Richter Dustin, Wascher Daniel C, Schenck Robert C
Department of Orthopaedics, University of New Mexico School of Medicine, MSC 10 5600, Albuquerque, NM, 87131, USA,
Clin Orthop Relat Res. 2014 Sep;472(9):2680-90. doi: 10.1007/s11999-014-3557-2.
Treatment of traumatic knee dislocations remains controversial and challenging. Current techniques for PCL reconstruction utilize either a transtibial approach with potential risk of vascular injury from drilling toward the popliteal artery or a tibial inlay technique with prone patient positioning, which is cumbersome and adds operative time. We therefore developed a surgical technique using a supine posteromedial approach for PCL tibial inlay reconstruction for the treatment of Schenck KDIIIM (ACL/PCL/medial collateral ligament) knee dislocations. In patients undergoing this technique, we evaluated patient-reported outcome scores, ROM, stability, and complications.
Tibial inlay PCL reconstructions were performed through a posteromedial approach with the patient supine, knee flexed, and hip externally rotated, thus avoiding prone patient positioning. The inlay approach uses the interval between the medial head of the gastrocnemius and the pes anserinus (gracilis and semitendinosus), with release of the semimembranosus tendon approximately 1 cm from its insertion on the tibia. Retraction of the medial gastrocnemius and semimembranosus allows access to the posteromedial aspect of the proximal tibia while protecting the neurovascular bundle.
All 11 patients sustaining a KDIIIM multiligamentous knee injury treated between 2002 and 2011 with a three-ligament reconstruction received this posteromedial approach. Seven patients were available for complete evaluation, and one completed telephone followup only. Mean followup was 6.0 years (range, 2.0-11.2 years). Clinical evaluation included Lysholm and Tegner activity scores and measurements of ROM and knee laxity. We also recorded complications.
Mean Lysholm and Tegner activity scores were 81 and 4.9, respectively, with three patients returning to recreational or competitive sports. Mean knee flexion was 120° (range, 106°-137°); however, two patients had stiffness in flexion, lacking greater than 20° of flexion compared to the contralateral side. Five had less than 3 mm of translation. Three returned to the operating room, two for arthrofibrosis or painful hardware and a third for ACL reinjury requiring revision reconstruction; there were no vascular injuries.
Outcome scores, stability, and complications using this surgical technique were comparable to those found in other studies. The posteromedial approach for tibial inlay avoids prone positioning and the incisions are minimized, allowing safe exposure for combined medial and posterior ligament reconstruction. Further studies are needed to compare this method with others in the treatment of KDIIIM knee dislocations.
创伤性膝关节脱位的治疗仍存在争议且具有挑战性。目前的后交叉韧带（PCL）重建技术，要么采用经胫骨入路，存在钻孔朝向腘动脉导致血管损伤的潜在风险，要么采用胫骨嵌体技术，但患者需俯卧位，操作繁琐且增加手术时间。因此，我们开发了一种采用仰卧位后内侧入路进行PCL胫骨嵌体重建的手术技术，用于治疗申克KDIIIM型（前交叉韧带/后交叉韧带/内侧副韧带）膝关节脱位。对于接受该技术治疗的患者，我们评估了患者报告的结局评分、关节活动度（ROM）、稳定性和并发症情况。
PCL胫骨嵌体重建通过后内侧入路进行，患者仰卧，膝关节屈曲，髋关节外旋，从而避免患者俯卧位。嵌体入路利用腓肠肌内侧头和鹅足（股薄肌和半腱肌）之间的间隙，在半膜肌腱距胫骨附着点约1 cm处进行松解。牵开腓肠肌内侧头和半膜肌，可显露胫骨近端的后内侧，同时保护神经血管束。
2002年至2011年间，所有11例接受三联韧带重建治疗KDIIIM型多韧带损伤膝关节的患者均采用了这种后内侧入路。7例患者可进行完整评估，1例仅完成了电话随访。平均随访时间为6.0年（范围2.0 - 11.2年）。临床评估包括Lysholm和Tegner活动评分以及ROM和膝关节松弛度测量。我们还记录了并发症情况。
平均Lysholm和Tegner活动评分分别为81分和4.9分，3例患者恢复了娱乐性或竞技性运动。平均膝关节屈曲度为120°（范围106° - 137°）；然而，2例患者存在屈曲僵硬，与对侧相比，屈曲度减少超过20°。5例患者的移位小于3 mm。3例患者返回手术室，2例因关节纤维化或内植物疼痛，第3例因前交叉韧带再次损伤需要翻修重建；未发生血管损伤。
使用该手术技术的结局评分、稳定性和并发症情况与其他研究结果相当。胫骨嵌体的后内侧入路避免了俯卧位，切口最小化，为内侧和后交叉韧带联合重建提供了安全的显露。需要进一步研究将该方法与其他方法在KDIIIM型膝关节脱位的治疗中进行比较。
