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首页> 外文期刊>Orthopaedic Journal of Sports Medicine >ACL Fibers Inserting on the Lateral Intercondylar Ridge Carry the Greatest Loads - Are Modern Anatomic Femoral Tunnel Positions Too Low?
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ACL Fibers Inserting on the Lateral Intercondylar Ridge Carry the Greatest Loads - Are Modern Anatomic Femoral Tunnel Positions Too Low?

机译：插入con突间外侧的ACL纤维承受的载荷最大-现代解剖型股骨隧道位置是否太低？

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Objectives: Histological studies have shown that the ACL has a direct and indirect insertion on the femur [1]. The direct insertion is located along the lateral intercondylar ridge and the indirect insertion is located ‘lower’ on the lateral wall of the notch. The trend towards anatomic ACL reconstruction using the anteromedial (AM) portal technique has resulted in ‘lower’ non-isometric femoral tunnel positions and increased graft failures [2]. To our knowledge, the load transfer properties of the direct and indirect ACL insertions have not been studied. This information may help in understanding the increased failures reported with AM portal drilling. The purpose of this study was, 1) to compare the load transferred across the native ACL at the direct and indirect femoral insertions and, 2) to determine the strain behavior of ACL grafts placed at different tunnel locations within the direct and indirect insertions. Methods: Ten fresh-frozen cadaveric knees (mean age, 52.5 years; range, 29-65) were mounted to a six degree of freedom robot. A 134N anterior load at 30 and 90° flexion and a combined valgus (8Nm) and internal (4Nm) rotational moment at 15° flexion were applied. The ACL was subsequently sectioned at the femoral footprint by detaching either the direct or indirect insertion (partially sectioned state), followed by the remainder of the ACL (completely sectioned state) (Figure 1). The kinematics of the intact knee were replayed after each stage of sectioning to determine the loads transferred across the direct and indirect ACL fibers. Loads were expressed as a percentage of the total load borne by the ACL. Strain behaviour was tested by generating 3D models of the femur and tibia from CT scans of each knee. Three tunnel locations (anteromedial bundle [AM], center [C], posterolateral bundle [PL]) each were selected for the direct and indirect insertions and a virtual ACL graft was inserted. The isometry of the virtual graft was calculated through a flexion path of 0 to 90°. Results: Under an anterior tibial load at 30° flexion, the direct insertion carried 83.9% of the total ACL load compared to 16.1% in the indirect insertion (p<0.001). The direct insertion also carried more load at 90° flexion (95.2% vs 4.8%; p<0.001). Under a combined rotatory load at 15° flexion, the direct insertion carried 84.2% of the total ACL load compared to 15.8% in the indirect insertion (p<0.001). A virtual ACL graft placed at the AM position in the direct insertion demonstrated the best strain behaviour with a mean 10.9% change in length. This value was significantly lower (p<0.001) than the isometry at all 3 tunnel positions in the indirect insertion (AM = 18.5%; C = 24.9%; PL = 30.9%). Conclusion: Fibers in the direct insertion of the ACL carry more load than fibers in the indirect insertion. Virtual ACL grafts placed in the ‘higher’ direct location are more isometric than in the ‘lower’ indirect location during range of motion testing. Clinical Relevance: ‘Low’ ACL grafts in the indirect ACL insertion, resulting from AM portal drilling techniques, may experience higher loads in-vivo due to unfavorable biomechanics. With the current shift towards anatomic ACL reconstruction, it may be beneficial to create a ‘higher’ femoral tunnel within the direct insertion at the lateral intercondylar ridge. This position remains anatomical but may also be biomechanically favorable.
机译：目的：组织学研究表明，ACL在股骨上有直接和间接的插入[1]。直接插入沿along间外侧脊定位，间接插入位于凹口侧壁上的“下方”位置。使用前内侧（AM）门技术重建解剖ACL的趋势导致非等距股骨隧道位置“降低”，并增加了移植失败率[2]。据我们所知，尚未研究直接和间接ACL插入的负载传递特性。此信息可能有助于理解AM门户钻探报告的故障增加。这项研究的目的是：1）比较在直接和间接股骨插入处通过天然ACL传递的载荷，以及2）确定放置在直接和间接股骨内不同隧道位置的ACL移植物的应变行为。方法：将十只新鲜冷冻的尸体膝盖（平均年龄52.5岁;范围29-65）安装到六自由度机器人上。施加30°和90°屈曲时的134N前载荷，以及15°屈曲时的外翻（8Nm）和内旋（4Nm）组合旋转力矩。随后，通过分离直接或间接插入（部分切开状态），然后在其余的ACL（完全切开状态）下，在股骨足迹上切开ACL（图1）。在每个切片阶段之后，重播完整膝盖的运动学，以确定通过直接和间接ACL纤维传递的负荷。负载表示为ACL承担的总负载的百分比。通过从每个膝盖的CT扫描生成股骨和胫骨的3D模型来测试应变行为。选择三个隧道位置（前束[AM]，中心[C]，后外侧束[PL]）进行直接和间接插入，并插入虚拟ACL移植物。通过0到90°的屈曲路径计算虚拟移植物的等轴测图。结果：在30度屈曲的胫骨前载荷下，直接插入占总ACL载荷的83.9％，而间接插入则为16.1％（p <0.001）。直接插入在90°屈曲时也承受了更大的负荷（95.2％对4.8％; p <0.001）。在15°屈曲的组合旋转载荷下，直接插入的载荷为ACL总载荷的84.2％，而间接插入的载荷为15.8％（p <0.001）。直接插入AM位置的虚拟ACL移植物表现出最佳的应变行为，平均长度变化为10.9％。在间接插入的所有三个隧道位置，该值均显着低于等轴测图（p <0.001）（AM = 18.5％; C = 24.9％; PL = 30.9％）。结论：ACL直接插入的光纤比间接插入的光纤承担更多的负载。在运动测试范围内，放置在“较高”直接位置的虚拟ACL移植物比“较低”间接位置的等距位置更大。临床相关性：AM门控钻孔技术导致间接ACL插入中的“低” ACL移植物可能由于不利的生物力学而承受更高的体内负荷。随着当前向解剖ACL重建的转变，在the外侧lateral直接插入内创建“更高”的股骨隧道可能是有益的。该位置仍然是解剖学上的，但在生物力学上也可能是有利的。

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