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1、ACL的解剖,研究表明，前交叉韧带由独立的两束构成: 前内束 (AM) 后外束 (PL) 怀孕16周的胎儿就能明显地看出两束 两束的命名是按胫骨的附着位置来定的 AM 束和 PL 束有不同的长度，宽度和附着点,Courtesy of Dr. F. Fu,“One could say that you are born with, you live with and you die with a double-bundle ACL” - Freddie Fu, Orthopaedics Today, 2007,16 weeks,25 Years,88 Years,Photo Courtesy o
2、f Dr. F Fu,ACL的双束结构伴随人的一生,Tibial Insertion of the AM and PL Bundles,Anteromedial Bundle (AM) Posterolateral Bundle (PL) These bundles are named according to their insertion site on the tibial footprint,PL,AM,ACL Femoral Insertion Sites,Photo Courtesy of Dr. Charles Brown,Morphology of the Intercondy
3、lar Notch,“Residents ridge” originally named by William G. Clancy Jr. MD The residents ridge is an osseous landmark in the medial wall of the lateral femoral condyle Runs from proximal to distal and anterior to posterior with the knee in the anatomic position Mistaking the residents ridge for the tr
4、ue over-the-top position leads to anterior placement of the ACL femoral tunnel,Photo Courtesy of Dr. F Fu,Important Boney Landmarks,Photo Courtesy of Dr. F Fu,It is essential to identify the appropriate footprint of the native ACL Avoid use of the shaver to remove soft tissue from the notch Use VULC
5、AN probe to clear soft tissue from the notch,Preserving Osseous Landmarks in the Notch,为什么要ACL解剖重建?,传统的重建(单束)有很好的结果,但是 只是前内束重建 手术医生只是建立了一个前内束的股骨隧道,后外束的胫骨隧道 正常膝关节的运动,特别是旋转稳定没有恢复 Georgoulis et al. 2003, Tashman et al. 2004 14-30% 病人有轴移 Grana et al. 1992, Karlson et al. 1994, Lerat et al. 1998 近来ACL重建仍
6、没有办法减低AO的发生危险 (相反可能会增高),解剖要点,Antero-Medial Bundle (Blue) 胫骨止点: 前 & 内 股骨止点: 上 & 后 直径粗 长度长( 3cm) 伸直位保持膝关节稳定 屈曲位保持前/后向稳定,Postero-Lateral Bundle (Red) 胫骨止点: 外/后(与 AM参照) 股骨止点: 下(与 AM参照) 较 AM短 非伸直位有助于膝关节稳定 屈曲时控制旋转稳定,ACL 解剖重建的目标,达到单束的前/后向稳定 改善单束不能控制的旋转稳定 尽可能地恢复膝关节的正常形态学与运动功能,前内束和后外束有不同的长度和直径,38.5 (+/-3),19
7、.7 (+/-2),AM,PL,7.0 mm,6.4 mm,AM,PL,解剖,PL bundle,AM bundle,伸直位,弯曲位,AM,PL,AM,PL,股骨止点位置和膝关节不同位置有关,AM,PL,单束/双束重建的选择,足印长度14mm,选择双束重建,足印长度14mm,选择单束重建,ACL传统重建和解剖关系,ACL 解剖重建入路 : Anteromedial Approach（前内入路）,当前最常用的ACL手术技术 在经胫骨隧道技术中，ACL的股骨通道是通过胫骨隧道来获得的,Transtibial Technique 经胫骨隧道技术,问题:以下两种ACL重建区别点？,经胫骨隧道技术,优点
8、 技术快速，简单 教给医生的主要技巧 大多数医生熟悉的技术 膝关节不需要求屈膝超过90,缺点 股骨隧道的位置无法自由选择 不考虑膝关节的解剖 技术受工具和导向器所限制 这种技术的最主要目的是恢复前交叉韧带的前后稳定结构 需要更长预置环的ENDOBUTTON CL（减少强度）,“Current tibial endoscopic ACL reconstruction techniques provide functional stability, but fall short of the ultimate goal of ACL reconstruction, to restore norma
9、l knee kinematics. Vertical graft placement results in restoration of normal antero-posterior stability with a negative Lachman test, but may not produce a stable knee in rotation, noted by a positive pivot shift.” “当前的胫骨ACL重建技术提供了功能稳定，但是离ACL的最终的恢复膝关节正常运动目标还很远。垂直移植物放置使得前后稳定得到恢复因而在LACHMAN实验中是满意的，但旋转的
10、稳定无法恢复，这点在轴移实验中能体现。”,William G. Clancy Jr.,MD Orthopedic Clinics North America,经胫骨隧道技术的局限性,The transtibial technique can produce tunnels centered in the ACL footprints, but a starting point close to the tibia joint line is required. This will result in a relatively short tibial tunnel. 经胫骨隧道技术可以使得股骨
11、隧道在ACL足印的中间，但胫骨的入点就要靠近胫骨关节线。这将导致胫骨隧道变得很短。,Am J Sports Med 2007,“It is our impression that graft placements with previously recommended trans-tibial tunnel drilling methods miss the central footprint and result in grafts that are more vertical than ideal.” Henning et al, Am J Sports Med 2007,用经胫骨隧道放置
12、股骨钻的方式导致移植物比理想位置更加垂直。,Produces a vertical ACL graft in both the coronal and sagittal planes 在ACL的冠状面和矢状面移植物位置偏垂直 Results in restoration of normal A-P stability with a negative Lachman test, but may not produce a stable knee in rotation 结果是恢复前后稳定，Lachman实验阴性，但旋转稳定无法恢复,经典的经胫骨隧道技术,Heming & al, Am J Spo
13、rts Med 2007,Internal Use Only,Transtibial Tunnel Technique misses the Femoral Anatomic Insertion Site,Photo Courtesy of Dr. Charles Brown,患者体位 仰卧位 无需腿架 侧面加强 手术时医生可以完全弯曲和伸直膝关节,前内入路技术,正确的入路选择最重要 前内入路尽量偏下（尽量靠近胫骨） 创建这个入路最好在影像引导下创建确保不要太低而损伤到下角的内侧半月板 该入路应尽可能偏内（避免损伤内侧股骨髁）,前内入路技术,MEDIAL,前内入路手术步骤,ACL 残端清除 髁
14、间凹准备，千万不要做髁间凹成型 + + 至少屈膝110，放置股骨导向器 放置线环用于移植物穿行 膝关节回到90，放置胫骨导向器 通过胫骨通道抓出缝线环 穿过移植物 上好ENDOBUTTON CL 后，确保至少活动20次膝关节 膝关节屈膝0到30固定胫骨,前内入路,钻股骨隧道时膝关节屈膝110到120 往往会产生更短的股骨隧道 (45 to 55 mm) 膝关节高度屈膝时，经验不足的医生可能会有一些轻微的空间定位障碍 经验: 用一个3.6 mm 空心导针放在同一入路，这样医生在钻股骨隧道时视野更好,通常是用表盘来作为ACL股骨隧道的参考 这种入路仅仅定义一个平面但是ACL并非在一个平面上 Thi
15、s approach does not allow shallow-deep placement along the wall of the notch to be accurately assessed,ACL 股骨隧道放置,Photo courtesy of Dr. Charles Brown,High/Superior,Deep/Low,Shallow,Deep,ACL 股骨隧道放置,ACL 股骨隧道放置,强调股骨定位位置是（10：30或者2：30） Emphasis is placed on the appropriate femoral insertion of the graft
16、(10:30 or 2:30) 强调位置位于患者自己原有解剖位置上 Emphasis on Anatomic placement of the graft at the patients own anatomic insertion site 强调等长重建 Emphasis on isometry 强调没有移植物撞击 Emphasis on no impingement of the graft,Acufex DIRECTOR Elite Femoral Aimer,股骨瞄准器修改 Anatomic hook allows for easy access through the fat pad
17、, 新设计使得容易通过脂肪垫到达所要的位置 Longer tip facilitates positioning at the femoral ACL footprint 在股骨足印那有更长的尖端 Size markings at the tip 尺寸标记在尖端,ACL Tibial Insertion Sites,Tibial Tunnel Placement,Thorough visualization of the ACL tibial footprint is critical for proper placement of the tibial tunnel Position the
18、 tibial tunnel using the ACUFEX DIRECTOR Drill Guide This guide achieves rigidity & accuracy in a one-handed operation Two aimers: ”Tip” Aimer, to be placed in the middle of the ACL tibial footprint “Elbow” Aimer, to be placed in the posterior fiber of the ACL tibial footprint,Advantages of AM Porta
19、l Technique,Socket placement is unconstrained compared with trans-tibial portal placement Essential for anatomic placement of posterolateral ACL femoral socket during double-bundle ACL reconstruction For femoral cannulated interference screw fixation option, ensures parallel socket and screw angle (
20、no divergence) because reaming and screwing are via same (AM) portal Helpful in revision situations where prior high, anterior, misplaced femoral sockets may be avoided because preexisting Trans-tibial femoral sockets are approached at a different reaming angle Dr James Lubowitz, Arthroscopy Journal
21、, January 2009,Advantages of AM Portal Technique,Fast Learning Curve (approx 10 procedures) 快速的学习曲线（大约10个手术） Femoral tunnel drilled independent of the tibial tunnel 股骨隧道的钻取和胫骨隧道无关 Can be used with any graft type 能用任何类型的移植物 Requires no special guides or instrumentation 无需特殊的导向器 Femoral socket is with
22、in the footprint of the ACL, at 10:30 (or 2:30) 股骨附着点位于ACL足印位置（10：30或2：30） Allows preservation of remaining intact ACL fibers facilitating isolated AMB or PLB reconstruction for the most advanced surgeons 对于高级医生可以实现部分韧带重建 Femoral tunnel can be drilled under ideal arthroscopic conditions without loss of joint distention from fluid extravasation through the tibial tunnel 钻取股骨隧道时不存在关节腔液体从胫骨隧道流出的现象 Femoral tunnel are shorter than in trans-tibial techniques 股骨隧道比经胫骨隧道方法更短,