Guenther Daniel, Irarrázaval Sebastián, Bell Kevin M, Rahnemai-Azar Amir Ata, Fu Freddie H, Debski Richard E, Musahl Volker
1Orthopaedic Robotics Laboratory (D.G., S.I., K.M.B., A.A.R.-A., F.H.F., R.E.D., and V.M.) and Departments of Orthopaedic Surgery (D.G., S.I., A.A.R.-A., F.H.F., and V.M.) and Bioengineering (K.M.B. and R.E.D.), University of Pittsburgh, Pittsburgh, Pennsylvania 2Trauma Department, Hannover Medical School (MHH), Hannover, Germany.
J Bone Joint Surg Am. 2017 Oct 4;99(19):1654-1660. doi: 10.2106/JBJS.16.01462.
The "gold standard" treatment of anterolateral capsular injuries in anterior cruciate ligament (ACL)-deficient knees has not been determined. The purpose of this study was to determine the effects of ACL reconstruction and extra-articular reconstruction on joint motion in the ACL-deficient knee and in the combined ACL and anterolateral capsule-deficient knee.
An anterior tibial load of 134 N and internal tibial torque of 7 Nm were applied to 7 fresh-frozen cadaveric knees using a robotic testing system continuously throughout the range of flexion. The resulting joint motion was recorded for 6 knee states: intact, ACL-deficient, ACL-reconstructed, combined ACL and anterolateral capsule-deficient, ACL-reconstructed + anterolateral capsule-deficient, and ACL-reconstructed + extra-articular tenodesis.
Anterior tibial translation of the ACL-reconstructed + anterolateral capsule-deficient knee in response to an anterior tibial load was restored to that of the intact knee at all knee-flexion angles (p > 0.05). However, for this knee state, internal tibial rotation in response to internal tibial torque was not restored to that of the intact knee at 60° or 90° of knee flexion (p < 0.05). For the knee state of ACL-reconstructed + extra-articular tenodesis, internal rotation in response to internal tibial torque was restored to the motion of the intact knee at each of the tested knee-flexion angles (p > 0.05). Compared with the intact knee, 2 of 7 specimens showed decreased internal tibial rotation with ACL reconstruction + extra-articular tenodesis.
In this study, an extra-articular tenodesis was necessary to restore rotatory knee stability in response to internal tibial torque in a combined ACL and anterolateral capsule-deficient knee. The amount of rotatory knee instability should be carefully assessed to avoid over-constraint of the knee in these combined ligament-reconstruction procedures.
On the basis of our findings, the surgical procedure needs to be personalized depending on the amount of rotatory knee instability in the injured knee and the amount of rotation in the contralateral knee.
前交叉韧带（ACL）损伤膝关节的前外侧关节囊损伤的“金标准”治疗方法尚未确定。本研究的目的是确定ACL重建和关节外重建对ACL损伤膝关节以及ACL和前外侧关节囊联合损伤膝关节的关节活动的影响。
使用机器人测试系统，在整个屈曲范围内，对7个新鲜冷冻尸体膝关节持续施加134 N的胫骨前负荷和7 Nm的胫骨内扭矩。记录6种膝关节状态下的关节活动情况：完整、ACL损伤、ACL重建、ACL和前外侧关节囊联合损伤、ACL重建+前外侧关节囊损伤、ACL重建+关节外腱固定术。
ACL重建+前外侧关节囊损伤膝关节在胫骨前负荷作用下的胫骨前移在所有膝关节屈曲角度均恢复到完整膝关节水平（p>0.05）。然而，对于这种膝关节状态，在膝关节屈曲60°或90°时，对胫骨内扭矩的胫骨内旋转未恢复到完整膝关节水平（p<0.05）。对于ACL重建+关节外腱固定术的膝关节状态，在每个测试的膝关节屈曲角度下，对胫骨内扭矩的内旋转恢复到完整膝关节的活动水平（p>0.05）。与完整膝关节相比，7个标本中有2个在ACL重建+关节外腱固定术时胫骨内旋转减少。
在本研究中，对于ACL和前外侧关节囊联合损伤的膝关节，关节外腱固定术对于恢复膝关节对胫骨内扭矩的旋转稳定性是必要的。应仔细评估膝关节旋转不稳定的程度，以避免在这些联合韧带重建手术中膝关节过度受限。
根据我们的研究结果，手术方案需要根据受伤膝关节的旋转不稳定程度和对侧膝关节的旋转程度进行个性化定制。
