Auxiliary reference significance of Blumensaat line for knee joint disease

doi:10.3969/j.issn.2095-4344.2016.44.021

Abstract

Abstract:

BACKGROUND: With the development of sports medicine and research of radiologic imaging techniques, Blumensaat line (the radio-opaque line at the roof of the intercondylar notch) has been paid increasing attention. Blumensaat line is considered as measurement indexes of knee diseases. Taking advantage of the Blumensaat line, many surgeons and radiography physicians are trying to diagnose some knee diseases.

OBJECTIVE: According to the knowledge about Blumensaat line in auxiliary diagnosis of knee disease, we hoped that it will have a wide application in clinic.

METHODS: A computer-based online search of CBM, CNKI, Wangfang Database and PubMed between 2000 and 2015 was performed for articles addressing Blumensaat line. We summarized its application as different diagnostic indicators. The key words were patella alta, Blumensaat line, anterior cruciate ligament (ACL) injuries and ACL reconstruction. Thirty-nine studies were accorded with the inclusion criteria.

RESULTS AND CONCLUSION: Blumensaat line represents the tangentially hit part of the roof in the intercondylar fossa. The line can be used for diagnosing ACL injuries and directing ACL restruction. (1) Blumensaat line and patella alta: Patella heights can be measured with the use of Blumensaat method, modified Blumensaat method and modified Blumensaat ratio. Modified Blumensaat ratio was found by Japanese researchers in 2014 and it is efficient. (2) Blumensaat line and ACL injuries: Blumensaat angle is formed by Blumensaat line and ACL. If this angle is negative or it is greater than 15°, we can draw a conclusion that the ACL was hurt. (3) Harner’s method can be used for choosing an accurate isometric point and a perfect bone tunnel’s angel in ACL reconstruction.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Knee Joint, Patella , Anterior Cruciate Ligament, Tissue Engineering

CLC Number:

R318

Cheng Xiang-yun, Zhang Sheng-xiao, Cao Wan-quan, Wang Gang, Lu Yan-hui, Zhu Hong, Yang Zi-quan. Auxiliary reference significance of Blumensaat line for knee joint disease[J]. Chinese Journal of Tissue Engineering Research, 2016, 20(44): 6682-6688.

Figures/Tables 5

目前在测量髌骨高度领域依靠X射线片被广泛认可和使用的经典指标主要还有以下几种：Insall-Salvat(IS)指数，Blackburne-Peel(BP)指数和Caton-Deschamps(CD)指数等。其中Blumensaat法、改良Blumensaat法这种直接方法已逐渐被经典的Insall-Salvat(IS)指数，Blackburne-Peel(BP)指数和Caton-Deschamps(CD)指数等取代。髌骨滑车指数是完全基于MRI技术的测量髌骨高度的方法，其于2006年由Biedert等提出，已获得一定认可度和使用度。通过影像学方法结合患者自身情况诊断高位髌骨后，对该疾病主要有以下治疗方法。早期症状较轻时可采用保守治疗，主要包括药物治疗(如注射玻璃酸钠、口服营养药物等)和行为治疗(避免过度运动等)。症状严重甚至出现髌骨脱位的患者则可以考虑手术治疗，目前主要术式包括髌韧带转位术、胫骨结节移位术、内侧髌股韧带重建，外侧支持带松解、滑车成形等，并辅助以关节镜下髌骨关节软骨表面化处理。对于重度髌股关节病的患者，可以考虑行膝关节置换[16]。就目前为止，高位髌骨仍缺乏经典、精准的测量方法以及比较全面的治疗标准。从最初的Blumensaat值到如今日本学者提出的改良Blumensaat率，高位髌骨的测量方法一直在更新、简化中。相信不久的将来，在同道的共同努力下，一个更能实际应用于临床，同时操作简便的髌骨测量方法会出现。在如今高速发展的医疗背景下，对于高位髌骨的治疗方法，相信很快会有根据患者严重程度、年龄、性别、种族人群而制定的治疗细则出现。 2.2 Blumensaat线与前交叉韧带损伤的判断 2.2.1 前交叉韧带损伤介绍膝关节前交叉韧带，为膝关节内的核心结构，起于股骨外侧髁内侧面，止于胫骨髁间隆起前方，并与外侧半月板的前中部相连[17]。它是维持膝关节稳定性的重要韧带，可防止胫骨向前移位等[18]。前交叉韧带损伤后可导致膝关节疼痛、活动障碍，如果诊治不当或延误治疗会导致膝关节的不稳定，并继发退行性关节炎等疾病，为此前交叉韧带损伤后及时准确的诊治是十分必要的[19]。 2.2.2 Blumensaat角辅助诊断前交叉韧带损伤前交叉韧带损伤后的诊断主要依靠一系列辅助检查[20]。Lachman试验和前抽屉试验这两种临床检查方法在诊断前交叉韧带损伤中比较常用。通过X射线及CT检查不能直接观察出前交叉韧带的损伤，但可判断前交叉韧带起止点是否有撕脱性细微骨折块以及其骨折块的的数量、大小。而MRI具有高分辨率、高软组织对比、无痛、无放射和多切面成像的特点，MRI是前交叉韧带损伤的最主要影像学检查[21]。膝关节MRI诊断前交叉韧带损伤可依据MRI影像的直接征象(如前交叉韧带消失，韧带连续性中断等)和间接征象(如Blumensaat角异常等)[22]。文章主要介绍的是MRI影像上依据Blumensaat角辅助诊断前交叉韧带损伤[23]。 Blumensaat角，即Blumensaat线和前交叉韧带远端部分延长交叉所形成的夹角，该角度在MRI图像的髁间窝部分矢状层面上比较容易观察(如图4所示)。正常人MRI上观察Blumensaat一般在0°-15°之间，若该角度大于15°，或者该角度呈负值(即两线相交于远端)，皆提示前交叉韧带损伤[24]。对此角度的认识可进一步增加相关工作者对MRI影像上前交叉韧带损伤的把握能力，进一步提高其准确率。"

Blumensaat角作为一个间接征象判断前交叉韧带损伤，有其独特的优势，但是也有局限的一面。Blumensaat角之所以能辅助判断前交叉韧带损伤，其原理如下：因为前交叉韧带起于股骨外侧髁内侧面，故在MRI图像上矢状面髁间窝部分，可看到Blumensaat线与前交叉韧带形成一个夹角。若前交叉韧带未损伤，可看到前交叉韧带和Blumensaat线的夹角很小(0°-15°)，其夹角相交于近端。当前交叉韧带发生损伤时，前交叉韧带会出现松弛迂曲或者直接发生断裂，此时前交叉韧带和Blumensaat线的夹角则会变大，甚至因为前交叉韧带断裂，其夹角相交于远端[25]。从此原理可以看出，Blumensaat角可以较好反映前交叉韧带损伤情况。对于一些陈旧性损伤的患者，前交叉韧带被吸收，Blumensaat角便不能发挥其辅助作用，但是此类患者单凭直接征象便可较好判断。利用Blumensaat角的另一局限性为，该角度的测量并没有统一完善的标准，对于前交叉韧带轻微撕裂的患者，由于前交叉韧带迂曲不明显，利用Blumensaat角进行测量，还是存在一定误差，此时应结合另外一些征象进行判断。前交叉韧带损伤的MRI征象：直接征象[26]：①前交叉韧带消失；②韧带连续性中断，实质断裂；③韧带扭曲，呈波浪状改变；④韧带内形成假瘤；⑤韧带出现部分或弥漫高信号；⑥起止点的撕脱骨折；⑦前交叉韧带走行异常。间接征象[27]：① Blumensaat角改变；②后交叉韧带弓形变；③后交叉韧带夹角< 105°；④半月板外周部垂直撕裂；⑤同时具有股骨外侧髁骨挫伤和胫骨平台前外侧骨挫伤的表现；⑥股骨外侧髁凹陷征(Notch征)；⑦Segond骨折；⑧胫骨前移位等。 2.3 Blumensaat线与前交叉韧带损伤重建的位置定位 2.3.1 关于前交叉韧带损伤重建前交叉韧带损伤后，患者步行时膝关节很大概率会出现漂浮不稳、无力，有脱出的感觉，严重影响患者的生活质量，并且会继发骨性关节炎。若前交叉韧带断裂1/4以上或完全断裂，目前主流的治疗措施是行膝前交叉韧带重建手术[28]。目前前交叉韧带重建手术依靠膝关节镜进行引导，就重建材料来分类主要包括自体肌腱重建和人工韧带重建。依据前交叉韧带重建方法，大致可分为单束重建和双束重建[29]。前交叉韧带重建手术步骤主要如下：对膝关节腔在关节镜下进行顺序检查，判断前交叉韧带损伤程度；取自体肌腱或人工肌腱；前交叉韧带等长点的确定；胫骨骨隧道的选择；钻取骨隧道；前交叉韧带移植物的引入与固定[30]。其中，一个关键步骤为等长点的确定，该步骤甚至可以决定该手术的成功与否[31]。因为移植物若位置不佳，很大概率会与股骨髁间窝发生撞击，或者与股骨外髁内侧面发生磨损，对患者术后恢复会造成不良影响。手术后的前交叉韧带需与原始前交叉韧带最大程度的保持等长，这样在运动中重建材料才能始终保持紧张，患膝不至于出现某个范围内的失稳。现在，如何进行有效定位也是现在的研究热点，利用Blumensaat线辅助定位前交叉韧带等长点已被越来越多的人认可[32]。 2.3.2 Blumensaat线和前交叉韧带损伤重建利用Blumensaat线确定前交叉韧带重建等长点最为经典的方法便是Harner四分法，其在X射线片上即可判断等长点的正确位置：将Blumensaat线四等分，便可确定股骨隧道等长点位置，其位置应在Blumensaat线后1/4的部分，而胫骨隧道等长点应在在胫骨平台关节面长度的第2个1/4处(如图5所示)。在手术中按照术前的Harner四分法测量同时参考膝内侧髁间隆起进行准确定位，手术后可根据X线片来进行评估分析。文献显示使用该定位方法，患者术后恢复良好，Lysholm膝关节功能评分术前(45.5±6.5)分，术后(96.2±2.2)分[33]。除等长点的确定，骨隧道钻取也非常重要，应保证胫骨隧道外口、胫骨隧道等长点、股骨隧道外口、股骨隧道等长点这4点应保持一条直线[34]。以上便是利用Blumensaat线定位前交叉韧带等长点的内容。其效果比较好的原因在于，骨道位置很接近原始前交叉韧带起止点的位置。现有研究表明，对于解剖重建可很有效的增加手术效果[35]。"

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