van der List Jelle P, DiFelice Gregory S
Hospital for Special Surgery, New York, NY.
Am J Orthop (Belle Mead NJ). 2016 Nov/Dec;45(7):E393-E405.
The gold standard of anterior cruciate ligament (ACL) injuries is currently single-bundle autograft reconstruction. However, many disadvantages of reconstructive surgery exist, such as: anterior knee pain, muscle atrophy, and loss of range of motion. In addition, native kinematics are not restored, and osteoarthritis is not prevented. Finally, revision surgery, if necessary, can be problematic due to tunnel widening, tunnel malpositioning, and preexisting hardware. Ligament preservation includes preservation of native tissues in order to optimize the biologic aspects, while decreasing the invasive nature of reconstructive surgery. In the 1970s and 1980s, ACL preservation via open primary repair was widely performed, but the technique was abandoned due to unpredictable results. Unfortunately, the influence of both tear location and tissue quality on primary repair outcomes was not adequately recognized. Augmented repair, essentially a combination of primary repair and reconstruction, was then performed in the 1980s and early 1990s. Despite excellent results, for multiple reasons the surgical community moved on to ACL reconstruction, which was adapted as the gold standard. With the current knowledge of the role of tear location and tissue quality on outcomes of ACL preservation, in combination with modern advances of magnetic resonance imaging, arthroscopic technology, and the benefits of early rehabilitation, there is likely a role for ACL preservation today. In this article, we (I) discuss the history of ACL preservation, (II) discuss how modern advances alter the risk-benefit ratio for ACL preservation, and (III) propose a treatment algorithm for ACL injuries that is based on tear location and tissue quality.
目前，前交叉韧带（ACL）损伤的金标准是单束自体移植物重建。然而，重建手术存在许多缺点，例如：膝关节前部疼痛、肌肉萎缩和活动范围丧失。此外，无法恢复正常的运动学，也无法预防骨关节炎。最后，如果需要进行翻修手术，由于隧道扩大、隧道位置不当和先前存在的硬件问题，可能会出现问题。韧带保留包括保留天然组织，以优化生物学方面，同时减少重建手术的侵入性。在20世纪70年代和80年代，通过开放一期修复保留ACL的手术被广泛开展，但由于结果不可预测，该技术被放弃。不幸的是，撕裂部位和组织质量对一期修复结果的影响没有得到充分认识。20世纪80年代和90年代初进行了增强修复，本质上是一期修复和重建的结合。尽管结果优异，但由于多种原因，外科界转向了ACL重建，后者被确立为金标准。鉴于目前对撕裂部位和组织质量在ACL保留结果中的作用的认识，结合磁共振成像、关节镜技术的现代进展以及早期康复的益处，如今ACL保留可能具有一定作用。在本文中，我们（I）讨论ACL保留的历史，（II）讨论现代进展如何改变ACL保留的风险效益比，以及（III）提出一种基于撕裂部位和组织质量的ACL损伤治疗算法。
