关节镜下前交叉韧带重建术后早期康复训练研究

目的:探讨关节镜下前交叉韧带重建术后早期进行康复训练的康复疗效。方法:回顾性分析单侧膝关节前交叉韧带断裂患者60例治疗康复情况,通过对比手术前后膝关节稳定性、活动范围、Lysholm评分及IKDC评分来评估疗效。结果:术后60例患者均获随访,早期康复训练组患者术后6月膝关节稳定性与活动度均良好,本体感觉得到恢复,可进行正常生活、工作。结论:关节镜下前交叉韧带重建术后早期进行康复训练可以恢复膝关节满意稳定性及活动度,疗效可靠。     

关节镜下多种移植物联合重建膝关节前、后交叉韧带

目的：评估关节镜下膝关节前交叉韧带（ACL）与后交叉韧带（PCL）同时重建的技术和临床效果。方法：自2003年6月～2009年10月,27例病人（28膝）经MRJ检查及关节镜检查证实ACL和PCL均断裂,其中9膝伴内侧副韧带损伤（MCL）,8膝伴后外侧角损伤（PLC）,5膝伴内侧半月板破裂,4膝伴外侧半月板损伤。27例患者于伤后3～10周在关节镜下行膝关节前、后交叉韧带联合重建。结果：本组术后早期均未发生严重并发症。术后随访12-88个月,平均（42．67±3．34）个月,Lysholm膝关节功能评分为78-93分,平均（86．67±5．21）分。国际膝关节文件编制委员会（mDC）综合评定由术前显著异常（D级）28膝,改进为随访时正常（A级）9膝、接近正常（B级）16膝、异常（C级）3膝。结论：关节镜下膝关节前交叉韧带（ACL）与后交叉韧带（PCL）同时重建创伤小、手术操作精细,术后膝关节功能恢复满意。     

关节镜下多种移植物联合重建膝关节前、后交叉韧带

目的:评估关节镜下膝关节前交叉韧带(ACL)与后交叉韧带(PCL)同时重建的技术和临床效果。方法:自2003年6月～2009年10月,27例病人(28膝)经MRI检查及关节镜检查证实ACL和PCL均断裂,其中9膝伴内侧副韧带损伤(MCL),8膝伴后外侧角损伤(PLC),5膝伴内侧半月板破裂,4膝伴外侧半月板损伤。27例患者于伤后3～10周在关节镜下行膝关节前、后交叉韧带联合重建。结果:本组术后早期均未发生严重并发症。术后随访12～88个月,平均(42.67±3.34)个月,Lysholm膝关节功能评分为78～93分,平均(86.67±5.21)分。国际膝关节文件编制委员会(IKDC)综合评定由术前显著异常(D级)28膝,改进为随访时正常(A级)9膝、接近正常(B级)16膝、异常(C级)3膝。结论:关节镜下膝关节前交叉韧带(ACL)与后交叉韧带(PCL)同时重建创伤小、手术操作精细,术后膝关节功能恢复满意。     

双源CT测量前交叉韧带单束重建术后隧道位置的临床研究

目的:应用双源CT(Dual-source computer tomography,DSCT)测量前交叉韧带(Anterior cruciate ligament,ACL)单束重建术后胫骨、股骨隧道位置,并对隧道位置进行评价。方法:对2013年1月至2014年6月我科收治的92例(男64例,女28例,平均年龄31.2岁)ACL单束重建患者术后膝关节进行双源CT三维重建,应用Adobe Photoshop CS6软件圈画隧道中心并采用Lorenz法测量胫骨隧道中心点相对位置百分比(Tx,Ty),采用Bernard四格表法测量股骨隧道中心点相对位置百分比(Fx,Fy)。结果:Tx平均为(54.54±3.42)%,Ty平均为(39.58±6.72)%,Fx平均为(28.98±6.51)%,Fy平均为(28.04±8.70)%。男、女性及左、右膝之间Tx、Ty、Fx、Fy的差异均无统计学意义(P0.05)。结论:双源CT能够清晰,三维显示ACL术后隧道,可以用来评估隧道位置,为改进前交叉韧带损伤后的手术方式及个体化解剖重建提供帮助。     

前交叉韧带重建术后黄曲霉感染1例

该文报道前交叉韧带重建术后感染黄曲霉1例。患者男,26岁。因陈旧性交叉韧带断裂在某医院行自体肌腱右膝前交叉韧带重建术。术后1周发生感染症状,常规抗细菌药物无效。根据病史、临床表现及真菌培养诊断为黄曲霉关节感染。经过关节腔内5%碳酸氢钠溶液冲洗并关节腔内两性霉素B灌注给药(1%两性霉素B 20 m L,qd),联合伏立康唑(200 mg,q12 h)口服抗真菌治疗,28 d后病情好转出院。     

军人前交叉韧带损伤的危险因素分析

目的:分析造成军人前交叉韧带损伤的危险因素,进而指导临床,为前交叉韧带损伤的预防提供理论依据.方法:回顾性分析本院2011年11月-2012年6月的58例前交叉韧带损伤的军人病例,分别以损伤动作及其机制、损伤时所穿鞋子及发生场地、BMI及雌激素水平、运动前有无准备活动为指标,研究生物力学危险因素、外在环境危险因素、内在危险因素、神经肌肉危险因素对前交叉韧带损伤的影响.结果:ACL损伤动作中军事训练23例,篮球22例所占比例最高(总计77.6％).在所有损伤动作中屈膝外翻38例,跳起落地10例,运动急停7例,暴力扭转3例.塑胶场地发生33例(占56.9％)为四大场地中损伤构成比最高的场地;运动时所穿鞋子类型为运动鞋12例(20.7％)、胶底鞋41例(70.6％)时损伤发生构成比明显高于其他类型的鞋子.BMI分组中超重者38例(65.5％)占据首位.雌激素分组中损伤一般发生于排卵期前后.神经肌肉因素调查中56例(96.5％)患者运动前未行专业的准备活动.结论:屈膝外翻位,活动中鞋子与地面摩擦力大,BMI指数高,体内雌激素含量增高,没有专业的运动前准备活动与前交叉韧带损伤的发生有关.诸多危险因素中唯有神经肌肉危险因素可调节控制.     

股四头肌腱双束重建前交叉韧带的生物力学特性研究

目的:探讨股四头肌腱的生物力学特性,为其能否应用于临床前交叉韧带(ACL)重建提供实验依据.方法:取32例新鲜尸体的1cm宽股四头肌腱,按其解剖结构分为两柬:股直肌、股内、外侧肌腱舍为A束,股中问肌腱为B束,用游标卡尺测量两束的宽度及厚度,然后将两束置于电子万能试验机上分别测其生物力学指标.结果:A 束厚度为4.39±1.72mm,宽度为8.19±1.18mm,生物力学强度为685.67±227.09N,抗拉强度为17.00±3.48Mpa;B束厚度为3.06±1.47mm,宽度为7.10±2.03mm,生物力学强度为435.04±205.80N,抗拉强度为13.16±4.02Mpa.A束生物力学强度与ACL比较,差异有统计学意义(p<0.05);B束生物力学强度与ACL比较,差异有统计学意义(p<0.05).结论:股四头肌腱的生物力学性能不能满足ACL双束重建的要求,其在临床上应用于ACL双束重建的价值有待于进一步的深入研究.

Abstract：

Objective: To investigate the biomechanics of the quadrieeps tendon and to provide theoretical basis for double-bundle reeonstruction of anterior cruciate iigament(ACL). Methods: 32 quadriceps tendons (width lena) taken from fresh cadaver were dissected into 2 bundles according to the anatomy, one bundle including rectus femoris, vastus medialis and vastus lateralis was named A bundle and the other was named B bundle. The width and thickness of the A and B bundle were detected respectively with a Vernier caliper and the biomechanics were determined by WDW-30 election universal testing machine. Results: The thickness, width, ultimate load and ultimate tensile strength of bundle A were 4.39± 1.72mm, 8.19± 1.18mm, 685.67± 227.09 N and 17.00± 3.48 Mpa respectively, while for bundle B,which were 3.06± 1.47 ram, 7.10± 2.03mm: 435.04±205.80 N and 13.16± 4.02 Mpa. There was difference between bundle A and the ACL (p<0.05). Conclusion: The ultimate load ofbundle A was much lower than the the ACL and bundle Bwas also lower than the ACL.     

股四头肌腱双束重建前交叉韧带的生物力学特性研究

目的：探讨股四头肌腱的生物力学特性,为其能否应用于临床前交叉韧带（ACL）重建提供实验依据。方法：取32例新鲜尸体的1cm宽股四头肌腱,按其解剖结构分为两束：股直肌、股内、外侧肌腱合为A束,股中间肌腱为B束,用游标卡尺测量两束的宽度及厚度,然后将两束置于电子万能试验机上分别测其生物力学指标。结果：A束厚度为4.39±1.72mm,宽度为8.19±1.18mm,生物力学强度为685.67±227.09N,抗拉强度为17.00±3.48Mpa;B束厚度为3.06±1.47mm,宽度为7.10±2.03mm,生物力学强度为435.04±205.80N,抗拉强度为13.16±4.02Mpa。A束生物力学强度与ACL比较,差异有统计学意义（p〈0.05）;B束生物力学强度与ACL比较,差异有统计学意义（p〈0.05）。结论：股四头肌腱的生物力学性能不能满足ACL双束重建的要求,其在临床上应用于ACL双束重建的价值有待于进一步的深入研究。     

双源CT三维重建前交叉韧带移植物新技术

目的:探讨双源CT(DSCT)三维重建前交叉韧带(anterior cruciate ligament,ACL)重建术后移植物的技术方法。方法:对30例ACL损伤后移植重建术后患者进行DSCT扫描,利用软件三维重建ACL移植物的三维图像,对图像效果进行分析。结果:采用设定的参数和方法,30例患者的ACL移植物均获得三维重现,其中24例获得清晰的移植物图像,6例移植物图像略模糊。结论:DSCT可以重建出移植术后ACL移植物的三维图像,对临床检验、评估重建技术、修正重建方法、实现解剖重建有重大价值。     

膝关节镜下自体中1/3骨-髌韧带-骨重建前交叉韧带手术配合

前交叉韧带 ( ACL)的撕裂是膝关节损伤中最常见的严重的韧带损伤 ,ACL损伤后严重影响膝关节功能 ,继发关节软骨、半月板等主要结构损伤 ,导致关节退变和骨关节病的早期发生。由于关节镜技术具有创伤小、操作精细、康复快的优点 ,用来修复 ACL明显提高了 ACL损伤的治愈率。关节镜内自体中 1 /3骨 -髌韧带 -骨 ( B- PT- B)重建 ACL是近几年标准的重建 ACL手术 [1] ,我院自2 0 0 2年 8月至 2 0 0 3年 3月共开展此类手术 5例 ,疗效确切 ,现将手术配合报道如下。1　临床资料　　本组共 5例患者 ,男 4例 ,女 1例 ,年龄最大46岁 ,最小 2 6…     

Males and females have different muscle activity patterns during gait after ACL injury and reconstruction

Kinematic and kinetic changes following anterior cruciate ligament (ACL) rupture and reconstruction (ACLR) have been fundamental to the understanding of mechanical disrupted load as it contributes to the development of posttraumatic osteoarthritis. These analyses overlook the potential contribution of muscle activity as it relates to the joint loading environment. Males and females classified as non-copers present with unique knee kinematics and kinetics after ACL injury. The purpose of this study was to perform sex-specific analyses in these individuals to explore muscle activity timing during gait after ACL rupture. Thirty-nine participants (12 females, 27 males) were enrolled. Muscle activity during gait was evaluated before and after pre-operative physical therapy, and six months after ACLR. Surface electromyography data were evaluated to determine timing (e.g., the time the muscle activity begins (‘On’) and ends (‘Off’)) for seven muscles: vastus lateralis and medialis (VL, VM), lateral and medial hamstrings (LH, MH), lateral and medial gastrocnemius (LG, MG), and soleus (SOL). General linear models with generalized estimating equations detected the effects of limb and time for muscle activity timing. Males presented with more limb asymmetries before and after pre-operative PT in the VL On (p < 0.001) and Off (p = 0.007), VM On and Off (p < 0.001), and MH off (p < 0.001), but all limb differences resolved by six months post ACLR. Changes in muscle activity in males were pervasive over time in both limbs. Females presented with no interlimb differences pre-operatively, and only involved limb VL off (p = 0.027) and VM off (p = 0.003) and the LH off in both limbs (p < 0.038) changed over time. Our data indicate that inter-limb differences in muscle activity across time points and changes in muscle activity timing over the course of physical therapy were sex specific. Males presented with more inter-limb differences in muscle activity across time points, and females presented with fewer asymmetries before and after pre-operative physical therapy. These data support that sex-specific adaptations should be taken into consideration when assessing biomechanical changes after ACLR.     

猪膝关节与人膝关节的对比及其在生物力学测试中的应用

人膝关节结构复杂,韧带较多,其中交叉韧带对维持膝关节的稳定性至为重要.后交叉韧带(posterior cruciate ligament,PCL)对于维持膝关节的后向稳定性和旋转稳定性具有至关重要的作用.PCL损伤后的主观不适症状要明显少于前交叉韧带损伤,所以过去对PCL的关注及研究要少于前交叉韧带.近年来高能量损伤致使PCL的损伤越来越多,学者们对PCL的关注度也在增加,进行了大量与PCL相关的实验,同时我们发现很多学者用动物的膝关节来代替人尸体进行体外生物力学实验,其中猪膝关节应用的最为广泛,基于这种情况,本文就猪膝关节的解剖结构与人的进行了比较,对其在体外生物力学实验中的应用进行了综述.     

基于加速康复外科理念的前交叉韧带重建术中麻醉方式的选择

摘要 目的：基于加速康复外科理念,比较分析收肌管阻滞和股神经阻滞两组麻醉方式术后早期反应,探讨其在ACL重建术中的应用。方法：选取符合手术条件的88名ACL损伤的患者,随机分为收肌管阻滞组和股神经阻滞组,手术均在全麻下由同一组医生实施,采用自体腘绳肌重建ACL。比较术后早期2h,4 h,8 h,24 h和48 h患者静息和主动活动时VAS评分;患者首次主动直腿抬高时间;首次自主下地时间;48 h内追加盐酸哌替啶的的人次数;以及不良反应的例数。分析比较两组麻醉方式在术后早期的不同。结果：收肌管阻滞组患者在术后首次直腿抬高的时间和首次自主下地时间两方面与股神经阻滞组相比较,差异有统计学意义（P＜0.05）;两组患者在术后2 h,4 h,8 h,24 h和48 h静息和主动活动时疼痛程度以及48 h内追加盐酸哌替啶的人次数和不良反应的例数之间差异无统计学意义（P＞0.05）。结论：收肌管阻滞能够满足ACL重建术后的早期康复需要,在术后早期对股四头肌的影响较小,有助于患者早期康复,是一种安全、有效的麻醉方式。     

前交叉韧带重建术股骨止点定位的治疗原则与临床效果研究

目的:探讨前交叉韧带重建术股骨止点定位的治疗原则与临床效果。方法:选取2011年9月~2013年1月在我院开展关节镜下前交叉韧带重建术的38例患者的临床治疗,观察术后治愈情况及不同临床结果下股骨止点定位的差异。结果:38例患者未出现重建失败病例,无翻修手术。手术前后对患者进行Lysholm评分与Tegner运动评级,发现术后患者Lysholm与Tegner评分均显著高于术前,有显著差异,具有统计学意义(P0.05)。根据患者临床疗效的不同,分为治疗满意组27例,不满意者11例,观察两种手术结果的股骨止点定位情况发现满意组股骨止点位置为(67.32%±6.53%),不满意组为(61.39%±5.86%),两组数值差异显著,具有统计学意义(P0.05)。结论:股骨止点定位对术后患者膝关节能力的恢复有重要作用,前交叉韧带重建术中保证股骨止点定位的有效性对患者临床治疗有显著效果。     

Principal component modeling of isokinetic moment curves for discriminating between the injured and healthy knees of unilateral ACL deficient patients

Bilateral knee strength evaluations of unilateral anterior cruciate ligament (ACL) deficient patients using isokinetic dynamometry are commonly performed in rehabilitation settings. The most frequently-used outcome measure is the peak moment value attained by the knee extensor and flexor muscle groups. However, other strength curve features may also be of clinical interest and utility. The purpose of this investigation was to identify, using Principal Component Analysis (PCA), strength curve features that explain the majority of variation between the injured and uninjured knee, and to assess the capabilities of these features to detect the presence of injury. A mixed gender cohort of 43 unilateral ACL deficient patients performed 6 continuous concentric knee extension and flexion repetitions bilaterally at 60° s⁻¹ and 180° s⁻¹ within a 90° range of motion. Moment waveforms were analyzed using PCA, and binary logistic regression was used to develop a discriminatory decision rule. For all directions and speeds, a statistically significant overall reduction in strength was noted for the involved knee in comparison to the uninvolved knee. The discriminatory decision rule yielded a specificity and sensitivity of 60.5% and 60.5%, respectively, corresponding to an accuracy of ∼62%. As such, the curve features extracted using PCA enabled only limited clinical usefulness in discerning between the ACL deficient and contra lateral, healthy knee. Improvement in discrimination capabilities may perhaps be achieved by consideration of different testing speeds and contraction modes, as well as utilization of other data analysis techniques.     

Role of knee ligaments in proprioception and regulation of muscle stiffness

Physiologic evidence for the sensory role of the knee joint ligaments are reviewed. The cruciate and collateral ligaments accomodate morphologically different sensory nerve endings with different capabilities of providing the central nervous system (CNS) with information not only about noxious and chemical stimuli but also about mechanical events, e.g., movement- and position-related stretches of the ligaments. Available data show that low-threshold joint/ligament receptor (i.e., mechanoreceptor) afferents evoke only weak and rare effects in skeletomotor neurons (α-motoneurons), whereas they frequently and powerfully influence fusimotor neurons (γ-motoneurons). The effects on the γ-muscle-spindle system in the muscles around the knee are so potent that even stretches of the cruciate ligaments at relatively moderate loads (not noxious) may induce major changes in responses of the muscle spindle afferents. As the activity in the primary muscle spindle afferents modifies stiffness in the muscles, the cruciate ligament receptors may, through the γ-muscle-spindle system, participate in regulation and preparatory adjustment of the stiffness of the muscles around the knee joint and thereby of knee joint stiffness. Thus, the sensory system of the cruciate ligaments is able to contribute significantly to the functional stability of the knee joint. The possible role of (ligamentous) joint receptors in genesis and spread of muscular tension in occupational muscle pain and in chronic musculoskeletal pain syndromes is also discussed.     

ADT、Lanchman试验与MRI对于诊断前交叉韧带断裂的可靠性研究

目的:回顾性分析因怀疑前交叉韧带断裂而住院行膝关节镜检查治疗术的患者当中,术前前抽屉试验(ADT)、Lanchman试验、核磁共振成像(MRI)检查提示韧带断裂的阳性率、敏感性以及特异性,讨论前交叉韧带断裂的最敏感非手术检查方法。方法:通过搜集近10年内我院骨科关节镜术中确诊的前交叉韧带损伤患者的临床病例资料,分析术前ADT、Lanchman试验及MRI检查数据,统计各种检查结果的阳性率、敏感性和特异性,比较各种检查方法的差异。结果:本次研究共搜集到210个关节镜手术病例,术前相关检查的确诊前交叉韧带断裂的阳性率依次为:ADT:61.4%;Lanchman试验:69.5%;MRI:87.1%。敏感性依次为:ADT:61.5%;Lanchman试验:69.5%;MRI:91.4%。特异性依次为:ADT:60.9%;Lanchman试验:69.6%;MRI:52.2%。结论:ADT、Lanchman试验、MRI对于诊断前交叉韧带断裂均存在偏差,临床诊疗过程中应将三种检查结果联合参考作为前交叉韧带断裂的诊断依据。     

Steeper posterior tibial slope markedly increases ACL force in both active gait and passive knee joint under compression

The role of the posterior tibial slope (PTS) in anterior cruciate ligament (ACL) risk of injury has been supported by many imaging studies but refuted by some in vitro works. The current investigation was carried out to compute the effect of ±5^o change in PTS on knee joint biomechanics in general and ACL force/strain in particular. Two validated finite element (FE) models of the knee joint were employed; one active lower extremity musculoskeletal model including a complex FE model of the knee joint driven by in vivo kinematics/kinetics collected in gait of asymptomatic subjects, and the other its isolated unconstrained passive tibiofemoral (TF) joint considered under 1400 N compression at four different knee flexion angles (0°–45°). In the TF model, the compression force was applied at the joint mechanical balance point causing no rotations in sagittal and frontal planes.     

Sharper angle,higher risk? The effect of cutting angle on knee mechanics in invasion sport athletes

IntroductionCutting is an important skill in team-sports, but unfortunately is also related to non-contact ACL injuries. The purpose was to examine knee kinetics and kinematics at different cutting angles.Material and methods13 males and 16 females performed cuts at different angles (45°, 90°, 135° and 180°) at maximum speed. 3D kinematics and kinetics were collected. To determine differences across cutting angles (45°, 90°, 135° and 180°) and sex (female, male), a 4 × 2 repeated measures ANOVA was conducted followed by post hoc comparisons (Bonferroni) with alpha level set at α ≤ 0.05 a priori.ResultsAt all cutting angles, males showed greater knee flexion angles than females (p < 0.01). Also, where males performed all cutting angles with no differences in the amount of knee flexion −42.53° ± 8.95°, females decreased their knee flexion angle from −40.6° ± 7.2° when cutting at 45° to −36.81° ± 9.10° when cutting at 90°, 135° and 180° (p < 0.01). Knee flexion moment decreased for both sexes when cutting towards sharper angles (p < 0.05). At 90°, 135° and 180°, males showed greater knee valgus moments than females. For both sexes, knee valgus moment increased towards the sharper cutting angles and then stabilized compared to the 45° cutting angle (p < 0.01). Both females and males showed smaller vGRF when cutting to sharper angles (p < 0.01).ConclusionIt can be concluded that different cutting angles demand different knee kinematics and kinetics. Sharper cutting angles place the knee more at risk. However, females and males handle this differently, which has implications for injury prevention.