保留残端的后交叉韧带解剖重建胫骨骨道软组织参考定位的研究

Soft landmarks for a low tibial tunnel in anatomical reconstruction of the posterior cruciate ligament with remnant preservation

目的探讨在后交叉韧带(PCL)保留残端重建术中以后纵隔等软组织为参考标志,在PCL胫骨足印区内创建低位骨道的方法。方法解剖新鲜成人膝关节尸体标本12具,观察PCL胫骨止点与后纵隔、后关节囊位置关系,并紧贴后关节囊远端反折和后纵隔定位低位骨道中心(SP),测量SP和胫骨止点中心(CP)与周围组织结构的定位关系。将所有标本随机分为两组(n=6)并分别以SP和CP为中心创建SP骨道和CP骨道,通过CT三维重建模型评估两个骨道的定位关系。对14例PCL重建术患者通过关节镜下定位后纵隔和后关节囊远端反折,证实SP骨道的安全性和临床可重复性。结果解剖发现12具标本中PCL胫骨止点的外缘和下缘分别紧贴后纵隔和后关节囊远端反折处,SP位于CP外侧(2.9±0.3)mm和下方(3.8±0.4)mm,距离后纵隔(4.3±0.3)mm,创建的SP骨道未损伤后纵隔的完整结构,骨道后壁距离后关节囊远端反折处为(1.6±0.3)mm。CT三维重建模型进一步证明SP骨道中心相对于CP骨道中心更偏外和更偏下。14例患者均成功在关节镜下行PCL重建术,刨刀辅助撑开后关节囊增大膝关节后方操作空间,可以在PCL足印区内紧贴后纵隔和后关节囊远端反折成功创建低位胫骨骨道行PCL解剖和保残重建。结论以后纵隔和后关节囊远端反折作为低位胫骨骨道定位标志,可以实现PCL的解剖和保残重建。

ObjectiveTo propose a low tunnel in the tibial footprint area of the posterior cruciate ligament(PCL)with the posterior septum and the posterior capsule as soft landmarks in PCL reconstruction with remnant preservation.MethodsA total of 12 fresh cadaveric adult specimens of the knee joint were dissected to observe the relationships between the tibial insertion of PCL and the posterior septum and the posterior capsule.The distal reflection of the posterior capsule and the posterior septum were preserved as soft landmarks to locate the center position of a low tibial tunnel(SP).The relationships between SP and the center of tibial insertion(CP)and other surrounding tissue structures were measured.All the specimens were randomly divided into 2 even groups(n=6)in which SP and CP were respectively used as the center to create a SP tunnel and a CP tunnel.The positioning relationship and safety of the tunnels were evaluated by three-dimensional CT reconstruction.In 14 patients undergoing PCL reconstruction,the posterior septum and distal reflection of the posterior capsule were arthroscopically localized to confirm the safety and clinical repeatability of the SP tunnel.ResultsThe anatomical dissection in the 12 specimens discovered that the lateral and inferior edges of the PCL tibial insertion were close to the posterior septum and the distal reflection of the posterior capsule,respectively.SP was located(2.9±0.3)mm outside CP and(3.8±0.4)mm below CP,and(4.3±0.3)mm away from the posterior septum.The SP tunnel created did not harm an intact structure of the posterior septum,for the distance between the posterior wall of the SP tunnel and the distal reflection of the posterior capsule was(1.6±0.3)mm.The CT three-dimensional reconstruction model further confirmed that the center of the SP tunnel was more downward and outward relative to the center of the CP tunnel.Arthroscopic PCL reconstruction was successful in all the 14 patients.With the aid of a shaver,the posterior capsule was expanded arthroscopically to increase the operating space in the posterior compartment of the knee joint so that a low tunnel in the tibial footprint area of PCL was created close to the posterior septum and the distal reflection of the posterior capsule for successful anatomical PCL reconstruction with remnant preservation.ConclusionA low tibial tunnel can be created using the posterior septum and the distal reflection of the posterior capsule as the soft landmarks for anatomical PCL reconstruction with remnant preservation.