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72 (2): 81 85 (2013) 81 Clinical Management of Anterior Cruciate Ligament Injury Yuki KATO Department of Orthopedics Surgery, Nihon University School of Medicine Anterior cruciate ligament (ACL) injury is one of the most common ligament injuries of the knee joint, especially in athletes. ACL reconstruction has been widely performed for many years. There have been many innovations of surgical instruments and improvements in surgical techniques, such as the single-incision endoscopic transtibial approach. Recently, many surgeons have focused on anatomic double-bundle ACL reconstruction. Anatomical graft position is one of the most important issues in ACL reconstruction, and it does not matter whether single- or double-bundle ACL reconstruction is performed. As clinicians we recommend anatomical ACL reconstruction for both athletes and non-athletes as a way of reducing the risk of knee osteoarthritis for ACL injured patients. Key words: Anterior cruciate ligament, anatomic, single-bundle, double-bundle, reconstruction (J. Nihon Univ. Med. Ass., 2013; 72 (2): 81 85) 4 (anterior cruciate ligament; ACL) (posterior cruciate ligament; PCL) (medial collateral ligament; MCL) (lateral collateral ligament; LCL) ACL ACL ACL (giving way) ACL I. ACL ACL MCL 1950 O Donoghue unhappy triad MCL ACL 25% 1) O Donoghue 1991 Shelbourne ACL MCL 52 80% 29% 2) II. ( 3 ) ( 3 ) pop sound 2013 1 16 2013 2 12

82 (ballottement of patella, patella tapping) 30 50 ml MCL (Fig. 1) 1 3 ACL ACL 28 3) ACL (Fig. 2) III. ACL 4) ( ) Hoteya ACL ACL (notch width index; NWI) 5) systematic review 6) 7) IV. ACL ACL ACL O ACL ACL 8) 9) Fig. 1 MRI sagittal view shows joint effusion and anterior cruciate ligament rupture. V. ACL ACL Fig. 2 Osteoarthritic change over 10 years after first ACL injury. (a) ACL remnant has disappeared. (b) Spur formation (arrows show) makes narrow intercondylar notch. (c) Exposed subchonral bone (arrows show) in the medial compartment of the knee joint.

72 (2) 2013 前十字靱帯損傷の臨床 83 Fig. 4 3D-CT scan. (a) Anatomic double-bundle ACL reconstruction. (b) Non-anatomic double-bundle ACL reconstruction. Fig. 3 Anatomical double-bundle anterior cruciate ligament reconstruction. (a) ACL remnant. (b) Removal of ACL remnant on the femoral footprint. (c) Two guide pins are inserted into each femoral footprint of antero-medial and posterolateral bundles. (d) Two guide pins are inserted into each tibial footprint of antero-medial and posterolateral bundles. (e) Antero-medial and postero-lateral bundles are inserted through each of tibial and femoral bone tunnels. (f) Checking graft tension using a probe. トでカバーできるよう 2 つの骨孔を ACL 付着部内に作成する解剖学的二重束 ACL 再建が行われるようになってきた解剖学的二重束再建術の利点としてはより正常 ACL に近い走行を再現できるため notch impingement が起こりにくく顆間窩形成術も必要としなくなった13) また生体力学的研究によりかつての古典的な骨孔位置に比べ解剖学的骨孔位置では制動性 (とくに回旋制動性) もグラフトとしてハムストリングや骨付き膝蓋腱を用いた増していることが証明された14, 15) Morimoto らは脛骨一重束再建であるこれまでは経脛骨的に大腿骨側の骨大腿関節の荷重面積および圧を一重束と二重束の両者で孔を作成する方法が一般的であった10) 再断裂を防止す比較し解剖学的二重束 ACL 再建術が正常膝に近く関るため膝のどの角度においてもグラフトへの緊張が変節症性変化の予防が期待できると報告している16) 当科化しない isometric point が主流となっていたが近年ででも洞口らを中心に解剖学的二重束 ACL 再建術をいち早はより解剖学的な骨孔位置に注目が集まっている正常く導入し良好な治療成績を報告している17, 18) (Fig. 3) ACL は本来 isometric な線維はほとんどなく膝伸展に従い緊張する over the top pattern であり isometric point を目指すことが非解剖学的再建の一因となっていることが示されている11) 大腿骨側の isometric point は顆間窩の天井 (intercondylar notch) の高い位置になっており膝関節伸展で再建靱帯が顆間窩天井部にぶつかり (notch impingement) 再断裂の原因となっていることが判明したそのため顆間窩形成術 (notchplasty) を行ったり脛骨骨孔をより後方に作成し notch impingement を防ぐようにするなどますます非解剖学的な再建となってしまっていた ACL の付着は円形ではなく楕円形を呈しており一重束では正常 ACL を模倣できないまた機能的にヒトの正常 ACL は前内側線維束 (anteromedial bundle; AMB) と後外側線維束 (posterolateral bundle; PLB) に分けられると言われている12) そのため ACL 付着の多くをグラフしかし解剖学的二重束 ACL 再建術は誰もが行ってよい術式ではない Double bundle or Double trouble? と警鐘を鳴らすコメントもあり19) 熟練した技術を要する解剖学的二重束 ACL 再建術と言っても実際は解剖学的に正しい位置に骨孔を作成するのは容易ではなく不良な骨孔位置は制動不良や再断裂の原因となり得る (Fig. 4) また ACL 再建自体が特殊な手術であり一重束であれば誰が行ってもよいというものではないが正しく手術が行えれば一重束と二重束の再建方法の間に臨床成績に有意差を認めないとの報告もあり20, 21) 術式の選択は慎重に行うべきである特殊な手術として成長期の ACL 損傷患者などに対して大腿骨側に骨孔を作成せず顆間窩から後方へグラフトを誘導し固定する術式所謂 over the top route 法があるこれは 1970 年代に MacIntosh 法として世界に広まったものであるその後 1981 年に守屋は over the top 部分に骨

84 Fig. 5 Second look 1 year after anatomic double-bundle ACL reconstruction. (a) Arthroscopic view just after ACL reconstruction. (b) Arthroscopic view over 1 year after ACL reconstruction shows increased graft volume and excellent synovial covering. 22 24) 25) 26) ACL 1 3 ACL 27) ACL 3 AMB, PLB (intermediate bundle; IMB) 28, 29) ACL 3 3 30) 3 ACL VI. 4 5 4 10 20 3 4 6 off 2 3 9 accelerated rehabilitation 31) 1 (2 nd look) (Fig. 5) 1 1) O Donoghue DH. Surgical treatment of fresh injuries to the major ligaments of the knee. The Journal of bone and joint surgery 1950; 32: 721 738. 2) Shelbourne KD, Nitz PA. The O Donoghue triad revisited. Combined knee injuries involving anterior cruciate and medial collateral ligament tears. The American journal of sports medicine 1991; 19: 474 477. 3) Finsterbush A, Frankl U, Matan Y, Mann G. Secondary damage to the knee after isolated injury of the anterior cruciate ligament. The American journal of sports medicine 1990; 18: 475 479. 4) Micheli LJ, Metzl JD, Di Canzio J, Zurakowski D. Anterior cruciate ligament reconstructive surgery in adolescent soccer and basketball players. Clin J Sport Med 1999; 9: 138 141. 5) Hoteya K, Kato Y, Motojima S, Ingham SJ, Horaguchi T, Saito A, et al. Association between intercondylar notch narrowing and bilateral anterior cruciate ligament injuries in athletes. Archives of orthopaedic and trauma surgery 2011; 131: 371 376.

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