Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland.
Clinic of Orthopaedics and Traumatology, Department of Surgery, Kantonsspital, Winterthur, Switzerland.
Arthroscopy. 2020 Jul;36(7):1942-1950. doi: 10.1016/j.arthro.2020.03.027. Epub 2020 Apr 3.
PURPOSE: To determine the stabilizing role of anterolateral ligament reconstruction (ALLR) and modified Lemaire lateral extra-articular tenodesis (LET) performed in combination with anterior cruciate ligament reconstruction (ACLR) and to determine whether either procedure was superior to the other. METHODS: Six nonpaired, human, fresh-frozen cadaveric knees were tested with a 6-df robotic system. Internal rotation and anterior translation of the knee were recorded from 0° to 90° of flexion after application of a 5-Nm internal rotation torque and a 134-N anterior load, respectively. A full kinematic assessment was performed in each of the following conditions: (1) intact knee, (2) after sectioning of the anterior cruciate ligament (ACL), (3) after sectioning of the ACL and anterolateral ligament, (4) after isolated ACLR, and (5) after combined ACLR and Lemaire LET and combined ACLR and ALLR. ALLR was performed using the gracilis tendon, whereas the modified Lemaire procedure was performed using the central strip of the iliotibial band. The different states were compared using a Tukey paired comparison test. RESULTS: In knees with combined deficiency of the ACL and anterolateral structures, anterior translation and internal rotation remained significantly increased after isolated ACLR compared with the intact knee (+2.33 ± 1.44 mm and +1.98° ± 1.06°, respectively; P < .01). On the other hand, the addition of ALLR or modified Lemaire LET to ACLR restored anterior translation and internal rotation to values similar to those in the intact knee. The 2 anterolateral procedures did not show statistically significantly different values for both tests. This difference was 0.67 ± 1.46 mm for anterior translation (P = .79) and 0.11° ± 1.11° for internal rotation (P = .99). CONCLUSIONS: In knees with ACL and anterolateral deficiency, combined ACLR and anterolateral reconstruction restored the native knee stability in anterior translation and internal rotation contrary to isolated ACLR. In addition, both types of extra-articular reconstruction-ALLR and modified Lemaire LET-were similar in terms of restoring knee kinematics, and neither overconstrained the knee. CLINICAL RELEVANCE: In knees with deficiency of the ACL and anterolateral structures, combined ACLR and anterolateral reconstruction increased knee stability at time zero after surgery. This biomechanical improvement could be responsible for the protective effect on ACL graft and meniscal repair reported in the literature after the combined procedure.
目的:确定前外侧韧带重建(ALLR)和改良 Lemaire 外侧关节外肌腱固定术(LET)与前交叉韧带重建(ACLR)联合应用的稳定作用,并确定这两种手术中哪一种更具优势。
方法:对 6 个非配对的、新鲜冷冻的人体膝关节进行了测试,使用 6 自由度机器人系统。在施加 5-Nm 内旋扭矩和 134-N 前向载荷后,分别从 0°到 90°的膝关节屈曲记录内旋和前向平移。在以下每种情况下都进行了完整的运动学评估:(1)完整的膝关节,(2)前交叉韧带(ACL)切断后,(3)ACL 和前外侧韧带切断后,(4)单独 ACLR 后,以及(5)联合 ACLR 和 Lemaire LET 以及联合 ACLR 和 ALLR 后。ALLR 使用股薄肌腱进行,而改良的 Lemaire 手术则使用阔筋膜带的中央带进行。使用 Tukey 配对比较检验比较不同状态。
结果:在 ACL 和前外侧结构联合缺失的膝关节中,与完整膝关节相比,单独 ACLR 后前向平移和内旋仍显著增加(分别增加 2.33 ± 1.44mm 和 1.98° ± 1.06°;P <.01)。另一方面,将 ALLR 或改良 Lemaire LET 添加到 ACLR 中可将前向平移和内旋恢复到与完整膝关节相似的值。这两种前外侧手术在这两个测试中没有显示出统计学上显著不同的值。前向平移的差异为 0.67 ± 1.46mm(P =.79),内旋的差异为 0.11° ± 1.11°(P =.99)。
结论:在 ACL 和前外侧结构缺失的膝关节中,联合 ACLR 和前外侧重建术可恢复前向平移和内旋的固有膝关节稳定性,与单独 ACLR 相反。此外,两种类型的关节外重建术-ALLR 和改良 Lemaire LET-在恢复膝关节运动学方面相似,并且两者都没有过度限制膝关节。
临床相关性:在 ACL 和前外侧结构缺失的膝关节中,ACL 和前外侧结构联合重建术可增加术后即刻膝关节的稳定性。这种生物力学的改善可能是文献中报道的联合手术后对 ACL 移植物和半月板修复的保护作用的原因。
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