Outcome of Two-Stage Treatment of Irreducible Posterolateral Knee Dislocation: 2 8 Year Follow-Up Hanxiao Zhu 1 ;Haobo Wu 1 ;Yan Xiong 1 ; Xuesong Dai

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1 An Analysis of the Posterior Cruciate Ligament Isometric Position Using an In Vivo 3-Dimensional Computed Tomography: A Cadaveric Study 有关 LARS 人工韧带重建术中后交叉韧带等长点的动态三维 CT 研究 Xuan Huang, Zimin Wang, Weidong Xu, Department of Orthopeadics, Changhai hospital, Shanghai, China Background: Isometric tunnel placement is important in posterior cruciate ligament (PCL) reconstruction when using a ligament advanced reinforcement system (LARS) artificial ligament. This study aimed to investigate the isometric point of the PCL based on insertional locations identified in recent anatomic studies by 3-dimensional CT scan. Methods: Ten fresh healthy knees were evaluated. High-resolution computed tomography scans were performed at 3 positions of 0, 90, and 135, and 3-dimensional knee images were constructed. Customized software was used to define tibial and femoral insertion points of the PCL, based on recently described anatomy. The femoral attachment site of the PCL was divided into 4 points (marked A through D), and the tibial attachment site was divided into 6 points (marked 1 through 6). Twenty-four virtual PCL bundles were created between these sectors, and their length was measured in the 3 knee flexion positions. Results: In 0 and 90 of knee flexion, the virtual bundle showing the least amount of length change (1.10±0.66 mm) was at point D-6, that is, a posteromedial bundle inserting into the most posterior femoral sector (point D) and the most distal tibial sector (point 6). This change was not significantly different compared with all other virtual bundles with tibial points connected to femoral point D (P >.05). An isometric position for the PCL (length change<2 mm) could not be found in 135 of knee flexion because of lengthening of all virtual bundles. Conclusion: None of the PCL graft positions was isometric. Our data suggest that the femoral attachment point is more important than the tibial attachment point: any of the 6 tibial bundles attached to the most posterior femoral sector had similar isometric properties. These data may assist surgeons in proper tunnel placement in LARS ligament reconstruction for PCL. Key words: posterior cruciate ligament reconstruction; isometric reconstruction; ligament advanced reinforcement system

2 Outcome of Two-Stage Treatment of Irreducible Posterolateral Knee Dislocation: 2 8 Year Follow-Up Hanxiao Zhu 1 ;Haobo Wu 1 ;Yan Xiong 1 ; Xuesong Dai 1 ; 1 AuthorAffiliation:Department of Orthopedic Surgery, Second Affiliated Hospital's Campus in Binjiang District, School of Medicine, Zhejiang University, Abstract Background Irreducible posterolateral dislocation is a rare subset of knee dislocation reported only in occasional case reports. A larger case series will provide information helpful for clinical decision making for the majority of orthopaedic surgeons for whom this injury remains a novelty. Methods This study was a retrospective case series with long term follow up of clinical and functional status of 9 patients with posterolateral knee dislocation diagnosed by physical examination, radiography and MRI. Two-stage treatment was applied for all 9 patients. Evaluation methods included joint stability, activity scales (Lysholm and Tegner), flexion loss, and range of motion. Results Mean age at injury was 42 years (19 to 68), with 2 8 year follow up. At initial evaluation, medial dimpling was not observed in two patients. In regard to knee stability and function, 8 of 9 patients (89%) had symmetrical posterior drawer on postoperative physical examination. All knees (100%) had symmetrical Lachman test and pivot shift, symmetrical varus, valgus, and rotation. Decreased activity (Tegner Score) was found between preinjury (mean 7.6) and recent follow up (mean 6.8; paired two-tailed t-test; P=0.023). 78% returned to their preinjury level of activity or one Tegner grade lower. 89% went back to work. Mean Lysholm knee ligament score was 90 (range 79 95). The mean flexion loss was 10 (range, 0 30 ) compared with the normal knee. Complications: no flexion contractures, nerve or vascular complications were found. Osteonecrosis in medial femoral condyle was found in one patient 16 months after operation. Conclusions The medial dimple is characteristic, but not always identified in irreducible posterolateral dislocation. Emergent operative reduction with highly successful results can be achieved through a well planned 2-stage surgery.

3 膝关节后外侧脱位治疗策略与疗效观察吴萌夏亚一兰州大学第二医院运动医学科摘要目的评估采用重建前后交叉韧带 (ACL\PCL) 及修复膝后内侧韧带结构 (PMC) 的方法, 治疗膝关节后外侧脱位的临床效果方法 2010 年 3 月至 2015 年 8 月, 收治膝关节后外侧脱位患者 30 例 ACL 重建均使用自体半腱肌股薄肌肌腱,PCL 重建使用 LARS 韧带 21 例, 自体半腱肌股薄肌肌腱重建 9 例, 膝后内侧韧带结构损伤行缝合修复,5 例行自体半腱肌加强术, 手术均为一期完成术后早期行 CPM 及主动活动训练结果术后患者均获随访, 随访时间月, 平均 30 个月术后 IKDC 评分 : 正常 18 例. 接近正常 9 例不正常 3 例一例出现关节滑液漏, 但均未引起化脓性关节炎, 经换药治疗后伤口愈合 2 例患者术后 6 月随访伴膝关节僵硬, 行功能锻炼后有所改善 Lysholm 评分 : 术前 (41.5±3.3) 分, 术后 (91±4) 分 ; 关节活动度术前 (85.5 ±10.5), 术后 (115 ±8.5) 术前术后比较差异均有统计学意义结论一期重建 ACL PCL 和修复其他膝后内侧韧带结构, 并辅以积极功能锻炼, 能较好恢复关节稳定性, 临床效果满意, 是治疗膝后外侧脱位的一种有效方法

4 膝关节多发韧带损伤关节镜下韧带重建后中长期疗效观察崔胜宇刘巍 * 朱新辉逸弘范建波南通市第一人民医院摘要 : 目的总结关节镜下应用同种异体肌腱, 对膝关节多发韧带损伤患者行韧带重建后 5-9 年的疗效方法我科至共收治多发韧带损伤患者 12 例采用经深低温和辐射处理的同种异体肌腱, 损伤的前后交叉韧带均在关节镜下重建, 同时修复或重建断裂的内侧副韧带或后外侧结构, 合并半月板损伤的同时行半月板缝合或成形术或重建术后按计划功能锻炼结果月的随访, 术后半年内患者每月到门诊复查, 之后每 2-3 月复查一次, 术后一年每年至少一次来院复查术后对患者行 Lachman 试验 KT-1000 检查及 Lysholm 膝关节功能评分国际膝关节文献委员会分级评分, 结果显示术后膝关节稳定性及功能较术前提高 (P3<0.05) 结论应用同种异体肌腱修复膝多发韧带损伤, 能够早期即刻稳定膝关节, 术后通过系统的康复治疗, 能可靠恢复膝关节功能在 5-9 年的随访中, 膝关节功能能很好的维持, 并未出现严重的骨性关节炎关键词 : 膝关节 ; 多发韧带损伤 ; 关节镜 ; 同种异体肌腱

5 132 例膝关节多韧带损伤早期修复重建的经验及教训郑佳鹏, 翟文亮, 郭志民, 丁真奇, 福建漳州解放军第 175 医院 ( 厦门大学附属东南医院 ) 全军骨科中心目的总结我院在处理膝关节多韧带损伤患者的经验及教训方法回顾我院 2010 年 1 月至 2014 年 10 月近 5 年间 132 例膝关节多韧带损伤患者的损伤特点在术前诊断上我们重视腘窝淤斑对多韧带伤的提示作用, 常规行深静脉彩超排除深静脉血栓, 排除血管及神经损伤后, 我们在伤后 2 周后对所有患者进行早期多韧带联合重建移植肌腱选择上均选用自体肌腱, 我们选用单根腓骨长肌腱或 2/3 腓骨长肌腱 + 对侧腘绳肌腱重建前后交叉韧带, 内侧副韧带及外侧副韧带损伤多数用锚钉一期修复在前后交叉韧带重建的固定方法上我们采用将膝关节屈曲 70, 助手辅助行膝关节前抽屉, 固定 PCL; 膝关节屈曲 30, 固定 ACL, 关节镜下参考髁间窝前方与原 ACL 残端的相对位置术后康复上我们采用术后伸直位或功能位固定 3 周后渐开始屈膝锻炼结果福建地区为膝关节多韧带损伤高发地区, 可能与摩托车多及交通混乱多山有关, 近 90% 的多韧带伤涉及内侧副韧带损伤且多为股骨侧损伤 ; 外侧副韧带损伤多为腓骨头侧撕脱, 可用锚钉一期修复腓骨长肌可作用多韧带损伤时的肌腱移植物, 临床效果良好且对踝关节的功能影响不大结论膝关节多韧带损伤后早期联合修复重建临床效果满意, 将腓骨长肌腱应用多韧带损伤的重建可很好的解决移植肌腱短缺这一难题多韧带早期联合修复重建术后的最大问题在于关节僵硬, 术后制动时间不宜过长, 制动 3 周较为合适

6 膝关节多韧带损伤一期重建 OR 二期重建的临床疗效姜鑫, 孙延山潍坊市人民医院目的 : 观察膝关节多韧带损伤一期 OR 二期重建的临床疗效方法 : 收集我院 2010 年至今 54 例患者, 双韧带损伤 42 例 ( 合并胫骨平台骨折排除 ), 其中三韧带损伤 8 例, 合并腓总神经断裂 1 例 ;4 韧带损伤 4 例, 合并腘静脉血栓 1 例. 2 韧带损伤均行一期重建 ;3 韧带损伤 7 例一期重建,1 例修复后外结构, 二期重建交叉韧带 4 韧带损伤, 均二期手术所有重建患者均术后 1 周屈膝 90 度功能锻炼结果 : 一期重建患者, 屈伸功能满意, 二期重建患者,7-12 度屈曲受限 ; 所有患者均膝关节无肿胀, 浮髌试验阴性术后 Lysholm 评分平均为 86.3(51~ 100),Tegner 活动评分为 5.2(2~8), 均较术前显著增加 (P 0.001) 1 例外翻试验为 2+,2 例 Lachman 试验或轴移试验 2+,6 例应力后沉征或后抽屉试验 2+,4 例内翻试验或反轴移试验 2+ 其余的对应各种体格检查均为 1+ 4 例合并腓总神经损伤者, 术后 3 例自行恢复,1 例未恢复结论 : 一期重建优点 : 缩短住院日, 患者早日的康复, 减少住院费用 ; 二期重建 : 病程长计, 费用增加膝关节脱位合并韧带多发损伤应首选关节镜下 Ⅰ 期重建 ; 重建材料最好选择异体肌腱或健侧肌腱, 以保证移植物强度和防止供区稳定性受影响 ; 术后积极功能锻炼, 若发生粘连则在 3 个月内在关节镜下行粘连松解对于多韧带损伤, 我们建议尽量一期手术,4 韧带损伤可分期手术, 先关节外手术, 再关节内手术

7 Minimally Invasive Treatment Of KD - type IV Knee Dislocation: A Evaluation Of The Results WU Hao,YU Haiyang,ZHAI Yunlei Department of Orthopedics,People's Hospital of Fuyang, Anhui,China Abstract Objective: Discuss the feasibility and clinical curative effect of type IV knees dislocation diagnoses using arthroscopy. Methods: Review 13 patients with type IV knee joint dislocation (9 male and 4 female, mean age, 37.4 years),from February 2007 to January2015;After surgery, the knee functions of these patients were evaluated according to Lysholm score, Tegner score, stability and mobility of the knee joint. Results: all patients were followed up on average 22.8 months (8 ~ 48 months). At the last follow-up, the score of Lysholm knee functional was increase from preoperative 11.6±4.8 (0-20) to 84.7±13.6 (55-100), and the rating of Tegner knee movement level was improved from preoperative 0 to 6.4±1.2 (3-7). Knee joint activity was from preoperative 63.2±8.1 (15-85 ) up to 124.1±8.6 ( ), the difference was statistically significant (P < 0.05). Conclusion: The method of using arthroscopy to treat type IV knee dislocation are safe and effective, and the reconstruction of knee joint ligament in one stage with reasonable joint function rehabilitation exercise has satisfactory curative effect,will not increase the risk of joint stillness.

8 Arthroscopic suture and screw double fixation method for avulsion fractures of both anterior and posterior cruciate ligament tibial insertions Dao hong Zhao 1, Hong Chen 2, Jun Zhang 3 First author: Daohong Zhao,the second hospital of Kunming medical university Second author: hong chen, the first people hospital of Kunming Third arthor: jun zhang, the second hospital of Kunming medical university Purpose: To analyze the characteristic and cause of both anterior and posterior cruciate ligament avulsion fractures of tibial insertions, and present the clinical results of a procedure for treating it using arthroscopic reduction with suture and screw double fixation. Methods: This prospective study analyzed 8 patients who underwent arthroscopic reduction with suture and screw double fixation for image-proven anterior and posterior cruciate ligament avulsion fractures of the tibial eminence. The mean follow-up period was 42.4 months (range, 24 to 65 months). Follow-up assessment included Lysholm knee score, International Knee Documentation Committee (IKDC) score, Tegner rating scales, KT-1000 arthrometry (MEDmetric, San Diego, CA) and radiographic evaluation. Results: The Lysholm score was 88 to 99, with a mean of 96.7± 1.9 (compared with before surgery, P <.05). The Tegner scores before injury, preoperatively, and at latest follow-up were 7.5±1.6, 3.3±1.0, and 7.0±1.0,respectively; there was no statistically significant difference between the preinjury and postoperative Tegner scores (P>.05). At the final follow-up, the International Knee Documentation Committee scores were observed to be normal(grade A) or nearly normal(grade B) in 7 patient (87.5%) and abnormal (grade C) in 1 patients (12.5%). All 8 fractures achieved union within 3 months. 7 of the 8 patients(87.5%) returned to their former activity level. No significant complications such as arthrofibrosis, loss of initial fixation, or wound infection were noted. there was neither extension nor flexion limitation in all patients. Conclusions: both anterior and posterior cruciate ligament avulsion fractures of tibial insertions is less common. Treatment of tibial avulsion fractures by arthroscopic suture and screw double fixation is a successful technique to restore tibial avulsion injuries with well-documented radiographic healing, good clinical outcomes, and low complication rates.

9 关节镜下经胫骨腱钉栓嵌入式后交叉韧带重建术逯代锋 ( 哈尔滨医科大学附属第四医院骨科 ) 一背景后交叉韧带重建技术中移植物的胫骨侧固定经典方法是经胫骨隧道技术, 但存在隧道与移植物成角小于 90 的问题, 移植物在隧道口出现机械性磨损, 变薄, 张力下降, 逐渐松弛, 由于胫骨髁近端骨质较为疏松的解剖结构, 胫骨侧的移植肌腱固定均有不同程度的术后近期固定牢固, 远期逐渐松动, 进而出现重建韧带松弛的现象针对此不足, 作者设计了一种经胫骨腱钉栓嵌入式胫骨侧接近于 PCL 止点处固定方法二材料本组 32 例, 男性 23 例, 女性 9 例 ; 年龄岁, 右膝关节 19 例, 左膝关节 13 例 ; 受伤距手术时间 :8 225d, 后抽屉试验 (+)Ⅲ,MRI 均可见后交叉韧带影像缺失, 手术为同一医生所做三方法 1 PCL 重建腱钉栓的制作 : 取材为自体股薄肌和半腱肌肌腱, 将半腱肌肌腱自 1/3 处反折, 并与股薄肌肌腱合并, 两端用 MB66 肌腱缝合线进行编织固定各 30mm 2 钉栓准备, 用编织好的肌腱中部将 PK 肌腱挤压钉包裹, 对折的肌腱端用 1 号线缝合, 将肌腱和钉体固定在一起, 形成一个腱钉栓腱钉栓 ( 胫骨侧 ) 为单束, 肌腱端 ( 股骨髁侧 ) 为双束 ( 图 1) 3 8 字形胫骨隧道的制作 : 膝关节后内外侧入路, 放置 PCL 隧道定位器, 钻骨隧道至胫骨髁后方, 用带双翼的胫骨隧道扩大凿, 经胫骨隧道外口制作横行 8 字形侧向沟槽, 容纳腱钉栓的栓部 4 腱钉栓的引入和固定 : 将编织好的腱钉栓经胫骨隧道引入, 将其栓柱嵌入 8 字形侧向沟槽内, 用 U 形腱钉栓打入器将其打入, 保留在胫骨后壁骨质在 10mm 有打实的感觉即可 ( 图 2) 四讨论经胫骨骨道技术过深的固定, 将影响膝关节后方的组织结构 ; 较浅的固定, 则会出现雨刷效应和蹦极效应, 腱钉栓固定体栓体为肌腱挤压钉修成的椭圆形固体, 取材方便, 修型简单, 抗压力变形强, 远期可与骨质完全整合 ; 腱钉栓固定体在 8 移字形胫骨隧道内, 无旋转, 完全嵌入侧槽中 ; 在腱钉栓固定体与胫骨后壁骨质贴固后, 减少了肌腱体在隧道内无效固定的距离, 避免了雨刷效应和蹦极效应的现象本组肌腱基底与胫骨隧道出口形成严密的栓塞, 关闭了关节腔和隧道的孔隙交通, 避免了滑液灌注效应的发生同时腱钉栓体贴近胫骨隧道后壁, 减少了肌腱基底的转弯成角, 减少了杀手转弯效应的出现腱钉栓为隧道内悬挂固定, 有悬挂式固定抗拉力大的优点, 又能弥补外悬挂式固定隧道和肌腱无效固定距离长度五结论应用腱钉栓固定体经胫骨嵌入 8 字形胫骨隧道重建后交叉韧带, 固定端贴近胫骨后侧, 减少肌腱体成角, 避免了杀手转弯现象的发生, 该术式是一种有效简便和安全的固定方法

10 保留残端双入路治疗后交叉韧带损伤疗效评估与分析 1 王轶博宋之明 2 * 张晓南 1 第一作者吉林大学第一医院运动医学科 2 第二作者吉林大学第一医院运动医学科 * 通讯作者吉林大学第一医院运动医学科背景 : 目前, 后交叉韧带断裂的手术远期效果还不能令人满意所以关于后交叉韧带的手术方法及手术时机的选择一直都是运动医学研究的热点本次通过对保留残端双入路重建后交叉韧带患者术后 2 年跟踪随访, 了解该治疗手段的手术效果, 并对比不同治疗时机保留残端重建后交叉韧带术后效果, 讨论治疗时机的选择材料 : 统计 2012 年 1 月至 2013 年 12 月在我科行后交叉韧带重建的患者纳入标准 :1 有明确外伤史,2 后抽屉实验 (+) 3 MRI 上后交叉无明显显影 4: 关节镜检查确定后交叉韧带断裂 5: 不伴有其他韧带损伤患者排除标准 :1 伴有其他韧带损伤患者 2 除外伤外其他原因导致后交叉韧带损伤患者共有 33 位患者被纳入, 其中男性 23 人女性 10 人年龄岁, 平均年龄 32±0.5 岁, 入院前外伤史 : 入院前 6 小时 -24 个月, 平均入院前受伤时间 5±0.3 月将患者按受伤时间分为急性组 : 外伤后 2 周内 ( 包含 2 周 ):10 人,4 男, 6 女, 平均受伤时间 7±0.8 天慢性组 : 外伤史 2 周以上 :23 人,10 男,13 女, 平均受伤时间 4±0.9 月方法 : 对比术前及术后 IKDC 评分 Lysholm 评分 90 度应力位 DR 片胫骨后移程度结果 :1 术后 2 年患者膝关节 IKDC 评分 Lysholm 较术前有明显改善,p< 度位应力下膝关节下后方移动度与健侧比无明显差异,p> 慢性组患者较急性组患者更多伴有半月板软骨损伤, 统计学分析 p<0.05 结论 : 1 保留残端双通路重建后交叉韧带是安全有效的手术方式 2 该方法在急性期治疗后交叉韧带损伤可得到满意结果 3 急性期行后交叉韧带重建可避免因膝关节不稳造成膝关节的进一步损伤

11 Anatomical repair of the posterior cruciate ligament avulsion fracture : clinical comparison of total arthroscopic fixation with small incision technique Zhonghaobo 1,Sunchunhanr 2 Department of Orthopedics, The First Hospital of Huizhou, Dr. ZHOGHAOBO, Department of Orthopedics, The First Hospital Of Huizhou, Huizhou , China @qq.com Background: the posterior cruciate ligament avulsion fracture patients, clinical comparison of arthroscopic with small incision technique. Material: 2011 September to 2014 July i, 42 cases, 39 patients received more than 1 year clinical follow-up. Methods: In 39 patients, 21patients small incision operation fix with hollow screws fixation. 18 patients received arthroscopic operation, with suture plate. Clinical evaluation set to 6, 12 weeks, 6 months, 1 year after operation. Assessment, with knee Lysholm score, VAS score of pain. Kee X-ray, check PDT.Comparing Results: The average age of 35 ± 8.7 years (21 to 44 years old). Small incision operation group and arthroscopic group, no significant difference after 6 to12weeks after the operation, and Lysholm.6 months scores were better than the small incision operation group (P<0.05). After 1 years two groups had no significant difference. VAS pain score no significant differences.,two groups kneepdt results showed no significant difference (P<0.05) Discussion and Conclusion: The avulsed bone block of anatomic reduction witharthroscopy assisted small incision,can early functional recovery. Keywords: posterior cruciate ligament avulsion fracture; small incision; arthroscopy assisted operation; fixation

12 PCL 重建 -- 应用 Fanelli 的方法定位胫骨隧道于斜坡下一定能改善 PCL 重建的效果吗? 王辉绵阳市骨科医院膝外科摘要目的探讨关节镜下 PCL 重建, 应用 Fanelli 的方法定位胫骨隧道于斜坡下是否一定能改善 PCL 重建的效果方法对 2013 年 12 月至 2015 年 1 月收治的 23 例 PCL 损伤患者进行回顾性分析其中单纯后交叉韧带患者 7 例 ;7 例患者合并前交叉韧带及内侧副韧带损伤 ;3 例患者为 PCL 合并 PMC 损伤 ;6 例为 PCL 损伤合并 PLC 损伤手术方法 : 保留 PCL 韧带残端, 关节镜下采用自体股薄半腱肌腱行 PCL 重建一期酌情行 PMC 修复 PLC 修复加重 ACL 重建及 MCL 修复处理采用穿后纵膈入路技术, 常规作后内后外侧入路, 清理 PCL 后方组织, 完全显露 PCL 胫骨止点足印, 后内后外侧入路监视下行胫骨隧道定位按 Fanelli 的方法, 定位胫骨内口隧道于斜坡下, 胫骨隧道内口位置位于胫骨平台后缘下 2-3cm 术中常规采用加强生 5 号减张线减张结果 : 全部患者随访 6-18 月 23 例患者中,PDT 或台阶征 (-)2 例,PDT 或台阶征 (+)16 例 ;PDT 或台阶征 (++)3 例,PDT 或台阶征 (+++)2 例结论 : 杀伤角效应是 PCL 重建失败的重要原因按 Fanelli 的方法, 定位胫骨内口隧道于斜坡下, 胫骨隧道内口位置位于胫骨平台后缘下 2-3cm; 这样能有效避免杀伤角效应本组 23 例病例随访, 从术后 X 片 MRI 分析 ;PCL 胫骨隧道内口均能达到斜坡下早期复查 MRI, 重建的 PCL 走形形态非常接近正常 PCL, 早期结果令人鼓舞 ; 但术后 6 月 -1 年复查 MRI, 大部分重建的 PCL 内夹杂部分高信号影, PCL 张力连续性尚可有 2 例 1 年复查 MRI 显示重建的 PCL 信号杂乱, 查体 PDT 或台阶征 (+++), 结果令人沮丧按 Fanelli 的方法定位胫骨隧道于斜坡下, 重建的 PCL 能有效避免杀伤角效应, 重建的 PCL 走形更接近于正常的 PCL 但是, 此方法并不一定能改善重建 PCL 的愈合远期效果需进一步随访

. 500. 中国骨与关节杂志 2015 年 6 月第 4 卷第 6 期 Chinese Journal of Bone and Joint, June 2015, Vol 4, No.6 and difficulties of the surgery and raise the

. 500. 中国骨与关节杂志 2015 年 6 月第 4 卷第 6 期 Chinese Journal of Bone and Joint, June 2015, Vol 4, No.6 and difficulties of the surgery and raise the 中国骨与关节杂志 2015 年 6 月第 4 卷第 6 期 Chinese Journal of Bone and Joint, June 2015, Vol 4, No.6. 499.. 论著 Original article. 极重度脊柱侧后凸患者的后路一期小切口撑开联合二期全脊柱截骨术治疗谭荣马华松吴