Zantop Thore, Kubo Seiji, Petersen Wolf, Musahl Volker, Fu Freddie H
Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
Arthroscopy. 2007 Sep;23(9):938-47. doi: 10.1016/j.arthro.2007.04.009.
The aim of this report is to summarize several techniques that are currently performed to reconstruct the anterior cruciate ligament (ACL) via an anatomic approach restoring the anteromedial (AM) bundle and posterolateral (PL) bundle separately.
A survey containing questions about technique and rehabilitation protocol and a picture of an anatomic specimen, where study participants were asked to locate the tunnels, was created. This was sent to surgeons identified either through an Internet-based search via the National Library of Medicine or who have presented clinical studies about anatomic ACL reconstruction at international meetings. The questions were presented in an open-fashioned way in an Excel-based data file (Microsoft, Redmond, WA) and addressed the profile of the panelists, number of total and anatomic ACL reconstruction per year, graft choice, graft fixation, advantages and disadvantages of anatomic ACL reconstruction, and rehabilitation protocol.
One of the most common techniques used 2 femoral and 2 tibial tunnels with a soft-tissue graft. All but 1 panelist used a hamstring graft. A great variance in tunnel placement of the PL bundle was noted. Most surgeons prefer a transtibial technique for the AM bundle. Of the study participants, 67% start by placing a tunnel at the tibial insertion of the ACL. All of the surgeons who started at the femoral insertion with the PL bundle used an accessory medial portal technique.
Anatomic reconstruction of the ACL remains a technically demanding procedure. Hamstring grafts are the most commonly used graft; an extracortical flip button technique is used at the femoral site, and a hybrid technique is used at the tibial site. The femoral tunnel placement of the PL bundle tunnel is statistically different from the AM bundle tunnel, and the same rehabilitation protocols as for single-bundle ACL reconstructions are used.
Knowledge of the pitfalls and current techniques used for an anatomic approach restoring both bundles of the ACL may provide important information for surgeons considering this technique.
Level V, expert opinion.
本报告旨在总结目前通过解剖学方法分别重建前交叉韧带（ACL）的前内侧（AM）束和后外侧（PL）束所采用的几种技术。
创建了一份调查问卷，其中包含有关技术和康复方案的问题以及一张解剖标本图片，要求研究参与者在图片中标出隧道位置。该问卷通过美国国立医学图书馆基于互联网的搜索确定的外科医生，或者在国际会议上发表过关于解剖学ACL重建临床研究的外科医生。问题以开放式方式呈现在基于Excel的数据文件（微软公司，华盛顿州雷德蒙德）中，涉及小组成员的概况、每年全膝关节置换术和解剖学ACL重建的数量、移植物选择、移植物固定、解剖学ACL重建的优缺点以及康复方案。
最常用的技术之一是使用2个股骨隧道和2个胫骨隧道，并采用软组织移植物。除1名小组成员外，其他所有成员都使用腘绳肌移植物。注意到PL束隧道位置存在很大差异。大多数外科医生更喜欢采用经胫骨技术重建AM束。在研究参与者中，67%从在ACL胫骨止点处放置隧道开始。所有从PL束的股骨止点开始操作的外科医生都采用了辅助内侧入路技术。
ACL的解剖学重建仍然是一项技术要求很高的手术。腘绳肌移植物是最常用的移植物；在股骨部位采用皮质外翻转纽扣技术，在胫骨部位采用混合技术。PL束隧道的股骨隧道位置与AM束隧道在统计学上存在差异，并且采用与单束ACL重建相同的康复方案。
了解解剖学方法重建ACL两束时的陷阱和当前技术，可能为考虑采用该技术的外科医生提供重要信息。
V级，专家意见。
