Injuries to the Medial Collateral Ligament and Associated Medial Structures of the Knee
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.
? 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)——即內(nèi)側(cè)副韌帶深層和后斜韌帶——是損傷最為多見(jiàn)的膝關(guān)節(jié)韌帶結(jié)構(gòu)。
? 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。
? 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。
? 由于非手術(shù)治療通?？色@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。
? 如必需進(jìn)行手術(shù)治療則推薦進(jìn)行解剖修復(fù)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.
對(duì)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(cè)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)——即內(nèi)側(cè)副韌帶深層和后斜韌帶——是損傷最為多見(jiàn)的膝關(guān)節(jié)韌帶結(jié)構(gòu)1-4。據(jù)報(bào)道5，在美國(guó)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(jiàn)，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。 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
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。 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.)
圖1
A為右膝后內(nèi)側(cè)面觀，顯示內(nèi)側(cè)副韌帶淺層（sMCL）和后斜韌帶（POL）。B為左膝內(nèi)側(cè)面觀，顯示內(nèi)側(cè)副韌帶深層的板股韌帶和板脛韌帶。（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.
后斜韌帶
后斜韌帶是半膜肌腱遠(yuǎn)端纖維的延伸，參與組成并加強(qiáng)后內(nèi)側(cè)關(guān)節(jié)囊（圖1-A），由附于膝關(guān)節(jié)的三組筋膜組成，其中以中央臂最為重要9,10。后斜韌帶中央臂在股骨上的附著點(diǎn)平均位于腓腸肌結(jié)節(jié)遠(yuǎn)端7.7mm前方2.9mm9。膝關(guān)節(jié)內(nèi)側(cè)解剖較早的研究認(rèn)為內(nèi)側(cè)副韌帶淺層與后斜韌帶屬于同一結(jié)構(gòu)的不同組成部分。Brantigan和Voshell所報(bào)道的內(nèi)側(cè)副韌帶淺層斜部，實(shí)際上就是目前所稱的后斜韌帶11,12。Slocum和Larson的研究認(rèn)為后上纖維和后下纖維自內(nèi)側(cè)副韌帶淺層后緣向后延伸形成三角形筋膜，覆蓋關(guān)節(jié)囊后內(nèi)側(cè)面并加強(qiáng)后方關(guān)節(jié)囊，最終也止于脛骨13。而他們卻沒(méi)有認(rèn)識(shí)到，按照這樣的描述其實(shí)和后斜韌帶中央臂的性狀是非常符合的9。
近來(lái)學(xué)者們注意到內(nèi)側(cè)副韌帶淺層和后斜韌帶是各自獨(dú)立的結(jié)構(gòu)，雖然對(duì)于后斜韌帶股骨附著點(diǎn)的描述仍存在很大差異14-16。后斜韌帶股骨附著點(diǎn)的范圍實(shí)際上超出了部分學(xué)者描述的內(nèi)側(cè)副韌帶淺層斜部的附著區(qū)域11-13,17,18，認(rèn)識(shí)到這一點(diǎn)是很重要的。直到最近，有研究發(fā)現(xiàn)在膝關(guān)節(jié)內(nèi)側(cè)面存在三個(gè)骨性突起，且后斜韌帶股骨附著點(diǎn)的描述也并不統(tǒng)一。然而，認(rèn)識(shí)清楚后斜韌帶股骨附著點(diǎn)的位置，相比內(nèi)收肌結(jié)節(jié)，其實(shí)更接近腓腸肌結(jié)節(jié)，這也很好地解釋了以上的種種混淆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, B). 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.
內(nèi)側(cè)副韌帶深層
內(nèi)側(cè)副韌帶深層主要由關(guān)節(jié)囊內(nèi)側(cè)部分增厚而形成，位于內(nèi)側(cè)副韌帶淺層的深面，可分為板股韌帶和板脛韌帶兩部分（圖1-B）。板股部分的附著點(diǎn)稍呈弧形凸起，在內(nèi)側(cè)副韌帶淺層深面，位于其股骨附著點(diǎn)以遠(yuǎn)12.6mm。板脛部分較板股部分更短更厚，止于脛骨內(nèi)側(cè)平臺(tái)關(guān)節(jié)軟骨緣稍遠(yuǎn)處，約位于內(nèi)側(cè)關(guān)節(jié)線下方3.2mm，距內(nèi)側(cè)副韌帶淺層近側(cè)脛骨止點(diǎn)上方9.0mm9。另外有學(xué)者也曾報(bào)道板股部分的附著點(diǎn)位于內(nèi)側(cè)副韌帶淺層的深面，而板脛部分則在脛骨關(guān)節(jié)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
通過(guò)體格檢查來(lái)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)（end point）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(guò)程中可以對(duì)側(cè)為基準(zhǔn)進(jìn)行對(duì)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(jí)評(píng)價(jià)方法，參照美國(guó)醫(yī)學(xué)會(huì)《運(yùn)動(dòng)損傷命名法標(biāo)準(zhǔn)》而制定（圖2，表1）20。按照該評(píng)價(jià)系統(tǒng)，單純I度：少量纖維撕裂，伴有局限性壓痛無(wú)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(jiàn)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(jí)。等級(jí)分為1 、2 和3 ，相當(dāng)于對(duì)內(nèi)側(cè)關(guān)節(jié)間隙進(jìn)行主觀評(píng)價(jià)，并與未受傷的對(duì)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(píng)價(jià)系統(tǒng)確定其最初的損傷等級(jí)，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。 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.
圖2
左膝前內(nèi)側(cè)面觀，所示為參照美國(guó)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(jí)評(píng)價(jià)標(biāo)準(zhǔn)20。單純I度損傷表現(xiàn)為局限性壓痛無(wú)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)力下可見(jiàn)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
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(zhǎng)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，膠原的退變明顯增加27。人們注意到制動(dòng)帶來(lái)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(lái)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)。 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.
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(duì)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(shí)清楚某一結(jié)構(gòu)損傷后導(dǎo)致關(guān)節(jié)異?；顒?dòng)的程度，對(duì)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(lái)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(guò)度外翻的作用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(lái)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?duì)內(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。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(shì)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(cè)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(duì)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(duì)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° 、20°及30°時(shí)，切斷內(nèi)側(cè)副韌帶深層和淺層都可觀測(cè)到后斜韌帶承載的負(fù)荷明顯增加42。這一觀測(cè)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(duì)膝關(guān)節(jié)的外翻穩(wěn)定有輔助作用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?jī)?nèi)側(cè)副韌帶深層相關(guān)功能的報(bào)道則相對(duì)較少。上文提到的順序切斷的研究對(duì)內(nèi)側(cè)副韌帶深層的功能進(jìn)行了評(píng)估，作者將其描述為一個(gè)對(duì)抗外翻負(fù)荷的輔助結(jié)構(gòu)41-43。更確切地說(shuō)，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(duì)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.
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(duì)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)立的膝關(guān)節(jié)內(nèi)側(cè)解剖重建方法（圖3）46，通過(guò)完全切開(kāi)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(guò)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46。這表明通過(guò)應(yīng)用這一方法可防止出現(xiàn)膝關(guān)節(jié)過(guò)緊，并可避免重建的移植物承受過(guò)大的負(fù)荷，而這些都是導(dǎo)致移植物失效的常見(jiàn)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.)
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(guò)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：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.
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(wèn)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(duì)邊動(dòng)作（side to side）時(shí)有不穩(wěn)的感覺(jué)，尤其患者是運(yùn)動(dòng)員，做斜切及扭轉(zhuǎn)動(dòng)作時(shí)則更為明顯。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.
臨床評(píng)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(duì)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(duì)于準(zhǔn)確地觸診和評(píng)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(wú)明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(píng)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(méi)有明確的終點(diǎn)，此時(shí)前交叉韌帶可能對(duì)外翻應(yīng)力提供一定的對(duì)抗作用41。因此，通過(guò)Lachman試驗(yàn)、前抽屜試驗(yàn)、軸移試驗(yàn)等對(duì)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. 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.
圖4
A：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?；颊叩拇笸戎糜跈z查床上以放松大腿的肌肉。通過(guò)足踝部對(duì)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)（dial test）陽(yáng)性41,48。如圖所示，患者的下肢置于90°屈膝位，并與對(duì)側(cè)正常的膝關(guān)節(jié)比對(duì)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, B). 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.
觸診膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)的股骨段和脛骨段通常可大致確定韌帶損傷的位置。前內(nèi)側(cè)抽屜試驗(yàn)，屈膝約90°并使足外旋10°至15°，然后對(duì)膝關(guān)節(jié)施加前內(nèi)側(cè)的推拉應(yīng)力，這可以用來(lái)檢查是否合并有后斜韌帶和/或后內(nèi)側(cè)關(guān)節(jié)囊的損傷。另外還有報(bào)道認(rèn)為內(nèi)側(cè)結(jié)構(gòu)完全損傷在膝關(guān)節(jié)屈曲30°和90°時(shí)都可出現(xiàn)過(guò)度外旋，導(dǎo)致脛骨外旋試驗(yàn)（dial test）陽(yáng)性41,48(圖4-B)。因此，仔細(xì)比對(duì)外翻應(yīng)力試驗(yàn)的結(jié)果，在進(jìn)行脛骨外旋試驗(yàn)時(shí)認(rèn)真評(píng)估脛骨不穩(wěn)的位置，對(duì)于辨別膝關(guān)節(jié)內(nèi)側(cè)損傷，排除可能存在的后外側(cè)損傷都是非常必要的。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).
影像評(píng)估
有研究曾報(bào)道，經(jīng)多位觀察者對(duì)相關(guān)影像學(xué)資料的判讀，可準(zhǔn)確判斷膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)的解剖標(biāo)志及相關(guān)骨性解剖的位置，可重復(fù)性良好49。在進(jìn)行膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)重建前，了解相關(guān)重要結(jié)構(gòu)附著點(diǎn)的解剖部位，比對(duì)影像學(xué)表現(xiàn)，有利于制定切實(shí)可行的術(shù)前計(jì)劃，并且也有助于術(shù)中和術(shù)后對(duì)重建或修復(fù)進(jìn)行確切的評(píng)價(jià)（圖5）。 Fig. 5 Illustrations (A) and lateral knee radiographs (B) 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.)
圖5
示意圖（A）和膝關(guān)節(jié)側(cè)位片（B）顯示基線的位置，將X線片與膝關(guān)節(jié)內(nèi)側(cè)重建時(shí)相關(guān)重要結(jié)構(gòu)附著點(diǎn)的解剖位置進(jìn)行比對(duì)。MPFL：內(nèi)側(cè)髕股韌帶附著點(diǎn)；POL：后斜韌帶；sMCL：內(nèi)側(cè)副韌帶淺層；DASM：半膜肌腱直頭附著點(diǎn)；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.
外翻應(yīng)力位X線片對(duì)于定量分析膝關(guān)節(jié)內(nèi)側(cè)損傷的程度以及明確內(nèi)側(cè)間隙增寬的位置都是很有用處的（圖6）。在一項(xiàng)研究中，臨床醫(yī)生對(duì)模擬的單純III度內(nèi)側(cè)副韌帶淺層損傷的膝關(guān)節(jié)加載負(fù)荷，使內(nèi)側(cè)關(guān)節(jié)間隙開(kāi)大，結(jié)果發(fā)現(xiàn)屈膝0° 和20°時(shí)關(guān)節(jié)間隙比正常完整的膝關(guān)節(jié)分別增寬1.7和3.2 mm50。而切斷內(nèi)側(cè)副韌帶淺層和深層以及后斜韌帶，造成膝關(guān)節(jié)內(nèi)側(cè)完全損傷后，在醫(yī)生施加的負(fù)荷下，屈膝0° 和20°時(shí)關(guān)節(jié)間隙分別增寬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.
圖6
外翻應(yīng)力位X線片顯示左膝內(nèi)側(cè)副韌帶淺層和后斜韌帶III度損傷。當(dāng)臨床醫(yī)生在屈膝20°施加應(yīng)力時(shí)，與正常的右膝相比，內(nèi)側(cè)關(guān)節(jié)間隙增寬了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通常用于評(píng)價(jià)膝關(guān)節(jié)內(nèi)側(cè)損傷的患者相關(guān)結(jié)構(gòu)的受累范圍（圖7）。在一項(xiàng)包括63例患者的研究中，由一位外科醫(yī)生對(duì)內(nèi)側(cè)副韌帶損傷進(jìn)行臨床評(píng)價(jià)后，再由一位經(jīng)驗(yàn)豐富的骨骼肌肉系統(tǒng)放射科醫(yī)生應(yīng)用1.5T MRI系統(tǒng)進(jìn)行評(píng)估，對(duì)該放射科醫(yī)生隱瞞相關(guān)的臨床表現(xiàn)，最終的結(jié)果表明，通過(guò)影像學(xué)發(fā)現(xiàn)評(píng)估內(nèi)側(cè)副韌帶損傷的準(zhǔn)確率為87%51。目前對(duì)于內(nèi)側(cè)副韌帶深層伴和/或不伴后斜韌帶損傷的研究很少。在Miller等52的前瞻性研究中，將單純內(nèi)側(cè)副韌帶損傷的患者分為骨小梁微骨折和骨挫傷兩類。在這些患者中，29例（45%）合并有骨挫傷，主要位于外側(cè)脛骨平臺(tái)（6例）或股骨外側(cè)髁（10例），或兩處均有（8例）。傷后2至4月，所有病例的損傷均完全緩解。 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.
圖7
質(zhì)子密度加權(quán)MRI顯示內(nèi)側(cè)副韌帶淺層和內(nèi)側(cè)副韌帶深層的板脛韌帶自其脛骨附著點(diǎn)上撕脫，為新鮮損傷。股骨外上髁可見(jiàn)骨小梁微骨折，這很可能是由壓縮暴力所致。箭頭所指為內(nèi)側(cè)副韌帶淺層的遠(yuǎn)端止點(diǎn)，已從脛骨附著點(diǎn)上撕脫。 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.
臨床療效
非手術(shù)治療
盡管內(nèi)側(cè)結(jié)構(gòu)的損傷在膝關(guān)節(jié)韌帶中最為常見(jiàn)，而關(guān)于其治療則仍然存在不少爭(zhēng)議。以往治療新鮮的內(nèi)側(cè)副韌帶損傷通常都采用保守療法，早期制動(dòng)并在保護(hù)下負(fù)重，據(jù)報(bào)道患者最終的療效良好53-59?？偟恼f(shuō)來(lái)，比較一致的觀點(diǎn)是，對(duì)于新鮮的單純I度或II度損傷都可首先進(jìn)行非手術(shù)治療，因?yàn)橥ǔ６伎色@得較好的臨床結(jié)果54,57,60-62。另外有幾個(gè)康復(fù)方案也是可取的，各自都獲得了滿意的療效59,61,63-66。值得注意的是，臨床醫(yī)生在處理患者時(shí)用到的這些治療方案各不相同，據(jù)我們所知，目前還沒(méi)有一項(xiàng)研究針對(duì)特定程度的膝關(guān)節(jié)內(nèi)側(cè)損傷，前瞻性地比較不同的康復(fù)治療方法（見(jiàn)附錄）。因此很難對(duì)這些研究進(jìn)行對(duì)比，然而，其所應(yīng)用的功能鍛煉及時(shí)限則有很大部分是類似的。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.
新鮮的III度膝關(guān)節(jié)內(nèi)側(cè)損傷常用非手術(shù)治療方案進(jìn)行處理，其中包括一個(gè)完整的功能康復(fù)計(jì)劃。早期的非手術(shù)治療主要指控制疼痛和腫脹，還可能包括應(yīng)用膝關(guān)節(jié)鉸鏈?zhǔn)街Ь?周，以避免其承受外翻應(yīng)力和外旋67,68。康復(fù)的方案包括即刻膝關(guān)節(jié)活動(dòng)范圍的練習(xí)，早期負(fù)重，以及漸進(jìn)性的力量訓(xùn)練，據(jù)報(bào)道可獲得優(yōu)秀的治療結(jié)果，恢復(fù)到傷前運(yùn)動(dòng)水平的比率很高69。另外還有一點(diǎn)值得引起重視，對(duì)于膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)完全斷裂的病例，非手術(shù)治療取得成功有賴于前交叉韌帶的完整性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.
手術(shù)治療
有研究表明，在新鮮的和陳舊性膝關(guān)節(jié)外翻不穩(wěn)中，內(nèi)側(cè)副韌帶淺層和后斜韌帶合并損傷的發(fā)生率很高，這也提示后斜韌帶對(duì)于維持膝關(guān)節(jié)內(nèi)側(cè)的靜態(tài)穩(wěn)定發(fā)揮了重要的作用2,14。處理這種合并損傷的手術(shù)方法包括對(duì)內(nèi)側(cè)副韌帶淺層和后斜韌帶的直接修復(fù)14、一期修復(fù)并增強(qiáng)71、內(nèi)側(cè)副韌帶淺層脛骨止點(diǎn)前移72、鵝足移位13、內(nèi)側(cè)副韌帶淺層止點(diǎn)前移伴鵝足移位73，以及重建術(shù)等，后者目前尚缺乏生物力學(xué)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.
對(duì)于傷及內(nèi)側(cè)副韌帶淺層、后斜韌帶以及內(nèi)側(cè)副韌帶深層的膝關(guān)節(jié)內(nèi)側(cè)完全損傷，我們更傾向于解剖重建內(nèi)側(cè)副韌帶淺層和后斜韌帶（圖3和8）。該方法應(yīng)用兩條移植物通過(guò)四個(gè)骨隧道分別重建膝關(guān)節(jié)內(nèi)側(cè)的兩個(gè)主要結(jié)構(gòu)46。通過(guò)一個(gè)前內(nèi)側(cè)切口或三個(gè)小的膝關(guān)節(jié)切口顯露內(nèi)側(cè)副韌帶淺層和后斜韌帶在股骨和脛骨上的解剖附著點(diǎn)46。生物力學(xué)研究顯示，切斷內(nèi)側(cè)結(jié)構(gòu)后，膝關(guān)節(jié)屈曲30°加載外翻應(yīng)力時(shí)關(guān)節(jié)間隙的松弛最為明顯，因此，正常情況下膝關(guān)節(jié)屈曲這一角度時(shí)內(nèi)側(cè)副韌帶淺層通常是繃緊的1,10,42,43。而后斜韌帶在膝關(guān)節(jié)屈曲0°時(shí)明顯繃緊，同樣按照上述的生物力學(xué)研究，膝關(guān)節(jié)屈曲0°時(shí)這一韌帶限制內(nèi)旋的作用最為明顯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.
圖8
A：術(shù)中照片顯示經(jīng)左膝單一前內(nèi)側(cè)切口暴露內(nèi)側(cè)副韌帶淺層（sMCL）和后斜韌帶（POL）在股骨和脛骨的解剖附著點(diǎn)。解剖重建須用到兩條相互獨(dú)立的移植肌腱并建立4個(gè)骨隧道46。圖中植入的內(nèi)側(cè)副韌帶淺層和后斜韌帶的股骨端均已固定在其股骨骨隧道中。B：在該圖中，內(nèi)側(cè)副韌帶淺層和后斜韌帶的移植肌腱沿其各自的解剖路徑，從縫匠肌筋膜深面穿出，而后斜韌帶移植肌腱的遠(yuǎn)端也已固定在其脛骨骨隧道中。接下來(lái)再將內(nèi)側(cè)副韌帶淺層的移植肌腱穿入骨隧道，在屈膝30°位時(shí)進(jìn)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).
術(shù)后康復(fù)
手術(shù)以后，必須在關(guān)節(jié)內(nèi)發(fā)生粘連之前盡早開(kāi)始活動(dòng)膝關(guān)節(jié)。重要的一點(diǎn)是術(shù)前應(yīng)告知患者，可能需要等到術(shù)后6至9個(gè)月才能完全恢復(fù)運(yùn)動(dòng)。我們醫(yī)院應(yīng)用的一套治療方案，非常注重早期活動(dòng)和力量練習(xí)（見(jiàn)附錄）。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.
在膝關(guān)節(jié)重建術(shù)后的第一周，避免進(jìn)行過(guò)度的關(guān)節(jié)活動(dòng)范圍的練習(xí)是非常關(guān)鍵的。然而，也必須告知患者在術(shù)后的前兩周內(nèi)，膝關(guān)節(jié)活動(dòng)范圍的練習(xí)應(yīng)在屈曲0°到90°之間；并且術(shù)后應(yīng)該立即佩戴鉸鏈?zhǔn)街Ь哌M(jìn)行簡(jiǎn)單的力量練習(xí)。主要包括股四頭肌的等長(zhǎng)練習(xí)、直腿抬舉、伸髖及外展練習(xí)等。最初的關(guān)節(jié)活動(dòng)范圍練習(xí)主要是為了防止粘連形成，伸展的范圍可達(dá)0°，但必須避免過(guò)伸以及屈曲超過(guò)90°，否則可能會(huì)使移植的肌腱承受過(guò)度的張力。最初兩周過(guò)后，如果患者能耐受則可逐漸進(jìn)行全范圍的膝關(guān)節(jié)屈曲活動(dòng)。一般推薦重建術(shù)后約4個(gè)月內(nèi)不要進(jìn)行對(duì)抗性的或反復(fù)的腘繩肌練習(xí)，以使關(guān)節(jié)的水平移位減至最小，而這種水平移位則可能會(huì)拉長(zhǎng)尚未愈合的移植肌腱。最初6周在保護(hù)下進(jìn)行負(fù)重練習(xí)，此后可進(jìn)行閉鏈運(yùn)動(dòng)以強(qiáng)化其功能。并可雙上肢抓扶下開(kāi)始進(jìn)行下蹲練習(xí)，但屈膝應(yīng)限制在70°以內(nèi)，以盡可能減少關(guān)節(jié)的過(guò)度移位。告知患者應(yīng)避免脛骨外旋和內(nèi)旋，務(wù)必向其宣教，在足部固定時(shí)不能做肢體的旋轉(zhuǎn)動(dòng)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周開(kāi)始可允許完全負(fù)重，此時(shí)應(yīng)特別注意恢復(fù)正常的步態(tài)。同樣，醫(yī)生也應(yīng)該注意觀察，判斷患者是否能耐受完全負(fù)重練習(xí)以及是否出現(xiàn)滲出、積液。持續(xù)的關(guān)節(jié)腔積液會(huì)使股四頭肌的功能受到抑制，此時(shí)應(yīng)暫停負(fù)重練習(xí)，加強(qiáng)力量訓(xùn)練。醫(yī)生必須密切觀察患者的步態(tài)，確認(rèn)其行走的站立期沒(méi)有出現(xiàn)膝關(guān)節(jié)過(guò)伸和股四頭肌廢用的情況。另外還有一點(diǎn)也非常關(guān)鍵，患者應(yīng)避免患足站立時(shí)倚靠在外側(cè)的支柱上以圖減輕關(guān)節(jié)的負(fù)荷，這個(gè)動(dòng)作實(shí)際上會(huì)增加膝關(guān)節(jié)的外翻力矩，甚至可能損傷移植的肌腱。術(shù)后16至20周，如果患肢的力量、關(guān)節(jié)活動(dòng)及本體感覺(jué)都恢復(fù)良好，則可以開(kāi)始進(jìn)行慢跑、基本的超等長(zhǎng)收縮訓(xùn)練和靈活性訓(xùn)練。患者在進(jìn)行間隙性的慢跑之前，必須能夠堅(jiān)持快走1至2英里（1.6至3.2km）無(wú)跛行，且單腿蹲時(shí)有足夠的運(yùn)動(dòng)控制能力。如果患者能夠順利完成這一康復(fù)計(jì)劃，功能測(cè)試提示力量恢復(fù)滿意且客觀的臨床檢查顯示膝關(guān)節(jié)穩(wěn)定性良好，此時(shí)外科醫(yī)生才可以考慮和患者探討完全恢復(fù)運(yùn)動(dòng)。膝關(guān)節(jié)內(nèi)側(cè)重建同時(shí)還進(jìn)行了前交叉韌帶重建的患者也可采用類似的康復(fù)計(jì)劃，不過(guò)完全恢復(fù)運(yùn)動(dòng)的時(shí)間還要更長(zhǎng)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.
有爭(zhēng)議的問(wèn)題
所謂的Pellegrini-Stieda綜合征一般都通過(guò)正位X線片來(lái)診斷，以內(nèi)側(cè)副韌帶股骨附著點(diǎn)附近的韌帶內(nèi)鈣化為特征，通常是由于韌帶的陳舊性撕裂所致（圖9）74。對(duì)于內(nèi)側(cè)副韌帶淺層創(chuàng)傷后異位骨化導(dǎo)致的局部輕到中度疼痛，有報(bào)道可采用局部皮質(zhì)類固醇注射及關(guān)節(jié)活動(dòng)范圍練習(xí)來(lái)治療75。而對(duì)于更為嚴(yán)重的病例，則可考慮切除鈣化的組織并對(duì)內(nèi)側(cè)副韌帶的陳舊性撕裂進(jìn)行妥善處理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).
圖9
右膝正位片顯示創(chuàng)傷后異位骨化，即所謂的Pellegrini-Stieda綜合征。其典型的表現(xiàn)為內(nèi)側(cè)副韌帶股骨附著點(diǎn)附近的韌帶內(nèi)鈣化（箭頭所示）。 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 reconstruction(s) and 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.
另外一個(gè)有爭(zhēng)議的問(wèn)題便是存在的合并損傷，這可能會(huì)干擾體格檢查的相關(guān)表現(xiàn)24。如果膝關(guān)節(jié)多發(fā)的韌帶損傷具備一期手術(shù)修補(bǔ)或重建的指征，則應(yīng)該在傷后盡早手術(shù)并同期進(jìn)行交叉韌帶重建，否則可能會(huì)出現(xiàn)瘢痕組織增生、殘留組織回縮以及組織壞死等問(wèn)題，這不僅會(huì)使殘余腱性組織的質(zhì)量下降，也有可能會(huì)影響修復(fù)手術(shù)的效果。此外，對(duì)于存在外翻畸形而需要進(jìn)行重建的患者，手術(shù)宜盡早進(jìn)行，因?yàn)橐坏┳兂申惻f性的損傷，重建后移植肌腱被拉出的風(fēng)險(xiǎn)明顯增高。為了防止關(guān)節(jié)腔滲液，無(wú)論在初次手術(shù)暴露之前還是之后，關(guān)節(jié)鏡檢查都是很有幫助的，可以明確是否存在半月板撕裂并且還可以確定內(nèi)側(cè)副韌帶深層損傷的部位。對(duì)于膝關(guān)節(jié)內(nèi)側(cè)嚴(yán)重?fù)p傷的患者，在出現(xiàn)關(guān)節(jié)腔積液之前進(jìn)行手術(shù)治療明確受損的內(nèi)側(cè)結(jié)構(gòu)是很有意義的，否則，確定相關(guān)損傷的診斷將會(huì)更加困難。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.
膝關(guān)節(jié)內(nèi)側(cè)韌帶完全損傷并非全部都會(huì)愈合，對(duì)于膝關(guān)節(jié)內(nèi)側(cè)陳舊性的損傷，如果患者出現(xiàn)不穩(wěn)定的癥狀、疼痛以及內(nèi)側(cè)關(guān)節(jié)間隙過(guò)大等，通常都適合進(jìn)行手術(shù)治療。而由于陳舊性撕裂具有韌帶斷端攣縮，瘢痕組織增生以及愈合的潛力喪失等特征，一般須要應(yīng)用自體或同種異體腘繩肌腱進(jìn)行重建。在最初的手術(shù)處理后，可應(yīng)用關(guān)節(jié)鏡進(jìn)行檢查，以識(shí)別并處理關(guān)節(jié)內(nèi)的損傷，比如軟骨缺損或半月板撕裂等。處理膝關(guān)節(jié)內(nèi)側(cè)損傷的方法有很多種，包括肌腱轉(zhuǎn)移、前置、緊縮手術(shù)，自體或同種異體肌腱重建等均有報(bào)道77-79。然而，陳舊性損傷由于關(guān)節(jié)囊周圍廣泛的瘢痕增生，往往須要對(duì)內(nèi)側(cè)副韌帶前側(cè)和后斜韌帶進(jìn)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.
膝關(guān)節(jié)內(nèi)側(cè)修復(fù)和重建的手術(shù)入路通常都采用前內(nèi)側(cè)切口40,46,78-82。隱神經(jīng)行經(jīng)膝關(guān)節(jié)內(nèi)側(cè)，術(shù)中較易導(dǎo)致神經(jīng)損傷。在膝關(guān)節(jié)水平損傷隱神經(jīng)可能會(huì)導(dǎo)致一系列的神經(jīng)癥狀，如一定程度的感覺(jué)障礙83以及神經(jīng)性疼痛84等。有解剖學(xué)研究明確了隱神經(jīng)縫匠肌支的具體位置，進(jìn)而指出了膝關(guān)節(jié)內(nèi)側(cè)重建手術(shù)的安全區(qū)域可避免傷及神經(jīng)（圖10）85。隱神經(jīng)縫匠肌支的走行位于內(nèi)側(cè)副韌帶淺層和后斜韌帶的稍后方，而這兩者恰是最常見(jiàn)的由于損傷而需要進(jìn)行修復(fù)或重建的膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)85,86。為了在完全修復(fù)或重建膝關(guān)節(jié)內(nèi)側(cè)結(jié)構(gòu)恢復(fù)其正常解剖形態(tài)的同時(shí)避免損傷神經(jīng)87，確切地了解隱神經(jīng)縫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].)
圖10
圖示為膝關(guān)節(jié)內(nèi)側(cè)面隱神經(jīng)及其縫匠肌支和髕下支的走行，所標(biāo)為神經(jīng)與相關(guān)解剖標(biāo)志之間測(cè)得的距離。（經(jīng)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').
附錄
表格中詳例了文獻(xiàn)中報(bào)道的有關(guān)膝關(guān)節(jié)內(nèi)側(cè)損傷的病例系列研究；另外還對(duì)這一損傷的康復(fù)計(jì)劃進(jìn)行了敘述。具體可通過(guò)我們的網(wǎng)站jbjs.org參閱本文的電子版（至本文題錄下點(diǎn)擊“Supporting data”）。
