomy and differential behavior of the two native bundles of ACL more effectively.     

Tension patterns of the anteromedial and posterolateral grafts in a double‐bundle anterior cruciate ligament reconstruction

The two functional bundles of the anterior cruciate ligament (ACL), namely, the anteromedial (AM) and posterolateral (PL) bundles, must work in concert to control displacement of the tibia relative to the femur for complex motions. Thus, the replacement graft(s) for a torn ACL should possess similar tension patterns. The objective of the study was to examine whether a double‐bundle ACL reconstruction with the semitendinosus‐gracilis autografts could replicate the tension patterns of those for the intact ACL under controlled in vitro loading conditions. By means of a robotic/universal force moment sensor (UFS) testing system, the in situ force vectors (both magnitude and direction) for the AM and PL bundles of the ACL, as well as their respective replacement grafts, were determined and compared on nine human cadaveric knees. It was found that double‐bundle ACL reconstruction could closely replicate the in situ force vectors. Under a 134‐N anterior tibial load, the resultant force vectors for the intact ACL and the reconstructed ACL had a difference of 5 to 11 N (p > 0.05) in magnitude and 1 to 13° (p > 0.05) in direction. Whereas, under combined rotatory loads of 10‐N‐m valgus and 5‐N‐m internal tibial torques, the corresponding differences were 10 to 16 N and 4° to 11°, respectively. Again, there were no statistically significant differences except at 30° of flexion where the force vector for the AM graft had a 15° (p < 0.05) lower elevation angle than did the AM bundle. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 879–884, 2009     

由外向内与经前内侧入路法重建前交叉韧带股骨隧道的比较

目的：研究由外向内法（OI）与经前内侧入路法（AM）重建前交叉韧带（ACL）股骨侧隧道相关参数及隧道长度与股骨髁部大小的关系,探寻二者区别。方法取15具新鲜解冻膝关节标本,测量股骨髁部左右径及股骨外侧髁前后径大小,采用自行改进的内钩槽游标卡尺,定位ACL股骨侧止点中心,分别模拟采用OI法与AM法定位股骨外侧壁隧道口点。测量隧道长度、隧道口点与股骨外上髁位置关系。正侧位X线位上股骨隧道与膝关节线、股骨纵轴夹角。结果 OI法股骨隧道长度为（36.9±2.5）mm,AM法为（35.0±2.1）mm,差异有统计学意义（P＜0.05）;OI法与AM法股骨外侧壁隧道口点均位于股骨外上髁近前侧。 OI法较AM法偏近心端分布,但AM法更为集中;股骨髁部越大,隧道长度越长。 OI法较AM法隧道更为垂直。结论采用OI法与AM法均可满足ACL重建术对股骨隧道长度及位置的要求。 OI法相比下更随意,不受屈膝角度的影响。     

关节镜下保留残端纤维的前交叉韧带单束解剖重建术

目的:探讨关节镜下保留残端纤维的前交叉韧带单束解剖重建术的方法及临床效果。方法:自2007年10月至2009年11月,对17例前交叉韧带断裂患者进行保留残端纤维的前交叉韧带单束解剖重建术。其中男10例,女7例;年龄28～62岁,平均39.3岁。致伤原因:交通事故9例,日常生活摔倒受伤6例,运动创伤2例。伤后至手术时间平均8.5d(2～14d)。采用国际膝关节文献委员会(IKDC)分级及Lysholm评分等评估患者手术疗效。结果:17例均获随访,时间24～39个月,平均29.5个月。所有患者未发现腘窝动脉、胫神经或腓总神经损伤等并发症。12例膝关节活动度达到正常;1例出现关节僵硬,术后6个月予以关节镜下松解,术后积极功能锻炼,术后膝关节屈曲20°缺失,伸直正常;3例有屈曲5°～10°缺失;1例有5°过伸受限。17例后抽屉试验和Lachman试验均阴性。17例IKDC评分均达到或接近正常。IKDC总评分16例正常,1例接近正常。末次随访时IKDC主观评分为94.3±5.1,Lysholm评分为94.7±3.1。结论:关节镜下保留残端纤维的前交叉韧带单束解剖重建术可获得良好的临床效果。     

Arthroscopic anatomic double bundle anterior cruciate ligament reconstruction: Our experience with follow-up of 4 years

BackgroundDouble bundle (DB) anterior cruciate ligament (ACL) reconstruction has been proposed to recreate the natural anatomy of ACL. Reconstruction of the anatomy of both the bundles of ACL has been thought to be able to restore the rotational stability of the knee joint. Nevertheless, it remains unclear whether DB reconstruction has better functional outcome than single bundle (SB) ACL reconstruction.PurposeTo evaluate the clinical outcomes, patient satisfaction and manual laxity tests of knee in patients treated with DB ACL reconstruction in Indian population.MethodsWe prospectively followed 25 patients with an isolated ACL injury operated for DB ACL reconstruction after applying the inclusion and exclusion criteria. Patients were evaluated pre-operatively and in the post-operative period at regular intervals with the minimum follow up of 4 years. Clinical stability was assessed by anterior drawer test, Lachman test and pivot shift test. Functional outcome was assessed by IKDC, Lysholm and Modified Cincinnati scores.ResultsAt the end of 4 years, functional outcome in terms of all subjective scores was satisfactory. Graded stability results of the Lachman, Anterior drawer and pivot shift tests were almost near to that in normal knee. No complication occurred post-operatively.ConclusionAnatomical DB ACL reconstruction seems to offer satisfactory results in terms of subjective scores and stability tests to patients with ACL tear. It has been found to be associated with no obvious complications and no failures. However a larger patient pool is desired for conclusive results.     

胫骨平台前外侧撕脱骨折合并前交叉韧带损伤的诊治

胫骨平台前外侧撕脱骨折(Segond骨折)合并前交叉韧带(ACL)损伤在临床中并不少见。对于Segond骨折合并ACL损伤患者如何诊治,越发的被重视起来。本文通过对Segond骨折合并ACL损伤的准确诊断、应急处理、恰当治疗、康复锻炼等方面作一综述,旨在对Segond骨折合并ACL损伤的诊治有所帮助,同时该合并伤应根据个体损伤情况制定个性化的方案。     

关节镜下膝关节前交叉韧带分束重建的临床研究

目的探讨关节镜下前交叉韧带（ACL）部分断裂的分束重建手术方法及近期疗效。方法在关节镜下对26例膝关节ACL部分断裂患者采用自体胭绳肌腱或同种异体肌腱进行分束重建术,观察其术后近期疗效,以Lysholm评分、Larson评分、IKDC评分评价膝关节功能。结果24例患者获随访,随访时间12～36个月,平均23个月,所有患膝关节活动度正常,平均Lysholm评分由术前（69±6．3）分提高到（92．4±2．6）分（t=17．5,P〈0．01）,Larson评分由术前（70±4．5）分提高到（93．2±2．5）分（t=23．0,P〈0．01）,IKDC评分由术前（67．3±6．4）分提高到（92．5±3．1）分（t=18．1,P〈0．01）,差异均有统计学意义;复查X线照片及MRI均未发现骨隧道扩大现象,未见关节间隙变窄及挤压螺钉松脱。结论根据ACL损伤的不同程度,进行关节镜下ACL分束重建手术操作简便,最大限度恢复解剖重建,功能恢复快,近期疗效佳。