1、InjuriestotheMedialCollateralLigamentandAssociatedMedialStructuresoftheKnee膝關(guān)節(jié)內(nèi)側(cè)副韌帶及相關(guān)內(nèi)側(cè)結(jié)構(gòu)的損傷CoenA.Wijdicks,PhDl,ChadJ.Griffith,MD2,SteinarJohansen,MD3,LarsEngebretsen,MD,PhD3andRobertF.LaPrade,MD,PhD4InvestigationperformedattheDepartmentofOrthopaedicSurgery,UniversityofMinnesota,Minneapolis,Minneso

2、ta,andtheOsloUniversityHospitalandFacultyofMedicine,UniversityofOslo,Oslo,NorwayThesuperficialmedialcollateralligamentandothermedialkneestabilizersi.e.,thedeepmedialcollateralligamentandtheposteriorobliqueligamentarethemostcommonlyinjuredligamentousstructuresoftheknee.Themainstructuresofthemedialasp

3、ectofthekneearetheproximalanddistaldivisionsofthesuperficialmedialcollateralligament,themeniscofemoralandmeniscotibialdivisionsofthedeepmedialcollateralligament,andtheposteriorobliqueligament.Physicalexaminationistheinitialmethodofchoiceforthediagnosisofmedialkneeinjuriesthroughtheapplicationofavalg

4、usloadbothatfullkneeextensionandbetween20and30ofkneeflexion.Becausenonoperativetreatmenthasafavorableoutcome,thereisaconsensusthatitshouldbethefirststepinthemanagementofacuteisolatedgrade-IIIinjuriesofthemedialcollateralligamentorsuchinjuriescombinedwithananteriorcruciateligamenttear.Ifoperativetrea

5、tmentisrequired,ananatomicrepairorreconstructionisrecommended.口內(nèi)側(cè)副韌帶淺層及其他內(nèi)側(cè)的膝關(guān)節(jié)穩(wěn)定結(jié)構(gòu)一一即內(nèi)側(cè)副韌帶深層和后斜韌帶一一是損傷最為多見的膝關(guān)節(jié)韌帶結(jié)構(gòu)。口膝關(guān)節(jié)內(nèi)側(cè)的主要結(jié)構(gòu)包括內(nèi)側(cè)副韌帶淺層的上段和下段，內(nèi)側(cè)副韌帶深層的板股韌帶和板脛韌帶，以及后斜韌帶。口在膝關(guān)節(jié)完全伸直以及屈曲20。-30。時(shí)施加外翻應(yīng)力進(jìn)行體格檢查是診斷膝關(guān)節(jié)內(nèi)側(cè)損傷的首要方法。口由于非手術(shù)治療通常可獲得良好的療效，一般認(rèn)為新鮮的單純III度內(nèi)側(cè)副韌帶損傷或內(nèi)側(cè)副韌帶合并前交叉韌帶損傷時(shí)才考慮一期進(jìn)行處理。口如必需進(jìn)行手術(shù)治療則推薦進(jìn)行解剖修

6、復(fù)或重建。Theunderstandingoftheanatomy,biomechanics,andtreatmentofmedialkneeinjuriescontinuestoevolve.Quantitativetechniquesforthemeasurementofanatomicstructuresandbiomechanicaltestinganddigitalradiographyhaveimprovedanatomicdefinitionoftheseverityofinjuries.Thedevelopmentofnewreconstructiontechniquesmay

7、leadtoimprovedsurgicaloutcomes.Thesuperficialmedialcollateralligamentandothermedialkneestabilizersi.e.,thedeepmedialcollateralligamentandtheposteriorobliqueligamentarethemostcommonlyinjuredligamentousstructuresofthekneel-4.Theincideneeofinjuriestothesemedialkneestructureshasbeenreportedtobe0.24per10

8、00intheUnitedStatesinanygivenyear5andtobetwiceashighinmales(0.36comparedwith0.18infemales)5.Themajorityofmedialkneeligamenttearsareisolated.Theseinjuriesoccurpredominantlyinyoungindividualsparticipatinginsportsactivities,withthemechanismofinjuryinvolvingvalguskneeloading,externalrotation,oracombined

9、forcevectoroccurringinsuchsportsasskiing,icehockey,andsoccer，whichrequirekneeflexion6-8.對膝關(guān)節(jié)內(nèi)側(cè)損傷的解剖、生物力學(xué)和治療的探索仍在不斷推進(jìn)，采用定量的方法測定解剖結(jié)構(gòu)以及相關(guān)的生物力學(xué)試驗(yàn)和數(shù)字X線攝影(DR)使得損傷的嚴(yán)重程度從解剖角度而言更加確切，而由此創(chuàng)立的新的重建方法則可能進(jìn)一步改善手術(shù)結(jié)果。內(nèi)側(cè)副韌帶淺層及其他內(nèi)側(cè)的膝關(guān)節(jié)穩(wěn)定結(jié)構(gòu)一一即內(nèi)側(cè)副韌帶深層和后斜韌帶一一是損傷最為多見的膝關(guān)節(jié)韌帶結(jié)構(gòu)1-4。據(jù)報(bào)道5,在美國每年這樣的膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)損傷的發(fā)生率約為每1000人0.24，而男性的發(fā)生率

10、則是女性的兩倍(0.36/0.18)。大多數(shù)膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)損傷均為單發(fā)，這些損傷在參加體育運(yùn)動(dòng)的年輕患者中尤其多見，受傷機(jī)制主要包括膝關(guān)節(jié)外翻暴力，外旋或者在需要屈膝的運(yùn)動(dòng)中，如滑雪、冰球、足球等，多個(gè)方向的應(yīng)力聯(lián)合作用導(dǎo)致?lián)p傷6-8。AnatomySuperficialMedialCollateralLigamentThesuperficialmedialcollateralligament,commonlycalledthetibialcollateralligament,isthelargeststructureofthemedialaspectoftheknee(Fig.1,A).Th

11、isstructureconsistsofonefemoralattachmentandtwotibialattachments9.Quantitativeassessmenthasshownthefemoralattachmenttobeovaland,ontheaverage,3.2mmproximaland4.8mmposteriortothemedialepicondyle.Asthesuperficialmedialcollateralligamentcoursesdistally,ithastwotibialattachments.Theproximaltibialattachme

12、ntisprimarilytosofttissueovertheterminationoftheanteriorarmofthesemimembranosustendonandislocatedanaverageof12.2mmdistaltothetibialjointline9.Thedistaltibialattachmentofthesuperficialmedialcollateralligamentisbroadandisdirectlytoboneatanaverageof61.2mmdistaltothetibialjointline;itislocatedjustanteri

13、ortotheposteromedialcrestofthetibia9.Thetwodistinettibialattachmentshavebeenreportedtoresultintwodistinctfunctioningdivisionsofthesuperficialmedialcollateralligament10.解剖內(nèi)側(cè)副韌帶淺層內(nèi)側(cè)副韌帶淺層，通常稱為脛側(cè)副韌帶，是膝關(guān)節(jié)內(nèi)側(cè)最大的結(jié)構(gòu)（圖1-A）。該結(jié)構(gòu)在股骨有一個(gè)附著點(diǎn)，在脛骨有兩個(gè)附著點(diǎn)9,定量研究顯示股骨附著點(diǎn)為卵圓形，平均距離內(nèi)上髁上方3.2mm后方4.8mm。內(nèi)側(cè)副韌帶淺層向遠(yuǎn)端延伸，在脛骨有兩個(gè)止點(diǎn)，近端止

14、點(diǎn)主要以一層軟組織覆蓋半膜肌腱前頭的止點(diǎn)，位于脛骨關(guān)節(jié)線下方平均12.2mm處9；遠(yuǎn)端止點(diǎn)較寬，直接附于骨上，距脛骨關(guān)節(jié)線遠(yuǎn)端平均61.2mm,恰位于脛骨后內(nèi)側(cè)嵴稍前方9。有研究表明內(nèi)側(cè)副韌帶淺層脛骨上兩個(gè)獨(dú)立的附著點(diǎn)使其成為了兩個(gè)不同的功能組分10。sMCL(proximal)POLsMCL(distal)snsoumqEaEE10mm,respectively,whencomparedwiththeuninjured,contralateralside3,21-24.Clinicianscanutilizethissystemtodefinetheinitialgradeofinjury,

15、toplantreatment(nonoperativeoroperative),andtodetermineevideneeofhealingwithnonoperativetreatment.分型通過體格檢查來了解膝關(guān)節(jié)內(nèi)側(cè)韌帶損傷的程度，主要依賴于兩個(gè)方面：患者放松的程度以及醫(yī)生在患膝屈曲20。至30時(shí)加載外翻負(fù)荷后檢出其終點(diǎn)(endpoint)的能力。如果患者由于疼痛而進(jìn)行保護(hù)或者醫(yī)生不愿給患者造成更嚴(yán)重的疼痛，外翻應(yīng)力試驗(yàn)或外翻應(yīng)力位X線攝影則可能會(huì)低估膝關(guān)節(jié)內(nèi)側(cè)的松弛程度。檢查過程中可以對側(cè)為基準(zhǔn)進(jìn)行對比。膝關(guān)節(jié)內(nèi)側(cè)損傷有一個(gè)被廣泛應(yīng)用的等級評價(jià)方法，參照美國醫(yī)學(xué)會(huì)運(yùn)動(dòng)損傷命名法標(biāo)

16、準(zhǔn)而制定(圖2,表1)20。按照該評價(jià)系統(tǒng)，單純I度：少量纖維撕裂，伴有局限性壓痛無松弛；單純II度：局限性壓痛，內(nèi)側(cè)副韌帶纖維及后斜纖維部分撕裂。纖維仍然存在一定的張力，伴或不伴有病理性的松弛；單純III度：表現(xiàn)為外翻應(yīng)力下可見完全斷裂及松弛。單純膝關(guān)節(jié)內(nèi)側(cè)損傷也可以按照施加外翻應(yīng)力時(shí)松弛的程度進(jìn)行分級。等級分為1+、2+和3+,相當(dāng)于對內(nèi)側(cè)關(guān)節(jié)間隙進(jìn)行主觀評價(jià)，并與未受傷的對側(cè)相比較，分別增寬3-5mm、6-10mm及10mm以上3,21-24。臨床醫(yī)生可以參照這一評價(jià)系統(tǒng)確定其最初的損傷等級，制定治療計(jì)劃(手術(shù)或非手術(shù))，并可作為非手術(shù)治療愈合與否的驗(yàn)證手段。PosteriorObliq

17、ueLigamentsuperficialMedialCollateralLigamentGradeIG日血IIFig.2Anteromedialviewoftheleftknee,showingtheinjurygradingscaleestablishedbytheAmericanMedicalAssociationStandardNomenclatureofAthleticInjuries20.Isolatedgrade-Iinjuriespresentwithlocalizedtendernessandnolaxity.Isolatedgrade-IIinjuriespresentwi

18、thabroaderareaoftendernessandpartiallytornmedialcollateralandposteriorobliquefibers.Isolatedgrade-IIIinjuriespresentwithcompletedisruption,andthereislaxitywithanappliedvalgusstress.圖2左膝前內(nèi)側(cè)面觀，所示為參照美國醫(yī)學(xué)會(huì)運(yùn)動(dòng)損傷命名法標(biāo)準(zhǔn)制定的損傷等級評價(jià)標(biāo)準(zhǔn)20。單純I度損傷表現(xiàn)為局限性壓痛無松弛；單純II度損傷表現(xiàn)為范圍更大的壓痛，內(nèi)側(cè)副韌帶纖維及后斜纖維部分撕裂；單純III度損傷表現(xiàn)為完全斷裂，在外翻應(yīng)力下可

19、見松弛。表1膝關(guān)節(jié)內(nèi)側(cè)損飭尊級評定標(biāo)準(zhǔn)分世運(yùn)義I度當(dāng)局限性壓疝無不誌II度局限性壓痣內(nèi)鯉副韌港纖維及后斜纖維剖分撫裂III度2&完全斷裂.外翻應(yīng)力下存在不穩(wěn)皿度量化標(biāo)準(zhǔn)上觀性臨床評價(jià)蘋131+松弛3-5mm2+松弛6-lOiniii3+松弛lOmui以.應(yīng)力位X線片單純內(nèi)側(cè)副韌帝攝傷膝關(guān)節(jié)師勵(lì)0時(shí)內(nèi)啊關(guān)節(jié)間20時(shí)增寬3.2mm膝關(guān)節(jié)內(nèi)刪絡(luò)構(gòu)完仝攬傷（內(nèi)側(cè)副韌帯法層、后膝關(guān)節(jié)師曲儼時(shí)內(nèi)啊關(guān)節(jié)問20斜韌帶、內(nèi)側(cè)詡韌帶深層、時(shí)增寬9.8nun*所例數(shù)值為項(xiàng)研究中的平均值，而非分空系統(tǒng)的評價(jià)標(biāo)準(zhǔn)DXVCHealingThesuperficialmedialcollateralligamenthasbe

20、enreportedtohaveanabundantvascularsupply.Healingofthisligamentfollowstheclassicmodelofhealinginvolvinghemorrhage,inflammation,repaii;andremodeling25.Studiesofthevariablesinvolvedinthehealingofthesuperficialmedialcollateralligamentinanimalshaveshownthatthehealingislocationdependent.Inonestudyofarabbi

21、tsuperficialmedialcollateralligamentinjurymodel,theligamenttooklongertohealwhenitwasinjuredneareitherattachmentsitethanwhenithadamidsubstaneeinjury26.Thebiologicaleffectsofimmobilizationhavealsobeenwidelystudiedinsuperficialmedialcollateralligamentinjurymodels.Inarabbitmodel,areductionofcollagenmass

22、andincreasedcollagendegradationwereobservedaftertwelveweeksofimmobilization27.Thesenegativeeffectsofimmobilizationwerenotedtobecausedbycollagenmatrixreorganizationandcatabolicbehaviorwithinthemedialcollateralligamentafterinjury28,29.Inanotherstudy,dogsthathadundergonesurgicaltransectionofthesuperfic

23、ialmedialcollateralligamentweredividedintothreetreatmentgroups:earlymotion,immobilizationforthreeweeks,andimmobilizationforsixweeks30.Theauthorsconcludedthatearlymotionprotocolsleadtoenhancedhealingandimprovedbiomechanicalpropertiesofthesuperficialmedialcollateralligament.Thisinformationwassubsequen

24、tlyusedtopromoteandreinforcesimilarnonoperativerehabilitationprotocolsfortheseinjuriesinhumans.愈合據(jù)研究報(bào)道，內(nèi)側(cè)副韌帶淺層血供豐富，其愈合通常遵循經(jīng)典的愈合模式：出血、炎癥、修復(fù)和重建25。但也有與之不同的報(bào)道，動(dòng)物實(shí)驗(yàn)顯示內(nèi)側(cè)副韌帶淺層的愈合與損傷的位置密切相關(guān)。有學(xué)者研究了兔子內(nèi)側(cè)副韌帶淺層的損傷模型，發(fā)現(xiàn)與韌帶中部損傷相比，兩個(gè)附著點(diǎn)附近的損傷愈合時(shí)間更長26。在內(nèi)側(cè)副韌帶淺層損傷的模型中制動(dòng)的生物學(xué)作用也是一個(gè)被廣泛研究的內(nèi)容。在一個(gè)兔子模型中，制動(dòng)12周以后觀察到膠原的含量減少，膠原的退

25、變明顯增加27。人們注意到制動(dòng)帶來的不良影響主要是由于內(nèi)側(cè)副韌帶損傷后內(nèi)部膠原基質(zhì)的重組和分解代謝28,29。在另一項(xiàng)研究中，狗的內(nèi)側(cè)副韌帶淺層經(jīng)手術(shù)橫行切斷，然后分成3個(gè)處理組：早期活動(dòng)、制動(dòng)3周和制動(dòng)6周30。作者的結(jié)論認(rèn)為早期活動(dòng)可促進(jìn)內(nèi)側(cè)副韌帶淺層損傷的愈合，改善其生物力學(xué)性能。這一結(jié)論后來也常常被引用，作為類似的非手術(shù)康復(fù)計(jì)劃在人類相關(guān)損傷中應(yīng)用的理論依據(jù)。ClinicallyRelevantBiomechanicsAcompleteunderstandingofmedialkneebiomechanicsisvaluablefortheassessmentofwhichinjure

26、dstructuresshouldberepairedorreconstructed.Anunderstandingofthedegreeofabnormaljointmotionthatoccurswhenastructureisinjuredgreatlyassistswiththeinterpretationoftheresultsoftheclinicalexaminationandhelpstodeterminethepresenceofconcurrentligamentinjury.Withthetrendtowardmoreanatomicreconstruction,itis

27、importanttounderstandthefunctionof,andthedifferencesbetween,theindividualcomponentsofthesemainmedialknee-stabilizingstructures.Biomechanicalstudieshaveshownthatthesuperficialmedialcollateralligamentistheprimaryrestrainttovalguslaxityoftheknee1,31-34.Onestudy,inwhichbuckletransducerswereused,quantita

28、tivelydemonstrateddifferencesbetweenthetwodivisionsofthesuperficialmedialcollateralligamentintermsoftheirresponsestoappliedloads10.Theimplicationsoftheseobservationsarethat,althoughthesuperficialmedialcollateralligamenthaspreviouslybeenbiomechanicallytestedandoperativelyreconstructedundertheassumpti

29、onthatitisonecontinuousstructure1,33,35-40,thetwodivisionsoftheligamentactuallyfunctionasconjoinedbutdistinctstructures.Thus,thebiomechanicalstudy10suggeststhattheaimofanoperativerepairorreconstructionofthesuperficialmedialcollateralligamentshouldbetorestorethedistinctfunctionsofbothdivisionsbyreatt

30、achingthetwotibialattachmentsinanattempttoreproducetheoverallfunctionofthesuperficialmedialcollateralligamentconstruct.臨床生物力學(xué)深入了解膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)的生物力學(xué)性能對于明確哪些結(jié)構(gòu)損傷必須進(jìn)行修復(fù)或重建意義重大。認(rèn)識清楚某一結(jié)構(gòu)損傷后導(dǎo)致關(guān)節(jié)異常活動(dòng)的程度，對于解釋臨床查體的結(jié)果以及確定是否存在合并的韌帶損傷都是很有幫助的。隨著越來越提倡解剖重建，理解膝關(guān)節(jié)內(nèi)側(cè)穩(wěn)定結(jié)構(gòu)各個(gè)組分的功能及其相互之間的差異則顯得尤為重要。生物力學(xué)研究顯示內(nèi)側(cè)副韌帶淺層主要起到限制膝關(guān)節(jié)過度外翻的

31、作用1,31-34。其中有一項(xiàng)研究，應(yīng)用環(huán)扣傳感器進(jìn)行了定量分析，結(jié)果顯示了內(nèi)側(cè)副韌帶淺層在加載負(fù)荷后兩個(gè)部分之間的反應(yīng)不同10。這一研究提示，盡管以前的生物力學(xué)試驗(yàn)和手術(shù)重建都將內(nèi)側(cè)副韌帶淺層當(dāng)作一個(gè)連續(xù)的結(jié)構(gòu)來處理1,33,35-40,而事實(shí)上該韌帶的兩個(gè)組分雖然協(xié)同作用但卻是兩個(gè)相互獨(dú)立的結(jié)構(gòu)。因此，有生物力學(xué)研究10主張?jiān)趯?nèi)側(cè)副韌帶淺層進(jìn)行手術(shù)修復(fù)或重建時(shí)，應(yīng)以恢復(fù)其兩個(gè)組分不同的功能為目的，分別重建兩個(gè)脛骨附著點(diǎn)以求還原內(nèi)側(cè)副韌帶淺層的所有功能。Theposteriorobliqueligamentreinforcestheposteromedialaspectofthecapsu

32、le,whichcoursesoffthedistalaspectofthesemimembranosustendon2,9,14.Fromabiomechanicalperspective,theposteriorobliqueligamentfunctionsasaninternalrotatorandvalgusstabilizeratbetween0and30ofkneeflexion1,2,10,35,37,38,41,42.Ithasalsobeenreportedthat,withappliedinternalrotationtorquesat0ofkneeflexion,the

33、loadsontheposteriorobliqueligamentaresignificantlyhigherthanthoseoneitherdivisionofthesuperficialmedialcollateralligament10.Inaddition,ithasbeenreportedthatthereisareciprocalloadresponsetointernalrotationtorquebetweentheposteriorobliqueligamentandthesuperficialmedialcollateralligamentasthedegreeofkn

34、eeflexionincreases,withahigherloadresponseinthesuperficialmedialcollateralligamentat90ofkneeflexion.Thisobservationdemonstratesthatthereisacomplementaryrelationshipbetweentheposteriorobliqueligamentandthesuperficialmedialcollateralligamentwithregardtotheresistanceofinternalrotationtorquesthatdepends

35、onthekneeflexionangle.Asubsequentstudyofloaddistributionwithbuckletransducersshowedthatsectioningofthecomponentsofboththedeepmedialcollateralligamentandthesuperficialmedialcollateralligamentresultedinsignificantincreases,comparedwiththeintactstate,intheforcesexperieneedbytheposteriorobliqueligamentu

36、ndervalgusloadsat0,20,and30ofkneeflexion42.Thisobservationcorrelatesbothwithpreviousreportsthattheposteriorobliqueligamentinintactkneesexperiencestensileloadwithvalgusforces,especiallyclosetokneeextension10,42,andthattheposteriorobliqueligamenthasasecondaryroleinprovidingvalgusstabilityoftheknee35,4

37、3,44.后斜韌帶遠(yuǎn)離半膜肌腱遠(yuǎn)端走行，加強(qiáng)后內(nèi)側(cè)關(guān)節(jié)囊2,9,14。從生物力學(xué)角度而言，在膝關(guān)節(jié)屈曲0至30。時(shí)后斜韌帶主要起到內(nèi)旋和外翻穩(wěn)定作用1,2,10,35,37,38,41,42。也有報(bào)道在膝關(guān)節(jié)屈曲0并加載內(nèi)旋扭矩時(shí)，后斜韌帶承受的負(fù)荷要明顯高于內(nèi)側(cè)副韌帶淺層的任一部分10。此外，還有研究指出，加載內(nèi)旋扭矩時(shí)，隨著膝關(guān)節(jié)屈曲的度數(shù)增加，后斜韌帶與內(nèi)側(cè)副韌帶淺層的負(fù)荷變化趨勢相反，屈膝90時(shí)內(nèi)側(cè)副韌帶淺層的負(fù)荷反應(yīng)較高。這一觀測顯示根據(jù)膝關(guān)節(jié)屈曲的角度不同，后斜韌帶與內(nèi)側(cè)副韌帶淺層對內(nèi)旋扭矩的抵抗存在互補(bǔ)關(guān)系。隨后的研究應(yīng)用環(huán)扣傳感器對負(fù)荷的分配進(jìn)行了探討，結(jié)果顯示膝關(guān)節(jié)屈曲0、2

38、0及30。時(shí)，切斷內(nèi)側(cè)副韌帶深層和淺層都可觀測到后斜韌帶承載的負(fù)荷明顯增加42。這一觀測結(jié)果與上文提到的兩方面的研究都是密切相關(guān)的，在完整的膝關(guān)節(jié)中加載外翻應(yīng)力時(shí)后斜韌帶承載張力負(fù)荷，膝關(guān)節(jié)接近于伸直時(shí)尤其明顯10,42；后斜韌帶對膝關(guān)節(jié)的外翻穩(wěn)定有輔助作用35,43,44。Comparedwiththenumberofstudiesonthefunctionofthesuperficialmedialcollateralligament,therearefewerreportsontheisolatedfunctionofthedeepmedialcollateralligament.The

39、authorsofprevioussequentialsectioningstudiesdonetoevaluatethefunctionofthedeepmedialcollateralligamentdescribeditasasecondaryrestrainttovalgusloads41-43.Morespecifically,theyfoundthatvalgusstabilizationwasprovidedbythemeniscofemoralportionofthedeepmedialcollateralligamentatalltestedflexionanglesandb

40、ythemeniscotibialportionofthedeepmedialcollateralligamentat60ofkneeflexion.Thedeepmedialcollateralligamentwasalsoreportedtoproviderestraintagainstexternalrotationtorqueinkneesflexedbetween30and9041,43.有關(guān)內(nèi)側(cè)副韌帶淺層功能的研究很多，與之相比，單純研究內(nèi)側(cè)副韌帶深層相關(guān)功能的報(bào)道則相對較少。上文提到的順序切斷的研究對內(nèi)側(cè)副韌帶深層的功能進(jìn)行了評估，作者將其描述為一個(gè)對抗外翻負(fù)荷的輔助結(jié)構(gòu)41-4

41、3。更確切地說，他們發(fā)現(xiàn)外翻穩(wěn)定性的維持在膝關(guān)節(jié)的各個(gè)屈曲角度，內(nèi)側(cè)副韌帶深層的板股韌帶更為重要，而屈膝60時(shí)內(nèi)側(cè)副韌帶深層的板脛韌帶則發(fā)揮主要作用。另外也有研究表明膝關(guān)節(jié)屈曲30至90時(shí)內(nèi)側(cè)副韌帶深層也可對抗外旋扭矩41,43。Theseresultsdemonstratethatinjuriestotheindividualcomponentsofthemedialaspectofthekneealtertheintricateload-sharingrelationshipsthatexistamongallofthemedialkneestructuresand,ifleftuntre

42、ated,couldpotentiallyincreasetheriskoffurtherinjury42,45.Therefore,onthebasisofthesynthesisofinformationfromtheliteratureandourpersonalperspective,webelievethat,incasesinwhichanoperativerepairorreconstructionisindicated,considerationshouldbegiventorepairingorreconstructingallinjuredmedialkneestructu

43、restorestorethenormalload-sharingrelationshipsamongthosestructuresatthetimeofoperativetreatment.Ananatomicmedialkneereconstructiontechnique(Fig.3)46,basedonpreviousquantitativeanatomic9andbiomechanicalstudies10,42,wasdevelopedinanattempttorestorenormalstabilitytoakneefollowingcompletesectioningofthe

44、superficialmedialcollateralligamentandposteriorobliqueligament.Itwasreportedthatthisreconstructionrestorednearlynormalstabilitytothekneeandthat,followinganappliedload,thereconstructedligamentsdidnothaveagreaterforceresponsethanintactligamentsatanypointduringtesting46.Thissuggeststhatoverconstraintof

45、thekneeandoverloadingofthereconstructiongrafts,whichcouldleadtograftfailure,waspreventedbytheuseofthistechnique.這些研究結(jié)果提示，膝關(guān)節(jié)內(nèi)側(cè)單一結(jié)構(gòu)的損傷，可改變膝關(guān)節(jié)內(nèi)側(cè)所有相關(guān)結(jié)構(gòu)之間存在的負(fù)荷分擔(dān)關(guān)系，如果不進(jìn)行妥善處理的話，可能會(huì)增加進(jìn)一步損傷的風(fēng)險(xiǎn)42,45。因此，綜合文獻(xiàn)中的信息及我們個(gè)人的觀點(diǎn)，我們認(rèn)為，對于具備手術(shù)修復(fù)或重建指征的病例，進(jìn)行手術(shù)治療時(shí)應(yīng)考慮修復(fù)或重建所有受損的膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)，以恢復(fù)這些結(jié)構(gòu)相互間正常的負(fù)荷分擔(dān)關(guān)系。以上述定量解剖和生物力學(xué)研究為基礎(chǔ)創(chuàng)立

46、的膝關(guān)節(jié)內(nèi)側(cè)解剖重建方法（圖3）46,通過完全切開暴露內(nèi)側(cè)副韌帶淺層和后斜韌帶，以期恢復(fù)膝關(guān)節(jié)正常的穩(wěn)定性。有研究認(rèn)為該重建方法可恢復(fù)幾近于正常的膝關(guān)節(jié)穩(wěn)定性，此外，在試驗(yàn)過程中加載負(fù)荷后，重建的韌帶任一點(diǎn)上的應(yīng)力反應(yīng)都不大于正常完整的韌帶46o這表明通過應(yīng)用這一方法可防止出現(xiàn)膝關(guān)節(jié)過緊，并可避免重建的移植物承受過大的負(fù)荷，而這些都是導(dǎo)致移植物失效的常見原因。Fig.3Illustrationofamedialkneereconstructonprocedure(medialviewofaleftknee).Thesuperficialmedialcollateralligament(sMCL

47、)andposteriorobliqueligament(POL)arereconstructedwithuseoftwoseparategraftsandfourreconstructiontunnels.Notethattheproximaltibialattachmentofthesuperficialmedialcollateralligament,whichisprimarilytosofttissuesandislocatedjustdistaltothejointline,wasrecreatedbysuturingthesuperficialmedialcollateralli

48、gamentgrafttotheanteriorarmofthesemimembranosusmuscle.(Reproduced,withpermission,from:CoobsBR,WijdicksCA,ArmitageBM,SpiridonovSI,WesterhausBD,JohansenS,EngebretsenL,LaPradeRF.Aninvitroanalysisofananatomicalmedialkneereconstruction.AmJSportsMed.2010;38:339-47.)圖3圖示為膝關(guān)節(jié)內(nèi)側(cè)重建方法(左膝內(nèi)側(cè)面觀)。內(nèi)側(cè)副韌帶淺層(sMCL)和后斜韌

49、帶(POL)分別應(yīng)用兩條移植腱經(jīng)4個(gè)骨隧道進(jìn)行重建。注意內(nèi)側(cè)副韌帶淺層的近側(cè)脛骨附著點(diǎn)主要通過軟組織附于關(guān)節(jié)線稍下方，術(shù)中可將內(nèi)側(cè)副韌帶淺層的移植物縫合到半膜肌的前頭進(jìn)行重建。(經(jīng)惠允引自：CoobsBR,WijdicksCA,ArmitageBM,SpiridonovSI,WesterhausBD,JohansenS,EngebretsenL,LaPradeRF.Aninvitroanalysisofananatomicalmedialkneereconstruction.AmJSportsMed.2010;38:339-47.)DiagnosisHistoryPatientsoftende

50、scribeamechanismofinjuryinvolvingacontactornoncontactvalgusforcetotheknee.Theyalsoreportpainandswellingalongthemedialaspectoftheknee.Whenaskedtoexplainthetypeofinstabilitythattheyfeelwithactivities,individualswithmedialkneeinjuriesinvolvingthesuperficialmedialcollateralligament,posteriorobliqueligam

51、ent,anddeepmedialcollateralligamentoftendescribedaside-to-sidefeelingofinstability,especiallywhentheywereathleteswhoperformedcuttingandpivotingmaneuvers.診斷病史患者自述的受傷機(jī)制通常包括膝關(guān)節(jié)接觸性或非接觸性的外翻暴力，主訴通常為膝關(guān)節(jié)內(nèi)側(cè)面的疼痛和腫脹。而為了判斷不穩(wěn)的類型而進(jìn)一步詢問其活動(dòng)時(shí)的感受時(shí)，膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)損傷的患者，包括內(nèi)側(cè)副韌帶淺層、后斜韌帶、內(nèi)側(cè)副韌帶深層，一般都會(huì)訴邊對邊動(dòng)作(sidetoside)時(shí)有不穩(wěn)的感覺，尤其患者

52、是運(yùn)動(dòng)員，做斜切及扭轉(zhuǎn)動(dòng)作時(shí)則更為明顯。ClinicalEvaluationPhysicalexaminationofthekneeremainsthemostsuitabletoolforobtainingadiagnosisofinjurytoitsmedialstructures.Beginningwithvisualinspection,cliniciansmayobservelocalizedswellingorecchymosisoverthefemoralortibialattachmentofthesuperficialmedialcollateralligament9.The

53、seareascanbepalpatedtohelptoidentifytendernessofthesuperficialmedialcollateralligament.Itisimportanttounderstandtheanatomyofthemedialsideofthekneetoappropriatelypalpateandassessthestructuresinvolved9.Avalgusloadappliedat20to30ofkneeflexionisusedtodetectmedialjointopening(Fig.4,A).Applyingthevalgusst

54、ressatboth0and30ofkneeflexioncanfurtherassistinthediagnosisoftheinjurypatternbecausewhenakneehasincreasedmedialjointspaceopeningat30offlexionbutnotat0theposteriorobliqueligamentismostlikelystillintact.Anadditionalassessmentperformedatthistimeofvalgusmomentapplicationisevaluationoftheintegrityoftheso

55、-calledendpoint.Ifthemedialkneestructuresarecompletelyruptured,therewillbenodefinitiveendpointandtheanteriorcruciateligamentmaybeprovidingasecondaryrestrainttothevalgusstress41.ItisthereforeimportanttoverifythisobservationwiththeLachman47,anteriordrawei,andpivotshifttestsandassesstheintegrityofthean

56、teriorcruciateligamentinassociationwithmedialkneeinjury.臨床評估膝關(guān)節(jié)的體格檢查仍然是診斷相關(guān)內(nèi)側(cè)結(jié)構(gòu)損傷最為合適的手段。首先進(jìn)行視診，醫(yī)生可以觀察局部腫脹，以及內(nèi)側(cè)副韌帶淺層股骨或脛骨附著點(diǎn)周圍的皮下瘀斑等情況9。對這些區(qū)域進(jìn)行觸診，明確內(nèi)側(cè)副韌帶淺層是否存在壓痛。深入了解膝關(guān)節(jié)內(nèi)側(cè)的解剖對于準(zhǔn)確地觸診和評估受累的結(jié)構(gòu)都是非常重要的9。膝關(guān)節(jié)屈曲20。至30，加載外翻負(fù)荷以檢查膝關(guān)節(jié)內(nèi)側(cè)間隙的寬度（圖4-A）。在膝關(guān)節(jié)屈曲0。和30。時(shí)施加外翻應(yīng)力可作為進(jìn)一步診斷損傷類型的輔助手段，因?yàn)橄リP(guān)節(jié)屈曲30。時(shí)內(nèi)側(cè)關(guān)節(jié)間隙增寬而屈曲0。時(shí)無明

57、顯增寬則意味著后斜韌帶很有可能仍保持完整。此時(shí)，加載外翻力矩后還須要評估其是否具有明顯的終點(diǎn)。如果膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)完全斷裂，則可能沒有明確的終點(diǎn)，此時(shí)前交叉韌帶可能對外翻應(yīng)力提供一定的對抗作用41。因此，通過Lachman試驗(yàn)、前抽屜試驗(yàn)、軸移試驗(yàn)等對這一檢查進(jìn)行驗(yàn)證，并檢查膝關(guān)節(jié)內(nèi)側(cè)損傷是否合并有前交叉韌帶損傷也是十分重要的。Fig.4A:Avalgusloadisappliedat20to30ofkneeflexiontodetectmedialjointopening.Thepatientsthighisallowedtorestontheexaminationtableinorderto

58、relaxthethighmuscles.Whilethevalgusforceisbeingappliedthroughthefootandankle,theexaminerpalpatesthemedialjointareatodeterminetheamountofmedialjointlinegapping.B:Completeinjurytothemedialstructuresincreasesexternalrotationatboth30and90ofkneeflexion,resultinginapositivedialtest41,48.Asdemonstrated,the

59、patientslowerlimbisplacedin9O5ofkneeflexionandtheamountofexternalrotationiscomparedwiththatofthenormal,contralateralknee.圖4A：屈膝20。至30施加外翻應(yīng)力檢查膝關(guān)節(jié)內(nèi)側(cè)間隙的寬度。患者的大腿置于檢查床上以放松大腿的肌肉。通過足踝部對膝關(guān)節(jié)施加外翻應(yīng)力，然后進(jìn)行觸診檢查膝關(guān)節(jié)內(nèi)側(cè)間隙的寬度，以確定關(guān)節(jié)間隙是否存在增寬。B：內(nèi)側(cè)結(jié)構(gòu)完全損傷在膝關(guān)節(jié)屈曲30。和90時(shí)都可使外旋異常增加，導(dǎo)致脛骨外旋試驗(yàn)(dialtest)陽性41,48。如圖所示，患者的下肢置于90屈膝位，并與

60、對側(cè)正常的膝關(guān)節(jié)比對其外旋的程度。Palpationofthefemur-basedandtibia-basedportionsofthemedialkneestructurescanoftendelineatethelocationoftheligamentinjury.Theanteromedialdrawertest,performedbyflexingthekneeapproximately90whileexternallyrotatingthefoot10to15andapplyingananteromedialrotationalforcetotheknee,shouldalsob