【作者】 宋矿朋；

【导师】 陈百成；

【作者基本信息】 河北医科大学 ， 外科学， 2012， 硕士

【摘要】 目的：移植物固定时的屈膝角度（即“移植物固定角度”）和初始张力是影响关节镜下前交叉韧带（anterior cruciate ligament, ACL）重建术后疗效的重要因素。大多数手术医师进行ACL单束重建时选择的移植物固定角度为0°³0°、初始张力为20N⁸0N，但有关两者的大小至今尚没有统一的标准。近年来，ACL解剖重建及术后膝关节的旋转稳定性问题越来越受关注。ACL单束解剖重建时，不同的移植物固定角度和初始张力对膝关节稳定性，尤其是侧方旋转稳定性有何影响？目前很少有这方面的研究报道。因此，本研究的目的是测定不同的移植物固定角度和初始张力进行ACL单束解剖重建时，术后即时的膝关节前向位移和内、外旋转角度的变化，探讨二者对膝关节稳定性的影响。方法：选取10具成人尸体膝关节标本,每具膝标本均无韧带损伤、明显的关节畸形及骨关节炎表现。所有标本保留关节间隙上、下9cm内的软组织和腓骨，于关节间隙上、下13cm处截除股骨和胫骨，残留腓骨固定在胫骨上。编制、缝合同种异体腘绳肌腱作为韧带移植物。实验时应用Electroforce生物力学系统（3520-AT,BOSE公司,美国）依次对10具膝关节标本的（1）ACL-完整（2）ACL-缺失（同时切除了内、外侧半月板）（3）6种不同移植物固定条件的ACL单束解剖重建等不同状态下膝关节屈曲30°时的最大前向位移（模拟Lachmann试验）和屈膝0°、30°、60°、90°时的最大内、外旋转角度进行测定，分别作为前向稳定性和侧方旋转稳定性的评估指标。6种移植物固定条件包括：①移植物固定角度0°、初始张力20N(F₀T₂₀)，②移植物固定角度0°、初始张力50N(F₀T₅₀)，③移植物固定角度0°、初始张力80N（F0T80），④移植物固定角度30°、初始张力20N(F₃₀T₂₀)，⑤移植物固定角度30°、初始张力50N(F₃₀T₅₀₀，⑥移植物固定角度30°、初始张力80N(F₃₀T₈₀)。每具膝关节的每种设定条件均重复测定3次，取平均值。应用SPSS13.0统计软件（SPSS Inc.，美国）采用方差分析（ANOVA）对实验数据进行处理。检验标准取α=0.05，P＜0.05时差异有统计学意义。结果：胫骨前向位移（ATT）：ACL单束解剖重建术后，各组(F0T20、F₀T₅₀、F₀T₈₀、F₃₀T₂₀、F₃₀T_500和F30T80胫骨的前向位移与ACL-缺失组相比均有明显减小（P<0.05）。与ACL-完整组相比，F₀T₅₀、F₀T₈₀、F₃₀T₍500和F30T80等4个重建组膝关节的前向位移均无统计学差异（P=0.255）。尽管F₃₀T₍500和F30T80的测定值比F₀T₅₀和F₀T₈₀更小，但各组间比较无统计学差异（P>0.05）,提示：移植物固定角度为0°或30°、初始张力为50N或80N(即F₀T₅₀、F₀T₈₀、F₃₀T_500和F30T80时，均能够初步恢复膝关节的前向稳定性。胫骨内、外侧旋转角度：ACL单束解剖重建术后，各组(F0T20、F₀T₅₀、F₀T₈₀、F₃₀T₂₀、F₃₀T_500和F30T80胫骨在0°、30°、60°、90位的内、外旋转角度与ACL-缺失组相比均有明显减小（P<0.05）。与ACL-完整组相比，屈膝0°位时，F₀T₅₀、F₀T₈₀、F₃₀T₍500和F30T80等4个重建组膝关节的内、外侧旋转角度差异均无统计学意义（P内旋=0.982，P外旋=0.904）；屈膝30°位时，F₃₀T₂₀、F₃₀T₍500和F30T80等3个重建组膝关节的内、外旋转角度差异均无统计学意义（P内旋=0.937，P外旋=0.900）；屈膝60°位时，仅F₃₀T₍500和F30T80等2个重建组膝关节的内、外旋转角度差异均无统计学意义（P内旋=0.961，P外旋=0.966）；屈膝90°位时，F0T20、F₀T₅₀、F₀T₈₀、F₃₀T₂₀、F₃₀T₍500和F30T80等6个重建组膝关节的内、外旋转角度差异均有统计学意义（P<0.05）,6组间比较差异均无统计学意义（P内旋=0.649，P外旋=0.381）。这些结果提示：移植物固定角度为30°、初始张力为50N或80N(即F₃₀T_500和F30T80时，可能会更好的恢复膝关节的内、外旋转稳定性。结论：ACL单束解剖重建时，不同的移植物固定角度和初始张力，对膝关节术后即时的前向稳定性和内、外旋转稳定性均有影响。尽管所有的ACL单束解剖重建组对膝关节前向及侧方旋转稳定性的恢复均未达到正常ACL的效果，但选择移植物固定角度为30°、初始张力50N或80N进行单束解剖重建的ACL，能够更接近正常的恢复膝关节的前向和侧方旋转稳定性,尤其是侧方旋转稳定性。即重建ACL时，选择合适的移植物固定角度和初始张力可能更有利于恢复膝关节的生物力学稳定性。更多还原

【Abstract】 Objective: Successful anterior cruciate ligament reconstruction（ACLR）depends on several important factors including knee flexion angle（namely,“graft fixation angle”） and initial graft tension when fixing the graft.But there is not yet consensus regarding the knee flexion angle or the initialgraft tension at the time of graft fixation in single-bundle ACLreconstruction（SB ACLR）. The range varies from0°（full extension） to30°ofknee flexion for graft fixation angle, and from20N to80N for initial grafttension. In additional, many investigators are paying close attention toanatomic SB ACLR and rotational stability of the knee postoperatively inrecent years. However, there has been few study evaluating the effects ofdifferent graft fixation angles and initial graft tensions on the knee stabilityespecially for the rotational stability during anatomic SB ACLR.Therefore, the purpose of this study is to measure the time-zero anteriortibial translation（ATT）, internal rotation（IR） and external rotation（ER） appliedwith different graft fixation angles and initial graft tensions in anatomic SBACLR, and explore the impact of both variables on the stability of knee.Method: Ten human cadaveric knees were included in this study. Therewas no ligament damage, apparent joint deformity and osteoarthritis in everyknee specimen. The femur and tibia were cut approximately13cm from thejoint line. The surrounding skin and muscles more than9cm away from thejoint line were removed to expose the bones, and the fibula was then rigidlyfixed to the tibia with a cortical screw. The allogenic hamstrings were suturedinto the graft for anatomic SB ACLR.Maximal anterior tibial translation（ATT） at30°as well as maximalinternal rotation（IR） and external rotation（ER） at0°,30°,60°and90°of knee flexion were measured by the Electroforce biomechanical system（3520-AT,BOSE company, USA） respectively at （1） ACL-intact,（2） ACL-deficient,（3）6anatomic SB ACLR groups in different graft fixation settings, which wereseparately as the assessment indicators of anterior stability and rotationalstability of the knee.6kinds of graft fixation settings were as follows:（1） kneeflexion at0°and initial graft tensions20N (F₀T₂₀),（2） knee flexion at0°andinitial graft tensions50N (F₀T₅₀),（3） knee flexion at0°and initial grafttensions80N (F₀T₈₀),（4） knee flexion at30°and initial graft tensions20N(F₃₀T₂₀),（5） knee flexion at30°and initial graft tensions50N (F₃₀T₅₀),（6）knee flexion at30°and initial graft tensions80N (F₃₀T₈₀). Every knee wasmeasured3times in each setting and the average value was recorded.The kinematic data from this study were analyzed using the ANOVA（SPSS13.0, SPSS Inc., USA）. Significance was set at p<0.05.Results: Anterior tibial translation（ATT）: All the anterior translations in6SB ACLR groups(F₀T₂₀, F₀T₅₀, F₀T₈₀, F₃₀T₂₀, F₃₀T₅₀and F₃₀T₈₀) weresignificantly less than in the ACL-deficient group（p<0.05）. Though there wereno significant differences among ACL-intact, F₀T₅₀, F₀T₈₀, F₃₀T₅₀andF₃₀T₈₀（P=0.255）, the average values of F₃₀T₅₀and F₃₀T₈₀were both less thanthe other groups(F₀T₅₀and F₀T₈₀), which suggested that anatomic SB ACLR inthe graft fixation settings of knee flexion at0°or30°, initial graft tensions50N or80N(F₀T₅₀, F₀T₈₀, F₃₀T₅₀and F₃₀T₈₀) could restore enough anteriorstability of the intact knee.Tibial IR and ER control:6SB ACLR groups(F₀T₂₀, F₀T₅₀, F₀T₈₀, F₃₀T₂₀,F₃₀T₅₀and F₃₀T₈₀)were significantly improved in both of tibial IR and ERcontrol compared with the ACL-deficient group at0°,30°,60°and90°of kneeflexion（p<0.001）. At0°of knee flexion, there were no significant differencesamong ACL-intact, F₀T₅₀, F₀T₈₀, F₃₀T₅₀and F₃₀T₈₀in the rotationalstability（PIR=0.982, PER=0.904）; at30°of knee flexion, there were nosignificant differences among ACL-intact, F₃₀T₂₀, F₃₀T₅₀and F₃₀T₈₀in therotational stability（PIR=0.937, PER=0.900）; at60°, there were no significantdifferences only among ACL-intact, F₃₀T₅₀and F₃₀T₈₀in the rotational stability(P_IR=0.961, P_ER=0.966); and at90°, none of the6ACLR groups wasable to efficiently restore the nomal rotational stability of knee（P<0.05）, butthere were no significant differences only among all the6groups（PIR=0.649,PER=0.381）. All these outcomes suggested that anatomic SB ACLR in the graftfixation settings of knee flexion at30°, initial graft tensions50N or80N(F₃₀T₅₀and F₃₀T₈₀) could more closely restore the rational stability of theintact knee.Conclusions: Different graft fixation angles and initial graft tensions inanatomic SB ACLR paly an important role in restoring the time-zero ATT, IRand ER of the knee. Though all the SB ACLR groups can’t regain the perfectknee stability of the intact knee, anatomic SB ACLR in the graft fixationsettings of knee flexion at30°, initial graft tensions50N or80N could moreclosely restore anterior stability and rational stability of the intact kneeespecially for the rational stability. In sum, the optimal graft fixation angle andinitial graft tension would extremely improve the biomechanical stability ofthe knee when performing an anatomic SB ACLR.更多还原