【作者】 邵德成；

【导师】 陈百成；

【作者基本信息】 河北医科大学 ， 外科学， 2008， 博士

【摘要】 1.后交叉韧带股骨止点及胫骨止点的临床解剖研究目的:研究后交叉韧带股骨止点及胫骨止点的解剖特点及位置,确定可应用于手术中的定位标记,以利于指导临床,有助于达到后交叉解剖重建。材料与方法:20例膝关节标本,排除膝关节明显退变、损伤。将PCL分为前外束及后内束,观察两束在其股骨止点及胫骨止点的形状、位置并进行测量。确定PCL两束的股骨止点及胫骨止点的位置、面积,并确定其止点中心位置。结果:在股骨侧:ALB主要附着在股骨髁间窝的顶部,而PMB主要附着在髁间窝的内侧壁。ALB止点位于9:00和12:30之间(左膝)。当与股骨长轴方向平行时,AL束中心位于10:20 ,据前方关节软骨7.8mm处。PMB止点在7:30和10:30间,其中心位于8:30,据前方股骨内髁边缘10.1mm处。而与Blumensaat线平行时,ALB中心位于11:20 ,据前方股骨内髁边缘7.1mm处。PMB止点在7:30和12:30间,其中心位于9:30,据前方关节软骨12.0mm处。ALB、PMB的中心之间距离为11.1mm。AL、PM的中心点至髁间窝顶的距离(与Blumensaat线垂直)分别为4.7mm和11.3mm。AL及PM股骨止点面积87.3±18.9mm2和80.2±17.8 mm2(P<0.05),两者之间有显著性差异。在胫骨侧:PCL胫骨止点位于后髁间窝,并向关节面远侧延伸。ALB及PMB基本为前后排列。ALB胫骨止点占据前部分大部,其形状为向后的梯形。PMB占据水平部分后侧的一小部分及冠状位部分,后内束的最后及最远附着点位于胫骨平台远端。其纤维与胫骨骨膜和附着在胫骨的关节囊交叉编织融合在一起。其上方附着点与前外束相邻。ALB胫骨止点近远径及分别为:8.3mm和9.1mm。PMB胫骨止点近远径及分别为:7.4mm和10.2mm。AL、PM中心与内侧胫骨平台距离为5.9mm和10.8 mm,与内侧半月板上缘距离为8.9mm和12.3 mm。AL、PM胫骨止点面积分别为70.6 mm2和75.3 mm2。结论:本文对PCL的前外束及后内束进行了精确的数学解剖研究,确定了PCL前外束及后内束股骨止点和胫骨止点确切位置及特点。有助于PCL重建时隧道的准确定位,达到PCL解剖重建,提高术后疗效。而且本文中的解剖资料有助于术后应用X片、CT或MRI对隧道位置进行评估。2.股骨足印迹胫骨双隧道重建后交叉韧带的实验研究目的:本文的研究目的是对胫骨单隧道股骨单隧道、胫骨单隧道股骨双隧道重建、股骨足印迹胫骨双隧道重建PCL进行比较,以确定股骨足印迹胫骨双隧道重建PCL成为PCL重建更好的方法,能达到解剖重建。材料与方法:选择15例新鲜冷冻膝关节标本,分为3组进行研究。每组5例,在PCL完整、PCL切断后及应用不同方法进行PCL重建后分别应用CSS-44020力学试验仪进行测量,并进行比较。第一组:胫骨单隧道股骨单隧道重建。第二组:胫骨单隧道股骨双隧道重建。第三组:股骨足印迹胫骨双隧道重建。胫骨近端施予100N后向力量时,测试膝关节位于0°、30°、60°、90°、120°时胫骨相对股骨后移的距离。对结果进行比较。结果:应用股骨足印迹胫骨双隧道重建PCL后,股骨及胫骨侧止点与正常PCL相似。当PCL完整时,膝关节位于0°、30°、60°、90°、120°时,于胫骨上端向后施加负荷,力量为100N时胫骨后移距离分别为5.5、6.3、4.3、3.2、3.3mm。切断PCL后,关节松驰度发生显著性变化,胫骨后移明显增加。膝关节位于0°、30°、60°、90°、120°力量为100N时胫骨后方移位为9.0、13.3、15.4、16.6、16.0mm;行胫骨单隧道股骨单隧道重建PCL后,后移距离分别为7.0、9.6、6.9、7.0、7.5mm;行胫骨单隧道股骨双隧道重建PCL后,胫骨后移距离分别为6.5、6.2、3.8、4.6、4.1mm。股骨足印迹胫骨双隧道重建PCL后,后移距离分别为5.7、6.2、3.6、3.4、3.3mm。结论:1胫骨单隧道股骨单隧道、胫骨单隧道股骨双隧道重建、股骨足印迹胫骨双隧道重建PCL均能很好地防止胫骨后移。2胫骨单隧道股骨双隧道重建、股骨足印迹胫骨双隧道重建PCL较单束重建能更好的恢复PCL的稳定性。3股骨足印迹胫骨双隧道重建PCL在形态更接近解剖重建,但尚需进一步研究。3.自体腘绳肌腱及同种异体跟腱经股骨双束双隧道重建后交叉韧带的临床前瞻性研究目的:观察自体腘绳肌腱及同种异体跟腱经股骨双束双隧道重建后交叉韧带的疗效与差异。材料与方法:自2005年9月~2006年9月,35例III度PCL损伤患者随机分为2组:A组:自体腘绳肌腱组18例,平均32.6岁,合并II度以下的后外侧结构(PLS)损伤4例。B组:同种异体跟腱组17例,平均31.7岁,合并II度以下的后外侧结构(PLS)损伤3例。两组均采用股骨双束双隧道胫骨单隧道技术进行PCL重建,前外束于屈曲70°时固定,后内束在近伸直位时固定。随访18~30个月,平均25个月,对患者情况,关节功能、韧带稳定性等进行评估。结果:两组患者术前各项指标(包括年龄、活动范围、随访时间、术前时间等)进行比较无显著性差异(P>0.05)。理学检查、Lysholm及Tenger评分,KT-1000检测,手术前后两组各项指标有显著差异(P<0.05);但两组间比较,B组手术耗时(67.8±9.4分钟)短于A组(84.5±9.8分钟),术后发热时间B组(5.4±1.2天)稍长于A组(3.5±1.3天)(P<0.05),其它各项指标均无明显统计学差异(P>0.05)。后抽屉试验术前两组均为III度,术后则分别为A组1.2士0.4度;B组1.3士0.3度。术前Lysholm评分评分A组50.7士7.1,B组50.8士6.1,术后分别为93.1士2.9和91.6士3.2。术前及术后Tegner评分A组分别为1.2士0.7和6.1士0.7;B组分别为1.3士0.7和6.0士0.7。术前A、B两组胫骨后移分别为11.8士1.6mm和11.9士1.8mm,术后则分别为2.6士1.2mm和2.8士1.5mm。术后健患侧对比,A组平均2.3士1.3mm,其中<3mm者14/18例(77.8%),>5mm2例(11.1%) , B组平均2.7士1.7mm , <3mm者12/17例(70.6%);>5mm2例(11.8%)。结论:同种异体跟腱与自体腘绳肌腱经股骨双束双隧道重建后交叉韧带的近期疗效相同,可较好的恢复关节功能,同种异体跟腱是重建PCL良好的替代物。同种异体跟腱经股骨双束双隧道移植重建膝关节后交叉韧带是一种既避免移植物供区损伤又符合后交叉韧带生物力学解剖重建的临床治疗方法,近期效果好,远期效果还需进一步观察研究。4.关节镜下应用异体跟腱股骨双束双隧道同时重建后交叉与前交叉韧带目的:评价关节镜下应用异体跟腱股骨双束双隧道同时重建后交叉韧带与前交叉韧带的治疗效果。材料与方法:14例前、后交叉韧带损伤患者,在关节镜下应用异体跟腱同时重建前、后交叉韧带,且后交叉韧带股骨侧应用双束双隧道重建。受伤至手术时间平均19.5 d。术后平均随访34.5个月。采用Lysholm评分和Tegner评分对患膝功能进行评估,通过KT-1000检查了解膝关节的前后松弛度。结果:术前屈膝活动度(123.6±2.5)°与术后(117.9±2.8)°无显著性差异(t=1.54, P=0.14)。术后Lachman试验阴性者13例(92.9%),后抽屉试验阴性者12例(85.7%)。KT-1000屈膝25°双侧胫骨前后松弛度差值在2mm以内9例, 3~5mm 4例, 6mm 1例。屈膝70°差值2 mm以内10例,3～5 mm 3例,6 mm 1例。Lysholm评分从(52.8±2.2)分提高至(92.9±3.3)分,差异具有统计学意义(t=17.009,P<0.001)。伤前Tegnar评分平均为(5.9±0. 5)分,术前为(1.2±0.9)分,术后终末随访时为(5.4±0. 8)分。手术前后的差异有统计学意义(F=4.2,P<0.01)。11例恢复到受伤前运动水平(78.6%),另外3例运动水平较受伤前有所降低结论:关节镜下应用异体跟腱股骨双束双隧道同时重建后交叉韧带与前交叉韧带,后交叉韧带股骨侧应用双束双隧道重建,更接近后交叉韧带解剖重建,能够恢复膝关节的稳定性,较满意地恢复膝关节功能。更多还原

【Abstract】 1、Anatomical study of the femoral and tibial insertions of the human posterior cruciate ligamentObjective:The aim of this study was to determine the precise anatomical measurements of the femoral and tibial insertions for anterolateral (ALB) and posteromedial bundles (PMB) of posterior cruciate ligament (PCL). The results of this study may be applied to the design of guidance system for anatomic PCL reconstruction.Methods:A total of 20 knees were selected after exclusion of knees that displayed macroscopically degenerative changes or evidence of trauma. PCL were divided into anterolateral bundles and posteromedial bundles to the insertion footprint, and those locations were measured and described. Data were obtained to describe the size, position and center of the PCL related to clock positions and referenced to anterior margin of the medial femoral condyle on the femur, as well as to the mediaolateral and anterioposterior dimensions of the tibia.Result:On the femur: It can be seen that the ALB attaches mostly to the roof of the intercondylar notch, while the PMB attaches mostly to the medial side wall of the notch on to the medial femoral condyle. The AL bundle was found to lie between the 9:00 and 12:30 o’clock(for a left knee). When viewed from parallel to the femoral long axis ,the AL bundle was centered at 7.8mm from the anterior margin of the medial femoral condyle at 10:20 o’clock. The PM bundle was between 7:30 and 10:30 o’clock, and was centered at 10.1mm from anterior margin of the medial femoral condyle at 8:30 o’clock. But When viewed from parallel to the Blumensaat’s line, the AL bundle was centered at 7.1mm from the anterior magin of the medial femoral condyle at 11:20 o’clock. The PM bundle was between 7:30 and 12:30 o’clock, and was centered at 12.0mm from the anterior margin of the medial femoral condyle at 9:30 o’clock. The distance between the center of ALB and PMB was 11.1mm. The distance from the center of the femoral insertions of the anterolateral, posteromedial bundles to the intercondylar roof averaged 4.8mm and 11.4 mm. The mean areas of the insertions of AL and PM on the femur were 87.3±18.9mm2 and 80.2±17.8 mm2(P<0.05)respectively. On the tibia: The tibial attachment site of PCL was situated in the intercondylar fossa, and extended over the posterior rim of the shelf. The tibial attachment site of ALB and PMB were arranged in the anterior and posterior on the whole. The ALB occupies a central area covering almost the PCL entire flat intercondylar surface of the posterior tibial plateau. Its shape is trapezoidal, wider posteriorly. The attachment of the PM fibre bundle includes the most posterior area above the shelf, and also the area immediately below the shelf. The bundle’s most posterior and distal attachment occurs distal to the tibial plateau. Its fibres blend with those of the tibial periosteum and the attachment of the knee joint capsule to the tibia. Superiorly, its attachment meets that of the AL bundle. The anteroposterior length and width of the ALB was 8.3mm and 9.1mm respectively. The anteroposterior length and width of the PMB was 7.4mm and 10.2mm respectively. The vertical distance from the center of the tibial insertions of the anterolateral, posteromedial bundles to the medial tibial plateau averaged 5.9mm and 10.8 mm, as to the medial meniscus averaged 8.9mm and 12.3 mm. The mean areas of the insertions of AL, PM on the tibia was 70.6 mm2 and 75.3 mm2 respectively.Conclusion: The present study described the numerical anatomical measurements of the insertions to the femur and tibia of the anterolateral and posteromedial bundles of PCL. The contribution of this study to a better understanding and definition of the anatomy of the anterolateral and posteromedial bundles of PCL will lead to more accurate tunnel placement, anatomic PCL reconstruction, better outcomes in PCL reconstructions. Furthermore, the anatomical information given here may be useful when evaluating tunnel placement using radiographs, CT, or MRI after reconstructive surgery in order to optimize reconstruction for more positive outcomes.2.Femoral footprint double-bundle transtibial tunnel posterior cruciate ligament reconstruction : an experimental study.Objective: The purpose of this study was to compare the femoral footprint double-bundle transtibial tunnel PCL reconstruction with the single-bundle PCL reconstruction and double-bundle PCL reconstruction,and make sure that femoral footprint double-bundle transtibial tunnel PCL reconstruction be a new method for anatomic PCL reconstruction.Methods: 15 fresh-frozen human knee speciments were divided into three groups. For each group, 5 specimens were tested with CSS-44020 load cell in the PCL intact, the PCL dissected, and the PCL reconstructed knee. In the first group, the single bundle PCL reconstruction was performed. In the second group, the single tibial tunnel double-bundle femoral tunnel PCL reconstruction was performed. In the third group , femoral footprint double-bundle transtibial tunnel PCL reconstruction was performed. While 100N posterior load was applied to the proximal part of the tibia, tibial posteror translation were measured as the knee was flexed at 0°、30°、60°、90°、120°. Analysis and comparation were done to the three reconstruction methods.Results:After femoral footprint double-bundle transtibial tunnel PCL reconstruction, the femoral and tibial attachment was similar to the PCL intact knee. While a 100N posterior force was applied to the proximal part of the tibia, posterior tibial translation of the intact PCL knee was 5.5, 6.3,4.3,3.2,3.3mm at 0°、30°、60°、90°、120°knee flextion respectively. In the PCL dissected knee, the tibial translation increased significantly, was 9.0 ,13.3,15.4,16.6,16.0mm respectively. After the single bundle PCL reconstruction, posterior tibial translation was 7.0,9.6,6.9,7.0,7.5mm respectively. After the single tibial tunnel double-bundle femoral tunnel PCL reconstruction, the posterior tibial translation was 6.5,6.2,3.8,4.6,4.1mm respectively. After femoral footprint double-bundle transtibial tunnel PCL reconstruction, the posterior tibial translation was 5.7,6.2,3.6,3.4,3.3mm respectively. The difference between single tibial tunnel double-bundle femoral tunnel PCL reconstruction,double-bundle transtibial tunnel femoral footprint PCL reconstruction and the intact PCL knee was not significant. The biomechanical properities of single tibial tunnel double-bundle femoral tunnel PCL reconstruction and double-bundle transtibial tunnel femoral footprint PCL reconstruction were more similar to that of the intact PCL knee, than the single bundle PCL reconstruction. The anatomic properities of femoral footprint double-bundle transtibial tunnel PCL reconstruction were similar to that of the intact PCL knee.Conclusion:1 Single bundle PCL reconstruction, single tibial tunnel double-bundle femoral tunnel PCL reconstruction and femoral footprint double-bundle transtibial tunnel PCL reconstruction can restore the posterior tibial translation2 Single tibial tunnel double-bundle femoral tunnel PCL reconstruction and femoral footprint double-bundle transtibial tunnel PCL reconstruction could restore normal knee laxity effectively across the full range of flexion.3 Femoral footprint double-bundle transtibial tunnel PCL reconstruction was anatomically similar to intact PCL, but further studies should be continued.3. Comparison of clinical results of arthroscopic transtibial double-bundle posterior cruciate ligament reconstruction using hamstring tendon autograft and Achillis tendon allograftObjective:This prospective clinical study was performed to compare clinical results of arthroscopic transtibial double-bundle posterior cruciate ligament reconstruction using hamstring tendon autograft and Achillis tendon allograft.Methods: From September 2005 to September 2006, 35 patients with PCL injuries of grade III were divided into 2 groups. Group A: 18 patients, averaged age 32.6 years old, recevied autogeneous hamstring tendon PCL reconstruction. Among the 18 patients, 4 patients accompanied with PLC injury less than grade II. Group B:17 patients, averaged age 31.7 years old, recevied Achillis tendon allograft PCL reconstruction. 3 patients in group B accompanied with PLS injury less than grade II. Arthroscopic transtibial double-bundle posterior cruciate ligament reconstruction was performed with a similar technique in both groups with the exception of graft selection. The anterolateral bundle was tightend and fixed at knee flexion 70°. The posteromedial bundle was tightened and fixed at knee flextion 0°. With an average follow-up of 25 months, the evaluation parameters included functional assessment, ligament laxity, functional score, kinematics evaluation.Result:Between the 2 groups, preoperative demographic factors( age, gender, activity level and mean duration to surgery) showed no statistically significant difference (P>0.05). The difference between preoperative and postoperative measures in physical examination, Lysholm and Tenger score,KT-1000 examination for both groups was statistically significant (P<0.05). The operative duration in Group B was 67.8±9.4 minutes, shorter than that in Group A ,84.5±9.8 minutes (P<0.05). The fever duration after operation in Group B was 5.4±1.2 days, longer than that in Group A, 3.5±1.3 days (P<0.05). As to other aspects, there were no statistically significant difference between group A and group B (P>0.05). The posterior drawer test showed grade III translation for all the preoperative patients. At final follow-up, it showed grade 1.2士0.4 for group A, and 1.3士0.3 for group B. The Lymsholm knee scores were 50.7士7.1 preoperative and 93.1士2.9 postoperative for Group A, and as to Group B , it was 50.8士6.1 preoperative and 91.6士3.2 postoperative. Tegner scores were 1.2士0.7 preoperative and 6.1士0.7 postoperative for Group A, and as to Group B, it was 1.3士0.7 preoperative and 6.0士0.7 postoperative. KT-1000 arthrometer testing showed that the tibia posterior translation was 11.8士1.6 mm and 11.9士1.8mm preoperative for group A and group B respectively. The tibia posterior translation was 2.6士1.2mm and 2.8士1.5mm postoperative for group A and group B respectively. In Group A, the side-to-side difference was 2.3士1.3mm,less than 3mm in 14/18(77.8%),>5mm in 2/18 (11.1%). In Group B, the side-to-side difference was 2.7士1.7mm, less than 3mm in 12/17(70.6%),>5mm in 2 /17(11.1%)。Conclusion:The clinical results of arthroscopic transtibial double-bundle posterior cruciate ligament reconstruction using hamstring tendon autograft and Achillis tendon allograft are equally effective in PCL reconstruction. Achillis tendon allograft was fit for PCL reconstruction. Double-bundle PCL recostruction using Achillis tendon allograft is a good surgical approach, which not only avoids injuring the donor area, but also accords with the anatomical structure of PCL. The shorter term outcome has been proved, but long-term outcome needs more observations。4. Arthroscopic simultaneous reconstruction of posterior cruciate ligament using double femoral tunnel technique and anterior cruciate ligament with Achilles allograftObjective:To introduce the technique of arthroscopic simultaneous reconstruction of posterior cruciate ligament (PCL) using double femoral tunnel, single-bundle transtibial tunnel PCL technique and anterior cruciate ligament (ACL) with Achilles allograft, and to evaluate the clinical outcome.Methods:We reviewed 14 patients with PCL and ACL injuries after a minimum follow-up 18 months. Arthroscopically assisted simultaneous ACL/PCL reconstruction with Achilles allograft were performed using the single-incision endoscopic ACL technique and the double femoral tunnel, single-bundle transtibial tunnel PCL technique. The Lysholm and Tegner knee score scale were used for functional evaluation . All patients were evaluated with physical examination and KT-1000 arthrometer testing.Result:The mean time from injury to the reconstructive procedure was 19.5 days. The mean knee flextion was (123.6±2.5)°preoperatively, (117.9±2.8)°postoperatively. There was no signifant difference(t=1.54, P=0.14). As to the Lachmen test for 14 patients , the results of 13 patients (92.9%) was negative. As to posterior drawer test, the results of 12 patients (85.7%) was negative. The Lysholm score was(52.8±2.2)preoperatively compared with (92.9±3.3) postoperatively at finial evaluation (t=17.009,P<0.001)。KT-1000 arthrometer testing at 25°knee flexion showed that the side-to-side difference was below 2mm in 9 cases,3~5mm in 4 cases, 6mm in 1 case。At 75°knee flexion the difference was below 2mm in 10 cases,3~5mm in 3 cases, 6mm in 1 case. The Tegner score was(5.9±0. 5) before injury,(1.2±0. 9)preoperatively, and(5.4±0. 8)postoperatively at finial evaluation. The difference between the preoperative score and the postoperative was statistically significant (F=4.2,P<0.01).Conclusion:Combined ACL and PCL injuries can be successfully treated with arthroscopic simultaneous reconstruction of PCL using double femoral tunnel technique and ACL with Achilles allograft. The double femoral tunnel technique more closely approximates the anatomic insertion the native PCL. Most patients recover a functionally stable knee.更多还原