The Basic And Clinical Study Of Arthroscopic Single-Bundle Anterior Cruciate Ligament Reconstruction

Part I Anatomical and Radiographic Study of Arthroscopic Single-bundle Anterior Cruciate Ligament ReconstructionObjective To observe the anatomical and radiographic feature of the tibial insertion,femur insertion,anterior cruciate ligament(ACL),reconstructed ACL as to offer anatomical guidance for single-bundle ACL reconstruction.Methods 8 adult cadaveric knees were dissected,exclude knee deformities,injuries,tumors,including 4 males and 4 females.The tibial insertion,femur insertion,anterior cruciate ligament(ACL),femor anterior medial bundle(AMB),posterior lateral bundle(PLB)were observed.The anterior medial bundle and the posterior medial bundle of the ACL,which were at the center point of the femoral condyle,posterior cruciate ligament(PCL),lateral meniscus were measure and reconded.Statistical analysis of the measured data was performed.3 2 patients with anterior cruciate ligament rupture were treated with MRI of the bilateral knee joints preoperative and treated with MRI of the affected postoperative.The MRI signal of the ACL was evaluated.Compared the Blumensaat angle,PCL angle,sagittal ACL angle with the normal knee joint of the 32 cases.The ACL signal was assessed by Rak's menthod:14 cases were in grade 1and 2cases were in grade 2.Results The ACL was flat and consisted of many fiber bundles.The anterior medial bundle and posterolateral bundle were visible in all 8 specimens.The tibial insertion of the ACL was arc-shaped and started from the lateral side of the tibial intercondylar spine.End at the front of the front corner of the lateral meniscus,The width of the ACL is(10.6±1.6)mm,the thickness of the ACL is(3.3±0.7)mm,the cross-sectional areathe ACL is(30.75±7.9)mm2.The diameter of the tibial insertion is about(9.6±1.9)mm,and the diameter of the front and rear is(12.0±10.7)mm about the tibial insertion.The cross-sectional area of the tibial insertion is(118.1±13.0)mm2.The width of anterior horn of the lateral meniscus is(11.5±1.8)mm.The distance between the ACL midpoint and the PCL and the anterior horn of the lateral meniscus were(12.60±4.50)mm and(19.5±3.57)mm,respectively.The distance between the anterior medial bundle(AMB)of the ACL and the PCL and the anterior hornthe of the lateral meniscus were(15.02±2.89)mm and(19.50±4.03)mm,respectively.The distance between the midpoint of the posterior lateral bundle(PLB)and the PCL and the anterior hornthe of the lateral meniscus were respectively It is(10.15±5.50)mmand(19.00±4.00)mm.The PLB center of the ACL inserted femoral condyle was located at the front of the femoral cartilage,and the distance between the PLB center and the femoral front cartilage is(8.30±1.20)mm.The distance between the PLB center and the femoral below cartilage is(5.30±0.80)mm.There was no significant difference between the two(p>0.05).The distance from the center of the femoral condyle to the rear cartilage margin was(8.60±1.50)mm.The center of the AMB inserted femoral condyle was located at the front of the femoral cartilage,and the distance between the AMB center and the femoral front cartilage is(14.80±2.50)mm.The distance between the AMB center and the femoral below cartilage is(9.13±1.55)mm.There was no significant difference between the two(p>0.05).The distance from the center of the femoral condyle to the rear cartilage margin was(6.10±0.70)mm.There was no significant difference between preoperative,postoperative and the normal group about the Blumensaat angle(p>0.05).The Brumensaat angle,PCL index,and tibia advancement of the operation group and the normal group were lower than preoperative(p<0.05).The angle of PCL between the operation group and the normal group was higher than that preoperative(p<0.05).The angle of PCL in the operation group was significantly higher than that in the normal group(p<0.05).Conclusion For the reconstruction of ACL injury,PCL and the lateral anterior horn of the lateral meniscus can be used as the positioning markers.At the knee flexion of 90°,the center of the femoral insertion of the posterior lateral ACL of the knee is at a height of 5.3 mm from the lower cartilage margin,and is at an almost equidistant position from the anterior and posterior cartilage margins.The center point of the femoral insertion of the anterior medial ACL is 9 mm from the lower cartilage margin and is about 1/3 of the front and rear lines.In the operation of ACL reconstruction,the results of this study can be used to determine the position of the anterior and posterior lateral bundle of the ACL on the femoral condyles.Preoperative and postoperative MRI of the ACL for anatomical reconstruction were compared with normal ACL MRI,indicating that the Blumensaat angle and the PCL angle can be used as an evaluation index for the ACL reconstruction.Part II Three Dimensional Finite Study of Arthroscopic Single-bundle Anterior Cruciate Ligament ReconstructionObjective The finite element mechanics method was used to analyze the knee joint under different flexion angles.The biomechanical characteristics of the anterior and posterior cruciate ligaments,the medial and lateral collateral ligaments and the meniscus were analyzed.Methods A healthy adult male was selected as the research object.The software was used to establish a three-dimensional finite element model of the right knee joint including the femur,tibia,anterior and posterior cruciate ligament,medial lateral collateral ligament,medial lateral meniscus and cartilage.Inmitated the knee joint was under the different flexion angles,the knee joint was applied with 134N force to the femur,10Nm moment of internal and external valgus,and 4 different loads of 10Nm and 5Nm combined moment of the internal rotation.The anterior cruciate ligament(ACL),the posterior cruciate ligament(PCL),the medial and lateral collateral ligaments and the meniscus were analyzed about the stress distribution and size.Results After the posterior 134N stress was applied to the femur,the ACL was the most stressed,the lateral collateral ligament was the least stressed,and the maximal stress of the medial collateral ligament was greater than the PCL after flexion at 0°,30°,60° and 90° for the knee joint,and the PCL increases with the increase of the buckling angle.At the load of 2,the force of the medial collateral ligament was the largest,followed by the anterior cruciate ligament,posterior cruciate ligament,and medial collateral ligament with the least stress.At the load of 3,the lateral collateral ligament was the most stressed,followed by the posterior cruciate ligament,anterior cruciate ligament,and medial side.The ligament stress is minimal;at load 4,the medial collateral ligament stress is greatest.Conclusion The successfully established three-dimensional finite element model of the knee joint can simulate the ligament and meniscus stress of the knee joint under different loads,and effectively analyze the biomechanical properties of the knee joint ligament and meniscus,and then speculate the damage mechanism.Part ? Clinical analysis of the accessory anteromedial portal technique for femoral tunnel drilling in single-bundle anterior cruciate ligament reconstructionObjective To observe the clinical results of the accessory anteromedial portal(AAMP)technique for femoral tunnel drilling in single-bundle anterior cruciate ligament(ACL)reconstruction.Methods A retrospective study was performed for single-bundle ACL reconstruction of ACL rupture with autologous semitendinosus and gracilis tendons in 43 patients from August of 2012 to September of 2016.The patient sex,age,BMI,affected side distribution,injury time,meniscus injury degree were compared.At last follow-up,The Lachman thest and pivot-shift test were used to evaluate AP and rotational stability respectively compared to the preoperative.The Lysholm knee scoring scale and the International Knee Documentation Committee(IKDC)score were used to evaluate clinical and functional results.The length of the femoral tunnel was measured intraoperatively,and the position of the ACL femoral tunnel was evaluated by observing the MRI image of the femoral axial position using the dial clock positioning method.Results 43 cases were followed up from 14 months to 25 months.The mean femoral tunnel length was(40.12±4.32)mm Non suffered from posterior wall intercondylar blowout.The mean femoral tunnel position were(45.83±3.58)° of the left knee,(309.00±6.83)° of the right knee respectively.The mean femoral tunnel coronal inclination angle were(32.13±9.15)°.No significant differences were observed between the two groups in the Lachman test,pivot-shift test,Lysholm knee scoring scale,or IKDC score.Conclusion The femoral ACL foot print was all excellently reconstructed via AAMP.The femoral tunnel position was more anatomical.The knee function was improved after operation.Part IV Clinical comparisons of two different portal technique for femoral tunnel drilling in single-bundle anterior cruciate ligament reconstructionObjective To compare the primary clinical results of the anteromedial portal(AMP)and accessory anteromedial portal(AAMP)techniques for femoral tunnel drilling in single-bundle anterior cruciate ligament(ACL)reconstruction.Methods A retrospective control review was performed for single-bundle ACL reconstruction of ACL rupture with autologous semitendinosus and gracilis tendons in 157 patients from February of 2011 to January of 2016.The femoral tunnels were drilled with AMP and AAMP techniques in 76 patients(AMP group)and 81 patients(AAMP group)respectively.The patient sex,age,BMI,affected side distribution,injury time,meniscus injury degree were compared.At last follow-up,the femoral tunnel position and femoral tunnel inclination angles were assessed on axial of the femoral and anterior-posterior(AP)magnetic resonance images of the knee.The length of the femoral tunnel measured in the intraoperative time between two groups was compared.The Lachman thest and pivot-shift test were used to evaluate AP and rotational stability respectively.The Lysholm knee scoring scale and the International Knee Documentation Committee(IKDC)score were used to evaluate clinical and functional results.Result 157 cases were followed up from 13 months to 36 months.The mean femoral tunnel length was(37.82±3.43)mm in the AMP group and(40.04±3.58)mm in the AAMP group(p<0.05).2 cases suffered from posterior wall intercondylar blowout in the AMP group,and none was happened in the AAMP group.The mean femoral tunnel position were(54.30±6.03)° of the left knee,(306.63±8.72)° of the right knee respectively in the AMP group and(47.85±4.32)° of the left knee,(312.00±6.50)° of the right knee respectively in the AAMP group(p>0.05).The mean femoral tunnel coronal inclination angle were(31.13±8.06)° in the AMP group and(30.17±9.02)° in the AAMP group respectively(p>0.05).No significant differences were observed between the two groups in the Lachman test,pivot-shift test,Lysholm knee scoring scale,or IKDC score.Conclusion The femoral ACL foot print was all excellently reconstructed via AMP and AAMP.The knee function was improved in two groups after operation.Compared to AMP group,the femoral tunnel position was more anatomical and femoral tunnel length was much longer in the A AMP group.Compared to the AAMP group,the AP and rotational stability were more outstanding in the AMP group.