Shino Konsei, Mae Tatsuo, Tachibana Yuta
Sports Orthopaedic Center, Yukioka Hospital, 2-2-3 Ukita, Kita-ku, Osaka, 530-0021, Japan,
J Orthop Sci. 2015 May;20(3):457-68. doi: 10.1007/s00776-015-0705-9. Epub 2015 Mar 11.
Anatomic ACL reconstruction is the reasonable approach to restore stability without loss of motion after ACL tear. To mimic the normal ACL like a ribbon, our preferred procedures is the anatomic rectangular tunnel (ART) technique with a bone-patellar tendon-bone (BTB) graft or the anatomic triple bundle (ATB) procedure with a hamstring (HS) tendon graft. It is important to create tunnel apertures inside the attachment areas to lessen the tunnel widening. To identify the crescent-shaped ACL femoral attachment area, the upper cartilage margin, the posterior cartilage margin and the resident's ridge are used as landmarks. To delineate the C-shaped tibial insertion, medial intercondylar ridge, Parson's knob and anterior horn of the lateral meniscus are helpful. In ART-BTB procedure which is suitable for male patients engaged in contact sports, the parallelepiped tunnels with rectangular apertures are made within the femoral and tibial attachment areas. In ATB-HS technique which is mainly applied to female athletes engaged in non-contact sports including skiing or basketball, 2 femoral and 3 tibial round tunnels are created inside the attachment areas. These techniques make it possible for the grafts to run as the native ACL without impingement to the notch or PCL. After femoral fixation with an interference screw or cortical fixation devices including Endobutton, the graft is pretensioned in situ by repetitive manual pulls at 15-20° of flexion, monitoring the graft tension with tensioners on a tensioning boot installed on the calf. Tibial fixation with pullout sutures is achieved using Double Spike Plate and a screw at the pre-determined amount of tension of 10-20N. While better outcomes with less failure rate are being obtained compared to those in the past, higher graft tear rate remains a problem. Improved preventive training may be required to avoid secondary ACL injuries.
解剖学前交叉韧带重建是在 ACL 撕裂后恢复稳定性且不损失活动度的合理方法。为了像丝带一样模拟正常的 ACL，我们首选的手术方法是采用骨-髌腱-骨（BTB）移植物的解剖学矩形隧道（ART）技术或采用腘绳肌腱移植物的解剖学三束（ATB）手术。在附着区域内创建隧道开口以减少隧道扩大很重要。为了识别新月形的 ACL 股骨附着区域，上软骨边缘、后软骨边缘和髁间嵴用作标志。为了描绘 C 形胫骨附着点，内侧髁间嵴、帕森斯结节和外侧半月板前角很有帮助。在适用于从事接触性运动的男性患者的 ART-BTB 手术中，在股骨和胫骨附着区域内制作具有矩形开口的平行六面体隧道。在主要应用于从事包括滑雪或篮球在内的非接触性运动的女性运动员的 ATB-HS 技术中，在附着区域内创建 2 个股骨圆形隧道和 3 个胫骨圆形隧道。这些技术使移植物能够像天然 ACL 一样运行，而不会撞击髁间窝或后交叉韧带（PCL）。在用干涉螺钉或包括 Endobutton 在内的皮质固定装置进行股骨固定后，通过在 15 - 20°屈曲时重复手动牵拉在原位对移植物进行预张紧，使用安装在小腿上的张紧靴上的张紧器监测移植物张力。使用双尖板和螺钉在 10 - 20N 的预定张力下通过拔出缝线实现胫骨固定。虽然与过去相比获得了更好的结果和更低的失败率，但更高的移植物撕裂率仍然是一个问题。可能需要改进预防性训练以避免继发性 ACL 损伤。
