目的:观察膝关节脱位多发韧带损伤一期同时重建并修复内侧不稳,中医药辅助治疗的临床疗效.方法:回顾性分析2017 年6月至2020年12 月我科收治的膝关节脱位多发韧带损伤患者 25 例,诊断为前十字韧带损伤和后十字韧带损伤合并内侧副韧带Ⅲ度°损伤.患者均一期行自体腘绳肌腱、腓骨长肌腱移植膝关节镜下重建前后十字韧带,联合有限切开修复内侧稳定结构,联合中医药辅助治疗.末次随访采用Lysholm评分、IKDC评分系统评价膝关节功能,并通过Lachman试验、PDT试验、外翻应力试验评价膝关节稳定性.结果:所有患者均全部获得随访,平均随访(25.61±8.62)个月.末次随访时,Lysholm、IKDC评分和膝关节活动度均明显恢复.Lachman试验:23例阴性,2例I度阳性,阴性率为92.0％(22/25).PDT试验:21例阴性,4例I度阳性,阴性率为84.0％(21/25).侧方(内翻)应力试验:阴性24例,阳性1例(I°),阴性率为96.0％(24/25).结论:对于合并膝关节内侧不稳定的多发韧带损伤患者,关节镜下行一期重建前后十字韧带并修复内侧损伤,联合中医药辅助治疗,可取得优良的初期临床疗效.

Our study assesses the role of a scaffold constructed by co-culture of autologous oxygen-releasing biomimetic scaffold (AONS) and chondrocytes in joint repair after trauma. A composite scaffold structure was used and a scaffold constructed of AONS and chondrocytes was transplanted into SD rats to create models of patellar cartilage fracture and hip osteochondral fracture, respectively followed by analysis of cell proliferation by immunofluorescence method, osteogenesis-related gene expression by RT-PCR, chondrocytes apoptosis by TUNEL staining. The blank control group and AONS composite chondrocytes have significant differences in apoptosis and cell proliferation of two fracture types (P <0.05). The autologous oxygen-releasing nanometers at 4 and 8 weeks showed a significant difference in the number of PCNA and TUNEL cells between biomimetic scaffold and chondrocytes in two groups (P < 0.05). The AONS and chondrocytes were effective for two types of fractures at 1, 4 and 8 weeks. The expression of various markers of intrachondral osteogenesis was decreased and the markers of hip osteochondral fracture were increased significantly (P < 0.05). Joint recovery was better than patellar cartilage fractures. The AONS composite chondrocyte scaffold promotes repair of patellar cartilage fractures and hip osteochondral fractures with a better effect on hip osteochondral fractures.

目的 分析膝关节镜下Endo-Button钛板结合高强缝线SMC结用于后交叉韧带(posterior cruciate ligament,PCL)撕脱骨折的疗效.方法 回顾分析自2018年6月至2020年12月甘肃省中医院采用膝关节镜下高强缝线结合Endo-Button钛板固定术治疗的24例PCL胫骨侧止点撕脱骨折患者资料,其中男10例,女14例;左膝11例,右膝13例;年龄24～48岁,平均(36.0±9.7)岁.交通意外伤13例,跌扑伤8例,其他原因3例;全部为闭合伤.受伤至手术时间5～10 d,平均(7.6±2.8)d.合并内侧半月板白区损伤2例,内侧副韧带(medial collateral ligament,MCL)I度损伤3例.手术均由同一术者主刀.采用Lysholm评分及国际膝关节文献委员会(international knee documentation committee,IKDC)膝关节评分评估患肢功能.结果 24例患者均获随访,随访时间6～21个月,平均(13.5±7.6)个月.患者切口均达甲级愈合,术后X线片及CT三维重建示骨折复位满意,无骨折并发症.术前、术后24周的IKDC评分为(38.8±1.5)分、(91.8±3.2)分,Lysholm评分为(30.2±5.6)分、(91.6±2.3)分,手术前后比较差异均有统计学意义(P＜0.05).结论 膝关节镜下应用Endo-Button钛板结合高强缝线SMC结治疗后交叉韧带撕脱骨折的固定效果确切.

目的:观察关节镜下Bankart损伤修复术联合Remplissage术治疗合并Hill-Sachs损伤的复发性肩关节前脱位的临床疗效.方法:2015年4月至2018年4月,采用关节镜下Bankart损伤修复术联合Remplissage术治疗复发性肩关节前脱位患者18例.男13例,女5例.年龄18～43岁,中位数31岁.均合并Hill-Sachs损伤,骨缺损体积均小于肱骨头体积的20％.合并肩胛骨关节盂骨缺损14例,骨缺损直径均小于关节盂直径的20％;合并肱二头肌肌腱炎4例、上盂唇损伤3例;均不合并盂肱韧带肱骨侧撕脱损伤、肱骨大小结节骨折及肩袖损伤.采用美国肩肘关节外科医师协会(American Shoulder and Elbow Surgeons,ASES)评分标准、美国加州大学洛杉矶分校(the University of California at Los Angeles,UCLA)肩关节评分标准评价临床疗效,记录手术前后肩关节屈曲活动度、外旋活动度.结果:所有患者均获随访,随访时间12～17个月,中位数15个月.ASES评分,术前(84.4±4.7)分,术后12个月(97.4±6.3)分;UCLA评分,术前(21.8±4.4)分,术后12个月(28.9±3.1)分;肩关节屈曲活动度,术前168.1° ±2.7°,术后167.8° ±2.9°;外旋活动度,术前71.0° ±9.4°,术后72.7° ±8.7°.末次随访时,所有患者均未发生肩关节再脱位.结论:关节镜下Bankart损伤修复术联合Remplissage术治疗合并Hill-Sachs损伤的复发性肩关节前脱位,有利于改善肩关节功能、维持肩关节正常活动,避免肩关节再脱位.

目的 探讨关节镜下髌骨成形、外侧支持带松解联合去神经化治疗髌股关节炎的疗效.方法 采用关节镜下髌骨成形、外侧支持带松解联合去神经化治疗52例髌股关节炎患者.测量髌股适合角、髌骨倾斜角,记录Lysholm评分.结果 患者均获得24个月随访.切口均愈合良好.髌股适合角、髌骨倾斜角及Lysholm评分末次随访均优于术前(P<0.05).结论 关节镜下髌骨成形、外侧支持带松解联合去神经化治疗髌股关节炎可明显改善患者临床症状,提高其生活质量.

目的 探讨关节镜下"8"字缝线与克氏针内固定治疗儿童前交叉韧带(ACL)胫骨止点撕脱骨折的临床疗效.方法 48例ACL胫骨止点撕脱骨折患儿采用关节镜下"8"字缝线("8"字缝线组,26例)与克氏针内固定(克氏针组,22例)治疗.末次随访时记录膝关节活动度、Lysholm评分和IKDC评分.结果 患儿均获得随访,时间12～24个月.两组前抽屉试验及Lachman试验均转为阴性.末次随访时,两组膝关节活动度、Lysholm评分和IKDC评分均高于术前(P<0.05);两组间3项比较差异均无统计学意义(P>0.05).结论 关节镜下"8"字缝线与克氏针内固定治疗儿童ACL胫骨止点撕脱骨折疗效相当,而"8"字缝线内固定无骨骺损伤风险,术后无需取出.

目的 评估关节镜辅助一期自体肌腱重建KD-Ⅲ-MC型多发韧带损伤的临床疗效,为膝关节多发韧带损伤的治疗提供数据支持.方法 我们选取甘肃中医药大学第一附属医院关节骨二科2015年7月至2018年7月,依据华西-膝关节脱位多发韧带损伤分期分型诊治体系标准收治符合KD-Ⅲ-MC型的患者32例,男24例,女8例;年龄16～70岁,平均(35.42±7.86)岁.致伤原因:交通事故伤14例,扭伤8例,砸伤6例,高处坠落伤4例.损伤至手术时间14～21 d,平均(16.25±2.87)d.所有患者国际膝关节文献委员会(international knee documentation committee,IKDC)评分均为D级,手术前、后抽屉试验均≥Ⅱ度,Lachman试验均为Ⅲ度,终末点消失,内侧副韧带(medial collateral ligament,MCL)损伤采用美国医学会三度分类法均为Ⅱ度以上.Tilos应力位X线检查提示:前向应力胫骨前移(8.15±3.46)mm、后向应力胫骨后移(12.51±3.98)mm、外翻应力内侧间隙(8.46±3.91)mm.术中均一期关节镜下取同侧自体肌腱进行前、后交叉韧带单束重建,内侧结构均采用带线锚钉固定加强缝合、关节囊紧缩必要时内侧解剖型自体肌腱修复.结果 术后所有患者切口均一期愈合,无感染;深静脉血栓1例.所有患者均获得随访,随访时间12～18个月,平均(14.18±2.45)个月.末次随访所有患者前、后抽屉试验及Lachman试验转阴,2例患者MCL损伤分级Ⅱ度,1例膝关节僵硬.IKDC综合评分:A级10例,B级16例,C级6例;与术前比较,差异有统计学意义(P＜0.05).同时将KI-Ⅲ-MC型中不同损伤类型的患者进行统计分组,观察相应时间段的Lysholm功能评分,结果发现术后末次膝关节Lysholm评分较术前相比差异有统计学意义(P＜0.05).术前各种损伤类型组间比较,差异无统计学意义(P＞0.05),术后末次随访软骨损伤组膝关节Lysholm功能评分低于其他组,说明韧带损伤组恢复欠佳与关节软骨损伤有一定关系.各组息膝术后3个月Lysholm评分均有明显的提高,差异相对较大,术后6个月、12个月相比术后3个月差异较小.结论 在KD-Ⅲ-MC型多发韧带损伤中,一期关节镜下取自体肌腱单束解剖重建前交叉韧带(anterior cruciate ligament,ACL)、后交叉韧带(posterior cruciate ligament,PCL),带线锚钉固定加强缝合、关节囊紧缩内侧解剖型自体肌腱分步重建固定可获得良好的近期疗效.

腘肌腱(PT)是构成膝关节后外侧复合体(PLC)的重要组成部分之一,如果损伤不仅会造成膝关节不稳,而且会引起严重患肢功能障碍,影响患者生活质量.过去人们认为PT有限制胫骨前后移位、胫骨外旋和膝关节内翻作用,以至Robert等称其为膝关节"第五韧带".近年来人们对PT的解剖结构和功能特点有了新的认识,有关其损伤后的治疗取得了进一步发展.

Objective:To investigate the effect of peroneus longus tendon reconstruction of the posterior cruciate ligament (PCL).Methods:Twenty-six patients after arthroscopic knee cruciate ligament rupture with the peroneus longus tendon were selected,including 21 males and 5 females;aged 17 to 53 years,with mean of 37.9 years;9 cases of left knee,and right knee 17 cases.Cause of injury:traffic accident in 7 cases,falls injury in 9 cases,10 cases of sports injuries.Preoperative tibial bone sink test,posterior drawer test and Lachman test were positive after tibial shift＞10 mm.And one-stage operation occuired in 24 cases,two-stage operation 2 cases.Preoperative Lysholm score was (17,15±1.29),IKDC2000 score was (31.04±1.46),and Tegner exercise capacity ratings were(1.85±1.01).The combined meniscus injury was in 5 cases,10 cases of anterior cruciate ligament,lateral collateral ligament rupture in 4 cases,and combined nerve injury in 4 cases.Results:All incisions were healed by first intention,and there was no nerve and vascular injury.All patients were followed up for 12 to 48 months with an average of 27.8 months.After 12 months,the posterior tibial sink test,posterior drawer test and Lachman test were negative,Lysholm score was (83.38±3.73),IKDC2000 score was (85.70±1.41),and Tegner exercise capacity rated (5.88±0.99).Compared with preoperative cases,differences were statistically significant (P＜0.05).Conclusion:Peroneus longus tendon in arthroscopicre construction of posterior cruciate ligament of the knee,may be the ideal donor for reconstruction of the PCL due to quicker recovery,small complications and ideal clinical effect.

Objective: To discuss the effects of integrative medicine rehabilitation therapy in the recovery of proprioceptive sense of the patients after knee anterior cruciate ligament (ACL) reconstruction. Methods: Sixty pa-tients were randomly divided into the observation group and the control group, 30 cases each group, the control group received common rehabilitation training method, and the observation group accepted TCM general therapy on the basis of the treatment the control group received. Proprioceptive senses of knee joints of the patients in both groups were detected in three months, six months and twelve months after the operation. Results: The difference had statistical meaning in the comparisons of Lysholm scales in three months after treating within two groups (P<0.05);the difference had statistical meaning in the comparison between both groups(P<0.05). The difference had no statis-tical meaning in the comparisons of bending knees in three months after the operation between both groups (P>0.05); the difference had statistical meaning in the comparisons between both groups in six months and twelve months after the operation (P<0.05). Conclusion: The mode of common rehabilitation method and TCM rehabilitation therapy could promote the recovery of proprioceptive sense of the patients after the surgery of ACL reconstruction obviously.

患者,男,69岁,摔伤后致左膝肿痛伴功能障碍。 X线片提示：左膝关节脱位、髁间嵴撕脱可能(见图1A)。在当地医院进行手法复位(见图1B),1 d后来我院治疗。查体：左膝关节肿胀明显,皮肤无破损,浮髌试验+,关节屈伸0°~30°,前、后抽屉试验, Lachman 试验,胫骨后沉,屈膝30°膝关节外旋试验(患侧-健侧>10°),小腿外侧皮肤及足背皮肤感觉减退、麻木,足背伸无力,足背动脉及胫后动脉可触及。临床诊断：左膝外侧旋转脱位[ KD-Ⅲ型前交叉韧带( ACL)+后交叉韧带( PCL)+后外侧复合体( PLC )]；左腓骨头撕脱骨折；左腓总神经损伤。立即给予膝关节支具固定,进行消肿止痛等对症处理。 MRI检查支持诊断。

Articular cartilage injury is common in clinical in recent years, due to the trauma or bone disease. There are many methods for the repair of articular cartilage injury currently, but each has its limitations. With the development of nanotechnology and bionic-technology, the scaffold plays an important role with tissue engineering technique in the repair of articular cartilage injury, in which the composite materials are the hot direction of the research and development, the ful application of nanotechnology and bionic-technology prospect in the future.

目的 探讨关节镜下前交叉韧带单束解剖保残重建并同期FAST-FIX 360缝合内侧半月板后角的临床疗效.方法 选择2014年1月～2015年4月在关节镜下进行前交叉韧带单束解剖保残重建并同期FAST-FIX 360缝合内侧半月板后角损伤患者共26例,均在关节镜下单束解剖保残重建前交叉韧带,股骨端采用Endeobutton固定,胫骨端采用胫骨固定翼系统固定,并同期FAST-FIX 360缝合内侧半月板后角纵裂或层裂.术前前抽屉试验和前向Lachman试验均为阳性,胫骨前移＞10mm,VAS疼痛评分为(6.39±1.13)分,Lysholm评分为(30.92±3.68)分,IKDC2000评分为(37.46±2.01)分,Tegner运动能力评分为(1.96±0.72)分.根据Barrett标准评判半月板愈合情况.结果 术后患者切口均Ⅰ期愈合,无感染和血管神经损伤等相关并发症发生.患者均获随访,随访时间12～48个月,平均24.8个月.术后12个月,前抽屉试验和前向Lachman试验均为阴性,VAS疼痛评分为(1.58±1.17)分,Lysholm评分为(92.19±3.24)分,IKDC2000评分为(86.85±3.32)分,Tegner运动能力评分为(5.01±0.89)分,与术前比较差异均有统计学意义(P＜0.05).结论 前交叉韧带断裂合并内侧半月板后角纵裂或层裂损伤应尽早进行前交叉韧带重建并同期FAST-FIX 360缝合内侧半月板后角.术后膝关节功能恢复好,临床愈合率高.

目的 探讨关节镜下髌骨支持带调整术与Fulkerson胫骨结节内移抬高术治疗复发性髌骨脱位的临床疗效.方法 将36例复发性髌骨脱位的患者分为观察组和对照组.观察组在关节镜下行髌骨支持带调整术,同时行Fulkerson胫骨结节内移抬高术联合髌股韧带重建术;对照组行前两种手术方式联合的二联术.术后对两组患者进行随访,对比分析两组患者治疗前后患肢功能恢复的情况.结果 两组患者的髌骨活动功能在术后6周基本恢复正常,较术前髌骨活动功能的各项指标有了明显改善(P<0.05),两组患者术后6周与术后3个月髌骨活动功能各项指标比较,也有显著性差异(P<0.05),观察组患者的改善情况优于对照组(P<0.05).两组患者的Lysholm综合评分与IKDC主观评分在术前比较,无显著性差异(P>0.05);两组患者这两项评分术后不同时期比较,有显著性差异(P<0.05),观察组患者的评分均高于对照组(P<0.05).结论 关节镜下髌骨支持带调整术联合Fulkerson胫骨结节内移抬高术与髌股韧带重建术对于复发性髌骨脱位有较好的疗效,适合临床推广应用.

2009年6月～ 2012年1月,我科手术治疗35例髌骨骨折合并对侧髌股外侧高压综合征患者,疗效满意,报道如下. 1 材料与方法 1.1 病例资料 本组35例,男12例,女23例,年龄30～65岁.患者均为一侧的单纯闭合新鲜髌骨骨折,伴有对侧髌股外侧高压症状.

目的：观察消肿止痛合剂配合依托考昔对膝关节前交叉韧带（ACL）重建术后的镇痛效果。方法将50例ACL重建患者随机分为研究组及对照组，研究组术后采用消肿止痛合剂配合依托考昔镇痛消肿，对照组术后口服依托考昔片镇痛，两组患者均维持镇痛3天。记录患者静息时不同时点的VAS评分（视觉模拟评分法）、3 d内吗啡类镇痛药物用量和不良反应的发生情况。结果研究组与对照组在术后72 h内各时点VAS评分和3 d内吗啡类镇痛药物用量上有显著性差异（P＜0.05），不良反应发生率有显著性差异（P<0.05）。结论消肿止痛合剂配合依托考昔对ACL重建术后的镇痛效果肯定，值得临床推广。

膝关节外伤手术治疗后的粘连所导致的活动功能障碍一直是关节外科关注的焦点.其原因既有高能量损伤后关节内及周围骨折创伤的系列反应,又和膝关节术后长时间固定而不及时锻炼相关.各种因素使膝关节组织病理反应加重,软骨退行性改变,组织修复能力严重受限,最终导致功能障碍.因此,术后有计划、有步骤的进行康复治疗尤为重要.

目的:观察消肿止痛合剂对软组织损伤患者血清肿瘤坏死因子-a（tumor necrosis factor alpha,TNF-a）、白细胞介素-6（interleukin 6,IL-6）的影响,探讨其活血化瘀、消肿止痛作用产生的机制。方法:以2010年1月-2011年12月在我院治疗的骨科患者为研究对象,分为治疗组45例,对照组43例。2组患者入院后治疗组内服消肿止痛合剂,每次50mL,每日2次;对照组口服草木犀流浸液片2片/次,2次/d。2组患者均以7d为1个疗程,共治疗2个疗程,分别于入院第2、7、14天运用免疫度量法测定促炎症细胞因子TNF-a、IL-6于血清中的含量,并进行分析。结果:入院第2天,2组患者血清TNF-a、IL-6的含量比较,差异无统计学意义（P＞0.05）;第7、14天2组血清TNF-a、IL-6的含量比较,差异有统计学意义（P＜0.05）。入院第7、14天与入院第2天血清TNF-a、IL-6含量比较,差异有统计学意义（P＜0.01）。结论:消肿止痛合剂能抑制创伤后致炎症因子释放。

自体或异体肌腱移植重建前交叉韧带已经成为前交叉韧带断裂治疗的首选方法.前交叉韧带重建术后关节早期的稳定性主要依靠内固定器械维持,而良好的远期疗效主要取决于腱-骨隧道内获得稳定可靠的腱-骨界面愈合.腱-骨界面愈合过程可形成直接止点和间接止点.正常前交叉韧带止点是典型的直接止点,以韧带与软骨的结合为特征,包括致密结缔组织、纤维软骨、钙化纤维软骨和骨组织.纤维软骨和钙化纤维软骨之间有嗜碱性染色的潮线.间接止点即在移植肌腱与骨隧道之间形成胶原纤维组织连接(Sharpey纤维),目前认为其在生物力学稳定性上不如直接止点.因此,使腱-骨界面愈合止点更类似于正常止点是促进腱-骨界面愈合的目标.本文对近年非手术技术方法促进腱-骨界面愈合所取得的进展作一综述。