关节镜辅助下治疗反式Segond骨折2例

正Segond骨折是外侧胫骨平台前外侧韧带止点的撕脱骨折,其损伤由暴力使膝关节屈曲内翻时胫骨内旋引起,常常合并有前交叉韧带(anterior cruciate ligament,ACL)损伤或外侧关节囊半月板损伤[1]。因此Segond骨折是ACL断裂的间接征象。反式Segond骨折位于胫骨平台内侧缘累及内侧副韧带深层的撕脱骨折,与Segond骨折位置相对应,于1997年,由Hall和Hochman[2]首先报道。其受伤机制与Segond     

膝关节多韧带损伤与胫骨平台骨折分型系统的相关性研究

目的观察膝关节多韧带损伤时胫骨平台骨折的形态,探讨胫骨平台骨折类型与韧带撕裂的相关性,同时分析3种胫骨平台骨折分类系统(Schatzker、AO、Duparc)的相关性。方法回顾性分析自2015-12—2017-12诊治的19例膝关节韧带损伤合并胫骨平台骨折。胫骨平台骨折分别按Schatzker、AO、Duparc系统分类,采用Spearman相关系数分析系统间的相关性,采用Logistic回归法估计骨折分级系统、胫骨平台骨折位置(内侧与外侧)与韧带损伤的关系。结果胫骨平台骨折Schatzker、AO、Duparc分类系统之间存在着合理的相关性。胫骨平台骨折Schatzker、Duparc分级的增加与内侧副韧带(MCL)、后外侧复合体(PLC)损伤存在相关性,而与前交叉韧带(ACL)、后交叉韧带(PCL)损伤无相关性。胫骨平台骨折AO分级与膝关节韧带损伤无相关性。ACL撕裂(P=0.110)、PCL撕裂(P=0.270)与胫骨平台骨折位置(内侧与外侧)无相关性,PLC撕裂(P=0.003)、MCL撕裂(P=0.004)与胫骨内侧平台骨折发生存在相关性。结论随着胫骨平台骨折Schatzker分型和Duparc分型等级的增高,膝关节MCL和PLC撕裂的可能性也随之增加。大多数胫骨平台骨折患者合并的膝关节多韧带损伤单发于内侧或外侧胫骨平台,胫骨内侧平台骨折与PLC撕裂相关,胫骨外侧平台骨折与MCL撕裂相关。     

前交叉韧带损伤:3.0TMR影像与关节镜对照分析

目的分析膝关节前交叉韧带损伤的3．0TMRI特征,并与关节镜手术结果对照。方法回顾性分析来我院行3．0T MR膝关节检查的36例前交叉韧带损伤患者的40个膝关节,全部病例经关节镜检查确诊。应用3．0T MR机（Philips Achieva型）,膝关节专用线圈,进行斜矢状位TSE T1WI、TSE T2WI、PD-SPIR和冠状位、轴位TSE T2WI扫描。前交叉韧带损伤分为完全断裂、撕裂（部分断裂）及胫骨端撕脱。将膝关节前交叉韧带损伤的3．0T MR影像特征与关节镜手术结果进行对照分析。结果前交叉韧带完全断裂MRI直接征象表现为韧带连续性中断,断端肿胀（21／25）,间接征象为交叉韧带过度弯曲、T2WI和PD-SPIR股骨髁间窝外侧骨挫伤;MRI与关节镜诊断完全符合率为84．00％。前交叉韧带撕裂（部分断裂）MRI直接征象为ACL矢状T2WI和PD-SPIR显示形态不规则、部分撕裂,ACL局部肿胀增粗,信号增高,仍可见连续存在的纤维低信号;MRI与关节镜诊断完全符合率为66．67％。前交叉韧带胫骨端撕脱MR检查直接征像为胫骨近端可见T1WI、T2WI低信号撕脱骨片（3／3）,ACL水肿、形态不规则,周围可见出血、积液,MRI与关节镜诊断符合率为100％。结论高场强3．0TMR膝关节诊断的多平面、多序列影像相结合可形成ACL立体影像观,结合临床能够有效诊断ACL损伤。     

胫骨平台骨折后漏诊的膝关节韧带损伤的诊治

目的提高对胫骨平台骨折伴膝关节韧带损伤的认识,从而降低漏诊率。方法回顾性分析2001年1月～2004年12月手术治疗的126例胫骨平台骨折患者中伴膝关节韧带损伤的15例患者。通过术后随访、临床表现、手术和MRI检查,明确是否伴有膝关节韧带损伤及膝关节明显不稳。证实存在膝关节韧带损伤者行手术治疗,内侧副韧带损伤患者行修补或“鹅足”转移成形术,前交叉韧带(ACL)损伤患者行Jones改良骨-韧带-骨重建术,后交叉韧带(PCL)损伤患者行Augustine术。结果术后患者获6～14个月(平均10个月)随访。15例胫骨平台骨折患者均伴有膝关节韧带损伤,行相应手术治疗后功能满意者12例,3例出现上、下楼梯困难,并且退变加重。结论胫骨平台骨折常伴膝关节韧带损伤,术前认识不足、术中探查不力、术后随访不到位是漏诊并遗留关节功能障碍的主要原因。     

胫骨平台后内缘骨折合并前十字韧带断裂

膝关节Segond骨折是膝外侧关节囊韧带的撕脱骨折，位于胫骨平台前外缘处，Segond骨折几乎100％合并膝前十字韧带（anterior cruciate ligament，ACL）断裂，因此Segond骨折是ACL断裂的间接征象，文献中已经有多篇报道。本文报告胫骨平台后内缘骨折合并ACL断裂3例，该类骨折既往在国内外文献中只有3例报道，本文报告了1例急性损伤（例3）。我们根据其损伤机制、影像学表现及切开术中所见，分析其损伤机制，并认为胫骨平台后内缘骨折也是ACL断裂的间接征象。[第一段]     

伴前交叉韧带损伤的胫骨外侧平台后侧骨折四例治疗报告

胫骨外侧平台后侧骨折伴前交叉韧带损伤的治疗不同于单纯的胫骨平台骨折,不仅需要骨折解剖复位,可靠固定,还必须修复损伤的韧带,这样才能获得良好功能。1995年3月～1996年11月我们采用胫骨外髁截骨复位植骨内固定韧带修复治疗4例伴前交叉韧带损伤的胫骨外侧平台后侧骨折,其疗效满意,现报告如下:1　临床资料11　一般资料　4例中男3例,女1例,年龄32-51岁,均为摩托车车祸所致,左侧3例,右侧1例,手术前均行Ｘ线拍片和ＣＴ检查,手术在伤后1周内进行。合并伤:4例均有外侧半月板和前交叉韧带损伤。12　手术方法　取膝关节外侧弧形切口,显露膝关节外…     

胫骨平台前外侧撕脱骨折合并前交叉韧带损伤的诊治

胫骨平台前外侧撕脱骨折(Segond骨折)合并前交叉韧带(ACL)损伤在临床中并不少见。对于Segond骨折合并ACL损伤患者如何诊治,越发的被重视起来。本文通过对Segond骨折合并ACL损伤的准确诊断、应急处理、恰当治疗、康复锻炼等方面作一综述,旨在对Segond骨折合并ACL损伤的诊治有所帮助,同时该合并伤应根据个体损伤情况制定个性化的方案。     

胫骨平台外侧缘撕脱骨折的特点及临床诊治分析

目的 :探讨膝关节损伤中胫骨平台外侧缘撕脱骨折的特点及临床诊治。方法 :自2011年1月至2015年12月运用关节镜技术微创治疗关节内损伤结合双锚钉内固定胫骨平台外侧缘撕脱骨折29例,男17例,女12例;年龄27~62岁,平均41岁。20例合并前交叉韧带断裂(包含前交叉韧带胫骨止点撕脱骨折),3例合并后交叉韧带断裂,1例同时合并前交叉韧带和后交叉韧带断裂,3例合并侧副韧带撕裂,2例合并胫骨平台骨折(内侧平台骨折和外侧平台骨折各1例)。术前均行X线、CT及MRI检查明确诊断,在受伤后5~14 d进行手术,平均7 d。采用Lysholm膝关节评分对膝关节术前、术后功能进行评价。结果:手术时间40~125 min,平均85 min;出血量10~30 ml,平均15 ml。术后所有患者获随访,时间12~18个月,平均14个月。Lysholm膝关节评分由术前的52.0±4.2明显提高至术后1年的91.9±1.4(t=-49.24,P0.05)。抽屉试验、Lachman试验及侧方应力试验均阴性,骨折均骨性愈合。结论 :胫骨平台外侧缘撕脱骨折提示合并有膝关节静力稳定结构(关节韧带、关节囊、半月板等)的损伤,甚至关节内骨折。常规要行CT和MRI检查,建议行关节镜探查,防止漏诊,以使患者能得到及时、全面的治疗,为膝关节功能最大限度恢复创造有利条件。     

Segond骨折与前交叉韧带损伤相关性的临床研究

Segond骨折是指胫骨平台外侧的撕脱骨折，也称外侧关节囊征，经常出现在新鲜的膝关节损伤中，几乎都伴随着前交叉韧带的损伤，现对我院收治的41例前交叉韧带损伤合并Segond骨折的患者的诊断及手术治疗经验进行总结。     

关节镜下空心钉内固定治疗青少年前交叉韧带胫骨止点撕脱骨折

目的探讨膝关节镜下空心钉内固定治疗青少年前交叉韧带(ACL)胫骨止点撕脱骨折的手术方法和疗效。方法对17例ACL胫骨止点撕脱骨折均采用关节镜下前外侧入路单或双枚空心钉内固定。结果 17例均获随访5～24个月,X线片示骨折复位满意,均骨性愈合。末次随访时Lysholm评分92～100分,平均96.7分。结论膝关节镜下单或双枚空心钉内固定前交叉韧带胫骨止点撕脱骨折技术具有微创、便捷、固定可靠的优点,值得推广。     

不同后交叉韧带指数测量方法对前交叉韧带损伤的诊断价值

目的:比较6种不同测量方法下的后交叉韧带(posterior cruciate ligament,PCL)指数(Index),分析验证其在前交叉韧带(anterior cruciate ligament,ACL)损伤中的临床诊断价值。方法:回顾性分析2018年5月至2022年3月收治的225例患者的膝关节MRI资料,年龄18～60岁,中位数32岁。根据ACL是否损伤,分为ACL正常组和ACL损伤组。在114例ACL损伤和111例ACL完整受试者的膝关节MRI矢状位图像上,测量MRI矢状位PCL在股骨附着点和胫骨附着点之间的直线距离(A)和该直线到矢状位图像上PCL弧形标记点之间的最大垂直距离(B),计算PCL Index并评估其对ACL损伤的诊断价值。结果:ACL正常组和ACL损伤组PCL Index1、2、3、6比较差异无统计学意义(P>0.05);两组PCL Index4、5比较,差异有统计学意义(P<0.001)。ACL正常组的PCL Index2、6与患者年龄呈负相关性(相关系数=-0.213,-0.189;P<0.05),ACL损伤组的PCL Index5与...     

Tibial articular cartilage and meniscus geometries combine to influence female risk of anterior cruciate ligament injury

Tibial plateau subchondral bone geometry has been associated with the risk of sustaining a non‐contact ACL injury; however, little is known regarding the influence of the meniscus and articular cartilage interface geometry on risk. We hypothesized that geometries of the tibial plateau articular cartilage surface and meniscus were individually associated with the risk of non‐contact ACL injury. In addition, we hypothesized that the associations were independent of the underlying subchondral bone geometry. MRI scans were acquired on 88 subjects that suffered non‐contact ACL injuries (27 males, 61 females) and 88 matched control subjects that were selected from the injured subject's teammates and were thus matched on sex, sport, level of play, and exposure to risk of injury. Multivariate analysis of the female data revealed that increased posterior‐inferior directed slope of the middle articular cartilage region and decreased height of the posterior horn of the meniscus in the lateral compartment were associated with increased risk of sustaining a first time, non‐contact ACL injury, independent of each other and of the slope of the tibial plateau subchondral bone. No measures were independently related to risk of non‐contact ACL injury among males. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:1487–1494, 2014.     

Proximal avulsion of five ligaments and revised diagonal principle in tibial plateau fractures

PurposeThe aim of the study was to analyze the incidence of proximal avulsion of the five main ligaments and to revise the diagonal tension/compression concept in tibial plateau fractures.MethodsComputed tomographic images of 1263 cases of tibial plateau fractures were retrospectively analyzed by the OTA/AO classification and four-column nine-segment classification. The correlation between proximal avulsion of five ligaments and the injury mechanism was analyzed.ResultsIn total, 1263 tibial plateau fractures in 1253 patients were included. A total of 92 cases (7.3%) associated with proximal avulsions were identified among the 1263 tibial plateau fracture cases obtained from our institution's database. The 92 avulsions occurred in 82 patients, among whom 10 patients had two different avulsions in a single knee. The incidence of proximal avulsion fracture of the medial and lateral collateral ligament was 3.6% (45/1263) and 2.1% (26/1263), respectively. The incidence of avulsion of the anterior cruciate ligament and avulsion of the posterior cruciate ligament was much lower at 0.2% (2/1263) and 0.1% (1/1263), respectively. Proximal avulsion of the patellar ligament occurred in 18 cases (incidence rate = 1.4%). Several combinations of injuries, composed of distal tibial plateau fractures and proximal avulsion of ligaments, were identified.ConclusionsAmong the patients with tibial plateau fracture, the incidence of proximal avulsion of the five ligaments was 7.3% (92/1263). The four-column and nine-segment classification is an exhaustive method for recording injuries in these ligaments. The revised diagonal injury concept is useful for understanding the injury mechanism and choosing the appropriate surgical strategy.     

Magnetic resonance imaging (MRI) and Computed topography (CT) analysis of Schatzker type IV tibial plateau fracture revealed possible mechanisms of injury beyond varus deforming force

BackgroundSchatzker type IV tibial plateau fractures (type IV TPFs) are known for complex fracture morphology and high frequency of knee subluxation. Varus deforming force has been believed to be the cause but which fails to explain the lateral tibial plateau comminution and the lateral femoral condyle bone edema observed on injury MRI. The purpose of this study is to further explore the mechanisms of injury of type IV TPFs by synthetically analysing the information obtained from MRI and CT of a cohort of patients.MethodsBetween 2010 and 2019, 49 type IV TPFs were surgically treated in our hospital. The patients with complete preoperative CT and MRI were enrolled. They were classified according to OTA/AO and Luo's updated three-column classification (uTCC) after fracture morphology analysing and measuring. Then the injuries of cruciate/collateral ligaments and bone contusion were studied on MRI. The discrepancy between obvious fracture and occult bone contusion/soft tissue disruption among the groups of uTCC were compared and analysed.ResultsThirty patients were eligible for this study. Under uTCC system, all the cases were caused by varus force according to the tibial plateau angle and were classified into three groups of uTCC referring the posterior tibial slope angle: 4 were into hyperextension-varus, 21 into the extension-varus and 5 into the flexion-varus group. Fracture morphology analysis found in the extension-varus group, there were two distinct subgroups: OTA/AO 41B1.2 (medial+posteromedial columns disruption) and 41B3.3f (41B1.2 +posterolateral column disruption). Injury MRI revealed 28 of the 30 cases had more than 2 ligamentous injuries. The incidences of anterior and posterior cruciate injury were 96.7% and 43.3% respectively while 70% for medial collateral ligament (MCL). Eighteen out of 30 demonstrated apparent lateral femoral condyle bone contusion sign. Chi-square analysis found in the extension-varus group, the posterolateral column comminution was closely associated with lateral femoral condylar contusion (p<0.05) and MCL injuries (p<0.05). This finding and the absence of medial femoral condylar contusion was unlikely caused by uTCC proposed varus deforming force.ConclusionIn contrast to varus impaction, some type IV TPFs was probably caused by valgus or rotation force.     

Evaluation of anatomic risk factors using magnetic resonance imaging in non-contact anterior cruciate ligament injury

BackgroundThe purpose of our study was to compare the significance of the tibio-femoral morphological variables (notch width index, notch shape index, intercondylar notch angle, medial and lateral tibial slopes) in predicting non-contact ACL (anterior cruciate ligament) injuries and to compare these factors between genders in South Asian population. The author hopes to provide a comprehensive analysis on the risk factors which would help in betterment of the patients at danger for anterior cruciate ligament injury.Materials and methodsA total of 110 MRI knees of patients with 55 subjects of noncontact ACL injury and 55 age and sex matched controls were included in a retrospective study. Notch width index, notch shape index, intercondylar notch angle were assessed in axial and coronal MR imaging along with medial and lateral posterior tibial slopes. Morphology of the notch was also assessed.ResultsACL injured group were found to have a statistically significant narrow notch width index and decreased intercondylar notch angle with increased lateral posterior tibial slope. Type-A notches were found to have increased risk of having ACL injuries. Gender comparative results showed no statistically significant differences.ConclusionACL tears are associated with decreased notch width index, intercondylar notch angle and increased lateral posterior tibial slope. Type-A notches are seen to have increased risk for ACL injuries.     

后方入路治疗胫骨平台后方骨折

目的:探讨后方入路治疗胫骨平台后方骨折的骨折类型、手术方法和临床疗效。方法:回顾性分析自2008年6月至2011年2月采用后方入路治疗且随访完整的8例胫骨平台后方骨折,男5例,女3例;年龄23～55岁,平均41.1岁。致伤原因:车祸伤5例,高处坠落伤3例。2例胫骨平台后方冠状面骨折伴后交叉韧带撕脱和1例后外侧平台劈裂伴塌陷骨折采用正后方"S"形入路,2例后内侧平台骨折采用后内侧倒"L"型入路,3例同时累及胫骨平台前后侧及胫骨干骺端骨折者采用后内侧倒"L"形入路联合前外侧入路行钢板螺钉内固定。关节面塌陷者采用同种异体骨或自体髂骨植骨术。结果:所有患者获得随访,时间8～39个月,平均20个月。全部病例获得影像学上的骨性愈合,愈合时间11～21周,平均14.5周。术中未出现血管、神经损伤,术后无一例出现切口感染、内固定松动及断裂。所有患者术后即刻与术后6个月胫骨平台内翻角(TPA)、内外侧平台后倾角(PA)度数均无统计学差异。术后末次随访Rasmussen膝关节功能评分为19～29分,平均25.60分,其中优4例,良3例,可1例。术后末次随访Rasmussen放射学评分14～18分,平均17.25分,其中优6例,良2例。结论:胫骨平台骨折以后侧为主时,后方入路能得到很好的骨折端暴露,有利于直视下复位固定,术后近期疗效满意。     

Tibial tunnel enlargement after anatomic anterior cruciate ligament reconstruction with a bone–patellar tendon–bone graft. Part 1: Morphological change in the tibial tunnel

BackgroundThree-dimensional (3D) computed tomography (CT) is reliable and accurate imaging modality for evaluating tunnel enlargement after anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to evaluate the tibial tunnel enlargement including the morphological change after anatomic ACL reconstruction with a bone–patellar tendon–bone (BTB) graft using 3D CT models.MethodsEighteen patients with unilateral ACL rupture were included. The anatomic rectangular-tunnel (ART) ACL reconstruction with a BTB autograft was performed. 3D CT models of the tibia, the tibial tunnel, and the bone plug at 3 weeks and 1 year after surgery were reconstructed and superimposed using a surface registration technique. The cross-sectional area (CSA) of the tibial tunnel perpendicular to the tunnel axis was evaluated at the aperture and 5, 10, and 15-mm distal from the aperture. The CSA was measured at 3 weeks and 1 year after surgery and compared between the two time points. The locations of the center and the anterior, posterior, medial, and lateral edges of the tunnel footprint were also evaluated based on the coordinate system for the tibial plateau and compared between the two time points.ResultsAt the aperture, the CSA of the tibial tunnel at 1 year after surgery was significantly larger by 21.9% than that at 3 weeks (P < 0.001). In contrast, the CSA at 1 year was significantly smaller than that at 3 weeks at 10 and 15-mm distal from the aperture (P = 0.041 and < 0.001, respectively). The center of the tunnel footprint significantly shifted postero-laterally with significant posterior shift of the anterior/posterior edges and lateral shift of the lateral edge (P < 0.001).ConclusionThe tibial tunnel enlarged at the aperture by 22% 1-year after anatomic ACL reconstruction with a BTB graft, and the tunnel morphology changed in a postero-lateral direction at the aperture and into conical shape inside the tunnel.     

Comparison of anatomical risk factors for noncontact anterior cruciate ligament injury using magnetic resonance imaging

PurposeTo compare the significance of the tibio-femoral geometrical indices (notch width index, medial and lateral tibial slopes) and patellar tendon- tibial shaft angle in predicting non-contact ACL injuries and to compare these factors between genders.MethodsRetrospective case control study evaluating 66 MRI knee of patients of age group of 18–60 years with 33 cases of noncontact ACL injury and 33 age matched controls. Notch width index, medial and lateral tibial slopes and patellar tendon tibial shaft angles were calculated and compared for statistical significance and was also compared between the genders. ROC curve was for plotted for the significant factors.ResultsStatistically significant difference was seen in notch width index and patellar tendon tibial shaft angles with cases showing a narrow notch width index and an increased patellar tendon tibial shaft angle. Gender comparative results showed no statistically significant differences. ROC curve plotted for NWI showed an optimal cut off value of 0.263 with a sensitivity of 88% and a specificity of 52%. ROC curve plotted for PTTS angle showed a cut off value of 26.7 degrees with a sensitivity of 67% and a specificity of 49%.ConclusionNarrow Notch width index and increased Patellar tendon tibial shaft angle are predictors of ACL injury. PTTS angle which has been studied as a function of knee flexion angle, can itself be an independent predictor of ACL injury (at a constant knee flexion angle).     

胫骨上段骨折并腘动脉分叉部闭合性损伤的临床观察

目的：探讨手术治疗胫骨上段骨折合并腘动脉特殊部位损伤的疗效,为临床提供可选择的显微手术方法。方法：2002年2月至2007年10月,胫骨上端骨折并腘动脉分叉处损伤患者19例,男15例,女4例;年龄21～48岁,平均35岁。合并胫骨平台骨折6例;合并神经损伤3例。采用外固定支架固定胫骨骨折,结合小腿近端后侧及前外侧切口对骨间膜开窗引洞,利用移植的大隐静脉（或＂Y＂形）桥接同时修复胫前及胫后动静脉。疗效评价依照Rasmussen评分法。结果：19例均恢复血运,骨折均愈合,愈合时间3～14个月,平均5.5个月。19例获得随访,随访时间8～23个月,平均13个月。疗效评价依照Rasmussen评分法,术后总评分达（27.0±2.9）分;疗效分级：优11例,良7例,可1例。结论：诊断明确后或高度怀疑有血管损伤者应该尽早手术探查。同时重建胫前、胫后动静脉血循环能够降低伤残并且有利于肢体功能恢复。