Lobenhoffer P, Tscherne H
Unfallchirurgische Klinik, Medizinischen Hochschule Hannover.
Unfallchirurg. 1993 Mar;96(3):150-68.
This article summarizes the present knowledge on the diagnosis of and treatment rationales for ruptures of the anterior cruciate ligament (ACL) of the knee. There is an increasing incidence of this injury due to the high number of persons involved in dynamic sports. The most significant diagnostic criterion is a positive pivot shift associated with a pathological anterior translation of the tibia in slight flexion of the knee. Instrumented testing of the knee is becoming increasing important and is standard in follow-up studies. A survey of the literature at present delineates very clearly the importance of an intact ACL for homeostasis of the knee. Loss of this structure leads to a high incidence of secondary meniscus tears with consecutive osteoarthritis of the knee. All valid studies also indicate an involuntary decrease of activity in the patients after loss of the ACL. Risk factors for early decompensation of the knee are a young age, high activity level, rupture of the collateral ligaments, congenital laxity, varus morphotype and high initial laxity. Primary repair of the ACL is possible, but results in stable ligament healing in only a limited percentage of cases. Reconstruction of the ACL with a free patellar tendon graft has become the standard procedure for many surgeons. ACL reconstruction can be performed either arthroscopically or through a "miniarthrotomy" with comparable results. Augmented repair or reconstruction using autologous flexor tendons is an alternative in certain cases. Augmentation with allogeneic material and the use of tendon allografts are still experimental and should be restricted to centers that can perform strict follow-up studies. The rehabilitation program after implantation of a patellar tendon graft can be accelerated markedly without endangering joint stability. Crutches are necessary only for the first 2-3 weeks. The success rate in terms of objective stability with an autologous patellar tendon graft is high, although specific disadvantages such as chronic patellar pain and a risk for loss of motion must be considered.
本文总结了目前关于膝关节前交叉韧带（ACL）断裂的诊断及治疗依据的知识。由于参与动态运动的人数众多，这种损伤的发生率正在上升。最重要的诊断标准是在膝关节轻度屈曲时，伴有胫骨病理性前向移位的阳性轴移试验。膝关节的仪器检测变得越来越重要，并且是随访研究的标准方法。目前的文献调查非常清楚地表明了完整的ACL对膝关节稳态的重要性。这种结构的丧失会导致继发性半月板撕裂和膝关节继发性骨关节炎的高发生率。所有有效的研究还表明，ACL丧失后患者的活动会不由自主地减少。膝关节早期失代偿的危险因素包括年轻、高活动水平、侧副韧带断裂、先天性松弛、内翻形态和初始高松弛度。ACL的一期修复是可行的，但仅在有限比例的病例中能实现韧带的稳定愈合。使用游离髌腱移植重建ACL已成为许多外科医生的标准手术方法。ACL重建可通过关节镜或“小切口手术”进行，结果相当。在某些情况下，使用自体屈肌腱进行增强修复或重建是一种替代方法。使用同种异体材料增强和使用同种异体肌腱移植仍处于实验阶段，应仅限于能够进行严格随访研究的中心。植入髌腱移植后的康复计划可以显著加速，而不会危及关节稳定性。仅在最初的2 - 3周需要使用拐杖。尽管必须考虑诸如慢性髌前疼痛和活动度丧失风险等特定缺点，但自体髌腱移植在客观稳定性方面的成功率很高。
