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膝关节内侧副韧带及相关内侧结构的损伤.doc

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膝关节内侧副韧带及相关内侧结构的损伤.doc膝关节内侧副韧带及相关内侧结构的损伤.doc Injuries to the Medial Collateral Ligament and Associated Medial Structures of the Knee 膝关节内侧副韧带及相关内侧结构的损伤 Coen A. Wijdicks, PhD1, Chad J. Griffith, MD2, Steinar Johansen, MD3, Lars Engebretsen, MD, PhD3 and Robert F. LaPrade, MD, PhD4 Inv...
膝关节内侧副韧带及相关内侧结构的损伤.doc
膝关节内侧副韧带及相关内侧结构的损伤.doc Injuries to the Medial Collateral Ligament and Associated Medial Structures of the Knee 膝关节内侧副韧带及相关内侧结构的损伤 Coen A. Wijdicks, PhD1, Chad J. Griffith, MD2, Steinar Johansen, MD3, Lars Engebretsen, MD, PhD3 and Robert F. LaPrade, MD, PhD4 Investigation performed at the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota, and the Oslo University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway The superficial medial collateral ligament and other medial knee stabilizers—i.e., the deep medial collateral ligament and the posterior oblique ligament—are the most commonly injured ligamentous structures of the knee. The main structures of the medial aspect of the knee are the proximal and distal divisions of the superficial medial collateral ligament, the meniscofemoral and meniscotibial divisions of the deep medial collateral ligament, and the posterior oblique ligament. Physical examination is the initial method of choice for the diagnosis of medial knee injuries through the application of a valgus load both at full knee extension and between 20? and 30? of knee flexion. Because nonoperative treatment has a favorable outcome, there is a consensus that it should be the first step in the management of acute isolated grade-III injuries of the medial collateral ligament or such injuries combined with an anterior cruciate ligament tear. If operative treatment is required, an anatomic repair or reconstruction is recommended. 内侧副韧带浅层及其他内侧的膝关节稳定结构——即内侧副韧带深层和后斜韧带——是损伤最为 多见的膝关节韧带结构。 膝关节内侧的主要结构包括内侧副韧带浅层的上段和下段,内侧副韧带深层的板股韧带和板胫韧 带,以及后斜韧带。 在膝关节完全伸直以及屈曲20?-30?时施加外翻应力进行体格检查是诊断膝关节内侧损伤的首要 方法。 由于非手术治疗通常可获得良好的疗效,一般认为新鲜的单纯III度内侧副韧带损伤或内侧副韧带 合并前交叉韧带损伤时才考虑一期进行处理。 如必需进行手术治疗则推荐进行解剖修复或重建。 The understanding of the anatomy, biomechanics, and treatment of medial knee injuries continues to evolve. Quantitative techniques for the measurement of anatomic structures and biomechanical testing and digital radiography have improved anatomic definition of the severity of injuries. The development of new reconstruction techniques may lead to improved surgical outcomes. The superficial medial collateral ligament and other medial knee stabilizers—i.e., the deep medial collateral ligament and the posterior oblique ligament—are the most commonly injured ligamentous structures of the knee1-4. The incidence of injuries to these medial knee structures has been reported to be 0.24 per 1000 in the United States in any given year5 and to be twice as high in males (0.36 compared with 0.18 in females)5. The majority of medial knee ligament tears are isolated. These injuries occur predominantly in young individuals participating in sports activities, with the mechanism of injury involving valgus knee loading, external rotation, or a combined force vector occurring in such sports as skiing, ice hockey, and soccer, which require knee flexion6-8. 对膝关节内侧损伤的解剖、生物力学和治疗的探索仍在不断推进,采用定量的方法测定解剖结构以及 相关的生物力学试验和数字X线摄影(DR)使得损伤的严重程度从解剖角度而言更加确切,而由此 创立的新的重建方法则可能进一步改善手术结果。 内侧副韧带浅层及其他内侧的膝关节稳定结构——即内侧副韧带深层和后斜韧带——是损伤最为多 见的膝关节韧带结构1-4。据报道5,在美国每年这样的膝关节内侧结构损伤的发生率约为每1000人 0.24,而男性的发生率则是女性的两倍(0.36/0.18)。大多数膝关节内侧结构损伤均为单发,这些损 伤在参加体育运动的年轻患者中尤其多见,受伤机制主要包括膝关节外翻暴力,外旋或者在需要屈膝 的运动中,如滑雪、冰球、足球等,多个方向的应力联合作用导致损伤6-8。 Anatomy Superficial Medial Collateral Ligament The superficial medial collateral ligament, commonly called the tibial collateral ligament, is the largest structure of the medial aspect of the knee (Fig. 1, A). This structure consists of one femoral attachment and two tibial attachments9. Quantitative assessment has shown the femoral attachment to be oval and, on the average, 3.2 mm proximal and 4.8 mm posterior to the medial epicondyle. As the superficial medial collateral ligament courses distally, it has two tibial attachments. The proximal tibial attachment is primarily to soft tissue over the termination of the anterior arm of the semimembranosus tendon and is located an average of 12.2 mm distal to the tibial joint line9. The distal tibial attachment of the superficial medial collateral ligament is broad and is directly to bone at an average of 61.2 mm distal to the tibial joint line; it is located just anterior to the posteromedial crest of the tibia9. The two distinct tibial attachments have been reported to result in two distinct functioning divisions of the superficial medial collateral ligament10. 解剖 内侧副韧带浅层 内侧副韧带浅层,通常称为胫侧副韧带,是膝关节内侧最大的结构(图1-A)。该结构在股骨有一个附 着点,在胫骨有两个附着点9,定量研究显示股骨附着点为卵圆形,平均距离内上髁上方3.2mm后方 4.8mm。内侧副韧带浅层向远端延伸,在胫骨有两个止点,近端止点主要以一层软组织覆盖半膜肌腱 前头的止点,位于胫骨关节线下方平均12.2mm处9;远端止点较宽,直接附于骨上,距胫骨关节线 远端平均61.2mm,恰位于胫骨后内侧嵴稍前方9。有研究表明内侧副韧带浅层胫骨上两个独立的附着 点使其成为了两个不同的功能组分10。 Fig. 1 A: Posteromedial view of the right knee, demonstrating the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL). B: Medial view of the left knee, showing the meniscofemoral and meniscotibial divisions of the deep medial collateral ligament. (Reprinted from: LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am. 2007;89:2000-10.) 图1 A为右膝后内侧面观,显示内侧副韧带浅层(sMCL)和后斜韧带(POL)。B为左膝内侧面观,显示 内侧副韧带深层的板股韧带和板胫韧带。(重印自:LaPrade RF, Engebretsen AH, Ly TV, Johansen S, Wentorf FA, Engebretsen L. The anatomy of the medial part of the knee. J Bone Joint Surg Am. 2007;89:2000-10.) Posterior Oblique Ligament The posterior oblique ligament is a fibrous extension off the distal aspect of the semimembranosus that blends with and reinforces the posteromedial aspect of the joint capsule (Fig. 1, A). It consists of three fascial attachments at the knee joint, with the most important portion being the central arm9,10. On the average, the central arm of the posterior oblique ligament attaches on the femur 7.7 mm distal and 2.9 mm anterior to the gastrocnemius tubercle9. In some of the earlier descriptions of medial knee anatomy, the superficial medial collateral ligament and the posterior oblique ligament were identified as one confluent structure. Brantigan and Voshell reported an oblique portion of the superficial medial collateral ligament, which is now recognized as the posterior oblique ligament11,12. Slocum and Larson reported that the posterosuperior and posteroinferior fibers that coursed off the posterior aspect of the superficial medial collateral ligament formed a triangular membrane, which coursed over the posteromedial aspect of the capsule, reinforcing the posterior aspect of the capsule, and also attached to the tibia13. While they did not identify it as such, their description fits closely with the description of the central arm of the posterior oblique ligament9. More recent authors have noted that the superficial medial collateral ligament and the posterior oblique ligament are separate structures, although there has been a wide variation in the descriptions of the femoral attachment site of the posterior oblique ligament14-16. It is important to recognize that the femoral attachment of the posterior oblique ligament extends outside of the zone described by some authors as the oblique portion of the superficial medial collateral ligament11-13,17,18. Until recently, when it was reported that there are three osseous prominences along the medial aspect of the knee, descriptions of the femoral attachment of the posterior oblique ligament were inconsistent. However, with the recognition that the femoral attachment of the posterior oblique ligament is located closer to the gastrocnemius tubercle than to the adductor tubercle, much of the above ambiguity has been elucidated9. 后斜韧带 后斜韧带是半膜肌腱远端纤维的延伸,参与组成并加强后内侧关节囊(图1-A),由附于膝关节的三组 筋膜组成,其中以中央臂最为重要9,10。后斜韧带中央臂在股骨上的附着点平均位于腓肠肌结节远端 7.7mm前方2.9mm9。膝关节内侧解剖较早的研究认为内侧副韧带浅层与后斜韧带属于同一结构的不 同组成部分。Brantigan和Voshell所报道的内侧副韧带浅层斜部,实际上就是目前所称的后斜韧带 11,12。Slocum和Larson的研究认为后上纤维和后下纤维自内侧副韧带浅层后缘向后延伸形成三角 形筋膜,覆盖关节囊后内侧面并加强后方关节囊,最终也止于胫骨13。而他们却没有认识到,按照这 样的描述其实和后斜韧带中央臂的性状是非常符合的9。 近来学者们注意到内侧副韧带浅层和后斜韧带是各自独立的结构,虽然对于后斜韧带股骨附着点的描 述仍存在很大差异14-16。后斜韧带股骨附着点的范围实际上超出了部分学者描述的内侧副韧带浅层 斜部的附着区域11-13,17,18,认识到这一点是很重要的。直到最近,有研究发现在膝关节内侧面存 在三个骨性突起,且后斜韧带股骨附着点的描述也并不统一。然而,认识清楚后斜韧带股骨附着点的 位置,相比内收肌结节,其实更接近腓肠肌结节,这也很好地解释了以上的种种混淆9。 Deep Medial Collateral Ligament The deep medial collateral ligament comprises the thickened medial aspect of the joint capsule that is deep to the superficial medial collateral ligament. It is divided into meniscofemoral and meniscotibial components (Fig. 1, . The meniscofemoral portion has a slightly curved convex attachment 12.6 mm distal and deep to the femoral attachment of the superficial medial collateral ligament. The meniscotibial portion, which is much shorter and thicker than the meniscofemoral portion, attaches just distal to the edge of the articular cartilage of the medial tibial plateau, 3.2 mm distal to the medial joint line, and 9.0 mm proximal to the proximal tibial attachment of the superficial medial collateral ligament9. Other authors have also reported that the meniscofemoral portion attaches deep to the superficial medial collateral ligament and the meniscotibial portion attaches just distal to the tibial articular surface13,19. 内侧副韧带深层 内侧副韧带深层主要由关节囊内侧部分增厚而形成,位于内侧副韧带浅层的深面,可分为板股韧带和 板胫韧带两部分(图1-B)。板股部分的附着点稍呈弧形凸起,在内侧副韧带浅层深面,位于其股骨附 着点以远12.6mm。板胫部分较板股部分更短更厚,止于胫骨内侧平台关节软骨缘稍远处,约位于内 侧关节线下方3.2mm,距内侧副韧带浅层近侧胫骨止点上方9.0mm9。另外有学者也曾报道板股部分 的附着点位于内侧副韧带浅层的深面,而板胫部分则在胫骨关节面的稍下方13,19。 Classification The grading of medial knee ligament injuries on physical examination relies on both the patient's ability to relax and the clinician's ability to detect an end point during the application of a valgus load at between 20? and 30? of knee flexion. When the patient has pain leading to guarding and the clinician does not wish to cause more pain, a valgus stress test or valgus stress radiograph may result in an underestimation of the amount of medial knee laxity. The uninjured contralateral side is used as a baseline for comparison. A widely utilized scale for grading medial knee injuries was established by the American Medical Association Standard Nomenclature of Athletic Injuries (Fig. 2, Table I)20. With this system, an isolated grade-I, first-degree tear presents with localized tenderness and no laxity. An isolated grade-II, second-degree tear presents with localized tenderness and partially torn medial collateral and posterior oblique fibers. The fibers are still opposed, and there may or may not be pathologic laxity. Isolated grade-III, third-degree tears present with complete disruption and laxity with an applied valgus stress. Isolated medial knee injuries have also been classified in accordance with the amount of laxity observed at 30? of knee flexion with a valgus applied moment. Grades 1+, 2+, and 3+ correspond to subjective gapping of the medial joint line of 3 to 5 mm, 6 to 10 mm, and >10 mm, respectively, when compared with the uninjured, contralateral side3,21-24. Clinicians can utilize this system to define the initial grade of injury, to plan treatment (nonoperative or operative), and to determine evidence of healing with nonoperative treatment. 分型 通过体格检查来了解膝关节内侧韧带损伤的程度,主要依赖于两个方面:患者放松的程度以及医生在 患膝屈曲20?至30?时加载外翻负荷后检出其终点(end point)的能力。如果患者由于疼痛而进行保护 或者医生不愿给患者造成更严重的疼痛,外翻应力试验或外翻应力位X线摄影则可能会低估膝关节内 侧的松弛程度。检查过程中可以对侧为基准进行对比。 膝关节内侧损伤有一个被广泛应用的等级评价方法,参照美国医学会《运动损伤命名法》而制定 (图2,表1)20。按照该评价系统,单纯I度:少量纤维撕裂,伴有局限性压痛无松弛;单纯II度: 局限性压痛,内侧副韧带纤维及后斜纤维部分撕裂。纤维仍然存在一定的张力,伴或不伴有病理性的 松弛;单纯III度:表现为外翻应力下可见完全断裂及松弛。单纯膝关节内侧损伤也可以按照施加外 翻应力时松弛的程度进行分级。等级分为1+、2+和3+,相当于对内侧关节间隙进行主观评价,并与 未受伤的对侧相比较,分别增宽3-5mm、6-10mm及10mm以上3,21-24。临床医生可以参照这一评 价系统确定其最初的损伤等级,制定治疗(手术或非手术),并可作为非手术治疗愈合与否的验 证手段。 Fig. 2 Anteromedial view of the left knee, showing the injury grading scale established by the American Medical Association Standard Nomenclature of Athletic Injuries20. Isolated grade-I injuries present with localized tenderness and no laxity. Isolated grade-II injuries present with a broader area of tenderness and partially torn medial collateral and posterior oblique fibers. Isolated grade-III injuries present with complete disruption, and there is laxity with an applied valgus stress. 图2 左膝前内侧面观,所示为参照美国医学会《运动损伤命名法标准》制定的损伤等级评价标准20。单 纯I度损伤表现为局限性压痛无松弛;单纯II度损伤表现为范围更大的压痛,内侧副韧带纤维及后斜 纤维部分撕裂;单纯III度损伤表现为完全断裂,在外翻应力下可见松弛。 Healing The superficial medial collateral ligament has been reported to have an abundant vascular supply. Healing of this ligament follows the classic model of healing involving hemorrhage, inflammation, repair, and remodeling25. Studies of the variables involved in the healing of the superficial medial collateral ligament in animals have shown that the healing is location dependent. In one study of a rabbit superficial medial collateral ligament injury model, the ligament took longer to heal when it was injured near either attachment site than when it had a midsubstance injury26. The biological effects of immobilization have also been widely studied in superficial medial collateral ligament injury models. In a rabbit model, a reduction of collagen mass and increased collagen degradation were observed after twelve weeks of immobilization27. These negative effects of immobilization were noted to be caused by collagen matrix reorganization and catabolic behavior within the medial collateral ligament after injury28,29. In another study, dogs that had undergone surgical transection of the superficial medial collateral ligament were divided into three treatment groups: early motion, immobilization for three weeks, and immobilization for six weeks30. The authors concluded that early motion protocols lead to enhanced healing and improved biomechanical properties of the superficial medial collateral ligament. This information was subsequently used to promote and reinforce similar nonoperative rehabilitation protocols for these injuries in humans. 愈合 据研究报道,内侧副韧带浅层血供丰富,其愈合通常遵循经典的愈合模式:出血、炎症、修复和重建 25。但也有与之不同的报道,动物实验显示内侧副韧带浅层的愈合与损伤的位置密切相关。有学者研 究了兔子内侧副韧带浅层的损伤模型,发现与韧带中部损伤相比,两个附着点附近的损伤愈合时间更 长26。 在内侧副韧带浅层损伤的模型中制动的生物学作用也是一个被广泛研究的内容。在一个兔子模型中, 制动12周以后观察到胶原的含量减少,胶原的退变明显增加27。人们注意到制动带来的不良影响主要 是由于内侧副韧带损伤后内部胶原基质的重组和分解代谢28,29。在另一项研究中,狗的内侧副韧带 浅层经手术横行切断,然后分成3个处理组:早期活动、制动3周和制动6周30。作者的结论认为早期 活动可促进内侧副韧带浅层损伤的愈合,改善其生物力学性能。这一结论后来也常常被引用,作为类 似的非手术康复计划在人类相关损伤中应用的理论依据。 Clinically Relevant Biomechanics A complete understanding of medial knee biomechanics is valuable for the assessment of which injured structures should be repaired or reconstructed. An understanding of the degree of abnormal joint motion that occurs when a structure is injured greatly assists with the interpretation of the results of the clinical examination and helps to determine the presence of concurrent ligament injury. With the trend toward more anatomic reconstruction, it is important to understand the function of, and the differences between, the individual components of these main medial knee-stabilizing structures. Biomechanical studies have shown that the superficial medial collateral ligament is the primary restraint to valgus laxity of the knee1,31-34. One study, in which buckle transducers were used, quantitatively demonstrated differences between the two divisions of the superficial medial collateral ligament in terms of their responses to applied loads10. The implications of these observations are that, although the superficial medial collateral ligament has previously been biomechanically tested and operatively reconstructed under the assumption that it is one continuous structure1,33,35-40, the two divisions of the ligament actually function as conjoined but distinct structures. Thus, the biomechanical study10 suggests that the aim of an operative repair or reconstruction of the superficial medial collateral ligament should be to restore the distinct functions of both divisions by reattaching the two tibial attachments in an attempt to reproduce the overall function of the superficial medial collateral ligament construct. 临床生物力学 深入了解膝关节内侧结构的生物力学性能对于明确哪些结构损伤必须进行修复或重建意义重大。认识 清楚某一结构损伤后导致关节异常活动的程度,对于解释临床查体的结果以及确定是否存在合并的韧 带损伤都是很有帮助的。随着越来越提倡解剖重建,理解膝关节内侧稳定结构各个组分的功能及其相 互之间的差异则显得尤为重要。生物力学研究显示内侧副韧带浅层主要起到限制膝关节过度外翻的作 用1,31-34。其中有一项研究,应用环扣传感器进行了定量,结果显示了内侧副韧带浅层在加载 负荷后两个部分之间的反应不同10。这一研究提示,尽管以前的生物力学试验和手术重建都将内侧副 韧带浅层当作一个连续的结构来处理1,33,35-40,而事实上该韧带的两个组分虽然协同作用但却是两 个相互独立的结构。因此,有生物力学研究10主张在对内侧副韧带浅层进行手术修复或重建时,应以 恢复其两个组分不同的功能为目的,分别重建两个胫骨附着点以求还原内侧副韧带浅层的所有功能。 The posterior oblique ligament reinforces the posteromedial aspect of the capsule, which courses off the distal aspect of the semimembranosus tendon2,9,14. From a biomechanical perspective, the posterior oblique ligament functions as an internal rotator and valgus stabilizer at between 0? and 30? of knee flexion1,2,10,35,37,38,41,42. It has also been reported that, with applied internal rotation torques at 0? of knee flexion, the loads on the posterior oblique ligament are significantly higher than those on either division of the superficial medial collateral ligament10. In addition, it has been reported that there is a reciprocal load response to internal rotation torque between the posterior oblique ligament and the superficial medial collateral ligament as the degree of knee flexion increases, with a higher load response in the superficial medial collateral ligament at 90? of knee flexion. This observation demonstrates that there is a complementary relationship between the posterior oblique ligament and the superficial medial collateral ligament with regard to the resistance of internal rotation torques that depends on the knee flexion angle. A subsequent study of load distribution with buckle transducers showed that sectioning of the components of both the deep medial collateral ligament and the superficial medial collateral ligament resulted in significant increases, compared with the intact state, in the forces experienced by the posterior oblique ligament under valgus loads at 0?, 20?, and 30? of knee flexion42. This observation correlates both with previous reports that the posterior oblique ligament in intact knees experiences tensile load with valgus forces, especially close to knee extension10,42, and that the posterior oblique ligament has a secondary role in providing valgus stability of the knee35,43,44. 后斜韧带远离半膜肌腱远端走行,加强后内侧关节囊2,9,14。从生物力学角度而言,在膝关节屈曲0? 至30?时后斜韧带主要起到内旋和外翻稳定作用1,2,10,35,37,38,41,42。也有报道在膝关节屈曲0?并加 载内旋扭矩时,后斜韧带承受的负荷要明显高于内侧副韧带浅层的任一部分10。此外,还有研究指出, 加载内旋扭矩时,随着膝关节屈曲的度数增加,后斜韧带与内侧副韧带浅层的负荷变化趋势相反,屈 膝90?时内侧副韧带浅层的负荷反应较高。这一观测显示根据膝关节屈曲的角度不同,后斜韧带与内 侧副韧带浅层对内旋扭矩的抵抗存在互补关系。随后的研究应用环扣传感器对负荷的分配进行了探 讨,结果显示膝关节屈曲0? 、20?及30?时,切断内侧副韧带深层和浅层都可观测到后斜韧带承载的 负荷明显增加42。这一观测结果与上文提到的两方面的研究都是密切相关的,在完整的膝关节中加载 外翻应力时后斜韧带承载张力负荷,膝关节接近于伸直时尤其明显10,42;后斜韧带对膝关节的外翻 稳定有辅助作用35,43,44。 Compared with the number of studies on the function of the superficial medial collateral ligament, there are fewer reports on the isolated function of the deep medial collateral ligament. The authors of previous sequential sectioning studies done to evaluate the function of the deep medial collateral ligament described it as a secondary restraint to valgus loads41-43. More specifically, they found that valgus stabilization was provided by the meniscofemoral portion of the deep medial collateral ligament at all tested flexion angles and by the meniscotibial portion of the deep medial collateral ligament at 60? of knee flexion. The deep medial collateral ligament was also reported to provide restraint against external rotation torque in knees flexed between 30? and 90?41,43. 有关内侧副韧带浅层功能的研究很多,与之相比,单纯研究内侧副韧带深层相关功能的报道则相对较 少。上文提到的顺序切断的研究对内侧副韧带深层的功能进行了评估,作者将其描述为一个对抗外翻 负荷的辅助结构41-43。更确切地说,他们发现外翻稳定性的维持在膝关节的各个屈曲角度,内侧副 韧带深层的板股韧带更为重要,而屈膝60?时内侧副韧带深层的板胫韧带则发挥主要作用。另外也有 研究表明膝关节屈曲30?至90?时内侧副韧带深层也可对抗外旋扭矩41,43。 These results demonstrate that injuries to the individual components of the medial aspect of the knee alter the intricate load-sharing relationships that exist among all of the medial knee structures and, if left untreated, could potentially increase the risk of further injury42,45. Therefore, on the basis of the synthesis of information from the literature and our personal perspective, we believe that, in cases in which an operative repair or reconstruction is indicated, consideration should be given to repairing or reconstructing all injured medial knee structures to restore the normal load-sharing relationships among those structures at the time of operative treatment. An anatomic medial knee reconstruction technique (Fig. 3)46, based on previous quantitative anatomic9 and biomechanical studies10,42, was developed in an attempt to restore normal stability to a knee following complete sectioning of the superficial medial collateral ligament and posterior oblique ligament. It was reported that this reconstruction restored nearly normal stability to the knee and that, following an applied load, the reconstructed ligaments did not have a greater force response than intact ligaments at any point during testing46. This suggests that overconstraint of the knee and overloading of the reconstruction grafts, which could lead to graft failure, was prevented by the use of this technique. 这些研究结果提示,膝关节内侧单一结构的损伤,可改变膝关节内侧所有相关结构之间存在的负荷分 担关系,如果不进行妥善处理的话,可能会增加进一步损伤的风险42,45。因此,综合文献中的信息 及我们个人的观点,我们认为,对于具备手术修复或重建指征的病例,进行手术治疗时应考虑修复或 重建所有受损的膝关节内侧结构,以恢复这些结构相互间正常的负荷分担关系。 以上述定量解剖和生物力学研究为基础创立的膝关节内侧解剖重建方法(图3)46,通过完全切开暴 露内侧副韧带浅层和后斜韧带,以期恢复膝关节正常的稳定性。有研究认为该重建方法可恢复几近于 正常的膝关节稳定性,此外,在试验过程中加载负荷后,重建的韧带任一点上的应力反应都不大于正 常完整的韧带46。这表明通过应用这一方法可防止出现膝关节过紧,并可避免重建的移植物承受过大 的负荷,而这些都是导致移植物失效的常见原因。 Fig. 3 Illustration of a medial knee reconstruction procedure (medial view of a left knee). The superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) are reconstructed with use of two separate grafts and four reconstruction tunnels. Note that the proximal tibial attachment of the superficial medial collateral ligament, which is primarily to soft tissues and is located just distal to the joint line, was recreated by suturing the superficial medial collateral ligament graft to the anterior arm of the semimembranosus muscle. (Reproduced, with permission, from: Coobs BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S, Engebretsen L, LaPrade RF. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med. 2010;38:339-47.) 图3 图示为膝关节内侧重建方法(左膝内侧面观)。内侧副韧带浅层(sMCL)和后斜韧带(POL)分别应 用两条移植腱经4个骨隧道进行重建。注意内侧副韧带浅层的近侧胫骨附着点主要通过软组织附于关 节线稍下方,术中可将内侧副韧带浅层的移植物缝合到半膜肌的前头进行重建。(经惠允引自:Coobs BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S, Engebretsen L, LaPrade RF. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med. 2010;38:339-47.) Diagnosis History Patients often describe a mechanism of injury involving a contact or noncontact valgus force to the knee. They also report pain and swelling along the medial aspect of the knee. When asked to explain the type of instability that they feel with activities, individuals with medial knee injuries involving the superficial medial collateral ligament, posterior oblique ligament, and deep medial collateral ligament often described a side-to-side feeling of instability, especially when they were athletes who performed cutting and pivoting maneuvers. 诊断 病史 患者自述的受伤机制通常包括膝关节接触性或非接触性的外翻暴力,主诉通常为膝关节内侧面的疼痛 和肿胀。而为了判断不稳的类型而进一步询问其活动时的感受时,膝关节内侧结构损伤的患者,包括 内侧副韧带浅层、后斜韧带、内侧副韧带深层,一般都会诉边对边动作(side to side)时有不稳的感 觉,尤其患者是运动员,做斜切及扭转动作时则更为明显。 Clinical Evaluation Physical examination of the knee remains the most suitable tool for obtaining a diagnosis of injury to its medial structures. Beginning with visual inspection, clinicians may observe localized swelling or ecchymosis over the femoral or tibial attachment of the superficial medial collateral ligament9. These areas can be palpated to help to identify tenderness of the superficial medial collateral ligament. It is important to understand the anatomy of the medial side of the knee to appropriately palpate and assess the structures involved9. A valgus load applied at 20? to 30? of knee flexion is used to detect medial joint opening (Fig. 4, A). Applying the valgus stress at both 0? and 30? of knee flexion can further assist in the diagnosis of the injury pattern because when a knee has increased medial joint space opening at 30? of flexion but not at 0? the posterior oblique ligament is most likely still intact. An additional assessment performed at this time of valgus moment application is evaluation of the integrity of the so-called end point. If the medial knee structures are completely ruptured, there will be no definitive end point and the anterior cruciate ligament may be providing a secondary restraint to the valgus stress41. It is therefore important to verify this observation with the Lachman47, anterior drawer, and pivot shift tests and assess the integrity of the anterior cruciate ligament in association with medial knee injury. 临床评估 膝关节的体格检查仍然是诊断相关内侧结构损伤最为合适的手段。首先进行视诊,医生可以观察局部 肿胀,以及内侧副韧带浅层股骨或胫骨附着点周围的皮下瘀斑等情况9。对这些区域进行触诊,明确 内侧副韧带浅层是否存在压痛。深入了解膝关节内侧的解剖对于准确地触诊和评估受累的结构都是非 常重要的9。 膝关节屈曲20?至 30?,加载外翻负荷以检查膝关节内侧间隙的宽度(图4-A)。在膝关节屈曲0?和30? 时施加外翻应力可作为进一步诊断损伤类型的辅助手段,因为膝关节屈曲30?时内侧关节间隙增宽而 屈曲0?时无明显增宽则意味着后斜韧带很有可能仍保持完整。此时,加载外翻力矩后还须要评估其是 否具有明显的终点。如果膝关节内侧结构完全断裂,则可能没有明确的终点,此时前交叉韧带可能对 外翻应力提供一定的对抗作用41。因此,通过Lachman试验、前抽屉试验、轴移试验等对这一检查 进行验证,并检查膝关节内侧损伤是否合并有前交叉韧带损伤也是十分重要的。 Fig. 4 A: A valgus load is applied at 20? to 30? of knee flexion to detect medial joint opening. The patient's thigh is allowed to rest on the examination table in order to relax the thigh muscles. While the valgus force is being applied through the foot and ankle, the examiner palpates the medial joint area to determine the amount of medial joint line gapping. B: Complete injury to the medial structures increases external rotation at both 30? and 90? of knee flexion, resulting in a positive dial test41,48. As demonstrated, the patient's lower limb is placed in 90? of knee flexion and the amount of external rotation is compared with that of the normal, contralateral knee. 图4 A:屈膝20?至30?施加外翻应力检查膝关节内侧间隙的宽度。患者的大腿置于检查床上以放松大腿的 肌肉。通过足踝部对膝关节施加外翻应力,然后进行触诊检查膝关节内侧间隙的宽度,以确定关节间 隙是否存在增宽。B:内侧结构完全损伤在膝关节屈曲30?和90?时都可使外旋异常增加,导致胫骨外 旋试验(dial test)阳性41,48。如图所示,患者的下肢置于90?屈膝位,并与对侧正常的膝关节比对 其外旋的程度。 Palpation of the femur-based and tibia-based portions of the medial knee structures can often delineate the location of the ligament injury. The anteromedial drawer test, performed by flexing the knee approximately 90? while externally rotating the foot 10? to 15? and applying an anteromedial rotational force to the knee, should also be done to determine if there is a concurrent injury to the posterior oblique ligament and/or the posteromedial aspect of the capsule. It has also been reported that a complete injury to the medial structures will cause increased external rotation at both 30? and 90? of knee flexion, resulting in a positive dial test41,48 (Fig. 4, . Therefore, careful correlation with the results of valgus stress testing and assessment of the location of tibial subluxation during the dial test are necessary to exclude the possibility of a posterolateral, rather than a medial, knee injury. 触诊膝关节内侧结构的股骨段和胫骨段通常可大致确定韧带损伤的位置。前内侧抽屉试验,屈膝约90? 并使足外旋10?至15?,然后对膝关节施加前内侧的推拉应力,这可以用来检查是否合并有后斜韧带和 /或后内侧关节囊的损伤。另外还有报道认为内侧结构完全损伤在膝关节屈曲30?和90?时都可出现过 度外旋,导致胫骨外旋试验(dial test)阳性41,48(图4-。因此,仔细比对外翻应力试验的结果, 在进行胫骨外旋试验时认真评估胫骨不稳的位置,对于辨别膝关节内侧损伤,排除可能存在的后外侧 损伤都是非常必要的。 Radiographic Evaluation It has been reported that the location of anatomic landmarks of the major medial knee structures and related osseous anatomy can be predicted accurately in a highly reproducible manner by multiple observers evaluating radiographs49. Correlating radiographic findings with known anatomic attachment sites of the primary structures of interest before a medial knee reconstruction allows improved preoperative planning and facilitates intraoperative and postoperative assessment of reconstructions or repairs (Fig. 5). 影像评估 有研究曾报道,经多位观察者对相关影像学资料的判读,可准确判断膝关节内侧结构的解剖标志及相 关骨性解剖的位置,可重复性良好49。在进行膝关节内侧结构重建前,了解相关重要结构附着点的解 剖部位,比对影像学表现,有利于制定切实可行的术前计划,并且也有助于术中和术后对重建或修复 进行确切的评价(图5)。 Fig. 5 Illustrations (A) and lateral knee radiographs (demonstrating the placement of the reference lines for correlating radiographs with the known anatomic attachment sites of the primary structures of interest in a medial knee reconstruction. MPFL = medial patellofemoral ligament attachment, POL = posterior oblique ligament attachment, sMCL = superficial medial collateral ligament attachment, DASM = direct arm of semimembranosus muscle attachment, quadrant 1 = anteroproximal, quadrant 2 = posteroproximal, quadrant 3 = anterodistal, and quadrant 4 = posterodistal. (Reprinted from: Wijdicks CA, Griffith CJ, LaPrade RF, Johansen S, Sunderland A, Arendt EA, Engebretsen L. Radiographic identification of the primary medial knee structures. J Bone Joint Surg Am. 2009;91:521-9.) 图5 示意图(A)和膝关节侧位片(B)显示基线的位置,将X线片与膝关节内侧重建时相关重要结构附 着点的解剖位置进行比对。MPFL:内侧髌股韧带附着点;POL:后斜韧带;sMCL:内侧副韧带浅层; DASM:半膜肌腱直头附着点;第1象限:前上;第2象限:后上;第3象限:前下;第4象限:后下。 (重印自:Wijdicks CA, Griffith CJ, LaPrade RF, Johansen S, Sunderland A, Arendt EA, Engebretsen L. Radiographic identification of the primary medial knee structures. J Bone Joint Surg Am. 2009;91:521-9.) Valgus stress radiographs can also be useful for quantitative grading of medial knee injuries and to verify the location of medial compartment gapping (Fig. 6). In one study, a load applied by a clinician to a knee with a simulated isolated grade-III superficial medial collateral ligament injury increased medial joint gapping, compared with that in the intact knee, by 1.7 and 3.2 mm at 0? and 20? of flexion, respectively50. A complete medial knee injury with sectioning of the superficial and deep medial collateral ligaments and the posterior oblique ligament increased gapping by 6.5 and 9.8 mm at 0? and 20?, respectively, under the clinician-applied load50. 外翻应力位X线片对于定量分析膝关节内侧损伤的程度以及明确内侧间隙增宽的位置都是很有用处 的(图6)。在一项研究中,临床医生对模拟的单纯III度内侧副韧带浅层损伤的膝关节加载负荷,使 内侧关节间隙开大,结果发现屈膝0? 和20?时关节间隙比正常完整的膝关节分别增宽1.7和3.2 mm50。而切断内侧副韧带浅层和深层以及后斜韧带,造成膝关节内侧完全损伤后,在医生施加的负 荷下,屈膝0? 和20?时关节间隙分别增宽6.5和9.8 mm50。 Fig. 6 Valgus stress radiographs demonstrating a grade-III injury of the left knee to the superficial medial collateral ligament and posterior oblique ligament. When a clinician applied a load at 20? of knee flexion, medial compartment gapping increased by 7.3 mm compared with that in the normal, right knee. 图6 外翻应力位X线片显示左膝内侧副韧带浅层和后斜韧带III度损伤。当临床医生在屈膝20?施加应力时, 与正常的右膝相比,内侧关节间隙增宽了7.3mm。 Magnetic resonance imaging is commonly used to assess the involved structures in patients with injuries to the medial side of the knee (Fig. 7). In a study of sixty-three patients who were clinically evaluated for a medial collateral ligament injury by an orthopaedic surgeon and then with a 1.5-T magnetic resonance imaging system by an experienced musculoskeletal radiologist who had no knowledge of the clinical findings, the imaging was found to have an accuracy of 87% for the assessment of medial collateral ligament injuries51. There have been few studies of the classification of deep medial collateral injury and/or involvement of the posterior oblique ligament. In a prospective study, Miller et al. classified trabecular microfractures and bone bruises in sixty-five patients with an isolated injury of the medial collateral ligament52. Of these patients, twenty-nine (45%) had associated bone bruises, which were predominantly located on the lateral tibial plateau (six patients) or lateral femoral condyle (ten patients), or both (eight patients). The lesions completely resolved in all cases, over the span of two to four months after the injury52. MRI通常用于评价膝关节内侧损伤的患者相关结构的受累范围(图7)。在一项包括63例患者的研究中, 由一位外科医生对内侧副韧带损伤进行临床评价后,再由一位经验丰富的骨骼肌肉系统放射科医生应 用1.5T MRI系统进行评估,对该放射科医生隐瞒相关的临床表现,最终的结果表明,通过影像学发 现评估内侧副韧带损伤的准确率为87%51。目前对于内侧副韧带深层伴和/或不伴后斜韧带损伤的研 究很少。在Miller等52的前瞻性研究中,将单纯内侧副韧带损伤的患者分为骨小梁微骨折和骨挫伤两 类。在这些患者中,29例(45%)合并有骨挫伤,主要位于外侧胫骨平台(6例)或股骨外侧髁(10 例),或两处均有(8例)。伤后2至4月,所有病例的损伤均完全缓解。 Fig. 7 Proton-density-weighted magnetic resonance image showing an acute avulsion of the superficial medial collateral ligament and the meniscotibial division of the deep medial collateral ligament off their tibial attachments. A trabecular microfracture of the lateral epicondyle, most likely caused by an impaction force, can be seen. The arrowhead indicates the distal attachment of the superficial medial collateral ligament, which has been avulsed from its tibial attachment. 图7 质子密度加权MRI显示内侧副韧带浅层和内侧副韧带深层的板胫韧带自其胫骨附着点上撕脱,为新 鲜损伤。股骨外上髁可见骨小梁微骨折,这很可能是由压缩暴力所致。箭头所指为内侧副韧带浅层的 远端止点,已从胫骨附着点上撕脱。 Results of Clinical Series Nonoperative Treatment Despite the fact that the medial structures are the most frequently injured knee ligaments, controversy remains concerning their treatment. Historically, treatment of acute medial collateral ligament injuries has focused on nonoperative therapies with early controlled motion and protected weight-bearing, and fairly good patient outcomes have been reported53-59. Overall, there is a consensus that nonoperative management should be the first step in the treatment of acute isolated grade-I or II injuries because of a typically acceptable clinical outcome54,57,60-62. Several rehabilitation protocols are available, and each has had successful results59,61,63-66. It should be noted that these treatment protocols vary according to the clinician providing them, and, to our knowledge, there has not yet been a study prospectively comparing different rehabilitation treatments for a specific grade of medial knee injury (see Appendix). It is therefore difficult to compare studies; yet, there is much overlap in the exercises and the time frames utilized. 临床疗效 非手术治疗 尽管内侧结构的损伤在膝关节韧带中最为常见,而关于其治疗则仍然存在不少争议。以往治疗新鲜的 内侧副韧带损伤通常都采用保守疗法,早期制动并在保护下负重,据报道患者最终的疗效良好53-59。 总的说来,比较一致的观点是,对于新鲜的单纯I度或II度损伤都可首先进行非手术治疗,因为通常 都可获得较好的临床结果54,57,60-62。另外有几个康复也是可取的,各自都获得了满意的疗效 59,61,63-66。值得注意的是,临床医生在处理患者时用到的这些治疗方案各不相同,据我们所知, 目前还没有一项研究针对特定程度的膝关节内侧损伤,前瞻性地比较不同的康复治疗方法(见附录)。 因此很难对这些研究进行对比,然而,其所应用的功能锻炼及时限则有很大部分是类似的。 Acute grade-III medial knee injuries are usually treated with a nonoperative protocol that includes a functional rehabilitation program. The initial nonoperative treatment includes control of pain and swelling and possibly the use of a hinged knee brace for six weeks to protect against valgus stress and external rotation67,68. A protocol including immediate knee range-of-motion exercises, early weight-bearing, and progressive strength training has been reported to produce excellent results and a high rate of return to the prior activity level69. It is also important to note that the success of nonoperative treatment of complete tears of the medial knee structures relies on an intact anterior cruciate ligament70. 新鲜的III度膝关节内侧损伤常用非手术治疗方案进行处理,其中包括一个完整的功能康复计划。早 期的非手术治疗主要指控制疼痛和肿胀,还可能包括应用膝关节铰链式支具6周,以避免其承受外翻 应力和外旋67,68。康复的方案包括即刻膝关节活动范围的练习,早期负重,以及渐进性的力量训练, 据报道可获得优秀的治疗结果,恢复到伤前运动水平的比率很高69。另外还有一点值得引起重视,对 于膝关节内侧结构完全断裂的病例,非手术治疗取得成功有赖于前交叉韧带的完整性70。 Operative Treatment A high frequency of combined superficial medial collateral ligament and posterior oblique ligament injuries has been reported in knees with severe acute or chronic valgus instability, signifying the important role of the posterior oblique ligament in providing static stabilization to the medial side of the knee2,14. Operative techniques for these combined injuries include direct repair of the superficial medial collateral ligament and posterior oblique ligament14, primary repair with augmentation71, advancement of the tibial insertion site of the superficial medial collateral ligament72, pes anserinus transfer13, advancement of the superficial medial collateral ligament with pes anserinus transfer73, and reconstruction techniques that have not been validated biomechanically40. 手术治疗 有研究表明,在新鲜的和陈旧性膝关节外翻不稳中,内侧副韧带浅层和后斜韧带合并损伤的发生率很 高,这也提示后斜韧带对于维持膝关节内侧的静态稳定发挥了重要的作用2,14。处理这种合并损伤的 手术方法包括对内侧副韧带浅层和后斜韧带的直接修复14、一期修复并增强71、内侧副韧带浅层胫骨 止点前移72、鹅足移位13、内侧副韧带浅层止点前移伴鹅足移位73,以及重建术等,后者目前尚缺 乏生物力学研究的支持40。 Our preferred technique for the treatment of complete medial knee injuries that involve the superficial medial collateral ligament, posterior oblique ligament, and deep medial collateral ligament is an anatomic reconstruction of the superficial medial collateral and posterior oblique ligaments (Figs. 3 and 8). The technique consists of a reconstruction of the two main structures of the medial side of the knee with use of two separate grafts with four reconstruction tunnels46. A single anteromedial incision or three small knee incisions are performed to access the anatomic femoral and tibial attachment points of the superficial medial collateral ligament and the posterior oblique ligament46. The superficial medial collateral ligament is tightened at 30? of knee flexion because biomechanical studies have demonstrated that sectioning of the medial structures at this flexion angle results in the greatest change in valgus laxity1,10,42,43. The posterior oblique ligament is tightened at 0? of knee flexion on the basis of previous biomechanical studies that demonstrated that this ligament has the greatest role in primary restraint of internal rotation at 0? of knee flexion10,42. 对于伤及内侧副韧带浅层、后斜韧带以及内侧副韧带深层的膝关节内侧完全损伤,我们更倾向于解剖 重建内侧副韧带浅层和后斜韧带(图3和8)。该方法应用两条移植物通过四个骨隧道分别重建膝关节 内侧的两个主要结构46。通过一个前内侧切口或三个小的膝关节切口显露内侧副韧带浅层和后斜韧带 在股骨和胫骨上的解剖附着点46。生物力学研究显示,切断内侧结构后,膝关节屈曲30?加载外翻应 力时关节间隙的松弛最为明显,因此,正常情况下膝关节屈曲这一角度时内侧副韧带浅层通常是绷紧 的1,10,42,43。而后斜韧带在膝关节屈曲0?时明显绷紧,同样按照上述的生物力学研究,膝关节屈曲 0?时这一韧带限制内旋的作用最为明显10,42。 Fig. 8 A: Intraoperative photograph demonstrating a single anteromedial incision performed on a left knee to access the anatomic femoral and tibial attachment points of the superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL). The anatomic reconstruction requires two separate grafts with four reconstruction tunnels46. The superficial medial collateral ligament and posterior oblique ligament grafts have been fixed into their femoral reconstruction tunnels. B: In this image, the superficial medial collateral and posterior oblique ligament grafts have been passed along their natural course under the sartorius fascia and the posterior oblique ligament graft has been fixed into its tibial tunnel. The superficial medial collateral ligament graft is about to be passed into its reconstruction tunnel and fixed at 30? of knee flexion. 图8 A:术中照片显示经左膝单一前内侧切口暴露内侧副韧带浅层(sMCL)和后斜韧带(POL)在股骨和 胫骨的解剖附着点。解剖重建须用到两条相互独立的移植肌腱并建立4个骨隧道46。图中植入的内侧 副韧带浅层和后斜韧带的股骨端均已固定在其股骨骨隧道中。B:在该图中,内侧副韧带浅层和后斜 韧带的移植肌腱沿其各自的解剖路径,从缝匠肌筋膜深面穿出,而后斜韧带移植肌腱的远端也已固定 在其胫骨骨隧道中。接下来再将内侧副韧带浅层的移植肌腱穿入骨隧道,在屈膝30?位时进行重建。 Postoperative Rehabilitation It is essential that motion of the knee be achieved as soon as possible after treatment so that intra-articular adhesions do not develop. It is important to inform patients prior to the operation that their full return to activity can take up to six to nine months postoperatively. At our institutions, we utilize a treatment protocol that focuses on early motion and strengthening exercises (see Appendix). 术后康复 手术以后,必须在关节内发生粘连之前尽早开始活动膝关节。重要的一点是术前应告知患者,可能需 要等到术后6至9个月才能完全恢复运动。我们医院应用的一套治疗方案,非常注重早期活动和力量练 习(见附录)。 For the first week after a medial knee reconstruction, it is vital to avoid aggressive range-of-motion exercises, which could stretch out the reconstruction grafts. However, the patient is instructed to initiate range-of-motion exercises between 0? and 90? of knee flexion in the first two weeks and simple strengthening exercises while wearing a hinged brace immediately postoperatively. These include quadriceps-setting exercises, straight-limb raises, and hip extension and abduction exercises. The initial range-of-motion exercises are performed to prevent adhesion formation; extension is allowed to 0?, but it is essential to avoid both hyperextension and flexion past 90?, which can place undue tension on the grafts. After the initial two weeks, knee flexion is progressed to a full range of motion as tolerated. It is recommended that no resistive or repetitive hamstring exercises be performed for approximately four months after the reconstruction to minimize joint translation, which could potentially stretch the healing grafts. After the initial six weeks of protected weight-bearing, closed-kinetic-chain exercises are permitted for functional strengthening. Two-limb-support squatting may be initiated, but it is limited to 70? of knee flexion to minimize excessive joint translation. Avoidance of tibial external and internal rotation is advised. The patient should be educated about avoiding pivoting motions of the limb on a planted foot. 在膝关节重建术后的第一周,避免进行过度的关节活动范围的练习是非常关键的。然而,也必须告知 患者在术后的前两周内,膝关节活动范围的练习应在屈曲0?到90?之间;并且术后应该立即佩戴铰链 式支具进行简单的力量练习。主要包括股四头肌的等长练习、直腿抬举、伸髋及外展练习等。最初的 关节活动范围练习主要是为了防止粘连形成,伸展的范围可达0?,但必须避免过伸以及屈曲超过90?, 否则可能会使移植的肌腱承受过度的张力。最初两周过后,如果患者能耐受则可逐渐进行全范围的膝 关节屈曲活动。一般推荐重建术后约4个月内不要进行对抗性的或反复的腘绳肌练习,以使关节的水 平移位减至最小,而这种水平移位则可能会拉长尚未愈合的移植肌腱。最初6周在保护下进行负重练 习,此后可进行闭链运动以强化其功能。并可双上肢抓扶下开始进行下蹲练习,但屈膝应限制在70? 以内,以尽可能减少关节的过度移位。告知患者应避免胫骨外旋和内旋,务必向其宣教,在足部固定 时不能做肢体的旋转动作。 Once full weight-bearing is permitted at the seven-week mark, special attention must be paid to the restoration of normal gait mechanics. Also, the therapist must observe that the return to full weight-bearing is tolerated and that an effusion does not develop. A persistent effusion in the joint can contribute to quadriceps muscle inhibition and negate the progress made with strengthening. The therapist must observe the gait pattern closely to ensure that the patient is not employing a quadriceps-avoidance pattern with a hyperextension thrust at the knee joint during stance phase. It is also critical that the patient avoid posting the foot of the surgically treated extremity lateral to the base of support in stance in an attempt to unload the joint. This movement pattern increases the valgus moment at the knee joint, potentially compromising the grafts. Provided that lower-extremity strength, motion, and proprioception have been appropriately regained, jogging and basic plyometric and agility exercises may be initiated at sixteen to twenty weeks postoperatively. The patient must be able to tolerate 1 to 2 mi (1.6 to 3.2 km) of brisk walking without a limp and demonstrate adequate kinematic control with single-limb squatting prior to initiating an interval jogging program. Once the patient has completed this rehabilitation program without problems, the surgeon can talk to the patient about returning to full activity if appropriate strength is noted on functional testing and objective knee stability is observed on clinical examination. A similar rehabilitation protocol is implemented after a medial knee reconstruction in combination with an anterior cruciate ligament reconstruction, although there is a longer delay before a full return to activity. 自第7周开始可允许完全负重,此时应特别注意恢复正常的步态。同样,医生也应该注意观察,判断 患者是否能耐受完全负重练习以及是否出现渗出、积液。持续的关节腔积液会使股四头肌的功能受到 抑制,此时应暂停负重练习,加强力量训练。医生必须密切观察患者的步态,确认其行走的站立期没 有出现膝关节过伸和股四头肌废用的情况。另外还有一点也非常关键,患者应避免患足站立时倚靠在 外侧的支柱上以图减轻关节的负荷,这个动作实际上会增加膝关节的外翻力矩,甚至可能损伤移植的 肌腱。术后16至20周,如果患肢的力量、关节活动及本体感觉都恢复良好,则可以开始进行慢跑、基 本的超等长收缩训练和灵活性训练。患者在进行间隙性的慢跑之前,必须能够坚持快走1至2英里(1.6 至3.2km)无跛行,且单腿蹲时有足够的运动控制能力。如果患者能够顺利完成这一康复计划,功能 测试提示力量恢复满意且客观的临床检查显示膝关节稳定性良好,此时外科医生才可以考虑和患者探 讨完全恢复运动。膝关节内侧重建同时还进行了前交叉韧带重建的患者也可采用类似的康复计划,不 过完全恢复运动的时间还要更长一些。 Confounding Variables The so-called Pellegrini-Stieda syndrome is typically diagnosed with the use of anteroposterior plain radiographs and is characterized by intraligamentous calcification in the region of the femoral attachment of the medial collateral ligament caused by the chronic tear of the ligament (Fig. 9)74. Treatments to alleviate pain over the sites of mild and moderate cases of posttraumatic heterotopic ossification of the superficial medial collateral ligament have been reported to include local corticosteroid injection and range-of-motion exercises75. Operative excision of the calcification and treatment of the chronic tear in the medial collateral ligament can be considered for more severe cases75,76. 有争议的问题 所谓的Pellegrini-Stieda综合征一般都通过正位X线片来诊断,以内侧副韧带股骨附着点附近的韧带 内钙化为特征,通常是由于韧带的陈旧性撕裂所致(图9)74。对于内侧副韧带浅层创伤后异位骨化 导致的局部轻到中度疼痛,有报道可采用局部皮质类固醇注射及关节活动范围练习来治疗75。而对于 更为严重的病例,则可考虑切除钙化的组织并对内侧副韧带的陈旧性撕裂进行妥善处理75,76。 Fig. 9 Anteroposterior plain radiograph of a right knee, showing posttraumatic ossification known as the Pellegrini-Stieda syndrome. This is typically characterized by intraligamentous calcification in the region of the femoral medial collateral ligament attachment (arrowheads). 图9 右膝正位片显示创伤后异位骨化,即所谓的Pellegrini-Stieda综合征。其典型的表现为内侧副韧带股 骨附着点附近的韧带内钙化(箭头所示)。 Another confounding variable is the presence of concurrent injuries, which can obscure the findings of the physical examination24. If a primary operative repair or reconstruction is indicated in the presence of multiple-ligament knee injuries, it should be performed concurrently with cruciate ligament reconstructionand shortly after the injury because scar tissue, tissue retraction, and tissue necrosis can develop and reduce the quality of the remaining tendon and of the repair. Also, patients with valgus alignment who need a reconstruction should undergo the procedure promptly because of the higher risk of the reconstruction stretching out if the injury becomes chronic. To prevent fluid extravasation, a diagnostic arthroscopy could be helpful either before or after the initial surgical exposure to identify meniscal tears and the site of the deep medial collateral ligament injury. In patients with severe medial knee injuries, it may be useful to perform the operative approach and identify the injured medial structures prior to fluid extravasation; otherwise, definition of the injury is more difficult. 另外一个有争议的问题便是存在的合并损伤,这可能会干扰体格检查的相关表现24。如果膝关节多发 的韧带损伤具备一期手术修补或重建的指征,则应该在伤后尽早手术并同期进行交叉韧带重建,否则 可能会出现瘢痕组织增生、残留组织回缩以及组织坏死等问题,这不仅会使残余腱性组织的质量下降, 也有可能会影响修复手术的效果。此外,对于存在外翻畸形而需要进行重建的患者,手术宜尽早进行, 因为一旦变成陈旧性的损伤,重建后移植肌腱被拉出的风险明显增高。为了防止关节腔渗液,无论在 初次手术暴露之前还是之后,关节镜检查都是很有帮助的,可以明确是否存在半月板撕裂并且还可以 确定内侧副韧带深层损伤的部位。对于膝关节内侧严重损伤的患者,在出现关节腔积液之前进行手术 治疗明确受损的内侧结构是很有意义的,否则,确定相关损伤的诊断将会更加困难。 Complete medial knee ligament injuries may not always heal. Operative treatment is usually indicated for chronic medial knee injuries in patients with symptomatic instability, pain, and excessive medial joint gapping. Because of contracture of the ligament ends, the formation of scar tissue, and the loss of the potential for healing that characterize chronic tears, a reconstruction with a hamstring autograft or allograft may be required. An arthroscopic examination can be performed after the initial operative approach to identify and treat intra-articular lesions such as chondral defects or meniscal tears. Various techniques for treatment of medial knee injuries, such as tendon transfer, advancement and retensioning procedures, and free autograft or allograft tendon reconstructions, have been described77-79. However, chronic injuries usually require complete reconstruction of the superficial medial collateral and posterior oblique ligaments because of extensive pericapsular scar formation. 膝关节内侧韧带完全损伤并非全部都会愈合,对于膝关节内侧陈旧性的损伤,如果患者出现不稳定的 症状、疼痛以及内侧关节间隙过大等,通常都适合进行手术治疗。而由于陈旧性撕裂具有韧带断端挛 缩,瘢痕组织增生以及愈合的潜力丧失等特征,一般须要应用自体或同种异体腘绳肌腱进行重建。在 最初的手术处理后,可应用关节镜进行检查,以识别并处理关节内的损伤,比如软骨缺损或半月板撕 裂等。处理膝关节内侧损伤的方法有很多种,包括肌腱转移、前置、紧缩手术,自体或同种异体肌腱 重建等均有报道77-79。然而,陈旧性损伤由于关节囊周围广泛的瘢痕增生,往往须要对内侧副韧带 前侧和后斜韧带进行完全重建。 The operative approaches for medial knee repairs and reconstructions predominantly involve an anteromedial incision40,46,78-82. The proximity of the saphenous nerve to the medial portion of the knee makes the nerve vulnerable to injury. Disruption of the saphenous nerve at the knee can result in a spectrum of neuropathy ranging from inconsequential sensory loss83 to painful neuralgia84. An anatomic study defined the location of the sartorial branch of the saphenous nerve and characterized a safe zone for a medial knee reconstruction that avoids compromise of the nerve (Fig. 10)85. The sartorial branch of the saphenous nerve courses slightly posterior to the superficial medial collateral ligament and the posterior oblique ligament, which are the most commonly repaired or reconstructed injured medial knee structures85,86. Accurate knowledge of the location of the sartorial branch of the saphenous nerve is necessary to avoid injury87 while at the same time being able to fully repair or reconstruct the medial knee structures to restore their native anatomic state. 膝关节内侧修复和重建的手术入路通常都采用前内侧切口40,46,78-82。隐神经行经膝关节内侧,术 中较易导致神经损伤。在膝关节水平损伤隐神经可能会导致一系列的神经症状,如一定程度的感觉障 碍83以及神经性疼痛84等。有解剖学研究明确了隐神经缝匠肌支的具体位置,进而指出了膝关节内侧 重建手术的安全区域可避免伤及神经(图10)85。隐神经缝匠肌支的走行位于内侧副韧带浅层和后斜 韧带的稍后方,而这两者恰是最常见的由于损伤而需要进行修复或重建的膝关节内侧结构85,86。为 了在完全修复或重建膝关节内侧结构恢复其正常解剖形态的同时避免损伤神经87,确切地了解隐神经 缝匠肌支的解剖位置是很有必要的。 Fig. 10 Diagrammatic representation of the medial side of the knee and the course of the saphenous nerve and its sartorial and infrapatellar branches. The distance measurements are in relation to the described landmarks. (Reproduced, with permission, from: Wijdicks CA, Westerhaus BD, Brand EJ, Johansen S, Engebretsen L, LaPrade RF. Sartorial branch of the saphenous nerve in relation to a medial knee ligament repair or reconstruction. Knee Surg Sports Traumatol Arthrosc. 2009 Oct 27 [Epub ahead of print].) 图10 图示为膝关节内侧面隐神经及其缝匠肌支和髌下支的走行,所标为神经与相关解剖标志之间测得的距 离。(经惠允引自:Wijdicks CA, Westerhaus BD, Brand EJ, Johansen S, Engebretsen L, LaPrade RF. Sartorial branch of the saphenous nerve in relation to a medial knee ligament repair or reconstruction. Knee Surg Sports Traumatol Arthrosc. 2009 Oct 27 [Epub ahead of print].) Appendix Tables listing clinical series of medial knee ligament injuries reported in the literature and describing rehabilitation protocols for these injuries are available with the electronic version of this article on our web site at jbjs.org (go to the article citation and click on "Supporting Data"). 附录 表格中详例了文献中报道的有关膝关节内侧损伤的病例系列研究;另外还对这一损伤的康复计划进行 了叙述。具体可通过我们的网站jbjs.org参阅本文的电子版(至本文题录下点击“Supporting data”)。
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