摘要目的 通过系统综述探讨前十字韧带类等长重建骨隧道位点的区域选择及解剖止点与等长性的关系.方法 在PubMed、Embase、中国知网中检索与前十字韧带类等长重建骨隧道位点以及前十字韧带解剖相关的中英文临床研究、成人标本研究和综述.结果 经查重筛选获得符合要求的文献21篇.多数为标本研究,近年文献多结合三维影像学动态分析膝关节屈伸运动中不同胫股骨隧道位点的等长性,也有少数病例分析和前瞻性临床研究.股骨侧常用于描述类等长区域的解剖标志为Blumensaat线、外侧髁间嵴与前十字韧带止点;胫骨侧常用于描述类等长区域的解剖标志为外侧半月板前角;胫骨侧的骨隧道定位研究少于股骨侧.结果 提示不同类等长研究的骨隧道重建位点有重合,解剖止点内的纤维束部分符合类等长的要求.结论 前十字韧带类等长股骨隧道位点在外侧髁间嵴前部附近,在外侧髁间嵴前部、股骨后皮质延长线的附近.关于前十字韧带类等长股骨隧道位点与前十字韧带解剖止点是否重叠说法不一,其中解剖止点内纤维束等长性最好的区域为外侧髁间嵴附近、分叉嵴前方的区域,这一区域也是前十字韧带的生物力学中心.目前与类等长重建相关的临床研究缺乏,结合术中观察与术后影像学检查能够更明确地证实前十字韧带股骨和胫骨的骨隧道类等长位点.

abstractsObjective To identify the optimal placement of bone tunnel during near-isometric anterior cruciate ligament reconstruction (ACLR),and its dimensional relationship with knee anatomic structure after summarizing published researches.Methods PubMed,Embase,and CNKI were screened for Chinese or English articles on clinical studies,cadaveric studies of knee and reviews on bone tunnel placement in anterior cruciate ligament near-isometric reconstruction and isometry of native anatomic fibers.Related articles were extracted and systematically reviewed.Results A total of 21 articles were finally included after screening.This systematic review found that most of the literatures were cadaveric studies,among which three dimensional imaging techniques,combined with cadaveric studies,were commonly used as a method of determining the length change between spots on the tibial plateau and lateral condyle of femur in recent years.There were 3 case series and 1 prospective cohort study.On the side of lateral condyle of femur,Blumensaat's line,lateral intercondylar ridge and insertion of intact anterior cruciate ligament were commonly used as reference to describe the near isometric area,while on the side of tibial plateau,the anterior horn of lateral meniscus were used as reference for reconstruction.The bone tunnel on tibial side was ignored compared with the femoral side when considering the isometry of reconstruction.There were overlaps among areas of bone tunnel placement found by different studies in near-isometric reconstruction.Not all native anterior cruciate ligament fibers were near-isometric.Conclusion The present study found that the area of femoral bone tunnel of anterior cruciate ligament near-isometric reconstruction were near the anterior part of lateral intercondylar ridge,deeply positioned with longitudinal axis close to the extension line of posterior cortical part of femur,coinciding with the distribution of direct fibers.There was contradiction on whether anterior cruciate ligament nearisometric reconstruction areas and anterior cruciate ligament anatomic insertion sites overlapped with each other.The most isometric area within the anatomic insertion site was the area of anterior fibers near lateral intercondylar ridge,which carried a large portion of the total anterior cruciate ligament load.Generally,there was a scarce of clinical researches in the field of isometry of ACLR.For the purpose of attesting the accuracy of the results we found,a combination of intra-operative observation on the displacement of graft relative to bone-tunnel and post-operative imaging such as MRI and three dimensional CT should be considered.