移植物固定角度和初始张力对前交叉韧带单束解剖重建术后膝关节稳定性的影响
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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20N~80N，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（F_0T_(20)），②移植物固定角度0°、初始张力50N（F_0T_(50)），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（F_(30)T_(20)），⑤移植物固定角度30°、初始张力50N（F_(30)T_(500），⑥移植物固定角度30°、初始张力80N（F_(30)T_(80)）。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、F_0T_(50)、F_0T_(80)、F_(30)T_(20)、F_(30)T_(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，F_0T_(50)、F_0T_(80)、F_(30)T_(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F_(30)T_(500和F30T80的测定值比F_0T_(50)和F_0T_(80)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F_0T_(50)、F_0T_(80)、F_(30)T_(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、F_0T_(50)、F_0T_(80)、F_(30)T_(20)、F_(30)T_(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，F_0T_(50)、F_0T_(80)、F_(30)T_(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，F_(30)T_(20)、F_(30)T_(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F_(30)T_(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、F_0T_(50)、F_0T_(80)、F_(30)T_(20)、F_(30)T_(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F_(30)T_(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。
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 (F_0T_(20)),(2) knee flexion at0°andinitial graft tensions50N (F_0T_(50)),(3) knee flexion at0°and initial grafttensions80N (F_0T_(80)),(4) knee flexion at30°and initial graft tensions20N(F_(30)T_(20)),(5) knee flexion at30°and initial graft tensions50N (F_(30)T_(50)),(6)knee flexion at30°and initial graft tensions80N (F_(30)T_(80)). 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(F_0T_(20), F_0T_(50), F_0T_(80), F_(30)T_(20), F_(30)T_(50)and F_(30)T_(80)) weresignificantly less than in the ACL-deficient group(p<0.05). Though there wereno significant differences among ACL-intact, F_0T_(50), F_0T_(80), F_(30)T_(50)andF_(30)T_(80)(P=0.255), the average values of F_(30)T_(50)and F_(30)T_(80)were both less thanthe other groups(F_0T_(50)and F_0T_(80)), which suggested that anatomic SB ACLR inthe graft fixation settings of knee flexion at0°or30°, initial graft tensions50N or80N(F_0T_(50), F_0T_(80), F_(30)T_(50)and F_(30)T_(80)) could restore enough anteriorstability of the intact knee.
Tibial IR and ER control:6SB ACLR groups(F_0T_(20), F_0T_(50), F_0T_(80), F_(30)T_(20),F_(30)T_(50)and F_(30)T_(80))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, F_0T_(50), F_0T_(80), F_(30)T_(50)and F_(30)T_(80)in the rotationalstability(PIR=0.982, PER=0.904); at30°of knee flexion, there were nosignificant differences among ACL-intact, F_(30)T_(20), F_(30)T_(50)and F_(30)T_(80)in therotational stability(PIR=0.937, PER=0.900); at60°, there were no significantdifferences only among ACL-intact, F_(30)T_(50)and F_(30)T_(80)in 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(F_(30)T_(50)and F_(30)T_(80)) 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.
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（F_0T_(20)），②移植物固定角度0°、初始张力50N（F_0T_(50)），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（F_(30)T_(20)），⑤移植物固定角度30°、初始张力50N（F_(30)T_(500），⑥移植物固定角度30°、初始张力80N（F_(30)T_(80)）。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、F_0T_(50)、F_0T_(80)、F_(30)T_(20)、F_(30)T_(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，F_0T_(50)、F_0T_(80)、F_(30)T_(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F_(30)T_(500和F30T80的测定值比F_0T_(50)和F_0T_(80)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F_0T_(50)、F_0T_(80)、F_(30)T_(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、F_0T_(50)、F_0T_(80)、F_(30)T_(20)、F_(30)T_(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，F_0T_(50)、F_0T_(80)、F_(30)T_(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，F_(30)T_(20)、F_(30)T_(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F_(30)T_(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、F_0T_(50)、F_0T_(80)、F_(30)T_(20)、F_(30)T_(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F_(30)T_(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。
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 (F_0T_(20)),(2) knee flexion at0°andinitial graft tensions50N (F_0T_(50)),(3) knee flexion at0°and initial grafttensions80N (F_0T_(80)),(4) knee flexion at30°and initial graft tensions20N(F_(30)T_(20)),(5) knee flexion at30°and initial graft tensions50N (F_(30)T_(50)),(6)knee flexion at30°and initial graft tensions80N (F_(30)T_(80)). 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(F_0T_(20), F_0T_(50), F_0T_(80), F_(30)T_(20), F_(30)T_(50)and F_(30)T_(80)) weresignificantly less than in the ACL-deficient group(p<0.05). Though there wereno significant differences among ACL-intact, F_0T_(50), F_0T_(80), F_(30)T_(50)andF_(30)T_(80)(P=0.255), the average values of F_(30)T_(50)and F_(30)T_(80)were both less thanthe other groups(F_0T_(50)and F_0T_(80)), which suggested that anatomic SB ACLR inthe graft fixation settings of knee flexion at0°or30°, initial graft tensions50N or80N(F_0T_(50), F_0T_(80), F_(30)T_(50)and F_(30)T_(80)) could restore enough anteriorstability of the intact knee.
Tibial IR and ER control:6SB ACLR groups(F_0T_(20), F_0T_(50), F_0T_(80), F_(30)T_(20),F_(30)T_(50)and F_(30)T_(80))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, F_0T_(50), F_0T_(80), F_(30)T_(50)and F_(30)T_(80)in the rotationalstability(PIR=0.982, PER=0.904); at30°of knee flexion, there were nosignificant differences among ACL-intact, F_(30)T_(20), F_(30)T_(50)and F_(30)T_(80)in therotational stability(PIR=0.937, PER=0.900); at60°, there were no significantdifferences only among ACL-intact, F_(30)T_(50)and F_(30)T_(80)in 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(F_(30)T_(50)and F_(30)T_(80)) 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.
引文
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12Anderson AF, Dome DC, Gautam S, et al. Correlation of anthropometricmeasurements, strength, anterior cruciate ligament size, and intercondylarnotch characteristics to sex differences in anterior cruciate ligament tearrates. Am J Sports Med,2001,29(1):58-66
13Harner CD, Baek GH, Vogrin TM, et al. Quantitative analysis of humancruciate ligament insertions. Arthroscopy,1999,15(7):741-749
14赵金忠.膝关节稳定性结构.膝关节重建外科学.河南科学技术出版社,2007:1-56
15Chhabra A, Starman JS, Ferretti M, et al. Anatomic, radiographic,biomechanical, and kinematic evaluation of the anterior cruciate ligamentand its two functional bundles. J Bone Joint Surg Am,2006,88(suppl4):2-10
16Ferretti M, Levicoff EA, Macpherson TA, et al. The fetal anteriorcruciate ligament: an anatomic and histologic study. Arthroscopy,2007,23(3):278-283
17Frank CB, Jackson DW. The science of reconstruction the anteriorcruciate ligament. J Bone Joint Surg Am,1997,79(10):1556-1576
18Ristanis S, Stergiou N, Patras K, et al. Follow-up evaluation2years afterACL reconstruction with bone-patellar tendon-bone graft shows that exc-essive tibial rotation persists. Clin J Sport Med,2006,16(2):111-116
19Lie DT, Bull AM, Amis AA. Persistence of the mini pivot shift afteranatomically placed anterior cruciate ligament reconstruction. ClinOrthop Relat Res,2007,457:203-209
20Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of theanteromedial and posterolateral bundles of the anterior cruciate ligamentusing hamstring tendon grafts. Arthroscopy,2004,20(10):1015-1025
21Harner CD, Poehling GG. Double bundle or double trouble? Arthroscopy,2004;20(10):1013-1014
22Zelle BA, Vidal AF, Brucker PU, et al. Double-bundle reconstruction ofthe anterior cruciate ligament: anatomic and biomechanical rationale. JAm Acad Orthop Surg,2007,15(2):87-96
23Woo SL, Kanamori A, Zeminski J, et al. The effectiveness of reconstruc-tion of the anterior cruciate ligament with hamstrings and patellar tendon.A cadaveric study comparing anterior tibial and rotational loads. J BoneJoint Surg AM,2002,84(6):907-914
24Fithian DC, Paxton EW, Stone ML, et al. Prospective trial of a treatmentalgorithm for the management of the anterior cruciate ligament-injuredknee. Am J Sports Med,2005,33(3):335-346
25Roe J, Pinczewski LA, Russell VJ, et al. A7-year follow-up of patellartendon and hamstring tendon grafts for arthroscopic anterior cruciateligament reconstruction: differences and similarities. Am J Sports Med,2005,33(9):1337-1345
26Loh JC, Fukuda Y, Tsuda E, et al. Knee stability and graft functionfollowing anterior cruciate ligament reconstruction: Comparison between
11o’ clock and10o’ clock femoral tunnel placement. Arthroscopy,2003,19(3):297-304
27周敬滨, Zachary Working, Carola F.van Eck, Freddie H.Fu1.前交叉韧带解剖重建理念与方法.中国运动医学杂志,2011,6(30):511-518
28Campbell's Operative Orthopaedics.10th ed. Copyright,2003, Mosby,Inc.2566-2570
29Marcacci M, Zaffagnini S, Iacono F, et al. Arthroscopic intra-andextra-articular anterior cruciate ligament reconstruction with gracilis andsemitendinosus tendons. Knee Surg Sports Traumatol Arthrosc,1998,6(2):68-75
30Fu FH, Karlsson J. A long journey to be anatomic. Knee Surg SportsTraumatol Arthrosc,2010,18(9):1151-1153
31Lebel B, Hulet C, Galaud B, et al. Arthroscopic reconstruction of theanterior cruciate ligament using bone-patellar tendon-bone autograft: aminimum10-year follow-up. Am J Sports Med,2008,36(7):1275-1282
32Shen W, Fu FH. Anterior cruciate ligament insertion site anatomy.Arthroscopy,2008,24(7):850-851
33Ferretti M, Ekdahl M, Shen W, et al. Osseous landmarks of the femoralattachment of the anterior cruciate ligament: an anatomic study.Arthroscopy,2007,23(11):1218-1225
34Buoncristiani AM, Tjoumakaris FP, Starman JS, et al. Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy,2006,22(9):1000-1006
35Zelle BA, Brucker PU, Feng MT, et al. Anatomical double-bundleanterior cruciate ligament reconstruction. Sports Med,2006,36(2):99-108
36Fu FH, Shen W, Starman JS, et al. Primary anatomic double-bundleanterior cruciate ligament reconstruction: a preliminary2-year prospec-tive study. Am J Sports Med,2008,36(7):1263-1274
37陆伟,王大平,韩云,等.关节镜下过顶位与解剖位腘绳肌腱单束重建前交叉韧带比较.中国临床解剖学杂志,2009,27(3):283-287
38Yoshiya S, Kurosaka M, Ouchi K, er al. Graft tension and knee stabilityafter anterior cruciate ligament reconstruction. Clin Orthop Relat Res,2002,394:154-160
39Paulos LE, Wnorowski DC, Greenwald AE. Infrapatellar contracturesyndrome. Diagnosis, treatment, and long-term followup. Am J SportsMed,1994,22(4):440-449
40Zampeli F, Ntoulia A, Giotis D, et al. Correlation between anteriorcruciate ligament graft obliquity and tibial rotation during dynamicpivoting activities in patients with anatomic anterior cruciate ligamentreconstruction: an in vivo examination. Arthroscopy,2006,28(2):234-246
41Boylan D, Greis PE, West JR, et al. Effects of initial graft tension on kn-ee stability after anterior cruciate ligament reconstruction using hamstr-ing tendons: a cadaver study. Arthroscopy,2003,19(7):700-705
42Gabriel MT, Wong EK, Woo SL, et al. Distribution of in situ forces in theanterior cruciate ligament in response to rotatory loads. J Orthop Res,2004,22(1):85-89
43Tashman S, Collon D, Anderson K, et al. Abnormal rotational kneemotion during running after anterior cruciate ligament reconstruction.Am J Sports Med,2004,32(4):975-983
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47Misonoo G, Kanamori A, Ida H, et al. Naoyuki Ochiai. Evaluation oftibial rotational stability of single-bundle vs. anatomical double-bundleanterior cruciate ligament reconstruction during a high-demand activity-a quasi-randomized trial. Knee,2012,19(2):87-93
48Wu C, Noorani S, Vercillo F, et al. Tension patterns of the antero-medialand posterolateral grafts in a double-bundle anterior cruciate ligamentreconstruction. J Orthop Res,2009,27(7):879-884
49Yasuda K, Ichiyama H, Kondo E, et al. An in vivo biomechanical studyon the tension-versus-knee flexion angle curves of2grafts in anatomicdouble-bundle anterior cruciate ligament reconstruction: effects of initialtension and internal tibial rotation. Arthroscopy,2008,24(3):276-284
50Musahl V, Citak M, O’Loughlin PF, et al. The effect of medial versuslateral meniscectomy on the stability of the anterior cruciate ligament-deficient knee. Am J Sports Med,2010,38(8):1591-1597
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42陆伟,王大平,韩云,等.关节镜下过顶位与解剖位腘绳肌腱单束重建前交叉韧带比较.中国临床解剖学杂志,2009,27(3):283-287
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53Yasuda K, Tsujino J, Ohkoshi Y, et al. Graft site morbidity withautogenous semitendinosus and gracilis tendons. Am J Sports Med,1995,23(6):706-714
54Ristanis S, Stergiou N, Patras K, et al. Excessive tibial rotation duringhigh-demand activities is not restored by anterior cruciate ligamentreconstruction. Arthroscopy,2005,21(11):1323-1329
55Tashman S, Collon D, Anderson K, et al. Abnormal rotational kneemotion during running after anterior cruciate ligament reconstruction.Am J Sports Med,2004,32(4):975-983
56Debandi A, Maeyama A, Asai S, et al. Effects of tunnel placement andknee flexion angle for graft fixation on rotational stability aftersingle-bundle ACL reconstruction. Arthroscopy,2011,27(suppl10):e82-e83
57Misonoo G, Kanamori A, Ida H, et al. Naoyuki Ochiai. Evaluation oftibial rotational stability of single-bundle vs. anatomical double-bundleanterior cruciate ligament reconstruction during a high-demand activity-a quasi-randomized trial. Knee,2012,19(2):87-93
58Zampeli F, Ntoulia A, Giotis D, et al. Correlation between anteriorcruciate ligament graft obliquity and tibial rotation during dynamicpivoting activities in patients with anatomic anterior cruciate ligamentreconstruction: an in vivo examination. Arthroscopy,2012,28(2):234-246
59Leiter JR, de Korompay N, MacDonald L, et al. Reliability of tunnelangle in ACL reconstruction: two-dimensional versus three-dimensionalguide technique. Knee Surg Sports Traumatol Arthrosc,2011,19(8):1258-1264
2Yagi M, Wong EK, Kanamori A, et al. Biomechanical analysis of ananatomic anterior cruciate ligament reconstruction. Am J Sports Med,2002,30(5):660-666
3Kato Y, Ingham SJ, Kramer S, et al. Effect of tunnel position for anato-mic single-bundle ACL reconstruction on knee biomechanics in a porcinemodel. Knee Surg Sports Traumatol Arthrosc,2010,18(1):2-10
4Debandi A, Maeyama A, Asai S, et al. Effects of tunnel placement andknee flexion angle for graft fixation on rotational stability aftersingle-bundle ACL reconstruction. Arthroscopy,2011,27(suppl10):e82-e83
5Karchin A, Hull ML, Howell SM. Initial tension and anterior load-displacement behavior of high-stiffness anterior cruciate ligament graftconstructs. J Bone Joint Surg Am,2004,86(8):1675-1683
6Amis AA, Jakob RP. Anterior cruciate ligament graft positioning, tension-ing and twisting. Knee Surg Sports Traumatol Arthrosc,1998;6(suppl1):s2-12
7沈灏,赵金忠,蒋垚,等.关节镜下前交叉韧带重建术现状和若干争议问题.国外医学.骨科学分册,2004,3:83-86
8Bedi A, Maak T, Musahl V, et al. Effect of tunnel position and graft sizein single-bundle anterior cruciate ligament reconstruction: an evaluationof time-zero knee stability. Arthroscopy,2011,27(11):1543-1551
9Koga H, Muneta T, Yagishita K, et al. The effect of graft fixation angleson anteroposterior and rotational knee laxity in double-bundle anteriorcruciate ligament reconstruction: evaluation using computerized naviga-tion. Am J Sports Med,2012,40(3):615-623
10Bedi A, Musahl V, O’Loughlin P, et al. A comparison of the effect ofcentral anatomical single-bundle anterior cruciate ligament reconstruc-tion and double-bundle anterior cruciate ligament reconstruction onpivot-shift kinematics. Am J Sports Med,2010,38(9):1788-1794
11Clark JM, Sidles JA. The interrelation of fiber bundles in the anteriorcruciate ligament. J Orthop Res,1990,8(2):180-188
12Anderson AF, Dome DC, Gautam S, et al. Correlation of anthropometricmeasurements, strength, anterior cruciate ligament size, and intercondylarnotch characteristics to sex differences in anterior cruciate ligament tearrates. Am J Sports Med,2001,29(1):58-66
13Harner CD, Baek GH, Vogrin TM, et al. Quantitative analysis of humancruciate ligament insertions. Arthroscopy,1999,15(7):741-749
14赵金忠.膝关节稳定性结构.膝关节重建外科学.河南科学技术出版社,2007:1-56
15Chhabra A, Starman JS, Ferretti M, et al. Anatomic, radiographic,biomechanical, and kinematic evaluation of the anterior cruciate ligamentand its two functional bundles. J Bone Joint Surg Am,2006,88(suppl4):2-10
16Ferretti M, Levicoff EA, Macpherson TA, et al. The fetal anteriorcruciate ligament: an anatomic and histologic study. Arthroscopy,2007,23(3):278-283
17Frank CB, Jackson DW. The science of reconstruction the anteriorcruciate ligament. J Bone Joint Surg Am,1997,79(10):1556-1576
18Ristanis S, Stergiou N, Patras K, et al. Follow-up evaluation2years afterACL reconstruction with bone-patellar tendon-bone graft shows that exc-essive tibial rotation persists. Clin J Sport Med,2006,16(2):111-116
19Lie DT, Bull AM, Amis AA. Persistence of the mini pivot shift afteranatomically placed anterior cruciate ligament reconstruction. ClinOrthop Relat Res,2007,457:203-209
20Yasuda K, Kondo E, Ichiyama H, et al. Anatomic reconstruction of theanteromedial and posterolateral bundles of the anterior cruciate ligamentusing hamstring tendon grafts. Arthroscopy,2004,20(10):1015-1025
21Harner CD, Poehling GG. Double bundle or double trouble? Arthroscopy,2004;20(10):1013-1014
22Zelle BA, Vidal AF, Brucker PU, et al. Double-bundle reconstruction ofthe anterior cruciate ligament: anatomic and biomechanical rationale. JAm Acad Orthop Surg,2007,15(2):87-96
23Woo SL, Kanamori A, Zeminski J, et al. The effectiveness of reconstruc-tion of the anterior cruciate ligament with hamstrings and patellar tendon.A cadaveric study comparing anterior tibial and rotational loads. J BoneJoint Surg AM,2002,84(6):907-914
24Fithian DC, Paxton EW, Stone ML, et al. Prospective trial of a treatmentalgorithm for the management of the anterior cruciate ligament-injuredknee. Am J Sports Med,2005,33(3):335-346
25Roe J, Pinczewski LA, Russell VJ, et al. A7-year follow-up of patellartendon and hamstring tendon grafts for arthroscopic anterior cruciateligament reconstruction: differences and similarities. Am J Sports Med,2005,33(9):1337-1345
26Loh JC, Fukuda Y, Tsuda E, et al. Knee stability and graft functionfollowing anterior cruciate ligament reconstruction: Comparison between
11o’ clock and10o’ clock femoral tunnel placement. Arthroscopy,2003,19(3):297-304
27周敬滨, Zachary Working, Carola F.van Eck, Freddie H.Fu1.前交叉韧带解剖重建理念与方法.中国运动医学杂志,2011,6(30):511-518
28Campbell's Operative Orthopaedics.10th ed. Copyright,2003, Mosby,Inc.2566-2570
29Marcacci M, Zaffagnini S, Iacono F, et al. Arthroscopic intra-andextra-articular anterior cruciate ligament reconstruction with gracilis andsemitendinosus tendons. Knee Surg Sports Traumatol Arthrosc,1998,6(2):68-75
30Fu FH, Karlsson J. A long journey to be anatomic. Knee Surg SportsTraumatol Arthrosc,2010,18(9):1151-1153
31Lebel B, Hulet C, Galaud B, et al. Arthroscopic reconstruction of theanterior cruciate ligament using bone-patellar tendon-bone autograft: aminimum10-year follow-up. Am J Sports Med,2008,36(7):1275-1282
32Shen W, Fu FH. Anterior cruciate ligament insertion site anatomy.Arthroscopy,2008,24(7):850-851
33Ferretti M, Ekdahl M, Shen W, et al. Osseous landmarks of the femoralattachment of the anterior cruciate ligament: an anatomic study.Arthroscopy,2007,23(11):1218-1225
34Buoncristiani AM, Tjoumakaris FP, Starman JS, et al. Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy,2006,22(9):1000-1006
35Zelle BA, Brucker PU, Feng MT, et al. Anatomical double-bundleanterior cruciate ligament reconstruction. Sports Med,2006,36(2):99-108
36Fu FH, Shen W, Starman JS, et al. Primary anatomic double-bundleanterior cruciate ligament reconstruction: a preliminary2-year prospec-tive study. Am J Sports Med,2008,36(7):1263-1274
37陆伟,王大平,韩云,等.关节镜下过顶位与解剖位腘绳肌腱单束重建前交叉韧带比较.中国临床解剖学杂志,2009,27(3):283-287
38Yoshiya S, Kurosaka M, Ouchi K, er al. Graft tension and knee stabilityafter anterior cruciate ligament reconstruction. Clin Orthop Relat Res,2002,394:154-160
39Paulos LE, Wnorowski DC, Greenwald AE. Infrapatellar contracturesyndrome. Diagnosis, treatment, and long-term followup. Am J SportsMed,1994,22(4):440-449
40Zampeli F, Ntoulia A, Giotis D, et al. Correlation between anteriorcruciate ligament graft obliquity and tibial rotation during dynamicpivoting activities in patients with anatomic anterior cruciate ligamentreconstruction: an in vivo examination. Arthroscopy,2006,28(2):234-246
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