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FLD FUHHS SKHQRPHQRQ RUD] UHODNVDFMD
SRGZSá\ZHPREFL*DQLD
)HQRPHQ FLHUSQL
FLD RNUH OD V\WXDFM
JG]LH SRG ZSá\ZHP VWDOH G]LDáDMFHM
QLH]PLHQQHM VLá\ ZL
]DGáR SRF]WNRZR XOHJD HORQJDFML SR F]\P MHJR GáXJR ü
pozostaje niezmieniona (Rycina 3).
5HODNVDFMD SRG ZSá\ZHP REFL*DQLD ± MH OL FKFHP\ UR]FLJQü ZL
]DGáR R SHZQ
ZDUWR ü ZJUDQLFDFKZNWyU\FKQLH]RVWDQLHXV]NRG]RQH WRVLáDMDNDMHVWSRWU]HEQD
DE\ XWU]\PDü W GáXJR ü PDOHMH JZDáWRZQLH Z SLHUZV]\FK NLONX JRG]LQDFK D Z
NROHMQ\FKPLHVLFDFKZRZLHOHZROQLHMV]\PWHPSLH Rycina 4).
12
:UD] ] ZLHNLHP REQL*DM VL
QDVW
SXMFH SDUDPHWU\ V]W\ZQR ü PDNV\PDOQH
REFL*HQLH LOR ü HQHUJLL DEVRUERZDQHM SU]\ ]HUZDQLX ZL
]DGáD :]UDVWD QDWRPLDVW
OLF]ED ZáyNLHQ NRODJHQRZ\FK Z SU]HOLF]HQLX QD µP NZDGUDWRZ\ 7áXPDF]\ VL
WR
]ZL
NV]RQOLF]EPDá\FKZáyNLHQNRODJHQRZ\FKNWyUHZPQLHMV]\PVWRSQLXVWDQRZL
RVLOHZL
]DGáD[10]&KRFLD*QLHNWyU]\DXWRU]\GRZRG]*HV]W\ZQR ü$&/QLH]DOH*\
DQLRGZLHNXDQLWDN*HRGSáFL[11].
Rycina 3
)HQRPHQFLHUSQL FLD IHQRPHQFUHHS
Rycina 4
5HODNVDFMDZL ]DGáDSRGZSá\ZHPREFL*DQLD
13
$1$720,$:, =$'à$.5=<)2:(*235=('1,(*2
:L
]DGáRNU]\*RZHSU]HGQLHUR]FLJDVL
RGW\OQHMF]
FLSU]\ URGNRZHMSRZLHU]FKQL
Ná\NFLD ERF]QHJR XGD GR GRáX NWyU\ ORNDOL]XMH VL
GR SU]RGX L ERNX RG JX]ND
SU]HGQLHJRSLV]F]HOL3U]\MPXMHVL
*HSRZLHU]FKQLDSU]\F]HSXXGRZHJRMHVWNV]WDáWX
RZDOQHJRRZ\PLDUDFK[PPJG]LHRGOHJáR üMHMFHQWUDOQHJRSXQNWXRGW\OQHJR
EU]HJX WU]RQX NR FL XGRZHM WR PP D RG W\OQHM JUDQLF\ SRZLHU]FKQL VWDZRZHM Z
URGNXGRáXPL
G]\Ná\NFLRZHJRPP[12]'DQHWHQDOH*\WUDNWRZDüRULHQWDF\MQLH
(66.$SU]\MPXMH*HSU]\F]HSWHQMHVWEDUG]LHMGRW\áXQL*]Z\NáRVL
XZD*Dü[13].
3U]\F]HSSLV]F]HORZ\MHVWV]HUV]\LPRFQLHMV]\DQL*HOL
Rycina 5.
/RNDOL]DFMHSU]\F]HSyZ$&/QDNR FLXGRZHMLSLV]F]HORZHM
XGRZ\.V]WDáWXRZDOQHJRRZ\PLDUDFK[PP]SXQNWHPFHQWUDOQ\PSU]\F]HSX
RGGDORQ\P RG SU]HGQLHM JUDQLF\ SRZLHU]FKQL VWDZRZHM Ná\NFLD SLV]F]HORZHJR
SU]\ URGNRZHJR R PP RUD] RG SU]HGQLHM JUDQLF\ SRáF]HQLD áNRWNL ] WRUHEN
VWDZRZQDZ\VRNR FLNá\NFLDSLV]F]HORZHJRSU]\ URGNRZHJRRPP[12]. ACL nie
VWDQRZLPRQRILODPHQWRZHJRS
F]NDDUDF]HMSU]\SRPLQDZDFKODU]=URWRZDQHMHVWQD
]HZQWU] ± ZáyNQD ]ORNDOL]RZDQH ] SU]RGX ELHJQFH RG NR FL XGRZHM GR SLV]F]HOL
SU]\F]HSLDMVL
EDUG]LHMGRERF]QLHQL*WH]ORNDOL]RZDQH]W\áX*G\E\$&/VWDQRZLáR
MHG\QH SRáF]HQLH SRPL
G]\ XGHP D SRGXG]LHP WR SLV]F]HO E\áDE\ ]URWRZDQD GR
ZHZQWU] R ° [14] ± VWDQRZL WR QDMOHSV]\ GRZyG VWZLHUG]HQLD *H $&/ QLH MHVW
14
SRVWURQNLHPUR]SRVWDUW\PSRPL
G]\GZRPDVWUXNWXUDPLNRVWQ\PL$&/G]L
NLZáD QLH
WDNLHPX SU]HELHJRZL ELHU]H XG]LDá Z RJUDQLF]DQLX RVLRZHM URWDFML SLV]F]HOL [15].
'áXJR ü$&/Z\QRVLPP[16]FKRFLD*VWDUV]HSXEOLNDFMHSRGDMQDZHWPP[17].
'OD ]UR]XPLHQLD G\QDPLNL G]LDáDQLD $&/ SU]\GDWQH MHVW Z\Uy*QLHQLH S
F]NyZ
SURZDG]F\FK JXLGLQJ EXQGOHV S
F]NyZ EH]SLHF]HVWZD VDIHW\ EXQGOHV RUD]
S
F]NyZ OLPLWXMF\FK OLPLWLQJ EXQGOHV [18] =JRGQLH ] W NRQFHSFM W\ONR S
F]NL
SURZDG]FHSR]RVWDMSRGVWDá\PQDSL
FLHPQLH]DOH*QLHRGSR]\FML]JL
FLRZHMNRODQD
3
F]NL EH]SLHF]HVWZD ]RVWDM QDSL
WH MHG\QLH Z GDQ\P SRáR*HQLX ]JL
FLRZ\P
SR]RVWDMFOX(Q\PLZLQQ\FK,ZUHV]FLHS
F]NLOLPLWXMFH±XOHJDMQDSL
FLXZV\WXDFML
NU\]\VRZHMEOLVNLHMXV]NRG]HQLXFDáHJRZL
]DGáD6WDQRZLZL
FRVWDWQLHWDSREURQ\
SU]HG V]NRGOLZ VLáD UR]FLJDMF )XVV NWyU\ MHVW DXWRUHP Z\PLHQLRQHJR SRG]LDáX
XZD*D *H UHNRQVWUXNFMD $&/ PR*H SU]\QLH ü RF]HNLZDQ VWDELOQR ü NRODQD MHG\QLH
ZWHG\JG\RGWZRU]\P\SUDZLGáRZHQDSL
FLHS
F]NyZSURZDG]F\FK[19].
: ZDUXQNDFK NOLQLF]Q\FK UR]Uy*QLDP\ S
F]HN SU]HGQLRSU]\ URGNRZ\ $0% RUD]
S
F]HN W\OQRERF]Q\ 3/% $0% ELHJQLH RG SU]HGQLHM F]
FL SU]\F]HSX XGRZHJR
$&/ GR SU]HGQLRSU]\ URGNRZHM F]
FL SU]\F]HSX SLV]F]HORZHJR $&/ 3/%
RGSRZLHGQLRRGW\OQHMGRW\OQRERF]QHMF]
FL3
F]NLWH]DFKRZXMVL
RGPLHQQLHZ
F]DVLH]JL
FLDLZ\SURVWXVWDZXNRODQRZHJR$0%QDSLQDVL
Z]JL
FLXLUR]OX(QLDZ
Z\SUR FLH 3/% QD RGZUyW ± QDSLQD VL
Z Z\SUR FLH L UR]OX(QLD Z ]JL
FLX 0D WR
LVWRWQH ]QDF]HQLD GOD RSHUDWRUD NWyU\ XVLáXMH ]QDOH(ü WDNLH PLHMVFH Z NWyU\P
]UHNRQVWUXRZDQH ZL
]DGáR SR]RVWDQLH QDSL
WH Z UyZQ\P VWRSQLX SU]H] FDá\ ]DNUHV
UXFKyZVWDZX3RJOG\GRW\F]FH$0%L3/%XOHJá\]PLDQRPQDSU]HVWU]HQLRVWDWQLFK
lat. Aktualnie dominuje tendencja do przyjmowania PLB jako reprezentanta ACL.
1DSL
FLH 3/% XOHJD ]PLDQRP Z WUDNFLH ]JLQDQLDSURVWRZDQLD VWDZX MDN RSLVDQR
SRZ\*HM6SDGHNQDSL
FLD3/%ZF]DVLH]JL
FLDQLHMHVWMHGQDNVWDá\±SU]H]SLHUZV]H
VWRSQLQDSL
FLH3/%Z]UDVWDDE\GRSLHURZWHG\QLHXVWDQQLHRSDGDüSU]H]NROHMQH
VWRSQLH ]JLQDQLD 'RNáDGQLH WDN VDP FKDUDNWHU\VW\N
SRVLDGD $&/ RF]\ZL FLH ]
ZL
NV]\PL EH]Z]JO
GQ\PL ZDUWR FLDPL QDSL
FLD [20]. W przypadku AMB linia
QDSL
FLD S
F]ND QLH ELHJQLH UyZQROHJOH GR OLQLL $&/ , PLPR *H $0% Z SHZQ\P
PRPHQFLHVWDMHVL
EDUG]LHMQDSL
WHQL*3/%SUyEXMF]EOL*\üVL
GRZDUWR FL$&/
:SR]\FMLZ\SURVWQHM$&/MHVWSUDZLHUyZQROHJáHGRVWURSXGRáXPL
G]\Ná\NFLRZHJR
15
3.2.4 PUNKTY IZOMETRYCZNE
3XQNW\L]RPHWU\F]QHZ\]QDF]DMWDNLHGZDPLHMVFDSU]\F]HSXACL na powierzchniach
SLV]F]HOL L XGD SRPL
G]\ NWyU\PL RGOHJáR ü SR]RVWDMH QLH]PLHQQD Z F]DVLH SHáQHJR
]DNUHVX UXFKyZ Z VWDZLH NRODQRZ\P 3XQNW\ WH QLHZWSOLZLH Z]EXG]DM ZLHOH
]DLQWHUHVRZDQLD Z UyG EDGDF]\ 2SLVDQH PLHMVFD DQDWRPLF]QHJR SU]\F]HSX $&/ QLH
RGSRZLDGDM MHGQDN QD S\WDQLH NWyUD F]
ü ZL
]DGáD QLH ]PLHQLD VZRMHM GáXJR FL D
ZL
FLQDSL
FLDZF]DVLHSHáQHJR]DNUHVXUXFKyZNRODQD'ODUR]ZD*DWHRUHW\F]Q\FK
SU]\MPXMH VL
*H Z VDP\P $&/ MHG\QLH S
F]NL SURZDG]FH VSHáQLDM WH NU\WHULD
,VWRWQ\GODFHOyZNOLQLF]Q\FKMHVWQDWRPLDVWIDNW*H3/%PDSRGREQNU]\ZQDSL
FLD
GR$&/:LHOXDXWRUyZSRGDZDáRUy*QORNDOL]DFM
PLHMVFL]RPHWU\F]Q\FKGOD$&/
[21-23].
)XVV ZSURZDG]Lá SRM
FLH L]RN\O\RQ OLQLL áF]FHM PLHMVFD ] NWyU\FK Z\FKRG]FH
ZáyNQD Z UyZQ\P VWRSQLX XOHJDM Z\GáX*HQLX Z F]DVLH UXFKX Z VWDZLH [24]. Mapa
L]RN\O\RQ SU]\SRPLQD PDS
] SR]LRPLFDPL áF]F\PL ]H VRE SXQNW\ R WHM VDPHM
Z\VRNR FLSRQDGSR]LRPHPPRU]D5y*QLFDSROHJDQDW\P*HSR]LRPLFDP]DZV]H
MHVWPSRQDGSR]LRPHPPRU]D±ZDUWR FLWHVEH]Z]JO
GQH1DWRPLDVWZSU]\SDGNX
L]RN\O\RQVRQHZ]JO
GQH'ODSU]\NáDGX ZSROXSU]\F]HSXXGRZHJR$&/L]RN\O\RQ
R ZDUWR FL R]QDF]D PLHMVFH Z NWyU\P ZáyNQD WDP Z\FKRG]FH Z QDMPQLHMV]\P
VWRSQLX XOHJDM Z\GáX*HQLX Z F]DVLH ]JL
FLDZ\SURVWX NRODQD QDWRPLDVW ZáyNQD
Z\FKRG]FH ] L]RN\O\RQ Z\GáX*DM VL
R ZDUWR FL ZáyNLHQ ] L]RN\O\RQ
,]RN\ORQ\SR]ZROLá\SRND]DüWDN]ZDQHORNDOQHSXQNW\L]RPHWU\F]QHDOHQLHGODFDáHJR
ACL.
3RZ\*V]HIDNW\VNáDQLDMDNWXDOQLHEDGDF]\GRVWZLHUG]HQLD*HPR*HQLHPDFDáNRZLFLH
izometrycznego punktu dla ACL, a istnieje tylko punkt prawie-izometryczny [25].
3U]\MPXMH VL
*H OH*\ RQ QD SU]HGQLRSURNV\PDOQHM JUDQLF\ SU]\F]HSX EOLVNR
SRáF]HQLD FLDQ\ SU]\ URGNRZHM Ná\NFLD XGRZHJR ERF]QHJR RUD] GDFKX GRáX
PL
G]\Ná\NFLRZHJR [21] 1DMEDUG]LHM SUHF\]\MQ\P MHVW MHGQDN VWZLHUG]HQLH *H $&/
]DFKRZXMHQLHL]RPHWUL
DOHL]RWRQL
[1].
16
1$3, &,(
3R]QDQLH QDSL
FLD MDNLHPX SRGGDZDQH MHVW $&/ MHVW QLH]E
GQH GR Sy(QLHMV]HM
SUDZLGáRZHM UHNRQVWUXNFML ZL
]DGáD '\VNXWRZDQH MX* E\áR ]DJDGQLHQLH L]RPHWULL
SRG]LDáX QD S
F]NL RUD] QLHMHGQRURGQHM SUDF\ ZL
]DGáD )DNW\ WH ]QDMGXM
RG]ZLHUFLHGOHQLHZZDUWR FLDFKQDSL
üZ$&/NWyUHPR*QD]PLHU]\üZF]DVLHSHáQHJR
]DNUHVX UXFKyZ NRODQD 3RGF]DV G]LDáDQLD VLá\ 1 VNLHURZDQHM SURVWRSDGOH L GR
SU]RGXZ]JO
GHPSLV]F]HOLZDUWR FLQDSL
üZ$&/Z\QRV] RNRáR1Z]JL
FLX
15°
Z GDOV]\P ]JL FLX GR ° VSDGHN GR 1 Z SHáQ\P Z\SUR FLH 1 [20].
1DSL
FLH WR ]ZL
NV]D VL
Z F]DVLH URWDFML ZHZQ
WU]QHM Rycina 1), a waryzacja daje
ZL
NV]\Z]URVWDQL*HOLZDOJL]DFMD[8].
0(&+$125(&(3725< 25$= 8.à$' 1(5:2:< : )81.&-,
67$%,/,=8-&(-$&/
$&/RSUyF]IXQNFMLUXFKRZHMVSHáQLDUyZQLH*IXQNFM
F]XFLRZSRSU]H]REHFQHZQLP
Uy*QHJRURG]DMXHOHPHQW\F]XFLRZH:\Uy*QLDP\WXWDM ]DNRF]HQLD5XIILQLHJRFLDáND
3DFLQLHJR]DNRF]HQLD*ROJLHJRRUD]ZROQH]DNRF]HQLDQHUZRZH.D*GH]QLFKSHáQL
LQQ IXQNFM
[26] D ZL
NV]R ü ]ORNDOL]RZDQ\FK MHVW SU]\ NRFDFK NRVWQ\FK $&/
QDWRPLDVW Z F]
FL URGNRZHM MHVW LFK QLHZLHOH %RG(FH QHUZRZH ELHJQ GR &61
SRSU]H]W\OQ\QHUZVWDZRZ\ 3$1 E
GF\JDá
]LW\OQHJRQHUZXSLV]F]HORZHJR[27].
Mechanoreceptory:
-
&LDáND 3DFLQLHJR DGDSWXM VL
V]\ENR L PDM QLVNL SUyJ SREXGOLZR FL ± V
]GHF\GRZDQLH G\QDPLF]Q\PL PHFKDQRUHFHSWRUDPL SR]RVWDMF QLHDNW\ZQ\PL Z
unieruchomionym stawie.
-
=DNRF]HQLD *ROJLHJR DGDSWXM VL
ZROQR PDM Z\VRNL SUyJ SREXGOLZR FL L
SR]RVWDM FDáNRZLFLH QLHDNW\ZQH Z XQLHUXFKRPLRQ\P VWDZLH 2GSRZLDGDM ]D
SRPLDUQDSL
FLDZL
]DGáDZSRáR*HQLDFKNUDFRZHJR]JL
FLDZ\SURVWXVWDZX
-
=DNRF]HQLD 5XIILQLHJR PDM QLVNL SUyJ SREXGOLZR FL L PRJ E\ü ]DUyZQR
statycznymi, jak i dynamicznymi mechanoreceptorami.
17
-
:ROQH]DNRF]HQLDQHUZRZH±ZIL]MRORJLF]Q\FKZDUXQNDFKSR]RVWDMQLHDNW\ZQH
$NW\ZRZDQH Z SU]\SDGNX REHFQR FL PHGLDWRUyZ QD SU]\NáDG VWDQX ]DSDOQHJR
DOERZSU]\SDGNXQLHIL]MRORJLF]QHJRQDFLJQL
FLDF]\GHIRUPDFML$&/
5HFHSWRU\WHG]LDáDM UDF]HM SRZROL L QLH SR]ZDODM QD ELH*FH LQIRUPRZDQLH &61 R
G\QDPLF]Q\FK ]PLDQDFK V]\ENR FL UXFKX NRODQD DOH SR]ZDODM QD GRVWDUF]DQLH
LQIRUPDFMLRSRáR*HQLXLVNUDMQ\FKUXFKDFKNRODQD
&LHNDZ\P ]DJDGQLHQLHP SR]RVWDMH UROD $&/ Z UHJXODFML QDSL
FLD PL
QLRZHJR
VWDELOL]DWRUyZPL
QLRZ\FKNRODQDDOERURODW\FKVWDELOL]DWRUyZZUHJXODFMLQDSL
FLD
$&/2SLQLHVWXWDM]JRGQHFRGRWHJR*HWR$&/PR*HZSá\ZDüQDWRQXVPL
QLRZ\
DQLHQDRGZUyW6DPRQDSL
FLHPL
QLRZHZ\QLND]GZyFKVNáDGRZ\FK ZHZQ
WU]QHM
V]W\ZQR FL ]DOH*QHM RG XNáDGyZ DNW\QRPLR]\QRZ\FK RUD] V]W\ZQR FL ]DOH*QHM RG
reakcji odruchowej [26]
5HDNFMHWRPRJZ\QLNDü]G]LDáDQLD α-motoneuronu lub γ-
motoneuronu. Co do roli α
PRWRQHXURQXRSLQLHVSRG]LHORQH]ZáDV]F]DMH OLP\ OLP\
R V\WXDFMDFK JG\ QD $&/ G]LDáDM QLHZLHONLH REFL*HQLD [28, 29]. Natomiast γ-
PRWRQHXURQSRSU]H]DNW\ZDFM
S
WOLγELHU]HXG]LDáZNRQWUROLQDSL
FLDPL
QLRZHJR
FKRFLD*W\ONRSU]\QLHZLHONLFKLZROQR]PLHQLDMF\FKVL
REFL*HQLDFK$&/:L
NV]
URO
SU]\SLVXMHVL
$&/ZQDXF]DQLXPL
QLDRGSRZLHGQLHJRWRQXVXNRQLHF]QHJRGR
zabezpieczenie stawu przed urazem. Z powodów czysto fizjologicznych, ACL nie jest
ZVWDQLHVSHáQLDü UROL UHJXOXMFHM ELH*F\ WRQXV PL
QL :L
]DGáR PXVLDáRE\ RGHEUDü
ERG]LHF NWyU\ PLDáE\ E\ü GDOHM SU]HND]DQ\ GR &61 D GDOHM ZUyFLü ZáyNQDPL
HIHUHQWQ\PL±ZV]\VWNRZF]DVLHNUyWV]\PQL*RNRáRPVW\OHERZLHPF]DVX]DMPXMH
]SHUFHSRZDQLHEyOXZZ\QLNXXUD]XZL
]DGáD2GUXFKRZ\VNXUF]PL
QLDQDVWSLáE\
QDWRPLDVWGRSLHURSRRNRáR PV[26]7R]E\WSy(QR:Sá\Z$&/QD&61MHVW
MHGQDNEH]G\VNXV\MQ\DEUDNERG(FyZDIHUHQWQ\FK]$&/ZV\WXDFMLMHJRXV]NRG]HQLD
RG]ZLHUFLHGOD VL
Z UHPRGHOOLQJX REUD]X LPSXOVyZ Z &61 [30]. Klinicznym tego
SRWZLHUG]HQLHPVZ\QLNLSRPLDUyZF]XFLDSRáR*HQLDVWDZX -36 RUD]GHWHNFMLUXFKX
pasywnego (TDPM) [31]. Bardziej obiektywnym badaniem jest tutaj TDPM, gdzie
SDFMHQWLQIRUPXMHR]SHUFHSRZDQ\P UXFKXVWDZXNWyU\MHVWSRUXV]DQ\ ZHGáXJ FL OH
XVWDORQHJR VFKHPDWX 2F]\ZL FLH Z VWDZLH NRODQRZ\P EH] $&/ F]XFLH
SURSULRFHSW\ZQH MHVW XSR OHG]RQH $OH WDND VDPD V\WXDFMD GRW\F]\ NRODQD ]GURZHJR
tego samego pacjenta [31, 32]
-HGQRF]H QLH ]PLHQLDM VL SDUDPHWU\ V\JQDáyZ
QHUZRZ\FK GRFLHUDMF\FK GR VWDELOL]DWRUyZ PL QLRZ\FK NRODQD [32] PL QLD
18
REV]HUQHJRERF]QHJRLSU]\ URGNRZHJRGZXJáRZHJRXGDVPXNáHJRSyá FL
JQLVWHJR
SyáEáRQLDVWHJR3RZ\NRQDQHMUHNRQVWUXNFML$&/QDVW
SXMHVWRSQLRZ\SRZUyWIXQNFML
proprioceptywnych ACL oraz normalizacja parametrów impulsów nerwowych
RSLV\ZDQ\FK SRZ\*HM 5HNRQZDOHVFHQFMD SU]HELHJD V]\EFLHM Z SU]\SDGNX
UHNRQVWUXNFML DUWURVNRSRZHM ER MX* PLHVLFH SR ]DELHJX SRSUDZD PR*H E\ü
oznaczalna [33]
: GDOV]\P RNUHVLH F]DVX Uy*QLFH SRPL G]\ UHNRQVWUXNFM
DUWURVNRSRZLRWZDUW]DFLHUDMVL
LZPLHVLFXSR]DELHJXQLH]DXZD*DVL
Uy*QLF
Z]JO
GHP]GURZ\FKJUXSNRQWUROQ\FK±GRW\F]\WRNRODQD]]UHNRQVWUXRZDQ\P$&/
oraz kolana zdrowego [33, 34]. Niestety powrót do stanu sprzed urazu nie dotyczy
FDáHJR]DNUHVXUXFKyZDW\ONRSRáR*HVNUDMQHJRZ\SURVWXL]JL
FLD:SRáR*HQLDFK
SR UHGQLFKGHILF\WF]XFLDSURSULRFHSW\ZQHJRXWU]\PXMHVL
QDZHWZGáXJLFKRNUHVDFK
obserwacji – 3,9 lat [33, 35]
0R*HWRE\üSU]\F]\QG\VNRPIRUWXSDFMHQWDDOERQDZHW
QLH]DGRZROHQLD]Z\NRQDQHJR]DELHJX7RZDU]\V]FHWHPX]PLDQ\Z&61RSLVDQH
SRZ\*HMPRJE\üRGELHUDQHSU]H]SDFMHQWDMDNREUDNNRQWUROLQDGVZRLPFLDáHP$E\
]PLQLPDOL]RZDü WHJR W\SX QLHGRJRGQR FL SRVWXORZDQR NRU]\VWDQLH ] IUDJPHQWyZ
XV]NRG]RQ\FK $&/ SUyEXMF Z\NRQ\ZDü V]HZ SLHUZRWQ\ ,QQ SURSR]\FM E\áR
VWRVRZDQLHPHWRG\DUWURVNRSRZHMUHNRQVWUXNFML$&/3LHUZV]DSURSR]\FMDRND]DáDVL
QLHVNXWHF]QD]SU]\F]\QF]\VWRPHFKDQLF]Q\FKGUXJDMHVWREHFQLHPHWRG]Z\ERUX
$OH *DGQD ] QLFK QLH ]QDOD]áD SRSDUFLD Z SRVWDFL V]\EV]HM SRSUDZ\ IXQNFML
proprioceptywnych po zabiegu [35].
:\GDMH VL
*H LGHDOQ\P UR]ZL]DQLHP E\áRE\ SRáF]HQLX SR]RVWDáR FL $&/ MDNLH
PR*QD ]QDOH(ü SR MHJR ]HUZDQLX ] PHWRG DUWURVNRSRZ 3R]RVWDáR FL $&/ PR*QD
Z\Uy*QLü MDNR SU]\UR QL
WH GR 3&/ OXE NR FL XGRZHM EG( VWDQRZLFH NLNXW
SLV]F]HORZ\ 0HFKDQRUHFHSWRU\ $&/ PRJ E\ü REHFQH Z SR]RVWDáR FLDFK ZL
]DGáD
nawet 10 lat [36]
: ZL NV]\P VWRSQLX VWDW\VW\F]QLH LVWRWQLH PHFKDQRUHFHSWRU\
SU]H*\ZDM OXE RU\JLQDOQLH MHVW LFK ZL
FHM EOL*HM 3&/ [37] &KRFLD* J
VWR ü
UHFHSWRUyZQLHZ\ND]XMHNRUHODFML]SRRSHUDF\MQ\PF]XFLHPSRáR*HQLDVWDZX WR LFK
LOR ü FL OH ] QLP NRUHOXMH [38] -HG\Q REDZ WDNLHJR SRVW
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19
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mechanizm (ponad 75 % przypadków),
2.
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3. przeprost w stawie kolanowym,
4.
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„dashboard injury”.
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QDWRPLDVW S
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4.
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punktu podparcia; leczenie nie obejmuje tutaj zaopatrzenia ACL, ale zespolenie
]áDPDQHJRIUDJPHQWXNRVWQHJR
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produkcji fibronektyny i kolagenu III,
20
SUROLIHUDFMD±REHFQDMHVWQLH]RUJDQL]RZDQDPDFLHU]WNDQNL]LDUQLQRZHM]GX*LOR FL
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urazie [40]
FR SR]RVWDMH Z VSU]HF]QR FL ] Z\QLNDPL EDGD X OXG]L [41]. Produkcja
NRODJHQXE
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DNW\ZQR FLPHWDORSURWHLQD]PDFLHU]\DQLLFKWNDQNRZHJRLQKLELWRUD 7,03 [41]. Brak
REHFQR FLN'D±JHODWLQD]\NRODJHQD]\RUD]7,03X]QDMHVL
]DJáyZQSU]\F]\Q
EUDNX JRMHQLD XV]NRG]HQLD SRQLHZD* QLH MHVW PR*OLZD SU]HEXGRZD VWUXNWXU
kolagenowych.
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WU]QHM
QDSUDZ\RUD]WHRULD]HZQ
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Z VXEVWUDW\ NRQLHF]QH GR QDSUDZ\ SRFKRG] VSR]D $&/ ± SRSU]H] QDF]\QLD
GRFKRG]FH GR MHJR SU]\F]HSX XGRZHJR L SLV]F]HORZHJR : WHRULL QDSUDZ\
21
ZHZQ
WU]QHM QDSUDZD MHVW PR*OLZD G]L
NL SUROLIHUDFML NRPyUHN HSLWHQRQ L HQGRWHQRQ
RUD]G]L
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3HZQ QDG]LHM L DOWHUQDW\Z GOD PHWRG RSHUDF\MQ\FK UHNRQVWUXNFML $&/ PR*H E\ü
LQ*\QLHULD JHQHW\F]QD JG]LH XGDáR VL
MX* QD PRGHOX LQ YLWUR X]\VNDü Z\VWDUF]DMF
PLJUDFM
NRPyUNRZNRQLHF]QGRQDSUDZ\XV]NRG]RQHJR$&/[42].
22
1,(67$%,/12 û67$:8.2/$12:(*2
32'=,$à
: OLWHUDWXU]H DQJORVDVNLHM RSHUXM
VL
SRM
FLHP ÄVSUDLQ´ L ÄVWUDLQ´ 6SUDLQ ± RNUH OD
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QLD OXE MHJR FL
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ü
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ZáyNQD
2.
VWRSLH ± NOLQLF]QLH EROHVQR ü VWDZX XSR OHG]HQLH MHJR IXQNFML PR*OLZD
QLHVWDELOQR ü XV]NRG]RQHZáyNQDZOLF]ELHZL
NV]HMQL*ZVWRSQLX
3.
VWRSLH ± NOLQLF]QLH EROHVQR ü VWDZX XSR OHG]HQLH MHJR IXQNFML QLHVWDELOQR ü
VWDZX FDáNRZLWHSU]HUZDQLHZáyNLHQZL
]DGáD
: REU
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+
do 5 mm
++
5 – 10 mm
+++
SRZ\*HMPP
=H Z]JO
GX QD XV]NRG]RQH VWUXNWXU\ ZL
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kolanowego dzielimy na [43]:
1. PROSTE
-
SU]\ URGNRZD
- boczna
- przednia
- tylna
2. ROTACYJNE
23
-
SU]HGQLR±SU]\ URGNRZD
- przednio – boczna
-
W\OQR±SU]\ URGNRZD
- tylno – boczna
3.
=à2)21(
-
URWDF\MQDSU]HGQLR±ERF]QD±SU]HGQLR±SU]\ URGNRZD
- rotacyjna przednio – boczna – tylno – boczna
-
URWDF\MQDSU]HGQLR±SU]\ URGNRZD±W\OQR±SU]\ URGNRZD
1LH SRGDMF V]F]HJyáyZ GRW\F]F\FK XV]NRG]H SRV]F]HJyOQ\FK ZL
]DGHá Z GDQ\FK
W\SDFK QLHVWDELOQR FL ZDUWR MHGQDN Z\RGU
EQLü JUXS\ QLHVWDELOQR FL ]áR*RQ\FK 2Wy*
MH OL GRFKRG]L GR SRZD*QHJR XV]NRG]HQLD Z MHGQ\P ] NZDGUDQWyZ NOLQLF]QLH
ZLGRF]QHJR MDNR QLHVWDELOQR ü URWDF\MQD QLHXQLNQLRQ\P V REUD*HQLD Z LQQ\FK
kwadrantach. Wynika to w prostej mierze z mechanizmu funkcjonowania stawu
NRODQRZHJRMDNR]DPNQL
WHJRXNáDGX3UDNW\F]QLHQLHPR*OLZHMHVWG]LDáDQLHW\ONRQD
MHGQVWUXNWXU
DQDWRPLF]Q=PLDQDZMHGQHMSRZRGXMHNRQLHF]QR ü NRPSHQVDFML Z
LQQHM 7R VDPR X]DVDGQLHQLH GRW\F]\ VWZLHUG]HQLD *H SUDNW\F]QLH QLH VSRW\NDP\
L]RORZDQ\FKXV]NRG]H$&/FRQDMZ\*HML]RORZDQHMHVWRQRNOLQLF]QLH
àDWZRSROLF]\ü*HPDP\W\SyZQLHVWDELOQR FL7\ONRZQLHVWDELOQR FLW\OQHMRUD]
W\OQRERF]QHMQLHGRFKRG]LGRXV]NRG]HQLD$&/:HZV]\VWNLFKSR]RVWDá\FKPDRQR
PLHMVFH 3RND]XMH QDP WD SURVWD VWDW\VW\ND MDN LVWRWQH MHVW $&/ Z UR]ZD*DQLDFK
GRW\F]F\FKQLHVWDELOQR FLVWDZXNRODQRZHJR
3.3.2 ROZPOZNAWANIE I OCENA STOPNIA USZKODZENIA ACL
,QQH FHFK\ Z\VXZDM VL
QD SLHUZV]\ SODQ Z QLHVWDELOQR FL SU]HZOHNáHM D LQQH Z
RVWU\P XUD]LH $&/ 8V]NRG]HQLH $&/ MHVW QDMF]
VWV] SU]\F]\Q NUZLDND Z VWDZLH
NRODQRZ\P 3DFMHQW LQIRUPXMH R ÄVSXFKQL
W\P NRODQLH´ EROHVQR FL RJUDQLF]HQLX
]DNUHVX UXFKyZ VWDZX &]
VWR ZVSRPLQD R WU]DVNX OXE SU]HVNRF]HQLX Z NRODQLH Z
FKZLOLXUD]X'\VNRPIRUWHPGODSDFMHQWDMHVWÄXFLHNDQLHNRODQD´LEUDNSHZQR FLFRGR
kontroli nad nim. W badaniu fizykalnym oprócz klasycznego badania stawu,
24
G\VSRQXMHP\FDá JDPWHVWyZ NOLQLF]Q\FK SRPDJDMF\FK LGHQW\ILNRZDü XV]NRG]RQH
VWUXNWXU\VWDZXNRODQRZHJR'RQDMF]
FLHMVWRVRZDQ\FKQDOH*
Test szuflady przedniej
3DFMHQW Z SR]\FML OH*FHM 6WDZ NRODQRZ\ ]JL
W\ ° VWRSD QD SRGáR*X %DGDQLH
SRZWDU]DP\ Z URWDFML QHXWUDOQHM ZHZQ
WU]QHM L ]HZQ
WU]QHM 5RWDFMD ZHZQ
WU]QD
SR]ZDODQDQDSL
FLH$&/RSLHUDMFJRR3&/ Rycina 1 1DVW
SQLHREXUF]FLJQLHP\
SLV]F]HO NRQWUROXMF MHGQRF]H QLH SU]HPLHV]F]HQLH MHM Ná\NFL Z]JO
GHP Ná\NFL
XGRZ\FK :\QLN WHVWX QRWXMHP\ ]JRGQLH ] ]DVDG RFHQ\ QLHVWDELOQR FL
5y*QLFDZ\QLNXWHVWXFKRUHMNRF]\Q\Z]JO
GHP]GURZHMRZL
FHMQL*PPVNáDQLD
QDV GR SU]\SXV]F]HQLD R SU]HUZDQLX $&/ 3U]\ WDN GX*\P SU]HPLHV]F]HQLX JROHQL
Z]JO
GHPXGDQLHRGF]XMHP\Z\UD(QHJRRSRUXMHVWWRWDN]ZDQ\ÄVRIWHQGSRLQW´:
SU]\SDGNX Z\QLNX XMHPQHJR RGF]XZDP\ QD NRFX RSyU ÄILUP HQG SRLQW´ 1DOH*\
SDPL
WDü *H Z SU]\SDGNX MHGQRF]HVQHJR XV]NRG]HQLD 3&/ PR*HP\ PLHü IDáV]\ZLH
GRGDWQLHSU]HGQLHZ\VXQL
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FLHE
G]LHZWHG\WDNQDSUDZG
VXP ZDUWR FL WHVWX V]XIODG\ SU]HGQLHM RUD] WHVWX V]XIODG\ W\OQHM :DUWR UyZQLH*
SDPL
WDü *H WHVW V]XIODG\ SU]HGQLHM PD QDMPQLHMV] VZRLVWR ü VSR UyG RPDZLDQ\FK
tutaj testów.
Test Lachmana
:V\WXDFMLJG\SDFMHQWSRGDMHVLOQHGROHJOLZR FLEyORZHVWDZPDREU\V\]DWDUWHMHVW
REU]
NQL
W\D]DNUHVUXFKyZVLOQLHRJUDQLF]RQ\UXFKRZRSRPRFQ\MHVWWHVW/DFKPDQD
7HVWZ\NRQXMHP\ZSR]\FMLOH*FHM]HVWDZHPSUDZLHZ\SURVWRZDQ\PZQLHZLHONLHM
URWDFML-HGQU
NVWDELOL]XMHP\XGRZPLDU
EOLVNRNá\NFLQDWRPLDVWGUXJFLJQLHP\
]D SLV]F]HO UyZQLH* EOLVNR V]SDU\ VWDZRZHM 2FHQD WHVWX MHVW WDND VDPD MDN Z
SU]\SDGNXWHVWXV]XIODG\SU]HGQLHM7HVWWHQPDQDMZL
NV]VZRLVWR ü
Boczny test pivot shift MacIntosh’a / Jerk test Hughston’a i Losee’a
:REXWHVWDFKSDFMHQWOH*\5RWXMHP\SLV]F]HOGRZHZQWU]WU]\PDMF]DVWRS
'UXJ
U
NZDOJL]XMHP\ZVWDZLHNRODQRZ\P:WH FLHSLYRWVKLIWUR]SRF]\QDP\ZSHáQ\P
Z\SUR FLHZVWDZLHNRODQRZ\PDQDVW
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SR]\FML ]JL
FLRZHM ° GRNRQXMH VL
Z\F]XZDOQH SRGZLFKQL
FLH FR SR]ZDOD QDP
P\ OHüRSU]HUZDQLX$&/:MHUNWH FLHUR]SRF]\QDP\RGPR*OLZLHSHáQHJR]JL
FLD
25
SRF]\PSURVWXMHP\NRF]\Q
2FHQDWHVWXMHVWWDNDVDPDMDNZSU]\SDGNXWHVWXSLYRW
shift.
3RZ\*V]HWHVW\F]DVDPLWUXGQRMHVWZ\NRQDü]UDFMLZ]PR*RQHJRQDSL
FLDPL
QLRZHJR
XSDFMHQWDE
GFHJRUHDNFMQDEyO'RSLHUREDGDQLHZ]QLHF]XOHQLXQDZHWGRSLHURQD
VWROHRSHUDF\MQ\PGDMHSHáQ\ZJOGZDNWXDOQV\WXDFM
, ZáD QLH GODWHJR PLPR SRZV]HFKQLH ]QDQHM L SRGNUH ODQHM LVWRWQR FL EDGDQLD
IL]\NDOQHJR ]D]Z\F]DM SRGSLHUDP\ VL
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SUDNW\FH MHVW XOWUDVRQRJUDILD 3RG\NWRZDQH MHVW WR F]
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RUD]áDWZR FLZGRVW
SLHGREDGDQLD8]QDQ\PVWDQGDUGHPSRVW
SRZDQLDMHVWMHGQDN
EDGDQLHSU]\X*\FLXUH]RQDQVXPDJQHW\F]QHJR 05, %DGDQLDUDGLRORJLF]QHFKRFLD*
QLHJG\ SUDNW\NRZDQHDNWXDOQLHQLH]QDMGXM]DVWRVRZDQLDZ GLDJQRVW\FHXV]NRG]H
ACL.
2SLVDQHSRZ\*HMWHVW\GLDJQR]XMFH]HUZDQLH$&/SR]ZDODMUyZQLH*QDMHJRRFHQ
LOR FLRZ ± WHVW SU]HGQLHM V]XIODG\ WHVW /DFKPDQD 2FHQD WD MHVW MHGQDN REDUF]RQD
Eá
GHPVXELHNW\ZQHMRFHQ\RVRE\EDGDMFHM6NáDGDMVL
QDWR
1.
EUDNVWDQGDU\]DFMLVLá\MDNX*\ZDP\GRSU]HPLHV]F]HQLDSLV]F]HOLZ]JO GHPXGD
2.
EUDNVWDQGDU\]DFMLSU]HGQLHJRZ\VXQL FLDSLV]F]HOL
%á
G\ WH PR*QD Z\HOLPLQRZDü VWRVXMF VSHFLDOLVW\F]QH XU]G]HQLD SRPLDURZH :
SLHUZV]\PSU]\SDGNXE
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GUXJLP PLHUQLN SU]HGQLRW\OQHM QLHVWDELOQR FL VWDZX NRODQRZHJR .7 $SDUDW
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w codziennej praktyce lekarskiej.
26
3.3.3 IKDC FORMULARZ
*UXSD FKLUXUJyZ NRODQD ] (XURS\ L 86$ ]DáR*\áD Z URNX 0L
G]\QDURGRZ\
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IKDC [44, 45] (aneks - Formularz 1). Jest to powszechnie aprobowany standard oceny
VWDZX NRODQRZHJR )RUPXODU] ,.'& SR]ZDOD QD XQLILNDFM
RFHQ\ NRODQD ]DUyZQR
SU]HG MDN L SR ]DELHJX 1LHVWHW\ QLH XGDáR VL
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odpowiedzi na nie.
3.3.4 LECZENIE
/HF]HQLH ]HUZDQHJR ZL
]DGáD NU]\*RZHJR SU]HGQLHJR ] UDFML MHJR XG]LDáX Z
VNRPSOLNRZDQ\PXNáDG]LHVWDELOL]DFMLNRODQDMHVWQLH]PLHUQLHWUXGQHFRSRGNUH ODáMX*
.X L*yUHFNL[46]. Leczeniem z wyboru przerwanego ACL jest zabieg rekonstrukcji,
DNWXDOQLH Z\NRQ\ZDQ\ DUWURVNRSRZR SU]\ X*\FLX SU]HV]F]HSyZ DXWRORJLF]Q\FK
DOOHJHQLF]Q\FKLV]WXF]Q\FK'RW\F]\WRQLHW\ONRRVyESURZDG]F\FKVWDFMRQDUQ\WU\E
*\FLDDOHUyZQLH*OXESU]HGHZV]\VWNLP]DZRGRZ\FKVSRUWRZFyZQDMZ\*V]HMNODV\
[47].
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2SRQHQFL]DVWDQDZLDOLVL
F]\ZDUWRLQJHURZDüRSHUDF\MQLHVNRURSDFMHQWIXQNFMRQXMH
SU]H] NLOND ODW EH] $&/ QLH SRGDMF ZL
NV]\FK GROHJOLZR FL SR]D QLH]QDF]Q
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RG]\VNDQLH SHáQHM OXE SUDZLH SHáQHM VSUDZQR FL -HG\QLH RNRáR OHF]RQ\FK
]DFKRZDZF]R SDFMHQWyZ ZUDFD GR SHáQHM DNW\ZQR FL UyZQLH* VSRUWRZHM [10].
-HGQRF]H QLH Z]UDVWD RGVHWHN XUD]yZ áNRWNL SU]\ URGNRZHM [48], a sama
PHQLVFHNWRPLD QDVLOD REMDZ\ QLHVWDELOQR FL NRODQD FR Z\ND]Dá .ZLDWNRZVNL [49].
:]URVW RGVHWND XUD]yZ áNRWNL SU]\ URGNRZHM MHVW VSRZRGRZDQ\ W\P *H URO
RJUDQLF]DMF SU]HGQLH SU]HVXQL
FLH SLV]F]HOL SU]HMPXM ZL
]DGáD SRERF]QH D QD
SODWHDX SLV]F]HOL VSDGD ZL
NV]H REFL*HQLH QL* Z VWDZLH ] ]DFKRZDQ\FK $&/ [50].
8V]NRG]HQLHáNRWNLVSU]\MD]NROHLDUWUR]LH[51]:\GDMHVL
*HQLHEH]SR UHGQLREUDN
ACL doprowadza do wtórnych zmian zwyrodnieniowych w stawie kolanowym, ale
27
EUDN F]\ XV]NRG]HQLH áNRWNL VSRZRGRZDQH QLHVWDELOQR FL VWDZX 1LH Z\NOXF]D WR
E\QDMPQLHMV\WXDFMLJG]LHQLHPD$&/áNRWNLV]DFKRZDQHDPLPRWRGRFKRG]LGR
zmian zwyrodnieniowych.
%UDN MHGQR]QDF]Q\FK GDQ\FK NWyUH SR]ZDODM VWZLHUG]Lü JG]LH WNZL SLHUZRWQD
SU]\F]\QD XV]NRG]HQLD FKU]VWNL VWDZRZHM [52]. Niemniej zmiany pourazowe kolana
]DOLF]D VL
GR HJ]RJHQQ\FK F]\QQLNyZ U\]\ND SRZVWDQLD ZWyUQ\FK ]PLDQ
zwyrodnieniowych kolana [53].
28
$57526.232:$5(.216758.&-$:, =$'à$.5=<)2:(*2
35=('1,(*235=(6=&=(3(0=:, =$'à$:à$ &,:(*25=(3.,
3.4.1 WYBÓR PRZESZCZEPU – porównanie B-PT-B z ACL
:VSRPQLDQH ]RVWDáR L* SU]HV]F]HS $&/ PR*H E\ü DXWRJHQLF]Q\ DOORJHQLF]Q\ DOER
V]WXF]Q\ 3U]HV]F]HS\ ] PDWHULDáyZ V]WXF]Q\FK ]DUH]HUZRZDQH V SUDNW\F]QLH GOD
V\WXDFML Z NWyU\FK QLH MHVW PR*OLZH ]DVWRVRZDQLH OXE SREUDQLH SU]HV]F]HSyZ
WNDQNRZ\FKSRZF]H QLHMZ\NRQDQ\FKZLHORNURWQ\FKUHNRQVWUXNFMDFK
'UyGáHPSU]HV]F]HSXPRJE\ü
-
NRPSOHNV EORF]HN NRVWQ\ SLV]F]HOL ± ZL
]DGáR ZáD FLZH U]HSNL ± EORF]HN NRVWQ\
rzepki (B-PT-B),
-
FL JQDPL QLDVPXNáHJRLSyá FL JQLVWHJR
-
EORF]HNNRVWQ\± FL JQRPL QLDF]ZRURJáRZHJRXGD
-
FL JQR$FKLOOHVD
-
SRZL (V]HURND
-
FL JQRPL QLDSLV]F]HORZHJRSU]HGQLHJR
-
FL JQD]JLQDF]\SDOXFKD
3U]HV]F]HS\WHPRJE\ü]DUyZQRDXWRMDNLDOORJHQLF]QH3U]HZDJDW\FKRVWDWQLFKQDG
autogenicznymi to brak problemów z gojeniem rany po pobraniu przeszczepu. Efekty
PHFKDQLF]QHLF]\QQR FLRZHQLHZ\ND]XMUy*QLFZREU
ELHW\FKGZyFKJUXSSRPLPR
WHJR *HVWHU\OL]DFMDLQD ZLHWODQLH]PLHQLDMZáD FLZR FL SU]HV]F]HSX REQL*DMF MHJR
Z\WU]\PDáR üQDUR]FLJDQLHRRNRáR[54].
3U]HV]F]HS\Uy*QLVL
PL
G]\VRESU]HGHZV]\VWNLPWDNLPSDUDPHWUDPLMDNGáXJR ü
SRZLHU]FKQLDSU]HNURMXV]HURNR üPDNV\PDOQHREFL*HQLHPDNV\PDOQ\QDFLVN-H OL
SRUyZQXMHP\$&/FHQWUDOQWU]HFLF]
ü%37% FL
JQRPL
QLDSyá FL
JQLVWHJR
67 RUD]VPXNáHJR * WR0/Z\QRVLRGSRZLHGQLR [55]: 1725 N, 2900 N, 1216 N,
1-H OLEUDüSRGXZDJ
W\ONRSDUDPHWU\Z\WU]\PDáR FLRZHWRVDPRG]LHOQLHW\ONR
%37% PR*H VáX*\ü MDNR SU]HV]F]HS GOD $&/ 2F]\ZL FLH VWRVXMH VL
MHV]F]H
SU]HV]F]HS\ FL
JQLVWHNWyUHRERN%37%VQDMF]
FLHMVWRVRZDQ\PPDWHULDáHPGR
UHNRQVWUXNFML$&/.RQLHF]QHMHVWMHGQDNLFKVNáDGDQLHQDOXEUD]\0yZLP\ZWHG\
29
R SU]HV]F]HSLH QD SU]\NáDG *67 SRGZyMQLH ]áR*RQH FL
JQD PL
QLD
Syá FL
JQLVWHJR RUD] VPXNáHJR 7DNL SU]HV]F]HS PD 0/ 1 D V]W\ZQR ü
kN/m [55, 56]
:DUWR FLWHVQDMZL NV]H]PR*OLZ\FKGRVW SQ\FK3U]HV]F]HS\67*
QLHNWyU]\DXWRU]\GRUDG]DMVWRVRZDüUDF]HMXVWDUV]\FKSDFMHQWyZ]UDFMLWHFKQLF]Q\FK
XZDUXQNRZDGRW\F]F\FKLFKPRFRZDQLD[57].
:OLWHUDWXU]HVSHFMDOLVW\F]QHMWRF]\VL
QLHXVWDMFDG\VNXVMDQDWHPDWZ\*V]R FLMHGQHM
PHWRG\QDGGUXJ'RW\F]\WR]DUyZQRDVSHNWyZPHG\F]Q\FKMDNLNRVPHW\F]Q\FK
$NWXDOQLH SU]HV]F]HS %37% PR*QD SRELHUDü WHFKQLN PLQL FL
FLD ÄVPDOO FXW´ FR
RJUDQLF]DG\VNXVM
ZNDWHJRULDFKNRVPHW\F]Q\FK[58].
0HWRGD %37% MHVW EDUG]LHM VWDQGDUGRZD ± PRFRZDQLH SU]HV]F]HSX QDVW
SXMH ]D
SRPRF UXE LQWHUIHUHQF\MQ\FK ZFKáDQLDOQ\FK OXE QLHZFKáDQLDOQ\FK : SU]\SDGNX
PHWRG\ *67 PRFRZDQLH SU]HV]F]HSX PR*H E\ü Z\NRQDQH Z V\VWHPLH (QGR%XWWRQ
7UDQV)L[5LJLG)L[OXE]DSRPRF UXELQWHUIHUHQF\MQ\FKPL
NNLFK1LHPQLHMPyZLFR
PHWRG]LH *67 WUDNWXMHP\ ZV]\VWNLH V\VWHP\ PRFRZDQLD MDNR MHGQ JUXS
*67
2SXEOLNRZDQRZLHOHGRQLHVLHRHIHNWDFKOHF]HQLDQLHVWDELOQR FLSU]HV]F]HSHP%37%
[59]
-HGQDN W\ONR SURVSHNW\ZQH UDQGRPL]RZDQH EDGDQLD PRJ RGSRZLHG]LHü QD
S\WDQLHNWyUD]PHWRGGDMHPQLHMSRZLNáDMHVWVNXWHF]QLHMV]DLPQLHMG\VNRPIRUWRZD
GODSDFMHQWD'RVW
SQHVMX*SXEOLNDFMH]Z\QLNDPLSURVSHNW\ZQ\FKSUyENOLQLF]Q\FK
]RNUHVHPREVHUZDFMLSRRSHUDF\MQHMOHWQLP&]
üSUDFSRND]XMH*HQLHPDLVWRWQ\FK
VWDW\VW\F]QLHUy*QLFZZ\QLNDFKRGWZRU]HQLDVWDELOQR FLVWDZX[60-64],QQHZVND]XM
*H%37%MHVWVNXWHF]QLHMV]PHWRGMH OLSRUyZQ\ZDüVWDELOQR ü[65]DOER*HPR*H
E\ü VNXWHF]QLHMV] PHWRG Z GáXJRF]DVRZHM REVHUZDFML [66] ,VWQLHM MHGQDN
GRQLHVLHQLD*H%37%PLPRL*SU]\ZUDFDVWDELOQR üWRVWDQRZLZL
NV]H]DJUR*HQLH
dla wczesnych zmian zwyrodnieniowych [67], a subiektywne odczucia dyskomfortu
SDFMHQWD V ZL
NV]H QL* Z PHWRG]LH *67 [68, 69] 'RVW
SQH V MHGQDN Z\QLNL QLH
SRWZLHUG]DMFHDQHJXMFHWHVWZLHUG]HQLD[65]-HG\Q\PUR]ZL]DQLHPWDNLHMV\WXDFMLL
RGSRZLHG]HQLHQDS\WDQLHNWyUDPHWRGDMHVWVNXWHF]QLHMV]DDMHGQRF]H QLHEH]SLHF]QD
GOD SDFMHQWD MHVW SRV]HU]HQLH JUXS\ EDGDQHM DOER PHWDDQDOL]D GRVW
SQ\FK EDGD
0HWDDQDOL]D WDND ]RVWDáD SU]HSURZDG]RQD Z URNX RSLHUDMF VL
MHGQDN QD
Z\QLNDFK EDGD RSXEOLNRZDQ\FK RG GR URNX [70] 1LH REM
áD ZL
F
FKRFLD*E\W\FKF\WRZDQ\FKSRZ\*HM'RPHWDDQDOL]\ZáF]RQREDGD%37%RUD]
13 G-ST. Wyniki tej oceny przedstawiono na stronie 30 (Tabela 1). Wyniki metaanalizy
SRND]XM*HVNXWHF]QLHMV]PHWRGMHVW]SHZQR FLSU]HV]F]HS]Z\NRU]\VWDQLHP%
30
37%6NXWHF]QR üPLHU]RQDZVSRVyERELHNW\ZQ\SU]\SRPRF\.7±VL
JD
natomiast subiektywne zadowolenie pacjenta wynosi 95 %. Przeszczep z
Z\NRU]\VWDQLHP *67 UyZQLH* GDMH GREUH Z\QLNL ER RGSRZLHGQLR L
1LHVWHW\ZL
NV]DVNXWHF]QR üPHWRG\%37%REDUF]RQDMHVW]ZL
NV]RQ\PU\]\NLHP
SRZLNáD
BPT-B
G-ST
RGVHWHNQLHSRZRG]H]SRZRGXXV]NRG]HQLD
przeszczepu w okresie pooperacyjnym
1,9 %
4,9 %
]DGDZDODMF\Z\QLNRGWZRU]HQLDVWDELOQR FLVWDZX
ZSRPLDU]H.7QLHZL
FHMQL*PP
79 %
73,8 %
odsetek satysfakcji pacjenta
95 %
87 %
GHILF\WZ\SURVWXSRZ\*HM°
1,9 %
0,7 %
meniscectomia w okresie pooperacyjnym
3,0 %
4,3 %
PDQLSXODFMHZHZQWU]VWDZRZH]NRQLHF]QR FL
znieczulenia, usuwanie zrostów
6,3 %
3,3 %
EyOSU]HGQLHJRSU]HG]LDáXNRODQD
17,4 %
11,5 %
Tabela 1
:\QLNLPHWDDQDOL]\SRUyZQXMFHMPHWRG UHNRQVWUXNFML$&/]X*\FLHP
%37%RUD]PHWRG ]X*\FLHP*67[70].
1DMF]
VWV]\P MHVW EyO SU]HGQLHJR SU]HG]LDáX NRODQD D GDOHM NRQLHF]QR ü PDQLSXODFML
ZHZQWU]VWDZRZ\FK NRQLHF]QR ü PHQLVFHFWRPLL RUD] GHILF\W Z\SURVWX 1LH R]QDF]D
WR*HPHWRGD*67MHVWSR]EDZLRQDW\FKSRZLNáDDOHVWDW\VW\F]QLH]GDU]DMVL
RQH
U]DG]LHM'RGHF\]MLFKLUXUJDLSDFMHQWDSR]RVWDMHZL
FGHF\]MDNWyUD]PHWRG]RVWDQLH
]DVWRVRZDQDDQDVW
SQLHMDNLE
G]LHVSRVyEILNVDFMLSU]HV]F]HSX
Na stronie 31 (Tabela 2
SU]HGVWDZLRQH ]RVWDá\ SRGVWDZRZH FHFK\ SU]HV]F]HSX 37
URGNRZDF]
üZL
]DGáDZáD FLZHJRU]HSNLV]HURNR üPP ZSRUyZQDQLX]$&/
[55, 56, 71, 72]
'DQHWDP]DPLHV]F]RQHQLHSRNU\ZDMVL ]HZV]\VWNLPLSXEOLNDFMDPL
QDWHQWHPDW Uy*QLFHZ\QLNDMSUDZGRSRGREQLH]Uy*QLFZPHWRGDFK]ELHUDQLDGDQ\FK
RUD]]Uy*QLFZLHNRZ\FKEDGDQ\FK]ZáRN0/]PLHQLDVL
]ZLHNLHPZSU]\SDGNX%±
37±%:JUXSLHZLHNRZHMSRZ\*HMODWZ]JO
GHP JUXS\SRQL*HMODW0/MHVW
PQLHMV]HR3R]RVWDáHSDUDPHWU\MDNSURFHQWZ\GáX*HQLDSU]\NWyU\PQDVW
SXMH
]HUZDQLH ZL
]DGáD SRZLHU]FKQLD MHJR SU]HNURMX L V]W\ZQR ü SR]RVWDM
31
niezmienione [71]
'DQHWHSR]ZDODMQDVWRVRZDQLHSU]HV]F]HSX%37%QLHW\ONRX
PáRGV]\FKSDFMHQWyZDOHLXVWDUV]\FK
PT
(1/3 centralna
F] ü37
V]HURNR ü
13,8 mm +/- 1,4)
ACL
ZDUWR FL37
Z]JO GHP$&/
'áXJR ü>PP@
48,7 +/- 3,8
26,9 +/- 1,1
181%
Powierzchnia przekroju
poprzecznego [mm2]
50,5 +/- 2,8
44,4 +/- 4
114%
0DNV\PDOQHREFL*HQLH>1@
2900 +/- 260
1725 +/- 269
168%
6]W\ZQR ü>N1P@PLHU]RQD
przy przyczepie
ZL
]DGáDSU]HV]F]HSX
685,2 +/- 85,6
182 +/- 33
376%
Tabela 2. Porównanie parametrów metrycznych przeszczepu PT do ACL [55, 56,
71, 72].
3.4.2 ANATOMIA ARTROSKOPOWA
:REUD]LHDUWURVNRSRZ\PZLG]LP\RF]\ZL FLHWHVDPHVWUXNWXU\FRSRDUWURWRPLLDOH
Z LQQ\P SRZL
NV]HQLX RUD] ] RJUDQLF]RQ\FK SXQNWyZ 3RUW\ Z SURFHGXU]H
UHNRQVWUXNFML $&/ V VWDQGDUGRZH ZDUWR MHGQDN SRUW SU]HGQLR ± ERF]Q\ ] RSW\N
XPLHMVFRZLü Z PLDU
EOLVNR ZL
]DGáD ZáD FLZHJR U]HSNL SRQLHZD* SR]ZDOD WR QD
GREU\ZJOGZGyáPL
G]\Ná\NFLRZ\RUD]PLHMVFHSU]\F]HSXXGRZHJR$&/0LQXVHP
WDNLHJRXPLHV]F]HQLDSRUWXMHVWU\]\NR]DNU\ZDQLDREUD]XSU]H]EáRQ
PD]LRZNRODQD
1LH]DZV]HXV]NRG]HQLH$&/MHVWHZLGHQWQHREHFQHVGZDNLNXW\NWyUHQLHEXG]
*DGQ\FKZWSOLZR FL&]
VWRZL
]DGáR]DFKRZXMHVZRMFLJáR üGRSLHURVSUDZG]HQLH
MHJRZ\GROQR FLPHFKDQLF]QHMKDF]\NLHPUR]VWU]\JDSUREOHP,QQZWSOLZV\WXDFM
jest przyklejenie kikuta ACL do PCL, z pozostawieniem niewydolnych mechanicznie
SRMHG\QF]\FK ZáyNLHQ $&/ SU]\F]HSLRQ\FK GR Ná\NFLD XGRZHJR %DUG]R FHQQ\P
objawem jest tutaj objaw czarnej dziury, „black hole sign”. W badaniu artroskopowym
NRODQDSU]HVWU]HSRPL
G]\3&/DNá\NFLHPXGRZ\PERF]Q\PMHVW]DVáRQL
WDSU]H]
32
$&/:SU]\SDGNXMHJREUDNXZLG]LP\F]DUQG]LXU
SRQLHZD* ZLDWáRDUWURVNRSXQLH
MHVWZVWDQLHR ZLHWOLüWDPW\FKREV]DUyZ2GVXZDMFSU]\ URGNRZRXV]NRG]RQH$&/
UyZQLH*PR*HP\X]\VNDüREMDZF]DUQHMG]LXU\
Rycina 6
2NUH ODQLHNLHUXQNyZZREUD]LHDUWURVNRSRZ\P
3.4.3 OPIS TECHNIKI OPERACYJNEJ STOSOWANEJ W KRAKOWSKIM
CENTRUM REHABILITACJI
3DFMHQW Z XáR*HQLX QD SOHFDFK QD VWROH RUWRSHG\F]Q\P ]áDPDQ\P .RF]\QD OX(QR
]ZLVD]JL
WDZNRODQLHGR °. Na udzie opaska uciskowa pneumatyczna. Preferowane
]QLHF]XOHQLHSRGSDM
F]\QyZNRZH
=DELHJG]LHOLVL
QDGZDHWDS\ SREUDQLHSU]HV]F]HSXRUD]LPSODQWDFM
SU]HV]F]HSX
Pobranie przeszczepu.
&L
FLHVNyUQHZOLQLL URGNRZHMNRF]\Q\VL
JDMFHRGFPSRZ\*HMGROQHJRELHJXQD
U]HSNL GR JX]RZDWR FL SLV]F]HOL 3UHSDURZDQLH WNDQHN REHMPXMH Z\RGU
EQLHQLH
SHULWHQGRQ ZL
]DGáD ZáD FLZHJR U]HSNL 3R RGVáRQL
FLX ZL
]DGáD ZáD FLZHJR
Z\NRQXMHP\GZDSRGáX*QHQDFL
FLDZL
]DGáDQDFDáHMMHJRGáXJR FLZ\FLQDMFMHJR
URGNRZ F]
ü R V]HURNR FL PP 1DVW
SQLH SU]\ SRPRF\ SLá\ RVF\ODF\MQHM
Z\FLQDP\ EORF]NL NRVWQH NROHMQR ] SLV]F]HOL L U]HSNL %ORF]NL NRVWQH SRZLQQ\ PLHü
V]HURNR üPPGáXJR ü±PPLJá
ERNR üPP1DSU]HNURMXSRSU]HF]Q\P
Z\FLQDQH EORF]NL SRZLQQ\ PLHü NV]WDáW WUDSH]X JG]LH UyZQROHJáH ERNL Uy*QL VL
33
PL
G]\ VRE GáXJR FL Z QLHZLHONLP VWRSQLX .ROHMQ\P HWDSHP MHVW SRGZD*HQLH
EORF]NyZ NRVWQ\FK L Z\M
FLH SU]HV]F]HSX (WDS WHQ MHVW QDMEDUG]LHM QLHEH]SLHF]Q\ L
Z\PDJDQDOH*\WHMXZDJLLZSUDZ\RSHUDWRUD3RU
F]QHMHVWSRGZD*\üQDMSLHUZEORF]HN
SLV]F]HORZ\DGRSLHURZGUXJLHMNROHMQR FLU]HSNRZ\0DMFMX*SRGZD*RQ\EORF]HN
SLV]F]HORZ\ RSHUDWRU PR*H VZRERGQLH Z\F]Xü SDOSDF\MQLH JUXER ü U]HSNL MHM
GRPQLHPDQ JUDQLF
SRZLHU]FKQL FKU]
VWQHM ']L
NL WDNLHM NRQWUROL PLQLPDOL]XMHP\
U\]\NRS
NQL
FLDU]HSNLZWUDNFLHSRELHUDQLDSU]HV]F]HSX3REUDQ\SU]HV]F]HS]RVWDMH
RSUDFRZDQ\ ± SU]HNURMH SRSU]HF]QH EORF]NyZ ]RVWDM REFL
WH GR NV]WDáWX NRáD R
UHGQLF\ *GDQHM SU]H] RSHUDWRUD UHGQLFD Z\QLND Z SURVWHM PLHU]H ] V]HURNR FL
SREUDQHJR EORF]ND 8 SDFMHQWyZ ] PDá U]HSN WUXGQR MHVW SRELHUDü EORF]HN R
V]HURNR FL PP X RVyE EDUG]LHM PDV\ZQ\FK EORF]HN PP PR*H RND]Dü VL
QLHZ\VWDUF]DMF\ GR ILNVDFML SU]HV]F]HSX 1LH MHVW NRQLHF]QH DE\ UHGQLFD REX
EORF]NyZ E\áD WDND VDPD ,VWRWQH MHVW *H MH OL Uy*QL VL
WR EORF]HN R PQLHMV]HM
UHGQLF\ PXVL E\ü ZV]F]HSLRQ\ Z NR ü XGRZ 8]DVDGQLHQLH Z SUDNW\FH ]QDMGXMH
UyZQLH*RGZUDFDQLHSU]HV]F]HSX
%ORF]NLQDZLHUFDQHVZGZyFKPLHMVFDFKFLHQNLPZLHUWáHPQS∅ 1 mm, przez które
SU]HSURZDG]DP\QLFLFLJQFH1DVW
SQLHGRNRQXMHP\NRQWUROL UHGQLF\SU]HV]F]HSX
SU]HSURZDG]DMFJRSU]H]VSHFMDOQHSURZDGQLFHV\PXOXMFHNDQDá\NRVWQH
:QLHNWyU\FKSU]\SDGNDFKX]DVDGQLRQ\PMHVWRGZUDFDQLHSU]HV]F]HSXF]\OLZNáDGDQLH
EORF]ND U]HSNRZHJR GR NDQDáX SLV]F]HORZHJR D EORF]ND SLV]F]HORZHJR GR NDQDáX
XGRZHJR6\WXDFMHWDNLHPDMPLHMVFH JG\EORF]HNU]HSNRZ\PDVLOQLH]DJL
WNR ü
NRURZLSU]\SRPLQDNOHSN
RGEHF]NL-HVWEDUG]RQLHZ\JRGQHDF]DVHPU\]\NRZQH
SU]HSURZDG]Dü WDNL EORF]HN SU]H] NDQDá SLV]F]HORZ\ D GRSLHUR SRWHP XGRZ\
5R]VGQ\P Z\GDMH VL
ZWHG\ SRSU]HVWDü QD SLV]F]HORZ\P D ZL
F RGZUyFLü
przeszczep.
1D W\P HWDSLH ZUDFDP\ GR NRODQD /R*
SR SREUDQ\P SU]HV]F]HSLH ]HV]\ZDP\
'RSXV]F]DOQHMHVWSR]RVWDZLHQLDZL
]DGáDQLH]HV]\WHJRSRQLHZD*QLHZSá\ZDWRQD
MHJRIXQNFM
[73]3HULWHQGRQ]HV]\ZDP\RGG]LHOQZDUVWZV]ZyZ:W\PPRPHQFLH
]DNáDGDP\ SRUW\ SU]HGQLR ± ERF]Q\ GOD DUWURVNRSX RUD] SU]HGQLR ± SU]\ URGNRZ\
URERF]\ =UHJXá\ SDFMHQW PLDá ZF]H QLHM Z\NRQDQ DUWURVNRSL
L PR*QD VSRG]LHZDü
VL
*HNRODQR]RVWDáRSU]\JRWRZDQHGR]DELHJXUHNRQVWUXNFMLDZL
FXVXQL
WRZROQH
IUDJPHQW\$&/ZL
]DGáDEáRQLDVWHJR-H OLQLHMHVWWRNRQLHF]QHSRQLHZD*IUDJPHQW\
WHMDNUyZQLH*QDGPLDUEáRQ\PD]LRZHME
GQDPXWUXGQLDá\RSHURZDQLHQDU]
G]LDPL
34
Implantacja przeszczepu.
1DU\QNXLVWQLHMHNLONDV\VWHPyZGRLPSODQWDFMLSU]HV]F]HSX%37%5y*QLFHPLHG]\
QLPLGRW\F]MHG\QLHV]F]HJyáyZWHFKQLF]Q\FKF]
VWRXáDWZLDMF\FKRSHUDWRURZLSUDF
1LHPQLHMZV]\VWNLHNLHUXMVL
WVDPLGHLPDMWHVDPHURG]DMHQDU]
G]L
Do stawu kolanowego, poprzez roboczy port, wprowadzamy celownik piszczelowy.
:L
NV]R ü V\VWHPyZ SRVLDGD UHJXODFM
NWD FHORZQLND -HJR JyUQH UDPL
XVWDZLDP\
UyZQROHJOH GR SRGáR*D GROQH SRG NWHP MDNL RGSRZLDGD RSHUDWRURZL D MHVW
SRG\NWRZDQ\FK
FLNRUHNFMLGáXJR FLSU]HV]F]HSX=Z\NOHMHVWWR° - 60°. Koniec
JyUQHJRUDPLHQLDORNXMHP\ZSXQNFLHSU]\F]HSXSLV]F]HORZHJR$&/JG]LH]DFKZLO
SU]HZLHUFRQ\ ]RVWDQLH NDQDá NRVWQ\ 3XQNW WHQ MHVW SXQNWHP L]RPHWU\F]Q\P 3U]\
pomocy wiertarki wprowadzamy drut kierunkowy. Wyjmujemy celownik i po
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NWyU\ E
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SXQNW L]RPHWU\F]Q\ GOD $&/ QD XG]LH 3U]\ UHNRQVWUXNFML SU]HV]F]HSHP R PDáHM
UHGQLF\ VWRVRZDQLH JUXEHJR FHORZQLND MHVW QLHSRU
F]QH D F]DVDPL XQLHPR*OLZLD
umiejscowienie go w punkcie izometrycznym. Pomocne w lokalizacji miejsca
LPSODQWDFML SU]HV]F]HSX QD NR FL XGRZHM PR*H E\ü ]QDOH]LHQLH ZLGRF]Q\FK PLHMVF
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35
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kanale ∅
PP L EORF]NX GáXJR FL PP PR*QD ]DSURSRQRZDü UXE ∅ 8 mm x
PP )LNVXMF NROHMQR EORF]HN Z NDQDOH XGRZ\P L SLV]F]HORZ\P QDOH*\ VWDOH
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FLD SU]HV]F]HSX SU]\ SRPRF\ KDF]\ND :
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ü
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NDQDáX Z\VWDMH FDá\ OXE SUDZLH FDá\ EORF]HN ZVND]DQH MHVW ]UH]\JQRZDü ]H UXE\
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W ten sposób procedura rekonstrukcji artroskopowej ACL przy pomocy przeszczepu B
± 37 ± % MHVW ]DNRF]RQD 3R]RVWDM MHV]F]H V]Z\ SRGVNyUQH L VNyUQH Z UDQLH SR
pobranym przeszczepie oraz szew skórny w ranie po artroskopie.
36
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GáXJR ü]HUZDQHJR$&/QLH0R*QDMHG\QLHRSLHUDüVL
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:
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WQHRV]DFRZDQLHSR*GDQHMGáXJR FL
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QLH]PLHQQ\ ER VWDQRZL SXQNW L]RPHWU\F]Q\ MHG\QH PR*OLZR FL GDMH ]PLDQD MHJR
Z\ORWX ]HZQWU]VWDZRZHJR 0R*QD WR RVLJQü ]PLHQLDMF NW SRFK\OHQLD GROQHJR
UDPLHQLD FHORZQLND (PSLU\F]QLH XVWDORQR *H ]ZL
NV]HQLH SRFK\OHQLD R ° daje
Z\GáX*HQLH NDQDáX SLV]F]HORZHJR R PP &, [74] -HGQRF]H QLH
QLHVWZLHUG]DVL
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G]\GáXJR FL$&/OXE37DZ]URVWHP[74].
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G]\$&/D37MHVWSU]\F]\QGDOV]\FKZWSOLZR FL
Bloczek piszczelowy, schowany w tunelu piszczelowym, nie dochodzi do jego brzegu
ZHZQWU]VWDZRZHJR DOH MHVW RGGDORQ\ R SHZLHQ G\VWDQV 5\FLQD 6WDQ WDNL
SUHG\VSRQXMHGRV\WXDFMLJG]LH FL
JQRRFLHUDVL
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GRSURZDG]Lü GR MHJR XV]NRG]HQLD $E\ ]OLNZLGRZDü WHQ VWDQ SUyERZDQR GZyFK
UR]ZL]D:SLHUZV]\PRGFLQDQRPPG\VWDOQHMF]
FLEORF]NDSLV]F]HORZHJRL
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JQD[75]. Bloczek rzepkowy implantowano do
SLV]F]HOL : WHQ VSRVyE X]\VNLZDQR Z]JO
GQH VNUyFHQLH FL
JQD GRSDVRZXMF MHJR
GáXJR ü GR GáXJR FL ZHZQWU]VWDZRZHM $&/ 3R PLHVLFDFK RG UHNRQVWUXNFML
Z\QLNLGRW\F]FHVWDELOQR FLL]DNUHVXUXFKyZE\á\WDNLHVDPH1DWRPLDVWF]
VWR üEyOX
37
RNROLF\ JX]RZDWR FLSLV]F]HOLE\áDZL
NV]DZ JUXSLH JG]LHEORF]HNU]HSNRZ\ ]RVWDá
ÄZ\GáX*RQ\´ 5\FLQD 'UXJDNRQFHSFMDSROHJDQDQLHMDNR]GZRMHQLX37L]áR*HQLX
obu bloczków kostnych razem (Rycina 8) [76]
2JUDQLF]HQLHPPHWRG\MHVWGáXJR ü37
$XWRU]\QLH]DOHFDMMHMZSU]\SDGNXJG\37MHVWNUyWV]HQL*PP:\QLNLSRGDZDQH
VMDNRGREUHQLHVWHW\QLHPDEDGDSRUyZQDZF]\FK]NODV\F]Q\PLSURFHGXUDPL
Rycina 7
3RáR*HQLHEORF]NDZNDQDOHSLV]F]HORZ\PZNODV\F]QHMUHNRQVWUXNFML
ACL z wykorzystaniem B-PT-B.
Rycina 8
3RáR*HQLHZNDQDOHSLV]F]HORZ\P $ Z\GáX*RQHJREORF]NDZ
rekonstrukcji ACL z wykorzystaniem B-PT-B, (B) zduplikowanego bloczka w
rekonstrukcji ACL z wykorzystaniem B-PT-B.
38
1$3, &,(:67 31( 35(&21',7,21,1*
3UHFRQGLWLRQLQJ MHVW DQJORM
]\F]Q\P WHUPLQHP L R]QDF]D ZLHORNURWQH REFL*DQLH
ZL
]DGáD Z MHJR GáXJLHM RVL G]LDáDMF VLá R ]DGDQ\FK ] JyU\ SDUDPHWUDFK ZDUWR ü
PDNV\PDOQDZDUWR üPLQLPDOQDF]DV]PLDQ\RGZDUWR FLPLQLPDOQHMGRPDNV\PDOQHM
L LOR ü ]PLDQ QD VHNXQG
PRGHO ]PLDQ\ ZDUWR FL VLá\ QD SU]\NáDG VLQXVRLGDOQ\
2PDZLDQR ZF]H QLHM IHQRPHQ FLHUSQL
FLD FUHHS SKHQRPHQRQ : V\WXDFML
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WHMVLá\E
G]LHVL
PLH FLáDZSHZQ\FKJUDQLFDFK±MH OLMHSU]HNURF]\ZL
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zerwaniu.
W czasie rekonstrukcji poddajemy przeszczep pewnemu ustalonemu empirycznie
QDSL
FLX NWyUH MHVW NRQLHF]QH GR RGWZRU]HQLD VWDELOQR FL VWDZX =JRGQLH MHGQDN ]
IHQRPHQHP FLHUSQL
FLD ZL
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G]LH SRZROL UR]OX(QLDü VL
D* RVLJQLH SHZQ
UyZQRZDJ
]PQLHMV]DMFMHGQDNW\PVDP\PVWDELOQR üVWDZX2EFL*HQLHZVW
SQHPD
QDFHOX]QLZHORZDüHIHNWIHQRPHQXFLHUSQL
FLD[77]. Zjawisko to dotyczy nie tylko B-
37%DOHUyZQLH*SU]HV]F]HSyZ FL
JQLVW\FK[78]-H OLSRGGDü%37%F\NOLF]QHPX
REFL*DQLXRVLOH1LF]
VWRWOLZR FL+]WRSRF\NODFKIHQRPHQFLHUSQL
FLD
praktycznie zanika [79].
0RGXá <RXQJD SRGDMH VWRVXQHN ZDUWR FL VLá\ G]LDáDMFHM QD GDQ\ SU]HNUyM ZL
]DGáD
Z]JO
GHPZ\GáX*HQLDWHJR*ZL
]DGáDNWyUHQDVWSLáRSRGZSá\ZHPG]LDáDMFHMVLá\:
VNUyFLH±PRGXá<RXQJDPyZLMDNEDUG]RPDWHULDáRGSRUQ\MHVWQDVLá
UR]FLJDMF,P
MHJRZDUWR üZ\*V]DW\PPDWHULDáVWDZLDVLOQLHMV]\RSyUG]LDáDMFHMVLOH[79].
0DNV\PDOQH REFL*HQLH GOD %37% WR RNRáR 1 [79] 0RGXá <RXQJD GOD
SU]HV]F]HSX QLHREFL*DQHJR ZVW
SQLH Z\QRVL SU]\ QDSL
FLDFK 1 L 1
RGSRZLHGQLR03DL 03DDGODREFL*DQHJRL03D
=PLHQLD VL
UyZQLH* PDNV\PDOQH QDSL
FLH 03D GR 03D QDWRPLDVW
PDNV\PDOQHZ\GáX*HQLHSR]RVWDMHEH]]PLDQ [79].
3RGGDQLH SU]HV]F]HSX REFL*DQLX ZVW
SQHPX XPR*OLZLD QDP Z SHáQL NRQWURORZDü
QDSL
FLHMDNLHSODQXMHP\]DVWRVRZDüZWUDNFLHUHNRQVWUXNFML$&/1LHVWHW\Z\GDMHVL
WRQLHSU]HNáDGDüQDOHSV]HZ\QLNLNOLQLF]QHZGZXOHWQLHMREVHUZDFML[80].
39
3.4.6 UMIEJSCOWIENIE TUNELI KOSTNYCH W PUNKTACH
IZOMETRYCZNYCH
1LH PD GZyFK SXQNWyZ L]RPHWU\F]Q\FK GOD $&/ PR*QD PyZLü MHG\QLH R PLHMVFX
prawie–izometrycznym. Podobna sytuacja dotyczy przeszczepu. Jednak prawie–
L]RPHWULD Z SU]\SDGNX Z\ERUX PLHMVFD LPSODQWDFML SU]HV]F]HSX PXVL PLHü SHZQH
JUDQLFH 0DNV\PDOQD HORQJDFMD GOD 37 WR RNRáR [55] :LDGRP\P MHVW UyZQLH*
MDNLHMHVWNRQLHF]QHPLQLPDOQHREFL*HQLHZVW
SQHDE\Z\áF]\üIHQRPHQFLHUSQL
FLD
– w przypadku ACL to 6% [81]
Z SU]\SDGNX 37 EUDN GDQ\FK DOH PR*QD WXWDM
Z\NRU]\VWDüZDUWR FLGOD$&/6]F]HJyá\GRW\F]FHIHQRPHQXFLHUSQL
FLDLREFL*HQLD
ZVW
SQHJR]RVWDá\RSLVDQHSU]HGQLR ZUR]G]LDáDFKQDVWURQLH 10 i 38 3DPL
WDMF*H
GáXJR ü 37 Z\QRVL UHGQLR PP Z\GáX*HQLH R R]QDF]D PP 8]\VNDQLH
ZL
NV]HJRZ\GáX*HQLDSU]HV]F]HSXZZ\QLNXREFL*DQLDZVW
SQHJRR]QDF]DáRE\XWUDW
MHJRZáD FLZR FLHODVW\F]Q\FKDZV\WXDFMLNUDFRZHM]HUZDQLH SRRVLJQL
FLX
'UyGáHPVLá\Z\NRQXMFHMREFL*DQLHZVW
SQHE\áE\WXWDMUXFK]JLQDQLDLSURVWRZDQLDZ
stawie kolanowym. Nie dowiedziono w 2 letnim okresie obserwacji przewagi
UHNRQVWUXNFML$&/]REFL*DQLHPZVW
SQ\PQDGUHNRQVWUXNFMEH]WDNLHJRREFL*DQLD
MH OLZ\QLNPLHU]\üUy*QLFZVWDELOQR FLVWDZX[80]:\ND]DQRQDWRPLDVWVNXWHF]QR ü
WDNLHJR REFL*DQLD Z OLNZLGRZDQLX IHQRPHQX FLHUSQL
FLD RUD] SRSUDZLH ZáD FLZR FL
HODVW\F]Q\FK%37%,VWRWQHQLHPQLHMMHVW*HMH OLREFL*DQLHZVW
SQHWRSU]HGDQLH
SR ILNVDFML SU]HV]F]HSX $E\ XQLNQü WDNLHM V\WXDFML EH]Z]JO
GQLH NRQLHF]QH MHVW
XPLHV]F]HQLHSU]HV]F]HSXZWDNLFKSXQNWDFKNWyUHE
GRGVLHELHRGGDORQHZF]DVLH
SHáQHJR]DNUHVXUXFKXRWDNLVDPG\VWDQV]WROHUDQFMPP
3RZ\*V]DWHRULDGRW\F]\MHGQDNV\WXDFMLJG\NRODQRSRUXV]DVL
]DZV]HZHGáXJWHJR
VDPHJRZ]RUFD1LHVWHW\QLHMHVWRQRVNRQVWUXRZDQH]HVWDOLDNá\NFLHQLHSRUXV]DMVL
SR V]W\ZQR Z\W\F]RQ\FK SURZDGQLFDFK =PLDQD REFL*HQLD NRODQD ZDOJL]DFMD
ZDU\]DFMD F]\ FKRüE\ OX(QH ]ZLVDQLH SRGXG]LD QD VWROH RSHUDF\MQ\P PD ZSá\Z QD
L]RPHWUL
L GHF\]M
RSHUDWRUD GRW\F]F ORNDOL]DFML Z\ORWyZ WXQHOX SLV]F]HORZHJR L
udowego [21].
3U]HV]F]HS%37%QLHPD UHGQLF\SXQNWRZHMDOHMHVWEORF]NLHPNRVWQ\PR UHGQLF\
NLONXPLOLPHWUyZ7RVSU]\MDEá
GQHPXZ\]QDF]HQLXPLHMVFDLPSODQWDFML:\ND]DQR
*HQDZHWMH OLX*\MHP\FLHQNLHJRSU]HV]F]HSXNHYODURZHJRR∅PPLXPLH FLP\JRZ
miejscu anatomicznego przyczepu, ACL nie mamy gwarancji na odtworzenie izometrii
40
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SU]\F]HSXXGRZHJR:REU
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NV]H
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SRZLHU]FKQL
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SURMHNFMLERF]QHMSRáR*HQLHWRPR*QDRNUH OLüMDNRJá
ERNR FLSLV]F]HOL Rycina
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FLX
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GHP XGD 1XPHU Ä´ R]QDF]D WXWDM SURFHQWRZ RGOHJáR ü SU]\F]HSX
piszczelowego ACL od przedniego brzegu piszczeli (Rycina 9). Ponadto, w takiej
NRQILJXUDFML SU]HV]F]HS $&/ RGGDOD VL
RG SU]\F]HSX 3&/ FR RVáDELD PHFKDQL]P
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WU]QD
41
SLV]F]HOLSU]\]JL
FLXZNRODQLH°ZSRUyZQDQLX]NODV\F]QSURFHGXU6WDELOQR ü
przednio-tylna pozostaje bez zmian [82].
Rycina 9. Lokalizacja piszczelowego przyczepu przeszczepu.
Rycina 10
.LHUXQHNLVLáDG]LDáDQLD$&/Z]DOH*QR FLRGSRáR*HQLDNDQDáX
piszczelowego.
=DREVHUZRZDQR UyZQLH* *H Z RNUHVLH SRRSHUDF\MQ\P G]L
NL SU]HEXGRZLH
SU]HV]F]HSX UHPRGHOOLQJ XOHJD RGWZRU]HQLX QDWXUDOQ\ NV]WDáW SU]\F]HSX $&/
RNUH ODQ\MDNRÄNDF]DVWRSD´[13]']L
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42
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ERNR FL SLV]F]HOL ZLG]LDQHM QD
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.$1$à8'2:<
8PLHMVFRZLHQLH NDQDáX XGRZHJR EXG]L R ZLHOH ZL
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]DGáDF]\WH*SU]HV]F]HSX
RUD]QLH]DZV]HVSUDZG]DQLHL]RPHWULLZFDá\P]DNUHVLHUXFKyZDRJUDQLF]DQLHVL
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SU]\NáDGGRSU]HG]LDáX°-90°.
3RND]XMH WR MDN WUXGQ\P ]DJDGQLHQLHP MHVW ZáD FLZD ORNDOL]DFMD LPSODQWRZDQHJR
przeszczepu.
=PLDQDSU]\F]HSXXGRZHJRZGX*\PVWRSQLXZSá\ZDQD]PLDQ
GáXJR FLLQDSL
FLD
przeszczepu w czasie ruchu zginania kolana. Zachowanie próbnych przeszczepów o
PDáHMJUXER FLXPLHMVFRZLRQ\FKZUy*Q\FKF]
FLDFKDQDWRPLF]QHJRSU]\F]HSX$&/
SRND]XMH *H ]PLDQ\ PP PRJ ZSá\ZDü QD ]DFKRZDQLH VL
SU]HV]F]HSX [25].
=JRGQLH ] ZF]H QLHMV]\PL LQIRUPDFMDPL 3.2.4 PUNKTY IZOMETRYCZNE), nie
poszukujemy idealnego punktu, ale strefy izometrycznej, która zapewni minimalne
]PLDQ\GáXJR FLSU]HV]F]HSX[83].
/LQLD%OXPHQVDDWMHVWOLQLNWyUDSU]\OHJDGRVWURSXGRáXPL
G]\Ná\NFLRZHJRLWZRU]\
] RVL XGD NW °- 60° [13, 21] 3U]HFLQD VL
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GáXJR FLRGWHMOLQLL Rycina 11 6SR UyGPHWRGUDGLRORJLF]QHMRFHQ\SRSUDZQR FL
SRáR*HQLDNDQDáXNRVWQHJRLLPSODQWXMHVWWRMHG\QDPHWRGDGDMFDGREUHZ\QLNL[84].
1LHVWHW\ WUXGQR M VZRERGQLH Z\NRU]\VW\ZDü Z SUDNW\FH RSHUDF\MQHM 'OD RSHUDWRUD
EDUG]LHMSRU
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i zabiegów.
3U]\F]HS XGRZ\ $&/ PD NV]WDáW RZDOQ\ L RNUH ORQ SRZLHU]FKQL
SU]\F]HS
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XGD :VSRPQLDá R W\P $PLV [21] ]DXZD*DMF *H F]
ü ZáyNLHQ $&/ XOHJD ZWHG\
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ü UR]OX(QLHQLX 3U]HGQLH ZáyNQD V QDSL
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43
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FLX :\MD QLD WR ]DFKRZDQLH VL
$0% RUD] 3/% RSLVDQH Z UR]G]LDOH 3.2.4
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SRáR*HQLX2NUH ODVL
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VL
ZWHG\ SRGREQLH GR RU\JLQDOQHJR $&/ ± PDNV\PDOQH QDSL
FLH RVLJD Z
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Z\SUR FLH
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WHFKQRORJLL NRPSXWHURZ\FK ] QDZLJDFM ZáF]QLH [86] ,FK DXWRU]\ SRGDM EDUG]R
GREUH Z\QLNL RWU]\PDQHM L]RPHWULL SRGNUH ODMF MHGQRF]H QLH NRQLHF]QR ü
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NRFD ]DXIDü XU]G]HQLRP SDPL
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LGHDOQHUH]XOWDW\
Rycina 11. Linia Blemansaat i udowe umiejscowienie przeszczepu.
F]\QQR FLRZH [88] :\QLNL RFHQ\ ORNDOL]DFML NDQDáyZ NRVWQ\FK QD SRGVWDZLH
UHQWJHQRJUDPyZ SRND]XM *H PLPR ZNáDGDQHJR Z\VLáNX QLH ]DZV]H RVLJDQ\ MHVW
sukces. W badaniu wykonanym przez Topliss [89]
Z\ND]DQR *H ORNDOL]DFMD
NDQDáyZ XGRZ\FK Z SURMHNFML ERF]QHM RUD] Z DS QLH VSHáQLáR RF]HNLZD
44
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] QLFK ]QDOD]áR VL
Z RPDZLDQHM JUXSLH : LQQ\P EDGDQLX Z\ND]DQR *H
SU]HNRQDQLHRSHUDWRUDRW\P JG]LH]ORNDOL]RZDáNDQDáNRVWQ\QLH]DZV]HNRUHOXMH]
U]HF]\ZLVWR FL±ORNDOL]DFMDNDQDáXXGRZHJRQDUHQWJHQRJUDPLHERF]Q\PNRUHORZDáD
] RF]HNLZDQ Z QD UWJ DS Z ORNDOL]DFMD NDQDáX SLV]F]HORZHJR QD UWJ
bocznym w 7%, na rtg a-p w 14% [90]
1LHZWSOLZLHFRSRGNUH OD%DUUHWWL7UHDF\
GR ZLDGF]HQLHRSHUDWRUDPDWXWDMRJURPQH]QDF]HQLH[91].
3.4.7 NAPINANIE PRZESZCZEPU PRZY JEGO MOCOWANIU
:DUWR üQDSL
FLDMDNDMHVWSU]\NáDGDQDGRPRFRZDQHJRSU]HV]F]HSX%37%XVWDORQD
]RVWDáD HPSLU\F]QLH RGQRV]F VL
GR ZLHONR FL SU]HGQLHJR SU]HVXQL
FLD SLV]F]HOL
:DUWR FL WH ]DOH* QLH W\ONR RG LQG\ZLGXDOQ\FK FHFK SDFMHQWD ± SDUDPHWUyZ
PHFKDQLF]Q\FKPL
QL FL
JLHQZL
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]RVWDQLHX*\W\[92]JG\*ND*G\PDFKDUDNWHU\VW\F]QHGODVLHELHZáD FLZR FL[55].
:\ND]DQRUyZQLH**HQDSL
FLHSU]HV]F]HSXPR*H]PQLHMV]\üVL
D*RZNUyWFHSR
LPSODQWDFMLMH OLQLHSRGGDQH]RVWDáRREFL*HQLXZVW
SQHPX[77].
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NWyU\PZ\VW
SXMHQDMZL
NV]DQLHVWDELOQR üL]UHNRQVWUXRZDQH$&/E
G]LHSRGGDZDQH
QDMZL
NV]\PQDSL
FLRP[93].
1LHPDMHGQR]QDF]Q\FKGDQ\FKPyZLF\FKMDNLQDSL
FLHSRZLQQRE\üVWRVRZDQHSU]\
ILNVDFMLSU]HV]F]HSX:\QLNLZOLWHUDWXU]HGRW\F]SUDFNOLQLF]Q\FKRUD]SURZDG]RQ\FK
QD ]ZLHU]
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WDü *H PRJ
Z\VW
SRZDü LVWRWQH Uy*QLFH Z Z\QLNDFK SRPL
G]\ Uy*Q\PL URG]DMDPL VWRVRZDQ\FK
przeszczepów.
=DVWRVRZDQLH ZL
NV]HJR QDSL
FLD QLH VWDQRZL RF]\ZL FLH *DGQHJR WHFKQLF]QHJR
SUREOHPX =ZL
NV]RQH SRQDG PLDU
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NRQVHNZHQFMH8GRNXPHQWRZDQHV]PLDQ\]Z\URGQLHQLRZHSU]HV]F]HSXRFKDUDNWHU]H
OX]RZDW\P QDSL
FLH 1 SRáF]RQH ] XWUDW FKDUDNWHU\VW\F]QHJR UyZQROHJáHJR
XNáDGX ZáyNLHQ NRODJHQRZ\FK [94]. Inne to gorsze ukrwienie przeszczepu,
]PQLHMV]HQLHLOR FLZáyNLHQRPDáHM UHGQLF\]HZ]URVWHPLOR FLW\FKRGX*HM UHGQLF\
[78]
RUD] RVáDELHQLH SDUDPHWUyZ PHFKDQLF]Q\FK QDSL FLH 1 ,VWQLHMH UyZQLH*
U\]\NRUR]ZLQL FLDZF]HVQ\FK]PLDQ]Z\URGQLHQLRZ\FKNRODQD=ZL NV]RQHQDSL FLH
45
EH] ZWSLHQLD RJUDQLF]D URWDFM
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DQW\URWDF\MQHM$&/SRWU]HEQHMHVWQDSL
FLH]DOHGZLH1[15].
1LHPQLHM LVWQLHM UyZQLH* SUDFH E
GFH Z RSR]\FML GR Z\*HM Z\PLHQLRQ\FK NWyUH
PyZL *H ]DVWRVRZDQLH QDSL
FLD 1 SRG NWHP ILNVDFML °, w porównaniu z
EUDNLHPQDSL
FLDGDMHZ]URVWVLá\ZL
]DGáD[95].
%\üPR*HRGWZRU]HQLHVWDELOQR FLNRODQDREDUF]RQHMHVWQLHXQLNQLRQ\P]ZL
NV]HQLHP
QDSL
FLD Z SU]HV]F]HSLH Z SRUyZQDQLX ] $&/ [96] D WR PR*H E\ü VSRZRGRZDQH
Eá
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PL
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3.1.2 STRUKTURY
=(:175=67$:2:( 1DSL
FLH OXE UR]OX(QLHQLH PL
QL XáR*HQLH NRODQD PR*H
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FLD[97].
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SR UHGQLR SRM
FLH PDNV\PDOQHM GáXJR FL EH]
REFL*HQLD 08/ [98] 0DNV\PDOQD RGOHJáR ü EH] REFL*DQLD VWDQRZL RGOHJáR ü
SRPL
G]\ZHZQ
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]DGáR37MHVWGáX*V]H
RG RU\JLQDOQHJR $&/ WR MHJR F]
ü E
G]LH VFKRZDQD Z WXQHOX Z NODV\F]QHM
SURFHGXU]HE
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ELHM
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SRPL
G]\ NDQDáDPL F]\OL UHJXOXMHP\ 08/ -H*HOL VNUyFLP\ 08/ GR SHZQHM
PLQLPDOQHM ZDUWR FL PQLHMV]HM RG 08/ RWDF]DMF\FK WNDQHN PL
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3.4.8 ROTACJA
Rotowanie przeszczepu ma na celu odtworzenie anatomicznego przebiegu ACL, które
ELHJQFNXSLV]F]HOLMHVW]URWRZDQHQD]HZQWU]R° [14]. Samuelson w badaniach na
SUHSDUDFLHNRODQDZ\ND]Dá*H]DVWRVRZDQLHURWDFML]HZQ
WU]QHM ° w chwili fiksacji B-
46
37% SU]\ZUDFD DQDWRPLF]Q URWDFM
SLV]F]HOL Z]JO
GHP XGD [14] %\ü PR*H
RGWZDU]DQLH WHJR V]F]HJyáX DQDWRPLF]QHJR SR]ZDOD QD ]DVWRVRZDQLH PQLHMV]HJR
QDSL
FLD NRQLHF]QHJR GR SU]\ZUyFHQLD SUDZLGáRZHM VWDELOQR FL NRODQD 5RWDFMD PD
UyZQLH*ZSá\ZQDVNUDFDQLHSU]HV]F]HSXFRPR*HE\üSRPRFQHZSU]\SDGNXGáXJLFK
SU]HV]F]HSyZQLHPLHV]F]F\FKVL
ZNDQDOHNRVWQ\P[99].
5RWDFMDXáDWZLDSRQDGWRXPLHMVFRZLHQLHSU]HV]F]HSXZNDQDOHNRVWQ\P[14], zmniejsza
XV]NRG]HQLDSU]HV]F]HSXXZ\ORWXNDQDáXNRVWQHJRSRSUDZLDMHJRL]RPHWUL
[99, 100].
=EDGDQRZSá\ZURWDFMLSU]HV]F]HSXQDMHJRZáD FLZR FLPHFKDQLF]QH:\ND]DQR *H
L]RORZDQ\SREUDQ\]H]ZáRN%37%V]HURNLQDPP]URWRZDQ\R ° zmienia swoje
parametry mechaniczne w porównaniu z takim samym B-PT-B niezrotowanym – ML
Z]UDVWDRQDWRPLDVWPDNV\PDOQHQDSL
FLHR'DOV]DURWDFMDGR° nie daje
MX*MHGQDN*DGQ\FK]PLDQ[101] (Tabela 3).
maksymalne
REFL*HQLH>1@
powierzchnia
[mm2]
maksymalne
QDSL FLH
[MPa]
10mm B-PT-B 0°
vs.
10mm B-PT-B 90° zewn.
2664 +/-395
3397 +/-378
34,9 +/-3,6
33,8 +/-3,4
77,6 +/-17,6
101,3 +/-14,0
10mm B-PT-B 90° zewn.
vs.
10mm B-PT-B 180° zewn.
2542 +/-606
2684 +/-684
41,2 +/-11,9
38,4 +/-10,8
64,5 +/-20,1
70,5 +/-19,3
Tabela 3
:áD FLZR FLPHFKDQLF]QH%37%Z]DOH*QR FLRGZLHONR FLMHJRURWDFML
[101].
0XHOOQHUZ\ND]DáQDL]RORZDQ\FK%37%SREUDQ\FK]H]ZáRN*HURWDFMDSU]HV]F]HSX
QLH ZSá\ZD QD MHJR SDUDPHWU\ PHFKDQLF]QH [102] 1LH Z\ND]DQR Uy*QLF Z
PDNV\PDOQ\P REFL*HQLX SRPL
G]\ JUXSDPL %37% ] URWDFM ZHZQ
WU]Q °,
]HZQ
WU]Q ° i bez rotacji.
7KDPE\DK UyZQLH* QD L]RORZDQ\FK %37% SREUDQ\FK ]H ]ZáRN XGRZRGQLá *H
V]W\ZQR ü PDNV\PDOQH REFL*HQLH RUD] PDNV\PDOQH Z\GáX*HQLH ]PLHQLDM VL
]DOH*QLH RG URWDFML SU]HV]F]HSX 3U]\ URWDFML ° Z\PLHQLRQH SDUDPHWU\ Z]UDVWDá\
odpowiednio o 82% (p=0,003), 120% (p=0,0001), 35% (p=0,01) [103].
47
$NWXDOQLHQLHPDMDVQ\FKRELHNW\ZQ\FK]DOHFHZVND]XMF\FKNLHUXQHNZDUWR üLZ
RJyOHSRWU]HE
URWDFML%37%ZUHNRQVWUXNFML$&/
3.4.9 FIKSACJA PRZESZCZEPU
Istnieje wiele systemów mocowanie przeszczepu [104]. W przypadku B-PT-B
PRFRZDQLHMHVWPR*OLZH]D SRPRF UXE LQWHUIHUHQF\MQ\FK NWyUH PRJ E\ü UyZQLH*
ELRZFKáDQLDOQH:SLHUZV]\PRNUHVLHZJDMDQLDVL
SU]HV]F]HSXMHG\QLHPHFKDQLF]QH
SRáF]HQLH ]D SRPRF UXE XWU]\PXMH SU]HV]F]HS Z SR*GDQ\P SRáR*HQLX $E\ WHQ
HIHNW RVLJQü SRáF]HQLH WR PXVL VSHáQLDü PLQLPDOQH Z\PRJL MDNLH VWDZLDM
FRG]LHQQH F]\QQR FL Z\NRQ\ZDQH SU]H] SDFMHQWD 1DMEDUG]LHM GOD $&/ Z\PDJDMFH
MHVWVFKRG]HQLHSRVFKRGDFK 1 PQLHMFKRG]HQLHSRSáDVNLPSRGáR*X RNRáR1
[105]
1LH MHVW WR GX*R GOD VDPHJR %37% 3.4.1 WYBÓR PRZESZCZEPU –
porównanie B-PT-B z ACL
'OD PRFRZDQLD EORF]ND NRVWQHJR %37% UXE
LQWHUIHUHQF\MQ PDNV\PDOQH REFL*HQLH WR ZHGáXJ Uy*Q\FK DXWRUyZ 1
:\WU]\PDáR ü WHJR SRáF]HQLD MHVW Z\VWDUF]DMFD GR FRG]LHQQ\FK F]\QQR FL
GRPRZ\FKZ\PDJDMHGQDNGDOV]HMUHKDELOLWDFMLLZJRMHQLDSU]HV]F]HSXMH OLP\ OHüR
maksymalnej jego eksploatacji.
0RFRZDQLH UXE\ Z NDQDOH XGRZ\P SRSU]H] SRUW SU]HGQLRSU]\ URGNRZ\ VWZDU]D
U\]\NR]E\WQLHJRRGFK\OHQLDRVLWXQHOXRGRVLZNU
FDQHM UXE\2GFK\OHQLHWRZL
NV]H
QL* ° ]QDF]QLH REQL*D VLá
PRFRZDQLD [106]. Procedura przeprowadzona jednak w
SUDZLGáRZ\VSRVyEQLHGDMHPR*OLZR FLWDNLFKSRZLNáD[107].
.7=*, &,$:&+:,/,),.6$&-,
.W ]JL
FLD Z VWDZLH NRODQRZ\P Z FKZLOL ILNVDFML SLV]F]HORZHM MDNR MHGHQ ] WU]HFK
HOHPHQWyZRERNXPLHMVFRZLHQLDLQDSL
FLDSU]HV]F]HSXPDZSá\ZQDHIHNWNOLQLF]Q\
]DELHJX ± VWDELOQR ü VWDZX NRODQRZHJR [108] =DOH*QR ü QDSL
FLD ZL
]DGáD Z
]DOH*QR FL RG NWD ]JL
FLD ]RVWDáD ZF]H QLHM RSLVDQD 1DOH*\ WXWDM EUDü SRG XZDJ
]DUyZQRL]RPHWUL
MDNLSR*GDQHPLHMVFHILNVDFMLRUD]QDWXUDOQ\SU]HELHJ$&/LMHJR
przeszczepu.
=JRGQLH]]DáR*HQLDPLL]RPHWULLMH OLSU]HV]F]HS]RVWDáXPLHMVFRZLRQ\ZW\PSXQNFLH
WREH]]QDF]HQLDMHVWNWZMDNLPJRPRFXMHP\[109].
48
-HVW WR MHGQDN SUDNW\F]QLH QLHPR*OLZH FR ZL
FHM RSW\PDOQLH MHVW DE\ SU]HV]F]HS
XPLHMVFRZLüDFHQWU\F]QLHZ]JO
GHPSXQNWXL]RPHWU\F]QHJR'ODWHJRWH*ZVND]DQHMHVW
PRFRZDQLHSU]HV]F]HSXZWDNLP]JL
FLXZMDNLPSRGOHJDRQQDMZL
NV]HPXQDSL
FLX
F]\OL]JL
FLX°-HVWWRUyZQLH*VZHJRURG]DMXIXUWNDEH]SLHF]HVWZDGODV\WXDFML
JG]LHRSHUDWRUSRSHáQLDEáGZORNDOL]DFMLPLHMVFDNDQDáyZNRVWQ\FK:VSRPQLDQ\NW
E
G]LHGODWHJREá
GXQDMPQLHMZ\PDJDMF\ZSU]HFLZLHVWZLHGRVNUDMQ\FKSRáR*H
]JL
FLDZ\SURVWXD]ZáDV]F]D]JL
FLD
:*$-$1,(6, 35=(6=&=(38
-DN ZVSRPQLDQR ZF]H QLHM SU]HV]F]HS %37% SR MHJR ]DPRFRZDQLX SRGOHJD
GDOV]\P SU]HPLDQRP NWyUH V NRQLHF]QH GR QRUPDOQHJR IXQNFMRQRZDQLD SDFMHQWD
(3.2.8 MECHANIZMY GOJENIA USZKODZENIA, 3.4.9 FIKSACJA
PRZESZCZEPU).
:LHG]DQDWHPDWSURFHVyZ]DFKRG]F\FKZSU]HV]F]HSLRQ\P%37%QLHMHVWGX*DL
RSLHUD VL
PL
G]\ LQQ\PL QD NRQWUROQ\FK DUWURVNRSLDFK Z\NRQ\ZDQ\FK ] Uy*Q\FK
powodów.
Shino i wsp. na podstawie swej pracy [110]
VWZLHUG]LOL*HSRSU]HV]F]HSLH$&/SR
tygodniach:
-
ZL ]DGáRSRNU\WHMHVWJUXESU]HNUZLRQWNDQNPD]LRZ
SRPLHVLFDFK
-
SRNU\ZD PD]LRZD MHVW FLHF]DáD DOH ZFL* JUXEV]D QL* QRUPDOQLH ± REHFQH V
*\ZHNRPyUNLLSU]HNUZLHQLH ILEUREODVW\]MGUDPLRNV]WDáFLHZU]HFLRQ
SRPLHVLFDFK
-
FL
JQRSRNU\WHMHVWFLHQNEáRQPD]LRZ S
F]NLNRODJHQXVUHJXODUQLHXáR*RQH
,QVKLEDVKLLZVSVWZLHUG]LOLWH**HEUDNMHVWPDUWZLF\ZL
]DGáD S
F]NLNRODJHQX
QLHWZRU]VLQXVRLGDOQHJRZ]RUX REHFQDWNDQND]LDUQLQRZDSRPL
G]\ZL
]DGáHPD
FLDQNDQDáXNRVWQHJR±PLPR*HQLHORNDOL]XMHVL
ZáyNLHQ6KDUSH\¶DWNDQNDWD
XNáDGDVL
ZNLHUXQNXSU]HELHJXS
F]NyZNRODJHQX[111],
SRPLHVLFDFK
-
ZL
]DGáRPDNURVNRSRZRSU]\SRPLQDQRUPDOQH$&/ VWUHIDQLHGRNUZLHQLDREHFQD
QDNRFDFKZL
]DGáDDSU]HNUZLHQLDZ URGNXGáXJR FLZL
]DGáD ,QVKLEDVKLLZVS
GRQRV] UyZQLH* *H MHVW ]PQLHMV]RQH SU]HNUZLHQLH RUD] OLF]ED NRPyUHN EUDN
49
PDUWZLF\ ZL
]DGáD ILEUREODVW\ V R EDUG]LHM MHGQRURGQ\P ZU]HFLRQRZDW\P
NV]WDáFLHZL
FHMMHVWSRGáX*QLHXáR*RQ\FKGRMU]Dá\FKS
F]NyZNRODJHQXEORF]HN
NRVWQ\QLHMHVWPR*OLZ\GRRGUy*QLHQLDRGRWDF]DMFHMJRNR FL[111]; Falconiero i
ZVS SRGDOL *H SU]HV]F]HS Z\JOGHP L XNáDGHP ZáyNLHQ SRGREQ\ MHVW GR $&/
[112]
QDWRPLDVW 6OXVV L ZVS SRGDM *H Z SRUyZQDQLX GR $&/ ]ZL NV]RQD MHVW
]DZDUWR üQLHGRMU]DáHJRNRODJHQXW\SX,,, RUD]NRODJHQX]ZáyNQDPLRPQLHMV]HM
UHGQLF\ VWZLHUG]D VL
WH* ZL
FHM Z\PLHQLRQHJR NRODJHQX Z XV]NRG]RQ\FK
SU]HV]F]HSDFKQL*ZW\FKVSUDZQLHIXQNFMRQXMF\FK[113],
SRPLHVLFDFKPR*QDVWZLHUG]Lü*HXSDFMHQWyZ]JRUV]\PZ\QLNLHPNOLQLF]Q\P
MHVWZL
NV]HSU]HNUZLHQLHZL
]DGáDLREUD]SU]\SRPLQDWHQSRPLHVLFDFK[110].
2SUyF] PHFKDQLF]QHM Z\GROQR FL LVWRWQ\ MHVW UyZQLH* SRZUyW IXQNFML QHXUDOQ\FK
1LHVWHW\ZSU]HFLZLHVWZLHGRZáyNLHQNRODJHQXDNW\ZQR üQHXUDOQDZZL
]DGOHQLH
zawsze zostaje odtworzona [114].
2FHQ
ZJDMDQLD SU]HV]F]HSX SURZDG]L VL
UyZQLH* SU]\ SRPRF\ WRPRJUDILL
komputerowej (CT) oraz rezonansu magnetycznego (MRI).
3U]\SRPRF\&7Z\ND]DQR*HEORF]NLNRVWQH%37%E\QDMPQLHMQLHZ\ND]XMSHáQHM
LQNRUSRUDFML]NR FLDZ\WZDU]DVL
MHG\QLHVNOHURW\F]QDVWUHIDZ]GáX*NDQDáX[115].
3R]RVWDMHWRZVSU]HF]QR FL]ZF]H QLHMF\WRZDQ\PLGRQLHVLHQLDPLDOHSRWZLHUG]RQH
MHVWWH*SU]H]LQQHJG]LHSRGDZDQ\E\áEUDNRVWHRLQWHJUDFML,QWHUHVXMF\PMHVWIDNW*H
EUDNRVWHRLQWHJUDFMLRSUyF]NOLQLF]Q\FKREMDZyZREMDZLDáVL
QDUHQWJHQRJUDPLHSRG
SRVWDFLVNOHURW\F]QHMOLQLLZRNyáWXQHOXSLV]F]HORZHJR[116].
05, VWDQRZL Z\JRGQH L VNXWHF]QH QDU]
G]LH Z RFHQLH LQNRUSRUDFML SU]HV]F]HSX
]DUyZQRZHZF]HVQ\PRNUHVLHGRPLHVL
F\RG]DELHJXMDNLZSy(Q\PSRURNXL
GáX*HM[117, 118].
:<1,.,,32:,.à$1,$
=SHZQR FLQDMZD*QLHMV]NZHVWLMHVWVWDELOQR üVWDZX: VXELHNW\ZQ\P RGF]XFLX
SDFMHQWDVXNFHVRGQRV]RQ\MHVWZ QDWRPLDVWZHGáXJRELHNW\ZQ\FKSRPLDUyZSU]\
pomocy aparatu KT-1000 w 79% [70] (Tabela 1
1LH VWZLHUG]D VL WXWDM Uy*QLF
SRPL G]\SáFLDPL[119].
50
'RQDMF]
FLHMVSRW\NDQ\FKSRZLNáDSRUHNRQVWUXNFML$&/]Z\NRU]\VWDQLHP%37%
]DOLF]DP\ QLHVWDELOQR ü NRODQD EyO SU]HGQLHJR SU]HG]LDáX NRODQD F]
FLHM X NRELHW
[120]
GHILF\W Z\SURVWX Z\VL NL GRVWDZRZH ]PLDQD SRáR*HQLD RUD] UHGQLF\ WXQHOL
kostnych, migracja bloczków kostnych, zmiany zwyrodnieniowe w stawie rzepkowo-
udowym (ale ryzyko zmian zwyrodnieniowych kolana po zerwaniu ACL wzrasta 10-15
krotnie [121]
]ZDSQLHQLDZOR*\SRSREUDQ\P37VNUyFHQLHOXESy(QHSU]HUZDQLH
SR]RVWDáHJRZL
]DGáDZáD FLZHJRU]HSNL]áDPDQLHU]HSNL]áDPDQLHSODWHDXSLV]F]HOL
]áDPDQLH Z REU
ELH NDQDáX XGRZHJR DUWURILEUR]D ]PLDQ\ PDUWZLF]H Z OR*\ SR
pobraniu przeszczepu B-PT-B, zmiana o typie cyklopa (cyclops lesion) [2, 85, 122-
138].
1LHIL]MRORJLF]QD NLQHPDW\ND VWDZX NRODQRZHJR SR UHNRQVWUXNFML $&/ PR*H E\ü
SU]\F]\QZF]HVQ\FK]PLDQ]Z\URGQLHQLRZ\FKVWDZX [139]. W minimum dwuletniej
REVHUZDFML RGVHWHN ]PLDQ ]Z\URGQLHQLRZ\FK Z\QRVL SRQDG QLH]DOH*QLH RG
metody rekonstrukcji [140].
51
4 HIPOTEZA BADAWCZA
5HNRQVWUXNFMDZL
]DGáDNU]\*RZHJRSU]HGQLHJRSU]HV]F]HSHP]ZL
]DGáDZáD FLZHJR
U]HSNL MHVW X]QDQ L V]HURNR VWRVRZDQ PHWRG OHF]QLF] -HVW RQD QDMVNXWHF]QLHMV]D
MH OL MDNR NU\WHULXP RFHQ\ SU]\MPLHP\ SU]\ZUyFRQ VWDELOQR ü NRODQD 0LPR WHJR
ZFL*QLHMHVWZLDGRPHMDNLHSDUDPHWU\QDSL
FLDRUD]URWDFMLVQDMEDUG]LHMSR*GDQH
DE\ ZGáXJRWHUPLQRZ\FKREVHUZDFMDFKRWU]\PDüGREUHUH]XOWDW\ 1LHVWHW\ SDUDPHWU\
PHFKDQLF]QH SU]HV]V]HSLDQHM F]
FL ZL
]DGáD ZáD FLZHJR U]HSNL RGELHJDM RG
SDUDPHWUyZ ZL
]DGáD NU]\*RZHJR SU]HGQLHJR 0R*H WR PLHü ZSá\Z QD WR *H
HPSLU\F]QLHXVWDORQHLVWRVRZDQHGRW\FKF]DVZDUWR FLQDSL
FLDLURWDFMLSU]HV]F]HSX]
ZL
]DGáD ZáD FLZHJR U]HSNL Uy*QL VL
RG W\FK REHFQ\FK Z ZL
]DGOH NU]\*RZ\P
SU]HGQLP 1DMEDUG]LHM LVWRWQ Uy*QLF Z\GDMH VL
E\ü QDSL
FLH -H OL ]D PDáH QLH
]RVWDQLH SU]\ZUyFRQD VWDELOQR ü NRODQD -H OL ]D GX*H LVWQLHMH U\]\NR ]DEXU]HQLD
ELRPHFKDQLNLNRODQDRUD]UR]ZLQL
FLDZWyUQ\FK]PLDQ]Z\URGQLHQLRZ\FK
%\ü PR*H ]DVWRVRZDQLH URWDFML ]HZQ
WU]QHM REHFQHM Z RU\JLQDOQ\P ZL
]DGOH
NU]\*RZ\PSU]HGQLPSR]ZROLQD]PQLHMV]HQLHQDSL
FLDNRQLHF]QHJRGRRGWZRU]HQLD
VWDELOQR FLNRODQD
3URZDG]HQLH WHJR W\SX EDGD MHVW WUXGQH ]H Z]JO
GX QD SUREOHP RGSRZLHGQLHM
VWDQGDU\]DFML Z\QLNyZ L PR*OLZR FL LFK SRUyZQ\ZDQLD 1LHZWSOLZLH QDMEDUG]LHM
RELHNW\ZQHSR]RVWDQEDGDQLDNOLQLF]QHSURZDG]RQHZIRUPLHEDGDSURVSHNW\ZQ\FK
UDQGRPL]RZDQ\FK 1LHPQLHM EDGDQLD QD ]ZáRNDFK PRJ E\ü UyZQLH RELHNW\ZQH L
ZDUWR FLRZH MH OL W\ONR LFK Z\QLNL E
G PRJá\ E\ü SU]HQRV]RQH EH]SR UHGQLR QD
warunki kliniczne.
:QLQLHMV]HMSUDF\SU]HSURZDG]RQRWDNLHEDGDQLDSUyEXMF RGSRZLHG]LHü QD S\WDQLD
]DPLHV]F]RQHZQDVW
SQ\PUR]G]LDOH
52
5 CELE PRACY
&HOHPQLQLHMV]HMSUDF\MHVWX]\VNDQLHRGSRZLHG]LQDSRQL*V]HS\WDQLD
1.
&]\Z]DELHJXUHNRQVWUXNFMLZL
]DGáDNU]\*RZHJRSU]HGQLHJR]HZQ
WU]QDURWDFMDR
180°
SU]HV]F]HSX]ZL ]DGáDZáD FLZHJRU]HSNLPDZSá\ZQDVWDELOQR üSU]HGQL
operowanego kolana w porównaniu do sytuacji, gdy takiej rotacji nie zastosowano?
2.
&]\ ]HZQ
WU]QH URWRZDQLH SU]HV]F]HSX %37% R ° PR*H SR]ZROLü QD
]PQLHMV]HQLH VWRVRZDQHJR QDSL
FLD SU]HV]F]HSX QLH ]PQLHMV]DMF MHGQRF]H QLH
VWDELOQR FLVWDZX"
3.
&]\ EH]Z]JO
GQH ZDUWR FL SRPLDUyZ X]\VNDQ\FK Z ]DVWRVRZDQ\P PRGHOX
EDGDZF]\PQD]ZáRNDFKPR*QDRGQLH üGRZDUXQNyZNOLQLF]Q\FK"
53
6 0(72'<.$%$'$
6.1 ZGODA KOMISJI BIOETYCZNEJ
%DGDQLDZREU
ELHJUXS\, GR ZLDGF]DOQHM SU]HSURZDG]RQR
-
Z .DWHGU]H L =DNáDG]LH 0HG\F\Q\ 6GRZHM &ROOHJLXP 0HGLFXP 8QLZHUV\WHWX
-DJLHOORVNLHJRZ.UDNRZLH
-
SR]DDSURERZDQLXSURMHNWXSU]H].RPLVM
%LRHW\F]Q8QLZHUV\WHWX-DJLHOORVNLHJR
± RSLQLD QU .%(7 % ] GQLD F]HUZFD RUD] Sy(QLHMV]H ]PLDQ\
'..%&0 ]GQLDSD(G]LHUQLND
-
]JRGQLH]HVWDQGDUGDPLLZ\PRJDPLSDQXMF\PLZ.DWHGU]HL=DNáDG]LH0HG\F\Q\
6GRZHM &ROOHJLXP 0HGLFXP 8QLZHUV\WHWX -DJLHOORVNLHJR D ]DDSURERZDQ\PL
przez Kierownika wymienionych jednostek.
%DGDQLDZREU
ELHJUXS\,, NRQWUROQHM SU]HSURZDG]RQRZ UyGURG]LQRGZLHG]DMF\FK
pacjentów leczonych w Klinice Chirurgii Urazowej, Ortopedii i Rehabilitacji. Osoby
WZRU]FH JUXS
NRQWUROQ ]RVWDá\ SRLQIRUPRZDQH R LVWRFLH EDGDQLD L Z\UD]Lá\ QD QLH
SLVHPQ]JRG
54
6.2 CHARAKTERYSTYKA BADANEJ GRUPY
*583$, '2 :,$'&=$/1$
nr
wiek
SáHü czas zgon-badanie przyczyna zgonu
1
50
M
G]LH
powieszenie
2
50
M
WHQVDPG]LH
nieznana
3
40
M
G]LH
powieszenie
4
40
M
G]LH
powieszenie
5
30
M
G]LH
nieznana
6
42
M
G]LH
wypadek samochodowy
7
35
M
G]LH
wypadek samochodowy
8
18
M
G]LH
nieznana
9
52
K
2 dni
wypadek samochodowy
10
48
M
2 dni
nieznana
11
55
M
G]LH
nieznana
12
50
K
G]LH
nieznana
13
45
K
G]LH
nieznana
14
40
M
G]LH
nieznana
15
17
M
2 dni
nieznana
16
25
M
WHQVDPG]LH
wypadek samochodowy
17
55
M
2 dni
SRVWU]Dá
18
56
M
G]LH
wypadek samochodowy
Tabela 4
2SLVEDGDQHMJUXS\GR ZLDGF]DOQHM
*UXS
GR ZLDGF]DOQVWDQRZLá\]ZáRNLOXG]NLH
.U\WHULDPLZáF]HQLD]ZáRNGREDGDQLDE\á\
- wiek 16-60 lat,
-
EUDNREUD*HNRF]\QGROQ\FK
-
F]DV MDNL XSá\Qá RG ]JRQX QLH SRZLQLHQ E\ü GáX*V]\ QL* JRG]LQ\ Z V\WXDFML
VNUDMQHMQDSU]\NáDGJRG]LQ ]DOLF]DQRZWHG\]ZáRNLGRJUXS\ÄGQL´ OXEZ
55
SU]\SDGNXEUDNXGDQ\FKRGRNáDGQHMGDFLH]JRQX±GHF\]M
SRGHMPRZDáEDGDMF\
QDSRGVWDZLHRJO
G]LQFLDáDRFHQLDMFVW
*HQLHSR PLHUWQH
- w badaniu fizykalnym brak cech zmian zwyrodnieniowych lub jakichkolwiek
GHIRUPDFMLNRF]\QGROQ\FK
.U\WHULDPLZ\áF]HQLD]EDGDQLDE\á\
-
RJyOQLH]á\VWDQFLDáD
-
QHJDW\ZQ\Z\QLNLQVSHNFMLVWDZXSRDUWURWRPLL±VWZLHUG]HQLHXV]NRG]HáNRWHN
zmian zwyrodnieniowych,
-
VWDQSRMDNLFKNROZLHNZLGRF]Q\FK ODGDFKSR]DELHJDFKRSHUDF\MQ\FKQDNRODQDFK
UWAGI:
- kolumna „czas zgonu-badanie”
a.
ZGRVW
SQ\FKNDUWRWHNDFKQLH]DZV]HSRGDZDQDMHVWGRNáDGQDJRG]LQD]JRQX
F]DVDPL MHVW RQD QLH]QDQD GODWHJR SU]\M
WR QDVW
SXMF ]DVDG
MH OL GDWD
EDGDQLD E\áD QS OLVWRSDGD R J D ]JRQ QDVWSLá OLVWRSDGD WR
QLH]DOH*QLHRGMHJRJRG]LQ\ZSLV\ZDQRÄG]LH´
b.
]JRGQLH]SRZ\*V]]DVDGÄGQL´QLHPXVLR]QDF]DüJRG]LQ
- kolumna „przyczyna zgonu”
adnotacja „nieznana” oznacza brak klinicznych podstaw do podania przyczyny
zgonu
:V]\VWNLH ]DNZDOLILNRZDQH ]ZáRNL VSHáQLDá\ NU\WHULD ZáF]HQLD )DGQ\FK QLH
zdyskwalifikowano po otwarciu stawów kolanowych.
=ZáRNL SR SU]\ZLH]LHQLX GR =DNáDG\ 0HG\F\Q\ 6GRZHM SU]HFKRZ\ZDQH E\á\ Z
REQL*RQHMWHPSHUDWXU]H
Charakterystyka grupy:
NRELHW\P
*F]\]Q
ZLHN ODW UHGQLD
56
6.2.2 GRUPA II (KONTROLNA)
nr
wiek
SáHü
1
50
M
2
37
M
3
38
M
4
41
M
5
28
M
6
45
M
7
31
M
8
37
M
9
52
K
10
45
M
11
53
M
12
59
K
13
24
K
14
31
M
15
31
M
16
27
M
17
54
M
18
57
M
*UXS
NRQWUROQ *. VWDQRZLá\]GURZHRVRE\
UHNUXWRZDQH VSR UyG URG]LQ RGZLHG]DMF\FK
pacjentów w Klinice. Osoby te dobierano pod
Z]JO
GHP SáFL L ZLHNX ZHGáXJ NROHMQR FL
RSHURZDQ\FK]ZáRN-H OL]ZáRNLQUQDOH*Dá\
GROHWQLHJRP
*F]\]Q\WRRVRE]DSUDV]DQ
GR JUXS\ NRQWUROQHM E\á P
*F]\]QD Z ZLHNX
RNRáR ODW :HGáXJ RSLVDQHJR DOJRU\WPX
JUXS
NRQWUROQXWZRU]\áRRVyE
*UXS
NRQWUROQ XVWDORQR GRSLHUR SR
]DNRF]HQLXEDGDQDGJUXSGR ZLDGF]DOQ
.U\WHULDPL Z\NOXF]DMF\PL ] JUXS\ NRQWUROQHM
E\á\
- zmiany zwyrodnieniowe kolan,
-
SU]HE\WHXUD]\OXE]DELHJLZREU ELHNRODQ
Charakterystyka grupy:
NRELHW\P
*F]\]Q
ZLHN ODW UHGQLD
Tabela 5. Charakterystyka grupy kontrolnej.
57
6.3 OPIS BADANIA
%DGDQLH]RVWDáRSRG]LHORQHQDGZDHWDS\
Etap I
=EDGDQLH QLHVWDELOQR FL VWDZX NRODQRZHJR Z JUXSLH , GR ZLDGF]DOQHM Z Uy*Q\FK
sytuacjach:
1. przed zabiegiem operacyjnym, kolano nienaruszone (ACL(+)),
2.
SRSREUDQLX%37%RUD]XVXQL FLXFLDáD+RII\ 37
3.
SRXVXQL FLX$&/ $&/
4. po pierwszym mocowaniu przeszczepu,
5. po drugim mocowaniu przeszczepu,
6. po trzecim mocowaniu przeszczepu,
7. po czwartym mocowaniu przeszczepu.
Etap II:
3RUyZQDQLH ]H VRE Z\QLNL SRPLDUyZ QLHVWDELOQR FL SU]HGQLHM JUXS\ ,, NRQWUROQHM
*. RUD]Z\QLNLSRPLDUyZ$&/ L37 ]JUXS\, GR ZLDGF]DOQHM
58
:<.25=<67$1(85='=(1,$320,$52:(25$=
INSTRUMENTARIUM
: QLQLHMV]\P EDGDQLX Z\NRU]\VWDQR QDVW
SXMFH XU]G]HQLH SRPLDURZH L
instrumentarium:
- aparat KT-1000 (MedMetric Co. , USA) (Fotografia 1),
- dynamometr DPS-44 (IMADA®, USA) (Fotografia 1),
- instrumentarium do artroskopowej rekonstrukcji ACL firmy ChM, Polska,
-
UXE\LQWHUIHUHQF\MQH∅ 8mm x 20mm firmy ChM, Polska.
320,$5<1,(67$%,/12 &,
:V]\VWNLH RSLV\ZDQH Z GDOV]HM F]
FL
SRPLDU\ QLHVWDELOQR FL VNáDGDá\ VL
] WHM
VDPHM
VHNZHQFML
F]\QQR FL
:\NRU]\VWXMF DSDUDW .7 EDGDQR
M Z ]JL
FLX Z VWDZLH NRODQRZ\P °,
90°
RUD] Z SHáQ\P Z\SUR FLH
SU]\NáDGDMF VLá
1 NRQWURORZDQ
przez dynamometr (Fotografia 1). Pomiar
GRNRQ\ZDQ\
E\á
WU]\NURWQLH
]
GRNáDGQR FL GR MHGQR FL L X UHGQLDQ\
UyZQLH*]GRNáDGQR FLGRMHGQR FL3U]\
pomiarze 90°
NRF]\QDOX(QR]ZLVDáDR
ZáDVQ\P FL
*DU]H Fotografia 2).
Wszystkie odczyty pomiarowe
GRNRQ\ZDáDWDVDPDRVRED
Fotografia 1. Aparat KT-1000 oraz dynamometr DPS-44.
59
Fotografia 2
3RPLDU\QLHVWDELOQR FLVWDZX
NRODQRZHJRZZ\SUR FLH]JL FLX°° i 90°° przy
X*\FLXDSDUDWX.7
35272.Ïà23(5$&<-1<
7HFKQLNDRSHUDF\MQD]DVWRVRZDQDZEDGDQLXZJUXSLH,Uy*QLáDVL
ZNLONXHOHPHQWDFK
od techniki stosowanej w warunkach klinicznych i opisanej w rozdziale 3.4.3 OPIS
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oryginalnej procedurze (Fotografia 3).
60
Fotografia 3. Pobranie przeszczepu B-PT-B.
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Fotografia 4
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tego samego schematu.
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5
:WDNSU]\JRWRZDQHRWZRU\ZSURZDG]DQR*\áN ∅ 0,7mm (Fotografia 6).
61
Fotografia 5. Opracowywanie bloczka B-PT-B.
Fotografia 6
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TECHNIKI OPERACYJNEJ STOSOWANEJ W KRAKOWSKIM CENTRUM
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przy pomocy celownika udowego lokalizowano punkt przyczepu na udzie i wiercono
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implantacji przeszczepu. Zanim jednak umieszczono przeszczep w kanale, przy pomocy
62
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1.
EH]URWDFML]QDSL FLHP1 °-50N; 0-50),
2.
EH]URWDFML]QDSL FLHP1 °-100N; 0-100),
3.
]URWDFM]HZQ WU]Q°LQDSL FLHP1 °-50N; 180-50),
4.
]URWDFM]HZQ WU]Q°LQDSL FLHP1 °-100N; 180-100).
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oraz doniesieniami w literaturze.
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SXMFR
1. pierwsza rotacja 0°/180°?
2.
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3.
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:WHQVSRVyERJUDQLF]RQR]PLDQ
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prawdopodobnie z obawy przed uszkodzeniem preparatu. B-PT-B wprowadzano do
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ZáyNQDPLZL
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6).
Fotografia 7
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Fotografia 8. B-PT-B w rotacji 0°° oraz 180°°.
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przeszczepu.
Fotografia 9
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czyli z przodu).
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w rozdziale
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6.4 ANALIZA STATYSTYCZNA
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takiej rotacji nie zastosowano?
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a priori SU]\M
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1,(67$%,/12 &,).
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66
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grupie kontrolnej?
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a priori SU]\M
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7 WYNIKI
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tabeli (Tabela 4).
stan
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ACL (+) PT (-) ACL (-)
0°°-50N
0°°-100N
180°°-50N 180°°-100N
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L F
LH
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ko
la
ni
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[°°
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ko
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[°°
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ko
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L F
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L F
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ko
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NR
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L F
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ko
la
ni
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[°°
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NR
OHM
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nr
0 30 90 0 30 90 0 30 90 0 30 90
0 30 90
0 30 90
0 30 90
1 2 3 5 1 3 5 5 5 8 4 3 6 4 4 3 5 3 3 5 10 1 1 3 4 2
2
3 1 3 3 1 4 3 3 8 5 5 8 6 1 2 8 5 2 4 4 4 3 4 7 3 4
4 1 8 3 1 7 3 5 7 9 3 4 2 1 5 8 6 2 4 11 4 3 4 7 3 4
5 2 3 0 2 3 1 8 14 5 7 4 2 1 3 5 2 2 5 5 2 3 2 7 6 4
6 2 3 0 1 3 0 3 9 4 5 7 4 1 4 7 7 2 6 9 5 3 3 5 4 4
7 9 7 6 9 7 4 7 13 4 6 13 4 2 7 7 6 1 7 5 4 4 5 7 5 3
8 3 8 6 7 8 6 7 13 5 5 9 4 2 4 9 4 1 3 9 4 4 3 9 4 3
9 5 3 2 2 3 5 5 11 5 2 5 5 4 3 4 3 3 3 4 3 1 3 4 3 2
10 5 3 2 5 4 2 6 12 6 5 7 5 4 6 6 5 3 6 6 7 1 4 4 4 2
11 3 5 5 4 4 4 7 10 7 6 3 3 3 6 5 3 4 7 6 4 2 6 6 3 1
12 5 6 4 4 6 4 7 12 7 5 6 4 1 4 5 3 2 4 7 3 3 3 7 3 4
13 3 6 4 3 7 3 8 11 8 5 11 4 4 5 11 3 3 4 12 6 2 4 8 4 1
14 3 8 4 3 8 5 9 12 10 8 10 7 3 8 10 5 4 8 10 8 2 8 5 7 1
15 3 5 4 3 4 3 6 12 6
16 3 5 4 3 4 4 6 12 6
17 7 10 10 6 10 7 8 12 8 7 9 7 2 6 9 7 1 7 8 7 3 7 7 7 4
68
stan
URG]DMNRPELQDFMLURWDFMD±QDSL FLH
ACL (+) PT (-) ACL (-)
0°°-50N
0°°-100N
180°°-50N 180°°-100N
]J
L F
LH
Z
ko
la
ni
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[°°
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L F
LH
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ko
la
ni
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[°°
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L F
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NR
OHM
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L F
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ko
la
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[°°
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NR
OHM
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ü
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L F
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ko
la
ni
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[°°
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NR
OHM
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ü
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L F
LH
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ko
la
ni
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[°°
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NR
OHM
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ü
nr
0 30 90 0 30 90 0 30 90 0 30 90
0 30 90
0 30 90
0 30 90
18 5 10 5 6 10 7 8 13 13 8 9 6 2 8 8 5 1 7 13 7 4 8 9 6 3
19 7 7 5 8 8 6 9 14 7
20 7 10 6 7 11 8 11 16 11 6 14 7 1 6 8 6 2 5 10 8 4 5 7 4 3
21 4 9 4 4 8 9 8 13 9 6 11 6 1 5 8 8 2 5 9 8 4 4 8 6 3
22 4 8 8 4 9 8 5 15 10 5 10 5 3 4 6 7 4 4 8 8 2 3 6 5 1
23 6 12 6 6 12 6 7 13 8 6 12 5 2 5 10 3 1 5 8 5 4 4 7 4 3
24 5 10 5 5 10 5 5 16 7 3 13 8 3 3 13 6 4 6 12 7 2 4 9 7 1
25 2 10 7 3 10 7 5 17 3 3 15 12 3 3 14 11 4 4 11 10 2 5 11 11 1
26 2 9 7 3 10 8 5 17 12 3 11 11 3 5 11 12 4 4 10 10 1 4 9 9 2
27 6 8 6 6 11 6 7 20 9 5 15 5 4 5 13 4 3 5 12 5 1 3 11 4 2
28 6 8 6 7 8 7 7 16 10 7 11 7 1 6 9 7 2 6 11 9 3 4 11 9 4
29 4 10 6 4 10 7 7 17 8 6 12 6 4 3 11 6 3 5 9 6 2 3 6 4 1
30 4 10 6 4 10 6 8 17 10 3 15 8 2 3 12 7 1 6 13 8 4 3 12 7 3
31 2 6 3 5 6 3 5 9 4 4 8 3 2 5 7 4 1 5 8 3 4 2 6 4 3
32 2 6 3 2 6 5 4 12 7 4 9 6 1 2 7 6 2 2 9 6 4 2 7 6 3
33 1 4 2 1 4 4 2 7 6 4 6 6 1 2 3 3 2 2 4 4 4 1 2 2 3
34 2 3 2 2 4 3 2 6 6 3 5 5 4 2 3 2 3 3 4 4 2 2 2 2 1
35 3 6 3 3 5 4 4 14 10 4 9 7 4 4 8 7 3 5 7 3 1 4 5 4 2
36 3 6 3 3 5 4 6 12 7 5 9 5 4 3 8 4 3 3 6 5 1 2 5 4 2
Tabela 6
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GR ZLDGF]DOQHM
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nr 15, 16
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nr 19
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kolejnych kolumnach znajdziemy: n (liczba analizowanych przypadków w grupie),
UHGQLD SRPLDUyZ QLHVWDELOQR FL Z GDQHM JUXSLH RUD] RGFK\OHQLH VWDQGDUGRZH 6'
ZDUWR ü SU]HG]LDáX XIQR FL &, RUD] ZDUWR FL PLQLPDOQH L PDNV\PDOQH
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70
chwili mocowania przeszczepu, mierzone w wyprostowanym stawie kolanowym. Dla
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RSHUDF\MQ\PLX]DOH*QLRQ\PLRGURWDFMLLQDSL
FLDZFKZLOLPRFRZDQLDSU]HV]F]HSXZ
Z\SURVWRZDQ\P VWDZLH NRODQRZ\P´ : FHOX Z\EUDQLD ZáD FLZHJR WHVWX
ZHU\ILNXMFHJR KLSRWH]
+R VSUDZG]RQR QRUPDOQR ü UR]NáDGX DQDOL]RZDQHM FHFK\ ±
QLHVWDELOQR FL 1RUPDOQR ü VSUDZG]RQR WHVWHP 6KDSLUR:LOND L Z\ND]DQR *H QLH
ZV]\VWNLHJUXS\PDMUR]NáDGQRUPDOQ\ 5\FLQD5\FLQD :REHFSRZ\*V]HJR
zastosowano nieparametryczny odpowiednik testu ANOVA – test Kruskala-Wallisa
7DEHOD 3RQLHZD* S S RGU]XFRQR KLSRWH]
+R 'OD SRUyZQDQLD
SRV]F]HJyOQ\FK JUXS ]DVWRVRZDQR DQDOL]
SRVWKRF ] ZLHORNURWQ\PL SRUyZQDQLDPL
UHGQLFKUDQJ Tabela 9). Przy porównaniu grupy 0-50 oraz 180-100 otrzymano p<0,05
S 1D SRGVWDZLH ZDUWR FL VXP\ UDQJ WHVWX .UXVNDOD:DOOLVD RUD] NOLQLF]QHM
SUDNW\NLSRUyZQDQRUyZQLH*JUXS
$&/ ]RUD]$&/ ]SU]\SRPRF\
WHVWX 0DQQD:KLWQH\D X]\VNXMF Z REX SU]\SDGNDFK S S RGSRZLHGQLR L
0,02) (Tabela 10).
n
UHGQLD
SD
CI (-95 %) CI (+95%)
min
maks
ACL (+) 35
3,77
1,99
3,09
4,45
1,00
9,00
ACL (-) 35
6,14
2,03
5,45
6,84
2,00
11,00
0-50
32
4,94
1,54
4,38
5,49
2,00
8,00
0-100
32
4,41
1,66
3,81
5,01
2,00
8,00
180-50 32
4,78
1,54
4,23
5,34
2,00
8,00
180-100 32
3,75
1,72
3,13
4,37
1,00
8,00
Tabela 7
6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKZJUXSLHGR ZLDGF]DOQHM
badanych w kolanach wyprostowanych – n (liczba analizowanych przypadków w
JUXSLH UHGQLDSRPLDUyZQLHVWDELOQR FLRGFK\OHQLHVWDQGDUGRZH 6'
ZDUWR FL SU]HG]LDáXXIQR FLZDUWR FLPLQLPDOQHMLPDNV\PDOQHM
QLHVWDELOQR FLSU]HGQLHMNRODQD
71
Rycina 12
0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLH
GR ZLDGF]DOQHMZSHáQ\PZ\SUR FLHNRODQ
Rycina 13
3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLH
GR ZLDGF]DOQHMZSHáQ\PZ\SUR FLHNRODQ
QLHVWDELOQR üSU]HGQLDNRODQDZZ\SUR FLH
PLHU]RQDDSDUDWHP.7
0HGLDQD
0LQ0DNV
$&/
$&/
QLHVWDELOQR üSU]HGQLDNRODQDZZ\SUR FLH
PLHU]RQDDSDUDWHP.7
UHGQLD
UHGQLD3U]HG]XIQ
UHGQLD 3U]HG]XIQ
$&/
$&/
72
Rycina 14
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZZ\SUR FLH
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH$&/ JUXS\
GR ZLDGF]DOQHM
Rycina 15
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQHMZZ\SUR FLH
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLHJUXS\
GR ZLDGF]DOQHM
+LVWRJUDP $&/
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZSHáQ\PZ\SUR FLHPLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
+LVWRJUDP
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZSHáQ\PZ\SUR FLHPLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
73
N
Suma RANG
ACL (+)
35
2324,50
0-50
32
3183,00
0-100
32
2700,00
180-50
32
3056,50
180-100
32
2102,00
Test Kruskala-Wallisa:
H (4, N= 163) =15,16; p =0,004
Tabela 8. Wyniki testu Kruskala-
:DOOLVDGODQLHVWDELOQR FLSU]HGQLFK
NRODQEDGDQ\FKZSHáQ\PZ\SUR FLH
ZJUXSLHGR ZLDGF]DOQHM
ACL (+)
0-50
0-100
180-50 180-100
ACL (+)
0,23
1,00
0,53
1,00
0-50
1,00
1,00
0,004
0-100
1,00
1,00
180-50
0,11
180-100
Tabela 9.
:DUWR üSGODSRUyZQDZLHORNURWQ\FK GZXVWURQQ\FK QLHVWDELOQR FL
SU]HGQLFKNRODQEDGDQ\FKZSHáQ\PZ\SUR FLHZJUXSLHGR ZLDGF]DOQHM
Suma rang ACL (+)
Suma rang 0-50
U
poziom p
976,00
1302,00
346,00
0,01
Suma rang ACL (+)
Suma rang 180-50
U
poziom p
998,50
1279,50
368,50
0,02
Tabela 10. Wyniki testów U Manna-Whitneya (p <0,05)
SRUyZQXMF\FK
QLHVWDELOQR FLSU]HGQLHSRPL G]\JUXSDPL$&/ LRUD]$&/ LZ
JUXSLHGR ZLDGF]DOQHMZSHáQ\PZ\SUR FLHNRODQ
ACL(+)
0-50
0-100
180-50
180-100
ACL(+)
0,01 (M-W)
=
0,02 (M-W)
=
0-50
=
=
0,004 (K-W)
0-100
=
=
180-50
=
180-100
Tabela 11
2VWDWHF]QHZ\QLNLSRUyZQDQLHVWDELOQR FLSU]HGQLFKNRODQSRPL G]\
SRV]F]HJyOQ\PLJUXSDPLZJUXSLHGR ZLDGF]DOQHMZSHáQ\PZ\SUR FLHNRODQ
Z\QLNLZWDEHOLSRGDMZDUWR FLSGODGDQHJRWHVWXRUD]MHJRVNUyW 0:GOD
Manna-Whitneya oraz K-W dla Kruskala-Wallisa).
74
320,$5<:=*, &,8.2/$1$°
3RPLDU\QLHVWDELOQR FLNRODQDZ\NRQDQRZ]JL
FLX°.
6WDW\VW\NDRSLVRZDSRV]F]HJyOQ\FKJUXSSRQL*HM Tabela 12).
: DQDOL]LH Z\ND]\ZDQH V HZHQWXDOQH Uy*QLFH Z SU]HGQLHM VWDELOQR FL VWDZX
NRODQRZHJR]DOH*QHRGNRPELQDFMLURWDFMDQDSL
FLHZFKZLOLPRFRZDQLDSU]HV]F]HSX
PLHU]RQHZ]JL
W\P° stawie kolanowym.
n
UHGQLD
SD
CI (-95 %)
CI (+95%)
min
maks
ACL (+) 35
6,80
2,65
5,89
7,71
3,00
12,00
ACL (-) 35
12,49
3,45
11,30
13,67
5,00
20,00
0-50
32
9,16
3,51
7,89
10,42
3,00
15,00
0-100
32
8,00
2,95
6,94
9,06
3,00
14,00
180-50 32
8,28
2,81
7,27
9,29
4,00
13,00
180-100 32
6,84
2,50
5,94
7,75
2,00
12,00
Tabela 12
6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKEDGDQ\FKZNRODQDFK
]JL W\FK°°ZJUXSLHGR ZLDGF]DOQHM
Rycina 16
0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLH
GR ZLDGF]DOQHMZ]JL FLXNRODQ°°.
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °
PLHU]RQDDSDUDWHP.7
0HGLDQD
0LQ0DNV
$&/
$&/
75
Rycina 17
3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLH
GR ZLDGF]DOQHMZ]JL FLXNRODQ°°.
+LSRWH]D+R QLHPDLVWRWQ\FKVWDW\VW\F]QLHUy*QLFZSU]\ZUDFDQLXVWDELOQR FLNRODQD
SRPL
G]\F]WHUHPDRSFMDPLRSHUDF\MQ\PLX]DOH*QLRQ\PLRGURWDFMLLQDSL
FLDZFKZLOL
PRFRZDQLD SU]HV]F]HSX Z ]JL
W\P VWDZLH NRODQRZ\P °. W celu wybrania
ZáD FLZHJR WHVWX ZHU\ILNXMFHJR KLSRWH]
+R VSUDZG]RQR QRUPDOQR ü UR]NáDGX
DQDOL]RZDQHMFHFK\±QLHVWDELOQR FL1RUPDOQR üVSUDZG]RQRWHVWHP6KDSLUR:LONDL
Z\ND]DQR *H QLH ZV]\VWNLH JUXS\ PDM UR]NáDG QRUPDOQ\ Rycina 18). Wobec
SRZ\*V]HJR ]DVWRVRZDQR QLHSDUDPHWU\F]Q\ RGSRZLHGQLN $129$ ± WHVW .UXVNDOD
Wallisa (Tabela 13
3RQLHZD* S S RGU]XFRQR KLSRWH] +R 'OD
SRUyZQDQLD SRV]F]HJyOQ\FK JUXS ]DVWRVRZDQR DQDOL]
SRVWKRF ] ZLHORNURWQ\PL
SRUyZQDQLDPL UHGQLFK UDQJ Tabela 14). Przy porównaniu grupy 0-50 oraz 180-100
RWU]\PDQRS S 1DSRGVWDZLHZDUWR FLVXP\UDQJWHVWX.UXVNDOD:DOOLVD
RUD] NOLQLF]QHM SUDNW\NL SRUyZQDQR UyZQLH* EH]SR UHGQLR JUXS
$&/ ] L
$&/ ]SU]\SRPRF\WHVWX0DQQD:KLWQH\DX]\VNXMFZREXSU]\SDGNDFK
p<0,05 (p= odpowiednio 0,01 i 0,04) (Tabela 15).
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °
PLHU]RQDDSDUDWHP.7
UHGQLD
UHGQLD3U]HG]XIQ
UHGQLD 3U]HG]XIQ
$&/
$&/
76
Rycina 18
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLX
kolan 30°°
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH
$&/ JUXS\GR ZLDGF]DOQHM
Test Kruskala-Wallisa: H ( 4, N= 163) =12,81; p =0,01
N
Suma
RANG
ACL (+)
35
2367,50
0-50
32
3230,50
0-100
32
2726,00
180-50
32
2891,50
180-100
32
2150,50
Tabela 13. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQ
EDGDQ\FKZ]JL FLXNRODQ°°ZJUXSLHGR ZLDGF]DOQHM
+LVWRJUDP $&/
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °PLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
77
ACL(+)
0-50
0-100
180-50 180-100
ACL(+)
0,22
1,00
1,00
1,00
0-50
1,00
1,00
0,01
0-100
1,00
1,00
180-50
0,50
180-100
Tabela 14.
:DUWR üSGODSRUyZQDZLHORNURWQ\FK GZXVWURQQ\FK QLHVWDELOQR FL
SU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ°°ZJUXSLHGR ZLDGF]DOQHM
Suma rang ACL (+)
Suma rang 0-50
U
poziom p
969,00
1309,00
339,00
0,01
Suma rang ACL (+)
Suma rang 180-50
U
poziom p
1028,50
1249,50
398,50
0,04
Tabela 15. Wyniki testów U Manna-Whitneya (p <0,05)
SRUyZQXMF\FK
QLHVWDELOQR FLSU]HGQLHNRODQSRPL G]\JUXSDPL$&/ LRUD]$&/ L
ZJUXSLHGR ZLDGF]DOQHMZ]JL FLXNRODQ°°.
ACL(+)
0-50
0-100
180-50
180-100
ACL(+)
0,01 (M-W)
=
0,04 (M-W)
=
0-50
=
=
0,01 (K-W)
0-100
=
=
180-50
=
180-100
Tabela 16
2VWDWHF]QHZ\QLNLSRUyZQDQLHVWDELOQR FLSU]HGQLHNRODQSRPL G]\
SRV]F]HJyOQ\PLJUXSDPLZJUXSLHGR ZLDGF]DOQHMZ]JL FLXNRODQ°°; wyniki w
WDEHOLSRGDMZDUWR FLSGODGDQHJRWHVWXRUD]MHJRVNUyW
78
320,$5<:=*, &,8.2/$1$ °
3RPLDU\QLHVWDELOQR FLNRODQDZ\NRQDQRZ]JL
FLX °.
6WDW\VW\NDRSLVRZDSRV]F]HJyOQ\FKJUXSSRQL*HM Tabela 17).
: DQDOL]LH Z\ND]\ZDQH V HZHQWXDOQH Uy*QLFH Z SU]HGQLHM VWDELOQR FL VWDZX
NRODQRZHJR]DOH*QHRGNRPELQDFMLURWDFMDQDSL
FLHZFKZLOLPRFRZDQLDSU]HV]F]HSX
PLHU]RQHZ]JL
W\P ° stawie kolanowym.
n
UHGQLD
SD
CI (-95 %)
CI (+95%)
min
maks
ACL (+) 35
4,43
2,13
3,70
5,16
0,00
10,00
ACL (-) 35
7,43
2,40
6,60
8,25
3,00
13,00
0-50
32
5,66
2,18
4,87
6,44
2,00
12,00
0-100
32
5,38
2,31
4,54
6,21
2,00
12,00
180-50 32
5,84
2,30
5,01
6,67
2,00
10,00
180-100 32
4,94
2,11
4,18
5,70
2,00
11,00
Tabela 17
6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKEDGDQ\FKZJUXSLH
GR ZLDGF]DOQHMZ]JL FLXNRODQ °°.
Rycina 19
0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLH
GR ZLDGF]DOQHMZ]JL FLXNRODQ °°.
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °
PLHU]RQDDSDUDWHP.7
0HGLDQD
0LQ0DNV
$&/
$&/
79
Rycina 20
3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLH
GR ZLDGF]DOQHMZ]JL FLXNRODQ °°.
+LSRWH]D+R QLHPDLVWRWQ\FKVWDW\VW\F]QLHUy*QLFZSU]\ZUDFDQLXVWDELOQR FLNRODQD
SRPL
G]\F]WHUHPDRSFMDPLRSHUDF\MQ\PLX]DOH*QLRQ\PLRGURWDFMLLQDSL
FLDZFKZLOL
PRFRZDQLD SU]HV]F]HSX Z ]JL
W\P VWDZLH NRODQRZ\P °. W celu wybrania
ZáD FLZHJR WHVWX ZHU\ILNXMFHJR KLSRWH]
+R VSUDZG]RQR QRUPDOQR ü UR]NáDGX
DQDOL]RZDQHMFHFK\±QLHVWDELOQR FL1RUPDOQR üVSUDZG]RQRWHVWHP6KDSLUR:LONDL
Z\ND]DQR *H QLH ZV]\VWNLH JUXS\ PDM UR]NáDG QRUPDOQ\ Rycina 21, Rycina 22,
Rycina 23
:REHFSRZ\*V]HJR]DVWRVRZDQRQLHSDUDPHWU\F]Q\RGSRZLHGQLN$129$
– test Kruskala-Wallisa (Tabela 18
3RQLHZD* S! S QLH PD SRGVWDZ GR
RGU]XFHQLD KLSRWH]\ +R -HGQDN NLHUXMF VL
ZDUWR FLDPL UDQJ SRUyZQDQR UyZQLH*
EH]SR UHGQLR $&/ ] RUD] $&/ ] SU]\ SRPRF\ WHVWX 0DQQD
:KLWQH\DX]\VNXMFZREXSU]\SDGNDFKS SRGSRZLHGQLRL Tabela
19).
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °
PLHU]RQDDSDUDWHP.7
UHGQLD
UHGQLD3U]HG]XIQ
UHGQLD 3U]HG]XIQ
$&/
$&/
80
Rycina 21
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLX
kolan 90°°
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH
JUXS\GR ZLDGF]DOQHM
Rycina 22
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLX
kolan 90°°
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH
JUXS\GR ZLDGF]DOQHM
+LVWRJUDP
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °PLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
+LVWRJUDP
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °PLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
81
Rycina 23
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLX
kolan 90°°
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH
JUXS\GR ZLDGF]DOQHM
Test Kruskala-Wallisa: H ( 4, N= 163) =8,26; p =0,08
N
Suma
RANG
ACL (+)
35
2343,50
0-50
32
2936,50
0-100
32
2696,50
180-50
32
3018,50
180-100
32
2371,00
Tabela 18. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQ
EDGDQ\FKZ]JL FLXNRODQ °°ZJUXSLHGR ZLDGF]DOQHM
+LVWRJUDP
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °PLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
82
Suma rang ACL (+)
Suma rang 0-50
U
poziom p
1019,50
1258,50
389,50
0,03
Suma rang ACL (+)
Suma rang 180-50
U
poziom p
1009,00
1269,00
379,00
0,02
Tabela 19. Wyniki testów U Manna-Whitneya (p <0,05)
SRUyZQXMF\FK
QLHVWDELOQR FLSU]HGQLHNRODQSRPL G]\JUXSDPL$&/ LRUD]$&/ L
ZJUXSLHGR ZLDGF]DOQHMZ]JL FLXNRODQ °°.
ACL(+)
0-50
0-100
180-50
180-100
ACL(+)
0,03(M-W)
=
0,02 (M-W)
=
0-50
=
=
=
0-100
=
=
180-50
=
180-100
Tabela 20
2VWDWHF]QHZ\QLNLSRUyZQDQLHVWDELOQR FLSU]HGQLHNRODQSRPL G]\
SRV]F]HJyOQ\PLJUXSDPLZJUXSLHGR ZLDGF]DOQHMZ]JL FLXNRODQ °°; wyniki w
WDEHOLSRGDMZDUWR FLSGODGDQHJRWHVWXRUD]MHJRVNUyW
83
%$'$1,(1,(67$%,/12 &,35=('1,(-.2/$1:2%5 %,(*583<,,
(KONTROLNEJ)
=ELRUF]HZ\QLNLEDGDQLDQLHVWDELOQR FLZJUXSLHNRQWUROQHM *. ]DPLHV]F]RQRSRQL*HM
(Tabela 21).
NW]JL FLDNRODQD
nr strona
0°°
30°°
90°°
1
L
3
6
8
2
P
3
7
5
3
L
4
7
5
4
P
2
5
7
5
L
2
5
5
6
P
4
5
6
7
L
4
5
5
8
P
3
5
8
9
L
2
3
4
10
P
2
5
5
11
L
3
7
5
12
P
4
6
3
13
L
3
4
3
14
P
3
5
3
15
L
3
3
6
16
P
3
4
7
17
L
3
6
5
18
P
3
7
8
19
L
3
6
8
20
P
3
7
7
21
L
2
7
4
22
P
3
6
6
23
L
2
7
3
24
P
2
3
7
25
L
3
6
5
26
P
4
6
5
27
L
4
6
6
28
P
2
5
5
29
L
2
5
4
30
P
3
4
4
31
L
5
6
6
32
P
4
5
4
33
L
2
6
4
34
P
3
2
3
35
L
5
10
7
36
P
2
6
6
Tabela 21
:\QLNLSRPLDUyZQLHVWDELOQR FLNRODQ*.
84
7.2.1 POMIARY W WYPROSTOWANYM KOLANIE
3RPLDU\QLHVWDELOQR FLNRODQDZ\NRQDQRZ]JL
FLX°.
6WDW\VW\NDRSLVRZDSRQL*HM Tabela 22).
: DQDOL]LH Z\ND]\ZDQH V HZHQWXDOQH Uy*QLFH Z SU]HGQLHM QLHVWDELOQR FL VWDZX
NRODQRZHJRSRPL
G]\*.$&/ D37
n
UHGQLD
SD
CI (-95 %)
CI (+95%)
min
maks
ACL (+) 35
3,77
1,99
3,09
4,45
1,00
9,00
PT (-)
35
3,94
2,14
3,21
4,68
1,00
9,00
GK
36
3,00
0,86
2,71
3,29
2,00
5,00
Tabela 22
6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKZJUXSLHGR ZLDGF]DOQHM
$&/ 37 RUD]NRQWUROQHMEDGDQ\FKZNRODQDFKZSHáQ\PZ\SUR FLH
Rycina 24
0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLHGR ZLDGF]DOQHM
$&/ 37 RUD]NRQWUROQHMEDGDQ\FKZSHáQ\PZ\SUR FLHNRODQ
QLHVWDELOQR üSU]HGQLDNRODQDZSHáQ\PZ\SUR FLH
PLHU]RQDDSDUDWHP.7
0HGLDQD
0LQ0DNV
$&/
37
*.
85
Rycina 25
3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLH
GR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMEDGDQ\FKZSHáQ\PZ\SUR FLH
kolan.
Rycina 26
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZSHáQ\P
Z\SUR FLHNRODQZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZ
JUXSLH$&/ JUXS\GR ZLDGF]DOQHM
+LSRWH]D+R QLHPDLVWRWQ\FKVWDW\VW\F]QLHUy*QLFSRPL
G]\QLHVWDELOQR FLEDGDQ\FK
JUXS : FHOX Z\EUDQLD ZáD FLZHJR WHVWX ZHU\ILNXMFHJR KLSRWH]
+R VSUDZG]RQR
+LVWRJUDP $&/
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZSHáQ\PZ\SUR FLHPLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
QLHVWDELOQR üSU]HGQLDNRODQDZSHáQ\PZ\SUR FLH
PLHU]RQDDSDUDWHP.7
UHGQLD
UHGQLD3U]HG]XIQ
UHGQLD 3U]HG]XIQ
$&/
37
=*.
86
QRUPDOQR ü UR]NáDGX DQDOL]RZDQHM FHFK\ ± QLHVWDELOQR FL 1RUPDOQR ü VSUDZG]RQR
WHVWHP 6KDSLUR:LOND L Z\ND]DQR *H QLH ZV]\VWNLH JUXS\ PDM UR]NáDG QRUPDOQ\
5\FLQD 5\FLQD 'ODWHJR WH* ]DVWRVRZDQR QLHSDUDPHWU\F]Q\ RGSRZLHGQLN
ANOVA – test Kruskala-Wallisa (Tabela 23
3RQLHZD* S! S QLH PD
SRGVWDZGRRGU]XFHQLDKLSRWH]\+RDZ]ZL]NX]W\PZFL*XWU]\PXMHP\*HQLHPD
]QDPLHQQLH VWDW\VW\F]QLH Uy*QLF Z QLHVWDELOQR FL NRODQD SRPL
G]\ WU]HPD EDGDQ\PL
JUXSDPLZZ\SUR FLHZVWDZLHNRODQRZ\P
Rycina 27
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZSHáQ\P
Z\SUR FLHNRODQZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZ
grupie kontrolnej (GK).
Test Kruskala-Wallisa: H ( 2, N= 106) =3,56; p =0,17
N
Suma
RANG
ACL (+)
35
1958,00
PT (-)
35
2058,00
ZGK
36
1655,00
Tabela 23. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQ
EDGDQ\FKZJUXSLHGR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZSHáQ\P
Z\SUR FLHNRODQ
+LVWRJUDP *.
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZSHáQ\PZ\SUR FLHPLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
87
320,$5<:=*, &,8.2/$1$°
3RPLDU\QLHVWDELOQR FLNRODQDZ\NRQDQRZ]JL
FLX°.
6WDW\VW\NDRSLVRZDSRV]F]HJyOQ\FKJUXSSRQL*HM Tabela 24).
: DQDOL]LH Z\ND]\ZDQH V HZHQWXDOQH Uy*QLFH Z SU]HGQLHM QLHVWDELOQR FL VWDZX
NRODQRZHJRSRPL
G]\*.$&/ D37 Z]JL
FLXNRODQD°.
n
UHGQLD
SD
CI (-95 %)
CI (+95%)
min
maks
ACL (+) 35
6,80
2,65
5,89
7,71
3,00
12,00
PT (-)
35
6,91
2,80
5,95
7,88
3,00
12,00
GK
36
5,50
1,50
4,99
6,01
2,00
10,00
Tabela 24
6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKZJUXSLHGR ZLDGF]DOQHM
$&/ 37 RUD]NRQWUROQHMEDGDQ\FKZ]JL FLXNRODQ°°.
Rycina 28
0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLH
GR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZ]JL FLXNRODQ°°.
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX
°
PLHU]RQDDSDUDWHP.7
0HGLDQD
0LQ0DNV
$&/
37
*.
88
Rycina 29
3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLH
GR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZ]JL FLXNRODQ°°.
Rycina 30
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLX
kolan 30°°
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH
$&/ JUXS\GR ZLDGF]DOQHM
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX
°
PLHU]RQDDSDUDWHP.7
UHGQLD
UHGQLD3U]HG]XIQ
UHGQLD 3U]HG]XIQ
$&/
37
*.
+LVWRJUDP $&/
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °PLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
89
Rycina 31
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLX
kolan 30°°
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH
37 JUXS\GR ZLDGF]DOQHM
Rycina 32
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLX
kolan 30°°
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH
kontrolnej.
+LVWRJUDP *.
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °PLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
+LVWRJUDP 37
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °PLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
90
+LSRWH]D+R QLHPDLVWRWQ\FKVWDW\VW\F]QLHUy*QLFSRPL
G]\QLHVWDELOQR FLEDGDQ\FK
JUXS : FHOX Z\EUDQLD ZáD FLZHJR WHVWX ZHU\ILNXMFHJR KLSRWH]
+R VSUDZG]RQR
QRUPDOQR ü UR]NáDGX DQDOL]RZDQHM FHFK\ ± QLHVWDELOQR FL 1RUPDOQR ü VSUDZG]RQR
WHVWHP6KDSLUR:LONDLZ\ND]DQR*HJUXS\QLHPDMUR]NáDGXQRUPDOQHJR Rycina 30,
Rycina 31, Rycina 32
'ODWHJR WH* ]DVWRVRZDQR QLHSDUDPHWU\F]Q\ RGSRZLHGQLN
ANOVA – test Kruskala-Wallisa (Tabela 25
3RQLHZD*S S RGU]XFDP\
KLSRWH]
+R 'OD SRUyZQDQLD SRV]F]HJyOQ\FK JUXS ]DVWRVRZDQR DQDOL]
SRVWKRF ]
ZLHORNURWQ\PLSRUyZQDQLDPL UHGQLFKJUXS Tabela 26 LZ\ND]DQRUy*QLFHSRPL
G]\
GK, a ACL(+) i LP(-) – odpowiednio p=0,0003 i p=0,001.
Test Kruskala-Wallisa: H ( 2, N= 106) =17,17; p =0,0002
N
Suma
RANG
ACL (+)
35
1516,00
LP (-)
35
1617,50
GK
36
2537,50
Tabela 25. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQ
EDGDQ\FKZJUXSLHGR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZ]JL FLX
kolan 30°°.
ACL (+)
LP (-)
GK
ACL (+)
1,00
0,0003
LP (-)
0,001
GK
Tabela 26.
:DUWR üSGODSRUyZQDZLHORNURWQ\FK GZXVWURQQ\FK QLHVWDELOQR FL
przednich kolan badanych w grupie
GR ZLDGF]DOQHM $&/ 37 RUD]
kontrolnej
Z]JL FLXNRODQ°°.
91
320,$5<:=*, &,8.2/$1$ °
3RPLDU\QLHVWDELOQR FLNRODQDZ\NRQDQRZ]JL
FLX °.
6WDW\VW\NDRSLVRZDSRV]F]HJyOQ\FKJUXSSRQL*HM Tabela 27).
: DQDOL]LH Z\ND]\ZDQH V HZHQWXDOQH Uy*QLFH Z SU]HGQLHM QLHVWDELOQR FL VWDZX
NRODQRZHJRSRPL
G]\*.$&/ D37 Z]JL
FLXNRODQD °.
n
UHGQLD
SD
CI (-95 %)
CI (+95%)
min
maks
ACL (+) 35
4,43
2,13
3,70
5,16
0,00
10,00
PT (-)
35
4,91
2,09
4,20
5,63
0,00
9,00
GK
36
5,33
1,55
4,81
5,86
3,00
8,00
Tabela 27
6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKZJUXSLHGR ZLDGF]DOQHM
$&/ 37 RUD]NRQWUROQHMEDGDQ\FKZ]JL FLXNRODQ °°.
Rycina 33
0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLH
GR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZ]JL FLXNRODQ °°.
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX
°
PLHU]RQDDSDUDWHP.7
0HGLDQD
0LQ0DNV
$&/
37
*.
92
Rycina 34
3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLH
GR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZ]JL FLXNRODQ °°.
Rycina 35
5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLX
kolan 90°°
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH
kontrolnej.
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX
°
PLHU]RQDDSDUDWHP.7
UHGQLD
UHGQLD3U]HG]XIQ
UHGQLD 3U]HG]XIQ
$&/
37
*.
+LVWRJUDP *.
6KDSLUR:LON: S
QLHVWDELOQR üSU]HGQLDNRODQDZ]JL FLX °PLHU]RQDDSDUDWHP.7
/LF]EDREVHUZDFML
93
+LSRWH]D+R QLHPDLVWRWQ\FKVWDW\VW\F]QLHUy*QLFSRPL
G]\QLHVWDELOQR FLEDGDQ\FK
JUXS : FHOX Z\EUDQLD ZáD FLZHJR WHVWX ZHU\ILNXMFHJR KLSRWH]
+R VSUDZG]RQR
QRUPDOQR ü UR]NáDGX DQDOL]RZDQHM FHFK\ ± QLHVWDELOQR FL 1RUPDOQR ü VSUDZG]RQR
WHVWHP6KDSLUR:LONDLZ\ND]DQR*HJUXSD*.QLHPDUR]NáDGXQRUPDOQHJR 5\FLQD
'ODWHJRWH*]DVWRVRZDQRQLHSDUDPHWU\F]Q\RGSRZLHGQLN$129$±WHVW.UXVNDOD
Wallisa (Tabela 28
3RQLHZD* S! S QLH PD SRGVWDZ GR RGU]XFHQLD
KLSRWH]\ +R D Z ]ZL]NX ] W\P ZFL* XWU]\PXMHP\ *H QLH PD ]QDPLHQQLH
VWDW\VW\F]QLH Uy*QLF Z QLHVWDELOQR FL NRODQD SRPL
G]\ WU]HPD EDGDQ\PL JUXSDPL Z
]JL
FLX °.
Test Kruskala-Wallisa: H ( 2, N= 106) =3,70; p =0,16
N
Suma
RANG
ACL (+)
35
1621,00
LP (-)
35
1884,50
GK
36
2165,50
Tabela 28. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQ
EDGDQ\FKZJUXSLHGR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZ]JL FLX
kolan 90°°.
94
8 OMÓWIENIE WYNIKÓW I DYSKUSJA
Przy wyprostowanym stawie kolanowym, kombinacja rotacji 0°
L QDSL FLD 1 QLH
SU]\QLRVáDVSRG]LHZDQHMSRSUDZ\VWDELOQR FL1LHVWDELOQR ü]PQLHMV]\áDVL
DOHZFL*
RGELHJDáD Z VSRVyE LVWRWQ\ VWDW\VW\F]QLH RG ZDUWR FL UHIHUHQF\MQHM $&/
:SURZDG]HQLH URWDFML ]HZQ
WU]QHM °1 QLF QLH ]PLHQLáR -HG\QLH NRPELQDFMH ]
QDSL
FLHP SRF]WNRZ\P 1 SR]ZROLá\ QD X]\VNDQLH GREUHM VWDELOQR FL VWDZX
-HGQRF]H QLH ]ZL
NV]HQLH URWDFML ] °-100N do 180°1 UyZQLH* QLH SU]\QLRVáR
*DGQ\FK ]PLDQ ± PL
G]\ W\PL NRPELQDFMDPL QLH ]DXZD*RQR *DGQHM LVWRWQHM
VWDW\VW\F]QLHUy*QLF\ Tabela 11).
Kombinacja 180°
1E\áDVNXWHF]QLHMV]DRG°-50N w sposób istotny statystycznie,
p=0,04.
3RZ\*V]HGDQHSR]ZDODMSRZLHG]LHü*HSU]\NRODQLHZZ\SUR FLHURWDFMD]HZQ
WU]QD
180°
QLH ZSá\ZD QD SRSUDZ VWDELOQR FL VWDZX DQL QLH REQL*D NRQLHF]QHJR GR
]DVWRVRZDQLDQDSL FLDSRF]WNRZHJR
:]JL
FLXNRODQD°RWU]\PDQREDUG]RSRGREQHZ\QLNL5yZQLH*W\ONRNRPELQDFMH]
QDSL
FLHP 1 SU]\ZUyFLá\ SRF]WNRZ VWDELOQR ü NRODQD .RPELQDFMD °-50N nie
SRWUDILáDXWU]\PDüSR*GDQVWDELOQR ü1LHSRPRJáR]ZL
NV]HQLHURWDFMLGR°-50N.
3RGREQLHMDNZF]H QLHMNRPELQDFMD°1RND]DáDVL
VNXWHF]QLHMV]DRG°-50N w
VSRVyELVWRWQ\VWDW\VW\F]QLH QLHZ\ND]DQRUy*QLFSRPL
G]\NRPELQDFMDPL°-100N i
180°-100N (Tabela 16).
: W\P SU]\SDGNX QLH PR*HP\ VWZLHUG]Lü DE\ VWRVRZDQLH URWDFML ]HZQ
WU]QHM °
SRSUDZLDáRVWDELOQR üVWDZXNRODQRZHJRDOERSR]ZDODáRREQL*\üQDSL
FLHNRQLHF]QH
GRRGWZRU]HQLDWHMVWDELOQR FL
3RPLDU\SU]\NRODQLH]JL
W\P °'RNáDGQLHMDNZSRSU]HGQLFKXVWDZLHQLDFKMHG\QLH
kombinacje 0°-100N oraz 180°
1 SU]\ZUyFLá\ SR*GDQ VWDELOQR ü =ZL NV]HQLH
rotacji z 0°-50N do 180°-50N oraz z 0°-100N do 180°
1 QLH SU]\QLRVáR *DGQHM
SRSUDZ\ZVWDELOQR FLNRODQDNWyUDE\áDE\LVWRWQDVWDW\VW\F]QLH Tabela 20).
95
7XWDMUyZQLH*QLHPR*HP\WZLHUG]Lü*HVWRVRZDQLHURWDFML]HZQ
WU]QHM°]ZL
NV]D
VWDELOQR ü VWDZX NRODQRZHJR DOER SR]ZDOD QD ]PQLHMV]HQLH VWRVRZDQHJR QDSL
FLD
QLH]E
GQHJRGRX]\VNDQLDZ\M FLRZHMVWDELOQR FL $&/
5HDVXPXMF QLH PR*QD WZLHUG]Lü *H VWRVRZDQLH URWDFML ]HZQ
WU]QHM ° poprawia
VWDELOQR ü VWDZX NRODQRZHJR OXE WH* SR]ZDOD QD VWRVRZDQLH QL*V]HJR QDSL
FLD
SRF]WNRZHJR SU]\ PRFRZDQLX SU]HV]F]HSX EH] V]NRG\ GOD Sy(QLHMV]HM VWDELOQR FL
VWDZX-HG\QLHQDSL
FLHSRF]WNRZHPDZSá\ZQDVWDELOQR üSU]HGQLNRODQD
: GDOV]HM F]
FL EDGDQLD SRUyZQ\ZDQR QLHVWDELOQR ü SU]HGQL Z JUXSDFK $&/
37 RUD] *. :\ND]DQR *H SRPLPR SRGREQHJR UR]NáDGX ZLHNX L SáFL Z REX
JUXSDFK LVWQLHM Z SR]\FML ]JL
FLRZHM NRODQD ° Uy*QLFH SRPL
G]\ W\PL JUXSDPL
(Tabela 26
5y*QLFW\FKQLHZ\ND]DQRZSR]\FMDFK° i 90° (Tabela 23, Tabela 28).
:\QLNLWH]PXV]DMGR]DVWDQRZLHQLDVL
F]\UH]XOWDW\EDGD]JUXSGR ZLDGF]DOQ
PR*QDEH]SR UHGQLRRGQLH üGRZDUXQNyZNOLQLF]Q\FK
-H OLFKRG]LRZDUWR FLEH]Z]JO
GQHWR]SHZQR FLQLH0R*HP\QDWRPLDVWWáXPDF]\ü
*HZND*GHM]F]WHUHFKNRPELQDFMLPRFRZDQLDSU]HV]F]HSXZGDQ\PNRODQLHLVWQLDá\
takie same warunki.
1DOH*\VL
MHGQDN]DVWDQRZLüGODF]HJRJUXS\WHUy*QLá\VL
'REyU]ZáRNSU]HELHJDá
]JRGQLH ] XVWDORQ\PL NU\WHULDPL D FDáD SURFHGXUD LFK RSUDFRZ\ZDQLD E\áD VXURZR
SU]HVWU]HJDQD 0R*QD QD WHM SRGVWDZLH SU]\SXV]F]Dü *H EDGDQLD QD ]ZáRNDFK PRJ
QDPMHG\QLHSRGDZDüSHZQHZVND]yZNLLZ\W\F]DüFHOHQDWRPLDVWLFKZ\QLNyZQLH
PR*QDZSURVW\VSRVyESU]HQRVLüQDREV]DUNOLQLNL0LPR*HSUyERZDQR]QLZHORZDü
ZSá\ZVW
*HQLDSR PLHUWQHJRQDZ\QLNLSRSU]H]VWDUDQQ\GREyU]ZáRNQLHXGDáRVL
MHGQDNSRPLQüWHJRF]\QQLND
1LHPQLHMMH OLSRUyZQXMHP\PL
G]\VREVWRVRZDQHZEDGDQLXNRPELQDFMHPRFRZD
WRZV]\VWNLHPLDá\]DSHZQLRQHWHVDPHZDUXQNL=WHJRWH*SRZRGXZ\QLNLMDNR FLRZH
PR*QD RGQRVLü GR FDáR FL SRSXODFML SRQLHZD* RSLVXM RQH Z]JO
GQH ]DFKRZDQLD
SRV]F]HJyOQ\FKNRPELQDFMLPRFRZDZ]JO
GHPVLHELH
=ZL
NV]HQLH URWDFML QLH SU]\QLRVáR SRSUDZ\ Z VWDELOQR FL NRODQD 1LH Z\NOXF]D WR
VWZLHUG]HQLD *H ]URWRZDQ\ SU]HV]F]HS PR*H PLHü Z\*V]H SDUDPHWU\ PHFKDQLF]QH
[101, 103]
FKRFLD*QLHZV]\VF\SRG]LHODMWHQSRJOG[102].
96
)DNW*H37MHVWEDUG]LHMZ\GROQHPHFKDQLF]QLHRG$&/PR*HQLHPLHüWXWDM*DGQHJR
]QDF]HQLD ± VWDZ NRODQRZ\ ZFDOH QLH PXVL SRWU]HERZDü GRGDWNRZHM Z\WU]\PDáR FL
&KRFLD* ZHGáXJ GRQLHVLH =DU]\FNLHJR L ZVS ZáD FLZR FL PHFKDQLF]QH %37%
QLHZLHOHZL
FHMSU]HZ\*V]DMZáD FLZR FL$&/[141].
%OXPLZVSZ\ND]DOL*HURWDFMDSU]HV]F]HSX]PQLHMV]DMHJRGáXJR üRUD]*HURWDFMD
]HZQ
WU]QDURELWR]QDF]QLHPRFQLHMQL*ZHZQ
WU]QD[99].
+DPHLZVSSU]HSURZDG]LOLWHVW\URWDFMLL]RORZDQ\FK%37%]H]ZáRNSU]\SRPRF\
VSHFMDOQHJR XU]G]HQLD V\PXOXMFHJR VWDZ NRODQRZ\ [142]. Kryterium
SRUyZQDZF]\PE\áRSU]HGQLHSU]HPLHV]F]HQLHSLV]F]HOL%DGDQLHSRG]LHORQHE\áRQD
WU]\ F]
FL Z ]DOH*QR FL RG PRPHQWX L URG]DMX URWDFML QDSL
FLH SU]HV]F]HSX GR
SR]LRPX ]HURZHJR SU]HPLHV]F]DQLD VL
SLV]F]HOL SU]\ ° ]JL
FLX Z NRODQLH !
URWDFMD SU]HV]F]HSX URWDFMD SU]HV]F]HSX ! QDSL
FLH SU]HV]F]HSX GR SR]LRPX
]HURZHJR SU]HPLHV]F]DQLD VL
SLV]F]HOL SU]\ ° ]JL
FLX QDSL
FLH SU]HV]F]HSX
23N, 44N, 68N lub 89N (przy 30°
]JL FLX ! URWDFMD SU]HV]F]HSX 5RWDFMH
Z\NRQ\ZDQH E\á\ GR ZHZQWU] L ]HZQWU] °, 180° D SRPLDU\ VWDELOQR FL Z
]JL
FLDFKNRODQD°, 30°, 90°.
:\QLNLSRND]Dá\*HMH OLFKRG]LR ZSá\Z URWDFML SU]HV]F]HSX QD VWDELOQR ü SU]\ MX*
XVWDORQ\PQDSL
FLX RSFMD WRQLHMHVWRQMHGQR]QDF]Q\7\ONRSU]\]JL
FLX° w
ND*GHM URWDFML X]\VNDQR OHSV]H Z\QLNL QL* Z URWDFML QHXWUDOQHM : ]JL
FLX ° rotacja
]HZQ
WU]QD °DZ]JL
FLX °ND*GDURWDFMDZHZQ
WU]QDQLHPLDá\ZSá\ZXQD]PLDQ
VWDELOQR FLSRUyZQXMFGRURWDFMLQHXWUDOQHM
-H OL QDMSLHUZ URWRZDü SU]HV]F]HS D SRWHP XVWDODü QDSL
FLH ZHGáXJ X]\VNDQ\FK
Z\QLNyZQLHPDWR*DGQHJRZSá\ZXQD]PLDQ
VWDELOQR FLVWDZX RSFMD
, NROHMQR RSFMD 7XWDM ND*GD URWDFMD SR]D ]HZQ
WU]Q ° ZSá\Q
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: QLQLHMV]HM SUDF\ VWRVRZDQR QDSL
FLH 1 OXE 1 SU]\NáDGDQH Z ° ]JL
FLX
kolana.
:DUWR ü QDSL
FLD SRF]WNRZHJR Z\GDMH VL
E\ü QDMZD*QLHMV]\P F]\QQLNLHP
ZDUXQNXMF\PRGWZRU]HQLHVWDELOQR FLNRODQD
%XUNVL/HODQGRNUH OLOLW
ZDUWR üGOD%37%MDNR1SU]\NRODQLH]JL
W\P°-25°
w chwili mocowania przeszczepu [146]
-HGQDN FL VDPL DXWRU]\ VWRVRZDOL ZF]H QLHM
]QDF]QLH ZL
NV]H QDSL
FLD ER 1 [147]. Friederich i O’Brien proponowali 27-
1SRGNUH ODMFIDNW*HMH OLSU]HV]F]HSMHVWXPLHV]F]RQ\ZVSRVyEL]RPHWU\F]Q\WR
NW ]JL
FLD NRODQD SRG MDNLP GRNRQXMHP\ PRFRZDQLD SU]HV]F]HSX QLH PD WXWDM
*DGQHJR ]QDF]HQLD [109] 2SHUDWRU ]DZV]H PD QDG]LHM
*H SU]HV]F]HS ]RVWDá
XPLHV]F]RQ\ Z SXQNWDFK L]RPHWU\F]Q\FK MHGQDN UR]VGQ\P Z\GDMH VL
PRFRZDü
SU]HV]F]HSZQLHZLHONLP]JL
FLXNRODQD*HUWHOLZVSSURSRQXM1OXE1[108,
148]
SU]\ NFLH ]JL FLD NRODQD °, co pozostaje w zgodzie z wynikami pracy
103
Bylskiego-Austrowa i wsp. [108, 148]. Odmienne zdanie prezentuje jednak Melby i
ZVSNWyU]\SU]HEDGDOLQDSL
FLDRG1GR 1]PRFRZDQLHPSU]HV]F]HSXZSHáQ\P
Z\SUR FLHNRODQDOXE°]JL
FLX8ZD*DMRQL*HZ\VWDUF]DMFHQDSL
FLHWR1SU]\
]JL
FLXNRODQD° [149]1LHFRZL
NV]HZDUWR FLSURSRQXM0DUNROILZVS±1
przy 30°
]JL FLX NRODQD Z FKZLOL PRFRZDQLD SU]HV]F]HSX [96]. Anderson i Uffe
UyZQLH*SUHIHUXMSRGREQHZDUWR FLER1Z°]JL
FLXNRODQD[150].
:V]\VWNLH SRZ\*V]H EDGDQLD SURZDG]RQH E\á\ QD OXG]NLFK ]ZáRNDFK 8]DVDGQLHQLD
SURSRQRZDQLDWDNLFKOXELQQ\FKQDSL
üE\á\GZRMDNLH
-HGQLDXWRU]\SRGDM*HGDQHQDSL
FLHZ\VWDUF]\DE\SU]\ZUyFLüSR*GDQVWDELOQR ü
kolana - Burks i Leland [146], Friederich i O’Brien [109], Gertel i wsp. [108, 148],
Bylski-Austrow i wsp. [108, 148].
3R]RVWDOL DXWRU]\ SURSRQRZDQH QDSL
FLH WáXPDF] IDNWHP *H MH OL ]RVWDQLH RQH
przekroczone, istnieje ryzyko uzyskania deficytu wyprostu - Melby i wsp.[149],
Markolf i wsp. [96], Anderson i Uffe [150].
2F]\ZL FLH SU]HNURF]HQLH SHZQHM JUDQLF]QHM ZDUWR FL QDSL
FLD GRSURZDG]L GR
]ZL
NV]RQHJR XFLVNX Ná\NFL XGRZ\FK L SLV]F]HORZ\FK DOH MH OL SU]HV]F]HS
XPLHV]F]RQ\ MHVW Z VSRVyE L]RPHWU\F]Q\ QLH QDOH*\ VSRG]LHZDü VL
SUREOHPyZ ]H
]JL
FLHPF]\Z\SURVWHPZVWDZLHNRODQRZ\P:QLQLHMV]HMSUDF\VWRVRZDQR]QDF]QLH
ZL
NV]H ZDUWR FL QDSL
FLD ± 1 L 1 :H ZV]\VWNLFK RSHURZDQ\FK SU]\SDGNDFK
NRQWUROD L]RPHWULL Z\SDGáD SRP\ OQLH ]PLDQD GáXJR FL %37% SRQL*HM PP L QLH
]DXZD*RQRGHILF\WXDQLZ\SURVWXDQL]JL
FLD
3U]\SRPQLMP\ *H Z QLQLHMV]HM SUDF\ MHG\QLH QDSL
FLH 1 SU]\ZUDFDáR VWDELOQR ü
kolana.
: SUDFDFK NOLQLF]Q\FK ZDUWR FL QDSL
FLD SRGDZDQH V QLHFR ZL
NV]H QL* Z W\FK
SU]HSURZDG]DQ\FKQD]ZáRNDFK
1DERUV L ZVS SURSRQXM 1 Z SHáQ\P Z\SUR FLH [151] 1LHFR PQLHMV]H ZDUWR FL
SRGDM +HLV L ZVS ± QDSL
FLH ZL
NV]H QL* 1 ]ZL
NV]D U\]\NR Z\VWSLHQLD
ograniczenia zakresu ruchów w stawie kolanowym [152]. Jednak van Kampen i wsp.
QLH ]DXZD*\OL SR URNX RG RSHUDFML *DGQHM Uy*QLF\ SRPL
G]\ VWDELOQR FL NRODQ
UHNRQVWUXRZDQ\FK ] QDSL
FLHP 1 L 1 GRZRG]F *H QLH PD SRWU]HE\ VWRVRZDü
QDSL
FLDZL
NV]HJRQL*1SU]\°]JL
FLXNRODQD[153]. Podobne wyniki prezentuje
Yoshiya [94]
8*\FLH QDSL FLD 1 RUD] 1 Z SHáQ\P Z\SUR FLH GDáR QDGPLHUQH
]ZDUFLHVWDZX:WU]HFLPPLHVLFXREVHUZDFMLX]\VNDQRMHGQDNZDUWR FLQLHVWDELOQR FL
104
SRUyZQ\ZDOQH ] SU]HFLZQ\P ]GURZ\P NRODQHP : NROHMQ\FK WU]HFK PLHVLFDFK
QLH]QDF]Q\ VSDGHN VWDELOQR FL XWU]\P\ZDá VL
QLH ]DREVHUZRZDQR MHGQDN Uy*QLF
SRPL
G]\JUXS]QDSL
FLHP1L1
5yZQLH*DXWRU]\UDQGRPL]RZDQ\FKEDGDSRUyZQXMF\FKPHWRG
UHNRQVWUXNFML$&/]
X*\FLHP%37%GRPHWRG\UHNRQVWUXNFML$&/]X*\FLHP*67QLHSR]RVWDM]JRGQL
FRGRZDUWR FLVWRVRZDQHJRQDSL
FLD
$XQHLZVSVWRVRZDOL 1SU]\SHáQ\P Z\SUR FLH Z NRODQLH [69]. Anderson i wsp.
stosowali 66N przy 10°
]JL FLXNRODQDX]\VNXMFGREUHZ\QLNLRGWZDU]DQLDVWDELOQR FL
przedniej kolana [66]
$JOLHWWLLZVSSURSRQXM1ZSHáQ\PZ\SUR FLHREDZLDMF
VL
RJUDQLF]HQLDZ\SURVWX[62].
1LHVWHW\ ZLHOX DXWRUyZ QLH SRGDMH ZDUWR FL QDSL
FLD MDNLH E\áR VWRVRZDQH OXE WH*
SRGDMHMHJRZDUWR üZVSRVyERSLVRZ\LQIRUPXMFQD SU]\NáDG L* RSHUDWRU QDFLJDá
SU]HV]F]HSU
F]QLHGRPDNVLPXPVZRLFKPR*OLZR FL
5R]ELH*QR FL WH XWUXGQLDM SRUyZQDQLH Z\QLNyZ DOH ] GUXJLHM VWURQ\ VWZDU]DM
PR*OLZR üREVHUZDFMLHZHQWXDOQ\FKWUXGQR FL±FKRüE\W\FKGRW\F]F\FKRJUDQLF]HQLD
zakresu ruchów w stawie kolanowym.
2LOHPR*QD]DXZD*\ü*HNW]JL
FLDNRODQDZPRPHQFLHILNVDFMLZDKDVL
SRPL
G]\
wyprostem a 30°
] SU]HZDJ °-30° WR UR]SL WR ü QDSL ü MDNLH XZD*DQH V ]D
Z\VWDUF]DMFHMHVWRZLHOHZL
NV]D$XWRU]\SURSRQXM]GHF\GRZDQLHQL*V]HZDUWR FL
GOD]ZáRNZ\*V]HGODFHOyZNOLQLF]Q\FK
1D SRGVWDZLH X]\VNDQ\FK Z\QLNyZ EDGD SRZ\*V]\FK UR]ZD*D RUD] DNWXDOQHJR
VWDQXZLHG]\SU]HGVWDZLRQHJRZHZF]H QLHMV]\FKUR]G]LDáDFKPR*HP\VWZLHUG]Lü*H
Z SU]\ZUDFDQLX VWDELOQR FL SU]HGQLHM VWDZX NOXF]RZ URO
RGJU\ZD L]RPHWULD
SU]HV]F]HSX RUD] RGSRZLHGQLH QDSL
FLH SRF]WNRZH 5RWRZDQLH SU]HV]F]HSX Z
SU]HSURZDG]RQ\P EDGDQLX QLH Z\GDMH VL
RGJU\ZDü ZD*QHM UROL Z SU]\ZUDFDQLX
VWDELOQR FLNRODQDDQLZUHGXNFMLNRQLHF]QHJRQDSL
FLDSRF]WNRZHJR
=DELHJURWDFML]HZQ
WU]QHMR°QLHSU]\QLyVá*DGQHMLVWRWQHMVWDW\VW\F]QLHSRSUDZ\
VWDELOQR FL VWDZX NRODQRZHJR 1LH Z\ND]DQR Z\*V]R FL NRPELQDFML ] URWDFMDPL QDG
W\PLEH]:\QLNLSUDFQDGL]RORZDQ\PL%37%QLHSRNU\ZDMVL
]W\PLNOLQLF]Q\PL
RUD]WXWDMSU]HSURZDG]RQ\PL=DJDGQLHQLHWRMHVWFK\EDEDUG]LHMVNRPSOLNRZDQHQL*
VL
SRZV]HFKQLH XZD*D 0R*OLZH *H VDPR QDSL
FLH SRG NWyU\P GRNRQXMHP\
105
PRFRZDQLD SU]HV]F]HSX MHVW F]\QQLNLHP ZáF]DMF\P G]LDáDQLH URWDFML OXE QLH
0R*OLZHUyZQLH**HURWDFMDZRJyOHQLHPDZSá\ZXQDQDSL
FLHZL
]DGáDLVWDELOQR ü
kolana.
,]RPHWULDSR]ZDODQD]DFKRZDQLHVWDáHJRQDSL
FLDZSU]HV]F]HSLHFR]DSRELHJDMHJR
XV]NRG]HQLRPDZVNUDMQ\PSU]\SDGNX]HUZDQLX-HGQRF]H QLH]DSRELHJD]ZL
NV]DQLX
QDFLVNX QD SRZLHU]FKQLH FKU]
VWQH RUD] ]PLDQLH ELRPHFKDQLNL VWDZX 0LPR *H QLH
Z\ND]DQREH]SR UHGQLHJR]ZL]NX]E\WGX*HJRQDSL
FLDSRF]WNRZHJR]ZF]HVQ\PL
]PLDQDPL ]Z\URGQLHQLRZ\PL WR SRGHMU]HZD VL
*H QDGPLHUQH QDSL
FLH PR*H PLHü
ZSá\ZQDWH]PLDQ\
5RWRZDQLHSU]HV]F]HSXSRPLPR*HSRSUDZLDMHJRSDUDPHWU\PHFKDQLF]QHQLHZSá\ZD
Z ZLHWOHX]\VNDQ\FKZ\QLNyZQD]ZL
NV]HQLHVWDELOQR FLVWDZXWX*SR]DELHJX1LH
ZLDGRPR MHGQDN MDNL ZSá\Z PR*H PLHü WR QD XWU]\PDQLH VWDELOQR FL VWDZX Z
GáXJROHWQLFKREVHUZDFMDFK
$NWXDOQLHQLHPDMDVQ\FKRELHNW\ZQ\FK]DOHFHZVND]XMF\FKNLHUXQHNZDUWR üLZ
RJyOHSRWU]HE
URWDFML%37%ZUHNRQVWUXNFML$&/
&]
üDXWRUyZZVZRLFKSUDFDFKVWRVXMHQDVW
SXMF\DOJRU\WP QDSL
FLH±URWDFMD[142,
144]
: ZDUXQNDFK RSHUDF\MQ\FK Z SU]\SDGNX %37% QLH MHVW PR*OLZH
SU]HSURZDG]HQLH WDNLHJR PDQHZUX :\GDMH VL
ZL
F UDFMRQDOQH VWRVRZDü SURFHGXU
NWyUDMHVWSRGREQDGRRU\JLQDOQHMLPR*OLZDGRZ\NRQDQLDZZDUXQNDFKNOLQLF]Q\FK
F]\OLQDMSLHUZURWDFMDDGRSLHURZWHG\QDSL
FLH
106
9 WNIOSKI
:EDGDQLDFKQD]ZáRNDFKZ]DELHJXUHNRQVWUXNFMLZL
]DGáDNU]\*RZHJRSU]HGQLHJR
SU]HV]F]HSHP]ZL
]DGáDZáD FLZHJRU]HSNLVWZLHUG]RQR*H
1.
]HZQ
WU]QD URWDFMD SU]HV]F]HSX R ° QLH ZSá\ZD QD SU]HGQL VWDELOQR ü
operowanego kolana w porównaniu do sytuacji, gdy takiej rotacji nie zastosowano,
QLH]DOH*QLHRG]DVWRVRZDQHJRZVW
SQHJRQDSL
FLD
2.
]HZQ
WU]QDURWDFMDSU]HV]F]HSXR° nie pozwala na zmniejszenie stosowanego
QDSL
FLDSU]HV]F]HSXQLH]PQLHMV]DMFMHGQRF]H QLHVWDELOQR FLVWDZX
3.
MHG\QLH NRPELQDFMH ] Z\VRNLP QDSL
FLHP SRF]WNRZ\P 1 SU]HV]F]HSLRQHJR
ZL
]DGáD]DSHZQLDMSUDZLGáRZSU]HGQLVWDELOQR üNRODQD
4. kombinacja rotacji 180°
] QDSL FLHP 1 Z ]DELHJX UHNRQVWUXNFML $&/
SU]HV]F]HSHP%37%OHSLHMRGWZDU]DVWDELOQR üQL*NRPELQDFMD°-50N.
5.
%H]Z]JO
GQH Z\QLNL SRPLDUyZ VWDELOQR FL VWDZX NRODQRZHJR X]\VNDQ\FK QD
]ZáRNDFK QLH SRZLQQ\ E\ü EH]SR UHGQLR RGQRV]RQH GR ZDUXQNyZ NOLQLF]Q\FK
SRZLQQ\MHG\QLHZ\W\F]DüNLHUXQNLGDOV]\FKEDGDNOLQLF]Q\FK
107
10
STRESZCZENIE
5HNRQVWUXNFMDDUWURVNRSRZD]HUZDQHJRZL
]DGáDNU]\*RZHJRSU]HGQLHJR $&/ SU]\
SRPRF\SU]HV]F]HSX]ZL
]DGáDZáD FLZHJRU]HSNL %37% MHVWQLHZWSOLZLHX]QDQL
V]HURNR VWRVRZDQ PHWRG OHF]QLF] 1LH RSUDFRZDQR MHGQDN FLVá\FK Z\W\F]Q\FK
GRW\F]F\FKWDNLFKSDUDPHWUyZMDNQDSL
FLHSU]\NáDGDQHGRSU]HV]F]HSXZFKZLOLMHJR
PRFRZDQLDRUD]VWRSLHURWDFMLSRGMDNLPWRPRFRZDQLHQDVW
SXMH&HOHPQLQLHMV]HM
SUDF\ E\áR RGSRZLHG]HQLH QD S\WDQLD F]\ Z ]DELHJX UHNRQVWUXNFML $&/ ]HZQ
WU]QD
rotacja B-PT-B o 180°
PD ZSá\Z QD SU]HGQL VWDELOQR ü RSHURZDQHJR NRODQD Z
SRUyZQDQLXGRV\WXDFMLJG\WDNLHMURWDFMLQLH]DVWRVRZDQR"F]\]HZQ
WU]QHURWRZDQLH
przeszczepu B-PT-B o 180°
PR*H SR]ZROLü QD ]PQLHMV]HQLH VWRVRZDQHJR QDSL FLD
SU]HV]F]HSX QLH ]PQLHMV]DMF MHGQRF]H QLH VWDELOQR FL VWDZX" F]\ EH]Z]JO
GQH
ZDUWR FL SRPLDUyZ X]\VNDQ\FK Z ]DVWRVRZDQ\P PRGHOX EDGDZF]\P QD ]ZáRNDFK
PR*QD RGQLH ü GR ZDUXQNyZ NOLQLF]Q\FK" %DGDQLH SU]HSURZDG]RQR QD OXG]NLFK
]ZáRNDFKZ\FLQDMF$&/DQDVW
SQLHMHUHNRQVWUXXMF0RFRZDQLHND*GHJR%37%
QDVW
SRZDáRF]WHURNURWQLHZQDVW
SXMF\FKNRPELQDFMDFKURWDFMLLQDSL
FLD °-50N, 0°-
100N, 180°-50N, 180°
1 6WRSLH QLHVWDELOQR FL NRODQD PLHU]RQR SU]\ SRPRF\
DSDUDWX .7 SU]HG ]DELHJLHP RUD] SR ND*G\P PRFRZDQLX 3RUyZQDQR UyZQLH*
Z\QLNLEDGDQLHVWDELOQR FLQD]ZáRNDFK]JUXSNRQWUROQ
5y*QLFHZQLHVWDELOQR FLSU]HGQLHMNRODQE\á\SRPL
G]\SRV]F]HJyOQ\PLNRPELQDFMDPL
PRFRZD EDUG]R SRGREQH ZH ZV]\VWNLFK WU]HFK SR]\FMDFK SRPLDURZ\FK SHáHQ
Z\SURVW]JL
FLH°]JL
FLH ° 1DSRGVWDZLHX]\VNDQ\FKZ\QLNyZVWZLHUG]RQR*H
]HZQ
WU]QDURWDFMDSU]HV]F]HSXR°QLHZSá\ZDQDSU]HGQLVWDELOQR üRSHURZDQHJR
NRODQD Z SRUyZQDQLX GR V\WXDFML JG\ WDNLHM URWDFML QLH ]DVWRVRZDQR QLH]DOH*QLH RG
]DVWRVRZDQHJRZVW
SQHJRQDSL
FLD3RQDGWR]HZQ
WU]QDURWDFMDSU]HV]F]HSXR° nie
SR]ZDOD QD ]PQLHMV]HQLH VWRVRZDQHJR QDSL
FLD SU]HV]F]HSX QLH ]PQLHMV]DMF
MHGQRF]H QLH VWDELOQR FL VWDZX -HG\QLH NRPELQDFMH ] Z\VRNLP QDSL
FLHP
SRF]WNRZ\P1]DSHZQLDMSUDZLGáRZSU]HGQLVWDELOQR üNRODQD
3RUyZQXMF Z\QLNL QLHVWDELOQR FL NRODQ SRPL
G]\ ]ZáRNDPL D JUXS NRQWUROQ
Z\ND]DQR*HZ]JL
FLXNRODQD°ZDUWR FLWHUy*QLá\VL
RGVLHELHZVSRVyELVWRWQ\
VWDW\VW\F]QLH :REHF SRZ\*V]HJR EH]Z]JO
GQH Z\QLNL SRPLDUyZ VWDELOQR FL VWDZX
NRODQRZHJR X]\VNDQ\FK QD ]ZáRNDFK QLH PRJ E\ü EH]SR UHGQLR RGQRV]RQH GR
warunków klinicznych.
108
10.1
SUMMARY
Arthroscopic reconstruction of anterior cruciate ligament (ACL) using patellar tendon
graft (B-PT-B) is undoubtedly well known and widely used procedure. But there are no
strict guidelines concerning such parameters as the tension and twisting applied to the
graft for the fixation. The aim of the present study was to answer the following
questions: Does 180° external twisting of the B-PT-B influence on anterior knee laxity,
compering to the lack of the rotation? Can 180° external twisting of the graft enable to
decrease the applied tension without increasing the knee laxity? Can the direct results in
the cadaver model be transferred into the clinical work?
The study was conducted with the cadavers, excising ACL and then replacing it with the
B-PT-B. Every graft fixation was repeated 4 times in different twisting and tension
combination: 0°-50N, 0°-100N, 180°-50N, 180°-100N. Laxity was measured with KT-
1000 tensiometer. The laxity results of the cadavers were also compered with the results
of the control group.
The results were similar in all three knee measuring positions: full extension, 30°
flexion, 90° flexion. 180° external twisting does not influence on the knee laxity,
compering tension both 50N and 100N. The twisting does not let decrease the applied
tension without the increase in the knee laxity. Only 100N tension is enough to restore
the previous laxity. The direct results from the cadaver model cannot be transferred into
the clinical work.
109
11 SPIS RYCIN, TABEL, FOTOGRAFII, RYSUNKÓW,
FORMULARZY
11.1 SPIS RYCIN
5\FLQD6FKHPDWZVSyáG]LDáDQLDZL ]DGáDNU]\*RZHJRSU]HGQLHJRLW\OQHJRSRGF]DVUXFKyZ
rotacyjnych. ..................................................................................................................................................9
5\FLQD=DOH*QR üGáXJR FLZL ]DGáDRGVLá\UR]FLJDMFHM ...................................................................11
5\FLQD)HQRPHQFLHUSQL FLD IHQRPHQFUHHS ......................................................................................12
5\FLQD5HODNVDFMDZL ]DGáDSRGZSá\ZHPREFL*DQLD .........................................................................12
5\FLQD/RNDOL]DFMHSU]\F]HSyZ$&/QDNR FLXGRZHMLSLV]F]HORZHM ...................................................13
5\FLQD2NUH ODQLHNLHUXQNyZZREUD]LHDUWURVNRSRZ\P......................................................................32
5\FLQD3RáR*HQLHEORF]NDZNDQDOHSLV]F]HORZ\PZNODV\F]QHMUHNRQVWUXNFML$&/]Z\NRU]\VWDQLHP%
PT-B............................................................................................................................................................37
5\FLQD3RáR*HQLHZNDQDOHSLV]F]HORZ\P $ Z\GáX*RQHJREORF]NDZUHNRQVWUXNFML$&/]
wykorzystaniem B-PT-B, (B) zduplikowanego bloczka w rekonstrukcji ACL z wykorzystaniem B-PT-B...37
Rycina 9. Lokalizacja piszczelowego przyczepu przeszczepu.....................................................................41
5\FLQD.LHUXQHNLVLáDG]LDáDQLD$&/Z]DOH*QR FLRGSRáR*HQLDNDQDáXSLV]F]HORZHJR....................41
Rycina 11. Linia Blemansaat i udowe umiejscowienie przeszczepu. ..........................................................43
5\FLQD0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLHGR ZLDGF]DOQHMZSHáQ\P
Z\SUR FLHNRODQ.........................................................................................................................................71
5\FLQD3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLHGR ZLDGF]DOQHMZSHáQ\P
Z\SUR FLHNRODQ.........................................................................................................................................71
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZZ\SUR FLHZVND]XMHQDEUDN
QRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH$&/ JUXS\GR ZLDGF]DOQHM...................................72
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQHMZZ\SUR FLHZVND]XMHQDEUDN
QRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLHJUXS\GR ZLDGF]DOQHM ..................................72
5\FLQD0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLHGR ZLDGF]DOQHMZ]JL
FLXNRODQ
30
°
. .............................................................................................................................................................74
5\FLQD3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLHGR ZLDGF]DOQHMZ]JL
FLXNRODQ
30
°
. .............................................................................................................................................................75
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
°
wskazuje na
EUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH$&/ JUXS\GR ZLDGF]DOQHM...........................76
5\FLQD 0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLHGR ZLDGF]DOQHMZ]JL
FLXNRODQ
90
°
. .............................................................................................................................................................78
5\FLQD3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLHGR ZLDGF]DOQHMZ]JL
FLXNRODQ
90
°
. .............................................................................................................................................................79
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
°
wskazuje na
EUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLHJUXS\GR ZLDGF]DOQHM................................80
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
°
wskazuje na
EUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLHJUXS\GR ZLDGF]DOQHM..............................80
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
°
wskazuje na
EUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLHJUXS\GR ZLDGF]DOQHM..........................81
5\FLQD0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLHGR ZLDGF]DOQHM $&/ 37 RUD]
NRQWUROQHMEDGDQ\FKZSHáQ\PZ\SUR FLHNRODQ .......................................................................................84
5\FLQD3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLHGR ZLDGF]DOQHM $&/ 37
RUD]NRQWUROQHMEDGDQ\FKZSHáQ\PZ\SUR FLHNRODQ ...............................................................................85
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZSHáQ\PZ\SUR FLHNRODQ
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH$&/ JUXS\GR ZLDGF]DOQHM ......85
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZSHáQ\PZ\SUR FLHNRODQ
ZVND]XMHQDEUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLHNRQWUROQHM *. .............................86
5\FLQD0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLHGR ZLDGF]DOQHM $&/ 37
RUD]NRQWUROQHMZ]JL FLXNRODQ
°
. ..........................................................................................................87
110
5\FLQD 3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLHGR ZLDGF]DOQHM $&/ 37
RUD]NRQWUROQHMZ]JL FLXNRODQ
°
. ..........................................................................................................88
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
°
wskazuje na
EUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH$&/ JUXS\GR ZLDGF]DOQHM...........................88
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
°
wskazuje na
EUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLH37 JUXS\GR ZLDGF]DOQHM..............................89
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
°
wskazuje na
EUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLHNRQWUROQHM ..........................................................89
5\FLQD0HGLDQ\QLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLHGR ZLDGF]DOQHM $&/ 37
RUD]NRQWUROQHMZ]JL FLXNRODQ
°
. ..........................................................................................................91
5\FLQD3U]HG]LDá\XIQR FLQLHVWDELOQR FLSU]HGQLFKNRODQZJUXSLHGR ZLDGF]DOQHM $&/ 37
RUD]NRQWUROQHMZ]JL FLXNRODQ
°
. ..........................................................................................................92
5\FLQD5R]NáDGZDUWR FLQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
°
wskazuje na
EUDNQRUPDOQR FL±EDGDQLHSU]HSURZDG]RQHZJUXSLHNRQWUROQHM ..........................................................92
111
11.2 SPIS TABEL
7DEHOD:\QLNLPHWDDQDOL]\SRUyZQXMFHMPHWRG UHNRQVWUXNFML$&/]X*\FLHP%37%RUD]PHWRG ]
X*\FLHP*67>@.....................................................................................................................................30
Tabela 2. Porównanie parametrów metrycznych przeszczepu PT do ACL [55, 56, 71, 72].......................31
7DEHOD:áD FLZR FLPHFKDQLF]QH%37%Z]DOH*QR FLRGZLHONR FLMHJRURWDFML>@ .....................46
7DEHOD2SLVEDGDQHMJUXS\GR ZLDGF]DOQHM..........................................................................................54
Tabela 5. Charakterystyka grupy kontrolnej. .............................................................................................56
7DEHOD:\QLNLSRPLDUyZQLHVWDELOQR FLSU]HGQLHMZREU ELHJUXS\, GR ZLDGF]DOQHM .......................68
7DEHOD6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKZJUXSLHGR ZLDGF]DOQHMEDGDQ\FKZNRODQDFK
Z\SURVWRZDQ\FK±Q OLF]EDDQDOL]RZDQ\FKSU]\SDGNyZZJUXSLH UHGQLDSRPLDUyZQLHVWDELOQR FL
RGFK\OHQLHVWDQGDUGRZH 6' ZDUWR FL SU]HG]LDáXXIQR FLZDUWR FLPLQLPDOQHMLPDNV\PDOQHM
QLHVWDELOQR FLSU]HGQLHMNRODQD .................................................................................................................70
Tabela 8. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZSHáQ\P
Z\SUR FLHZJUXSLHGR ZLDGF]DOQHM ..........................................................................................................73
Tabela 9.
:DUWR üSGODSRUyZQDZLHORNURWQ\FK GZXVWURQQ\FK QLHVWDELOQR FLSU]HGQLFKNRODQ
EDGDQ\FKZSHáQ\PZ\SUR FLHZJUXSLHGR ZLDGF]DOQHM..........................................................................73
Tabela 10. Wyniki testów U Manna-Whitneya (p <0,05)
SRUyZQXMF\FKQLHVWDELOQR FLSU]HGQLHSRPL G]\
JUXSDPL$&/ LRUD]$&/ LZJUXSLHGR ZLDGF]DOQHMZSHáQ\PZ\SUR FLHNRODQ ......73
7DEHOD2VWDWHF]QHZ\QLNLSRUyZQDQLHVWDELOQR FLSU]HGQLFKNRODQSRPL G]\SRV]F]HJyOQ\PL
JUXSDPLZJUXSLHGR ZLDGF]DOQHMZSHáQ\PZ\SUR FLHNRODQ Z\QLNLZWDEHOLSRGDMZDUWR FLSGOD
danego testu oraz jego skrót (M-W dla Manna-Whitneya oraz K-W dla Kruskala-Wallisa). ....................73
7DEHOD6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKEDGDQ\FKZNRODQDFK]JL
W\FK
°
w grupie
GR ZLDGF]DOQHM ..........................................................................................................................................74
Tabela 13. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
30
°
ZJUXSLHGR ZLDGF]DOQHM.....................................................................................................................76
Tabela 14.
:DUWR üSGODSRUyZQDZLHORNURWQ\FK GZXVWURQQ\FK QLHVWDELOQR FLSU]HGQLFKNRODQ
EDGDQ\FKZ]JL FLXNRODQ
°
ZJUXSLHGR ZLDGF]DOQHM...........................................................................77
Tabela 15. Wyniki testów U Manna-Whitneya (p <0,05)
SRUyZQXMF\FKQLHVWDELOQR FLSU]HGQLHNRODQ
SRPL G]\JUXSDPL$&/ LRUD]$&/ LZJUXSLHGR ZLDGF]DOQHMZ]JL FLXNRODQ
°
..77
7DEHOD2VWDWHF]QHZ\QLNLSRUyZQDQLHVWDELOQR FLSU]HGQLHNRODQSRPL G]\SRV]F]HJyOQ\PLJUXSDPL
ZJUXSLHGR ZLDGF]DOQHMZ]JL FLXNRODQ
°
Z\QLNLZWDEHOLSRGDMZDUWR FLSGODGDQHJRWHVWXRUD]
jego skrót. ...................................................................................................................................................77
7DEHOD6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKEDGDQ\FKZJUXSLHGR ZLDGF]DOQHMZ]JL
FLX
kolan 90
°
.....................................................................................................................................................78
Tabela 18. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZ]JL FLXNRODQ
90
°
ZJUXSLHGR ZLDGF]DOQHM.....................................................................................................................81
Tabela 19. Wyniki testów U Manna-Whitneya (p <0,05)
SRUyZQXMF\FKQLHVWDELOQR FLSU]HGQLHNRODQ
SRPL G]\JUXSDPL$&/ LRUD]$&/ LZJUXSLHGR ZLDGF]DOQHMZ]JL FLXNRODQ
°
..82
7DEHOD2VWDWHF]QHZ\QLNLSRUyZQDQLHVWDELOQR FLSU]HGQLHNRODQSRPL G]\SRV]F]HJyOQ\PLJUXSDPL
ZJUXSLHGR ZLDGF]DOQHMZ]JL FLXNRODQ
°
Z\QLNLZWDEHOLSRGDMZDUWR FLSGODGDQHJRWHVWXRUD]
jego skrót. ...................................................................................................................................................82
7DEHOD:\QLNLSRPLDUyZQLHVWDELOQR FLNRODQ*. .............................................................................83
7DEHOD6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKZJUXSLHGR ZLDGF]DOQHM $&/ 37 RUD]
NRQWUROQHMEDGDQ\FKZNRODQDFKZSHáQ\PZ\SUR FLH..............................................................................84
Tabela 23. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLH
GR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZSHáQ\PZ\SUR FLHNRODQ ...........................................86
7DEHOD6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKZJUXSLHGR ZLDGF]DOQHM $&/ 37 RUD]
NRQWUROQHMEDGDQ\FKZ]JL FLXNRODQ
°
...................................................................................................87
Tabela 25. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLH
GR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZ]JL FLXNRODQ
°
. ......................................................90
Tabela 26.
:DUWR üSGODSRUyZQDZLHORNURWQ\FK GZXVWURQQ\FK QLHVWDELOQR FLSU]HGQLFKNRODQ
badanych w grupie
GR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZ]JL FLXNRODQ
°
........................90
7DEHOD6WDW\VW\NDRSLVRZDQLHVWDELOQR FLSU]HGQLFKZJUXSLHGR ZLDGF]DOQHM $&/ 37 RUD]
NRQWUROQHMEDGDQ\FKZ]JL FLXNRODQ
°
...................................................................................................91
Tabela 28. Wyniki testu
.UXVNDOD:DOOLVDGODQLHVWDELOQR FLSU]HGQLFKNRODQEDGDQ\FKZJUXSLH
GR ZLDGF]DOQHM $&/ 37 RUD]NRQWUROQHMZ]JL FLXNRODQ
°
. ......................................................93
112
11.3 SPIS FOTOGRAFII
Fotografia 1. Aparat KT-1000 oraz dynamometr DPS-44. ........................................................................58
)RWRJUDILD3RPLDU\QLHVWDELOQR FLVWDZXNRODQRZHJRZZ\SUR FLH]JL
FLX
°
i 90
°
SU]\X*\FLX
aparatu KT-1000. .......................................................................................................................................59
Fotografia 3. Pobranie przeszczepu B-PT-B..............................................................................................60
)RWRJUDILD8VXQL FLHFLDáD+RII\XZLGRF]QLHQLH$&/ .........................................................................60
Fotografia 5. Opracowywanie bloczka B-PT-B. ........................................................................................61
)RWRJUDILD*RWRZ\NRPSOHNV%37%]*\áNDPLRUD] UXELQWHUIHUHQF\MQ.........................................61
)RWRJUDILD0RFRZDQLHSU]HV]F]HSXSU]\SRPRF\ UXE\LQWHUIHUHQF\MQHM NRQWURODQDSL FLDSU]\
pomocy dynamometru DPS-44. ..................................................................................................................63
Fotografia 8. B-PT-B w rotacji 0
°
oraz 180
°
. ............................................................................................63
)RWRJUDILD /RNDOL]DFMD UXE\Z]JO GHPWHJRVDPHJREORF]NDZURWDFML
°
SROHZHM± UXEDSRG
EORF]NLHPF]\OL]W\áX L
°
SRSUDZHM± UXEDQDGEORF]NLHPF]\OL]SU]RGX .......................................64
11.4 SPIS RYSUNKÓW
5\VXQHN=PLDQDGáXJR FLS F]NyZZáyNLHQNRODJHQRZ\FKRGGDORQ\FKRGVLHELHRPPZF]DVLH
G]LDáDQLDVLá\UR]FLJDMFHM.....................................................................................................................123
5\VXQHN=PLDQDGáXJR FLS F]NyZZáyNLHQNRODJHQRZ\FKRGGDORQ\FKRGVLHELHRPPZF]DVLH
G]LDáDQLDVLá\UR]FLJDMFHMLURWXMFHM....................................................................................................123
5\VXQHN=PLDQDGáXJR FLS F]NyZZáyNLHQNRODJHQRZ\FKRGGDORQ\FKRGVLHELHRPPZF]DVLH
G]LDáDQLDVLá\UR]FLJDMFHM.....................................................................................................................123
5\VXQHN=PLDQDGáXJR FLS F]NyZZáyNLHQNRODJHQRZ\FKRGGDORQ\FKRGVLHELHRPPZF]DVLH
G]LDáDQLDVLá\UR]FLJDMFHMLURWXMFHM....................................................................................................123
11.5 SPIS FORMULARZY
Formularz 1. Formularz IKDC.................................................................................................................124
113
12 3,
0,(11,&7:2
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13 ANEKS
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Formularz 1. Formularz IKDC.
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