膝关节后外侧角损伤研究进展

膝关节后外侧角(PLC)是膝关节重要的动力性与静力性稳定结构,生物力学研究显示其在限制膝内翻、胫骨外旋与后坠等方面起重要作用。PLC解剖结构复杂,主要包括腓侧副韧带、腘腓韧带、腘肌及腘肌腱、豆腓韧带、弓状韧带等一系列的韧带样结构。忽视或延误PLC损伤的治疗将导致患者出现膝关节不稳,甚至其他韧带结构手术重建的失败。膝关节体格检查是诊断PLC损伤的关键。对于A型和部分B型PLC损伤患者可采用非手术治疗,孤立性或伴发性C型PLC损伤、非手术治疗失败的患者则需要手术治疗。根据损伤类型不同,手术方式可采用直接修复、邻近肌腱转位加强术、游离肌腱移植重建等。     

关节镜下单束同种异体跟腱重建前交叉韧带断裂

目的评估关节镜下单束同种异体跟腱重建前交叉韧带（ACL）断裂的疗效。方法选取2007年3月至2011年3月,ACL完全断裂患者13例（不包括止点撕脱骨折）,在关节镜下用同种异体跟腱重建前交叉韧带断裂,手术前后用Lysholm膝关节功能评分系统进行评分。结果本组病例均在关节镜下完成手术,术后无切口感染、排异病例,均获得10～46个月的随访,13例患者术前Lysholm评分平均43．6分;术后10个月后Lyshohn评分平均89．3分,优良率达100％。结论关节镜下单束同种异体跟腱重建前交叉韧带断裂能够取得满意的疗效,避免了供区并发症,明显缩短手术时间。     

半腱肌腱与同种异体肌腱解剖重建踝关节外侧副韧带治疗慢性踝关节不稳的疗效比较

目的比较自体半腱肌腱与同种异体肌腱重建踝关节外侧副韧带治疗慢性踝关节不稳的临床疗效。方法回顾性分析自2012-06—2014-12在踝关节镜联合小切口下分别应用同种异体肌腱与自体半腱肌腱解剖重建踝关节外侧副韧带治疗慢性踝关节不稳68例。半腱肌腱组35例,异体肌腱组33例。比较2组手术时间、住院时间、手术费用,以及末次随访时VAS评分、AOFAS评分、IKDC评分、距骨倾斜角和距骨前移距离。结果 68例均获得13~38(22.7±5.2)个月随访。半腱肌腱组手术时间明显长于异体肌腱组,但在住院时间和手术费用方面优于异体肌腱组,差异有统计学意义(P0.05)。2组末次随访时VAS评分、AOFAS评分、IKDC评分、距骨倾斜角和距骨前移距离比较差异无统计学意义(P0.05)。结论同种异体肌腱与自体半腱肌腱重建踝关节外侧副韧带治疗慢性踝关节不稳均能获得良好临床疗效,临床中可根据患肢膝关节健康状况、运动期望值及经济承受能力综合分析,个体化选择移植物。     

关节镜下应用同种异体跟腱重建膝关节交叉韧带的临床应用

目的 探讨关节镜下使用同种异体跟腱重建膝关节交叉韧带的临床疗效.方法 回顾性分析应用异体跟腱在关节镜下修复26例膝关节交叉韧带损伤患者.其中前交叉韧带15例,后交叉韧带5例,前、后交叉韧带合并内侧副韧带损伤Ⅰ期修复6例.结果 采用Lysholm评分,手术前50±5分,术后平均90.50±3.42分.所有病例手术后随访2～24个月,平均13.2个月.本组优20例,良3例.优良率88.5%.结论 应用同种异体跟腱重建修复膝关节前、后交叉韧带损伤,取材方便,避免取自体肌腱对供区的损害,手术操作简单,重建后膝关节稳定性可靠,临床疗效确切,具有临床应用价值.     

膝关节后外侧复合体

膝关节后外侧复合体（posterolateral complex,PLC）也称膝关节后外侧结构,是一个多条肌腱、韧带组成的解剖及功能复杂的膝关节后外方稳定性结构。PLC由静力性稳定结构和动力性稳定结构共同组成,主要结构有外侧副韧带、胭肌腱和胭腓韧带复合体,次要结构有膝关节后外侧关节囊、豆腓韧带、弓状韧带、髂胫束、股二头肌腱、腓肠肌外侧头。其中外侧副韧带、胭肌腱和胭腓韧带复合体具有解剖学的稳定性。外侧副韧带主要防止膝关节内翻,同时也辅助防止胫骨外旋和后坠。     

解剖重建治疗膝关节后外侧角损伤

目的探讨膝关节后外侧角损伤的诊断、治疗，以及解剖重建后的临床疗效评价。方法2003年3月～2005年12月，对16例膝关节后外侧角损伤达Ⅲ级以上、存在内翻、外旋严重不稳的患者，予以解剖重建，采用Lysholm、IKIX：（international knee documentation committee）等膝关节评分标准评价术后疗效。其中男14例，女2例；年龄19～46岁，平均38岁。损伤至手术时间4～12d，平均8d。术前麻醉状态下行内翻应力试验（varus stress test，VST），在屈膝0°及30°位与健侧相比，内翻不稳均在10°以上；外旋试验显示，在屈膝30°及90 位与健侧相比，外旋不稳则在10°以上。合并前交叉韧带（anterior cruciate ligament，ACL）断裂5例，后交叉韧带（posterior crueiate ligament，PCL）断裂8例，ACL和PCL均断裂3例；伴腓总神经麻痹4例。结果患者均获随访7～18个月，平均13个月。术后无膝关节不稳。VST0°位与健侧相比未见异常，30°位3例患者出现外侧不稳，但均在5°以下．外旋试验显示，30°位外旋不稳1例，在5°以下，90°位与健侧相比无异常。关节活动度，屈曲75～130°，平均118°；伸0～5°，平均1°。膝关节Lysholm评分54～96分，平均82．8分；IKDC评分，主观评价：正常5例（31％），近似正常8例（50％），不正常3例（19％），无严重异常；客观评价46～94分，平均82分。结论后外侧角损伤在膝关节韧带损伤中所占比例较少，但后外侧角在防止膝内翻、胫骨外旋及胫骨后坠具有极其重要的作用，如疏于治疗，极易导致膝关节严重不稳甚至退变，必须引起足够重视。     

同种异体腱移植重建膝关节交叉韧带的研究

目的从实验角度观察程序冷冻液氮保存和-80℃深低温保存方法处理同种异体髌腱后重建膝关节交叉韧带的愈合过程并比较其差异。方法将兔的1/2骨-髌腱-骨复合体经-80℃深低温保存和程序冷冻液氮保存2周后观察冻存变化差异并行同种异体移植重建前交叉韧带,分别于术后3周和8周观察细胞毒反应、细胞活性、最大载荷和形态学变化等指标进行比较并与自体移植组对照。结果a）经程序冷冻液氮保存方法处理后,髌腱的最大载荷无明显下降,细胞活性得到了较好的保存,组织学观察冷冻损伤较-80℃深低温保存方法轻微;b）程序冷冻液氮保存处理的移植物在术后未表现明显的排斥反应,且免疫反应随时间的推移而下降;c）移植后3周,各组移植物的最大载荷无显著差异（P〉0.05）,移植后8周,程序冷冻液氮保存组移植物的最大载荷（55.87±1.86）N优于-80℃深低温保存组（52.14±2.79）,而和自体移植组相近（57.70±2.76）N;d）从组织学观察看,-80℃深低温保存组和程序冷冻液氮保存组移植后的愈合过程均和自体移植组相似,而程序冷冻液氮保存组的愈合过程和组织学行为更接近于自体移植组。结论经深低温保存的兔异体髌腱重建膝关节交叉韧带后愈合过程和自体韧带移植重建过程相似。程序冷冻液氮保存法优于传统的-80℃深低温保存法。     

同种异体材料移植重建膝关节交叉韧带

膝关节交叉韧带断裂公认的手术方法是韧带的重建 ,但由于 :( 1)自体材料移植重建以牺牲已有功能缺陷的膝关节的正常的动力和稳定结构为代价 ,有可能进一步增加膝关节的功能障碍 ;( 2 )人工韧带假体发展不成熟 ,尚不能达到令人满意的组织学、生物力学的要求及远期的临床疗效。近 2 0年来 ,许多学者致力于同种异体韧带和肌腱移植重建交叉韧带的基础与临床研究 ,并取得了一定的共识和进展。本文就此作以扼要综述。1　组织类型自从Ｗｅｂｓｔｅｒ( 1983)和Ｓｈｉｎｏ( 1984 )首次用冻干同种异体屈肌腱和新鲜冰冻膑腱进行了前交叉韧带(ＡＣＬ)重…     

应用异体跟腱重建前十字韧带和内侧副韧带

目的　探索应用同种异体跟腱在重建前十字韧带 (ACL)的同时 ,重建受损的内侧副韧带 (MCL)的新方法 ,避免由自体取材造成的再损伤及由此引起的并发症。方法　首先在关节镜下应用经深低温冷冻处理的同种异体跟腱 ,采用等长重建、生物固定的方法 ,重建受损的ACL。然后在辅助切口下同时重建受损的MCL。结果　 9例患者应用同种异体跟腱重建ACL和MCL ,全部病例获得了随访 ,采用Lysholm评分法评估患者手术前后的功能 ,术前平均 4 3 2分 ,术后平均 79 8分 ,优良率77 8%。客观检查 :前抽屉试验术前 9例阳性 ,术后均阴性 ;Lachman征术前 9例阳性 ,术后 1例弱阳性。膝外翻实验术前 9例阳性 ,术后均阴性。术后遗留膝关节疼痛 2例 ;膝关节活动受限 3例。结论　应用同种异体跟腱重建ACL ,可同时重建MCL。供材可提前制作 ,减少了自体取材造成的再损伤及其相应的并发症 ,该技术取材方便 ,手术方法简单 ,无需内固定物     

应用异体跟腱重建前十字韧带和内侧副韧带

目的 探索应用同种异体跟腱在重建前十字韧带(ACL)的同时，重建受损的内侧副韧带(MCL)的新方法，避免由自体取材造成的再损伤及由此引起的并发症。方法 首先在关节镜下应用经深低温冷冻处理的同种异体跟腱，采用等长重建、生物固定的方法，重建受损的ACL。然后在辅助切口下同时重建受损的MCL。结果 9例患者应用同种异体跟腱重建ACL和MCL，全部病例获得了随访，采用Lysholm评分法评估患者手术前后的功能，术前平均43．2分，术后平均79．8分，优良率77．8％。客观检查：前抽屉试验术前9例阳性，术后均阴性；Lachman征术前9例阳性，术后1例弱阳性。膝外翻实验术前9例阳性，术后均阴性。术后遗留膝关节疼痛2例；膝关节活动受限3例。结论 应用同种异体跟腱重建ACL，可同时重建MCL。供材可提前制作，减少了自体取材造成的再损伤及其相应的并发症，该技术取材方便，手术方法简单，无需内固定物。     

Evaluation of the mechanical properties of posterolateral structures and supporting posterolateral instability of the knee

The objectives of this study are to evaluate the contributions of the popliteofibular ligament (PFL), the popliteus tendon (PT), and the lateral (fibular) collateral ligament (LCL) to the posterolateral stability of the knee by changing the sequence of selective transection. Twelve fresh‐frozen cadaveric knees were divided into two groups. Group 1 has a cutting sequence as follows: PFL, PT, LCL. Group 2 has a cutting sequence as follows: PT, PFL, LCL. Each specimen was mounted on the apparatuses using the Ilizarov external fixator for measuring external rotatory and varus laxities at every 30° from 0° to 90° of knee flexion. In both groups, there was no significant difference between the PFL and PT in the increment of respective external rotatory laxity after transection at each knee flexion angle, except 0° in group 2. The transection of the LCL significantly increased the external rotation laxity at 0° and 30°. Varus instability was increased significantly only after cutting the LCL at every knee flexion angle. In conclusion, both the PFL and PT equally contribute to the external rotatory stability. The LCL also contributes to the external rotatory stability at early range of knee flexion. The LCL is a main structure for varus stability in the knee. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 26:1371–1376, 2008     

Results of isolated posterolateral corner reconstruction

Background  

Isolated posterolateral corner (PLC) tears are relatively rare events. Various surgical techniques to treat posterolateral knee instability have been described; because surgical results are linked to cruciate reconstructions it has been difficult to date to define whether one surgical procedure has better prognosis than another. The goal of this study is to determine the clinical outcome of PLC reconstruction following fibular-based technique.     

Anatomy and biomechanics of the posterolateral aspect of the canine knee.

The purpose of this study was to describe the anatomy and characterize the biomechanics of the posterolateral aspect of the canine knee. Ten adult canine knees were each used for anatomy and biomechanical testing. Distances and motion limits were measured using a 6 degree-of-freedom electromagnetic tracking system. Canine knee dissection reproducibly identified structures present in the human posterolateral knee. The course and attachment sites of the fibular collateral ligament, popliteofibular ligament, and popliteus tendon were similar to human anatomy. Sequential sectioning of the fibular collateral ligament, popliteofibular ligament, and popliteus tendon all significantly increased varus translation at full extension, 60 degrees , and 90 degrees of knee flexion. Sectioning of the fibular collateral ligament significantly increased external rotation at flexion angles near full extension, while popliteus tendon sectioning also significantly increased external rotation at 90 degrees of knee flexion. Based on the fact that the anatomy of the fibular collateral ligament, popliteus tendon, popliteofibular ligament, and the biomechanical properties of the canine posterolateral knee are similar to the human knee, we believe the canine knee is a suitable model to study the natural history of posterolateral knee injuries. The canine model will also prove valuable in the validation of reconstruction techniques and studying the potential development of medial compartment osteoarthritis following posterolateral knee injuries.     

Improving outcomes for posterolateral knee injuries

Until recently, the posterolateral corner of the knee was noted both for its complex anatomy and diagnostic challenges. To improve the understanding of the posterolateral knee, we completed a comprehensive and stepwise research program with a focus on five primary areas: (1) surgical approach and relevant anatomy; (2) diagnosis; (3) clinically relevant biomechanics; (4) natural history; and (5) surgical treatment. Based on this comprehensive research program, the diagnosis and outcomes following treatment of posterolateral knee injuries have been significantly improved comparing the preoperative state to the state of the knee at a minimum 2 year follow‐up in the cases series presented here. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:485–491, 2014.     

肘关节外侧副韧带复合体修复治疗急性后外侧旋转不稳定的临床疗效

目的探讨肘关节外侧副韧带复合体修复治疗急性后外侧旋转不稳定的临床疗效。 方法选择2013年6月至2017年12月上海新华医院连续收治的急性肘关节后外侧旋转不稳定患者20例,其中手术组11例,对照组（保守治疗）9例。20例患者均有肘关节脱位史。在麻醉下检查时,20例患者侧方轴移试验和后外侧抽屉试验均为阳性。手术组患者均使用带线锚钉修复外侧副韧带复合体。术后随访评估患者的疼痛、活动范围及稳定性,采用视觉模拟评分和Mayo肘关节功能评分进行评价和评级。 结果20例患者经过6~24个月的随访,手术组和对照组治疗后视觉模拟评分分别为（0.27±0.19）分和（1.56±0.41）分,Mayo肘关节功能评分分别为（91.27±2.28）分和（77.78±4.96）分,手术组明显优于对照组,差异有统计学意义。 结论急性肘关节后外侧旋转不稳定的正确诊断对于治疗方案的选取非常重要。肘关节外侧副韧带复合体修复术可以很好地恢复肘关节的稳定性和功能。     

Endoscopic reconstruction for chronic Achilles tendon ruptures using a hamstring tendon autograft

BackgroundTo determine the safety and efficacy of endoscopic reconstruction of chronic Achilles tendon ruptures using a hamstring tendon autograft at mid-term follow-up.MethodsWe reviewed the medical records of patients with chronic Achilles tendon rupture treated surgically by endoscopic reconstruction using a hamstring tendon autograft at our institution between March 2010 and October 2015. Radiologic outcomes were assessed using pre- and postoperative magnetic resonance imaging (MRI). Functional outcomes were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot Scale, the Plantar Flexion Strength (PFS), the Victorian Institute of Sport Assessment-Achilles (VISA-A) scale, the Visual Analogue Scale (VAS) pain score, and the Arner-Lindholm standard. All patients achieved primary healing with no lengthening of the Achilles tendon, skin necrosis, infection, deep vein thrombosis or other complications.ResultsMean follow-up period was 15 ± 3 months (range, 12–18 months). There was no Achilles tendon re-rupture. MRI examination revealed that Achilles tendon continuity was restored. Patients’ mean AOFAS, PFS, and VISA-A scores were significantly higher and mean VAS pain score was significantly lower after surgery compared to before (P < 0.05). According to Arner-Lindholm standards, there were twenty (76.9%) excellent, six (23.1%) good, and zero bad outcomes.ConclusionEndoscopic reconstruction utilizing a hamstring tendon autograft is a safe and efficacious option for repair of chronic Achilles tendon ruptures. Studies with larger sample sizes and a longer follow-up are required to confirm the advantage of this technique compared to open surgery.     

微创切取长屈肌腱重建慢性跟腱断裂

目的探讨微创切取长屈肌腱转移重建慢性跟腱断裂的临床效果。方法 2006年7月-2009年12月,收治22例22足慢性跟腱断裂患者。男16例,女6例;年龄28～65岁,中位年龄48岁。21例有患足用力蹬地史,1例无明显诱因。患者出现症状至手术时间为27～1 025 d,中位时间51 d。均有走路无力症状,Thompson试验呈阳性。根据美国矫形足踝协会(AOFAS)踝与后足疗效评价标准评分为(53.04±6.75)分。MRI示跟腱缺损长度为4.2～8.0 cm。术中作中足足底内侧切口和趾间关节跖侧平行横纹的小切口分步切取长屈肌腱,切取长度为超过跟骨结节10.5～13.5 cm,作3束反折编织缝合。界面螺钉或锚钉于跟骨后结节固定肌腱。结果术后患者切口均Ⅰ期愈合,无早期并发症发生。22例均获随访,随访时间12～42个月,平均16.7个月。术后12个月根据AOFAS踝与后足疗效评价标准评分为(92.98±5.72)分,与术前比较差异有统计学意义(t=—40.903,P=0.000);获优18例,良2例,可2例,优良率90.9%。随访期间均未见胫、腓肠神经损伤、跖底部痛性瘢痕、足底内外侧神经损伤。结论微创切取长屈肌腱转移重建慢性跟腱断裂具有切口小、术后恢复快、肌腱固定强度高以及并发症少的优点。     

Anatomy of the posterolateral aspect of the goat knee.

The purpose of this study was to determine the anatomy of the posterolateral aspect of the goat knee for future in vivo studies using a goat model to examine the natural history of posterolateral knee injuries. Twelve non-paired, fresh-frozen, adult goat knees were dissected to determine the anatomy of the posterolateral corner. The main posterolateral structures identified in the goat knee were the lateral collateral ligament, the popliteus muscle and tendon, popliteomeniscal fascicles, and the lateral gastrocnemius muscle. The lateral collateral ligament was extra-articular and coursed from its proximal attachment, located posterior and proximal to the lateral epicondyle, to its distal attachment on the lateral aspect of the fused proximal tibiofibula. The popliteus muscle attached to the medial edge of the posterodistal tibia, traveled anterolaterally, became intra-articular at its musculotendinous junction, and attached to the lateral femur just distal to the lateral epicondyle. Distinct popliteomeniscal fascicles attached the lateral meniscus to the popliteus muscle and tendon, and a fascial attachment from the musculotendinous junction of the popliteus muscle coursed to the lateral tibial plateau. This study provided information on the structures present in the posterolateral aspect of the goat knee and enhanced our understanding of their relationships to analogous structures in the human knee. This information is important to enable future development of potential models of the natural history of posterolateral knee injuries and also to test surgical techniques and the in vivo effects of these injuries on cruciate ligament reconstructions.