关节镜下膝关节腘肌腱重建的实验研究

Experimental Study of Arthroscopic Popliteus Tendon Reconstruction Technique in Knee Joint

目的：进一步研究膝关节后外复合体（posterolateral complex,PLC）与腘肌复合体的解剖特点,设计关节镜下重建腘肌腱的手术方法。方法：通过10例成人膝关节尸体标本进行两部分研究,每部分各取5例标本：第一部分进行大体解剖研究,对腘肌复合体（包括腘肌腱、肌腹、股骨附着点、肌腱-肌腹交界区）的解剖特点以及周围相邻解剖结构（包括胫骨平台、外侧半月板后角、后交叉韧带、腘腓韧带、血管）进行观察和测量。第二部分进行关节镜下手术重建技术的流程设计。设计显露腘肌腱的股骨附着点和肌腱-肌腹交界点的关节镜入路以及股骨和胫骨隧道的定位与制备方法,引入移植物并固定,完成腘肌腱的重建。结果：第一部分：腘肌腱的股骨附着点位于滑膜反折区,属滑膜外结构;止于股骨的腘肌腱沟的最近端,与关节软骨边缘紧邻,与外侧副韧带股骨附着点中心相距1.5-1.6cm。腘肌腱走行于腘肌腱浅沟内、肌腱-肌腹交界点位于胫骨后外侧平台的内、外中线与关节软骨面远侧1.0cm线的交点上,内侧距离后交叉韧带外侧边缘1.2-2.0cm、外侧与上胫腓关节的内侧缘紧邻。第二部分：进行膝关节镜下手术操作。采用前外入路及外侧辅助关节镜入路切除腘肌腱近端附着点周围滑膜反折,显露整个附着区,并利用克氏针确定中心点,自外向内制备股骨隧道。通过后外、后内及穿后间隔关节镜入路,沿腘肌腱走行局部切开与后关节囊的结合部,显露肌腱-肌腹交界点,并利用前交叉韧带重建胫骨导向器定位,自Gerdy结节向该交界点制备前后方向胫骨骨隧道。将移植物引入两隧道,并用挤压螺钉固定。5例标本手术均获成功,移植物可有效控制外旋稳定性。结论：根据解剖研究确定腘肌腱远近端的定位标志,通过关节镜技术进行显露及定位,在关节镜下完成腘肌腱的重建手术具有可行性。

Objectives This study was conducted for defining the anatomical features of popliteus and was designed for arthroscopic reconstruction of posterolateral complex（PLC）. Methods Ten fresh-frozen human cadaveric knees were used for this two-part study. Part Ⅰ （gross anatomy of cadaver dissection of the popliteus muscle complex, including the popliteus tendon, the femoral insertion and the musculotendinous junction） was carried out in 5 human adult cadaver knees. The anatomical relationships between popliteus and its surrounding structures including posterolateral tibia plateau, posterior horn of lateral meniscus, posterior cruciate ligament, popliteofibular ligament, and neurovascular system were observed and measured. Part Ⅱ was designed for arthroscopic reconstruction and working procedure of popliteus tendon in another 5 cadaveric knee models. Arthroscopic portals were designed for exploration and localization of the proximal insertion and distal museulotendoninous junction of popliteus, Femoral and tibial tunnel location, drilling, graft irnplanation and fixation technique were used to complete the procedure. Results Part I： The dissection of all speciments revealed that the popliteus tendon attached on the femur extraarticularly and had an attachment at the most proximal end of popliteal sulcus that was close to the cartilage edge. The distance betweent the center of femoral attachment of popliteus and lateral collateral ligament was 1.5-1.6cm. The musculotendinous iunction was at the intersection point of the middle line of medial-lateral posterolateral tibia plateaus and the line of 1.0cm distal to the joint line of tibial plateau. The distance of the junction to the lateral border of posterior crucate ligament was 1.2-2.0cm and slightly medial to the proximal tibiofibular joint. Part Ⅱ： Five knee arthroscopy were performed. With the anterolateral and lateral accessory portals, synoveal fold around the popliteus femoral attachment was resected to explore the footprint and thus K-wire localization and tunnel drilling can he made. With posterolateal, posteromedial and transeptal portals, the posterior capsular attachment of the popliteus was minimally resected for identification of the musculotendinous junction. The tibia aimer of anterior cruciate ligament reconstruction was placed through posterolateral portal to verify the anterior-posterior tibial tunnel drilling. Finally, graft was implanted and fixed with bioabsorbable interference screws in both the femoral and tibial tunnels. Five cadaveric surgeries were successful and all the popliteus reconstructive graft can effectively restore external rotation of knee joint. Conclusions According to the anatomical features of popliteus from the present cadaveric study, arthroseopic popliteus reconstruction is feasible.