Moatshe Gilbert, Slette Erik L, Engebretsen Lars, LaPrade Robert F
Steadman Philippon Research Institute, Vail, Colorado, USA
Oslo University Hospital, Oslo, Norway.
Am J Sports Med. 2016 Nov;44(11):2864-2869. doi: 10.1177/0363546516656371. Epub 2016 Jul 28.
Knee dislocations are rare but potentially devastating injuries, often involving tears of multiple knee ligaments. Several studies have reported improved clinical and functional outcomes with surgical management of torn knee ligaments compared with nonsurgical management. Most multiple ligament reconstruction techniques involve creating several tunnels for various reconstruction grafts, posing a risk of tunnel convergence in the proximal tibia.
To assess the risk of tunnel convergence and determine the optimal tunnel placement for the reconstruction of multiple ligaments in the tibia.
Descriptive laboratory study.
Three-dimensional knee models were developed using customized software from computed tomography images of 21 patients. Mimics software was used to create tunnels for each of the 4 primary ligamentous structures, replicating a surgical approach that would be used in actual multiple ligament reconstruction surgery. The tunnel orientation was varied in anatomically relevant directions to find orientations that did not result in tunnel convergence.
There was a high risk of tunnel convergence (66.7%) between the posterior cruciate ligament (PCL) and posterior oblique ligament (POL) tunnels when the POL tunnel was aimed toward the Gerdy tubercle as suggested in the literature. No tunnel convergence was observed when the POL tunnel was aimed 15 mm medial to the Gerdy tubercle. No tunnel convergence was observed between the anterior cruciate ligament (ACL) and POL. Tunnel convergence was observed between the PCL and superficial medial collateral ligament (sMCL) in 19.0% of cases when the sMCL tunnel was aimed transversely across the tibia. Aiming the sMCL tunnel transversely and directing 30° distally significantly increased the mean distance between the sMCL and PCL to 6.9 mm (P < .001), and no tunnel convergence was observed. No tunnel convergence was observed between the PCL and posterolateral corner tunnels or between the ACL and PCL tunnels.
There is a high risk of tunnel convergence in the proximal tibia during the reconstruction of multiple knee ligaments. Aiming the POL tunnel 15 mm medial to the Gerdy tubercle and the sMCL tunnel transversely across the tibia (anterior to the fibula) and 30° distal to the horizontal plane reduces the risk of tunnel convergence.
The tunnel orientation of the POL and sMCL on the tibia should be adjusted to avoid convergence with the PCL tunnel during multiple ligament knee reconstruction.
膝关节脱位虽罕见，但可能造成严重损伤，常伴有多条膝关节韧带撕裂。多项研究报告称，与非手术治疗相比，手术治疗撕裂的膝关节韧带可改善临床和功能预后。多数多韧带重建技术需要为各种重建移植物创建多个隧道，这存在胫骨近端隧道汇聚的风险。
评估隧道汇聚的风险，并确定胫骨多韧带重建的最佳隧道位置。
描述性实验室研究。
利用定制软件根据21例患者的计算机断层扫描图像构建三维膝关节模型。使用Mimics软件为4条主要韧带结构分别创建隧道，复制实际多韧带重建手术中使用的手术方法。在解剖学相关方向上改变隧道方向，以找到不会导致隧道汇聚的方向。
当按照文献建议将后斜韧带（POL）隧道对准Gerdy结节时，后交叉韧带（PCL）和POL隧道之间存在较高的隧道汇聚风险（66.7%）。当POL隧道对准Gerdy结节内侧15 mm处时，未观察到隧道汇聚。前交叉韧带（ACL）和POL之间未观察到隧道汇聚。当浅层内侧副韧带（sMCL）隧道横向穿过胫骨时，PCL和sMCL之间在19.0%的病例中观察到隧道汇聚。将sMCL隧道横向设置并向远端倾斜30°可使sMCL和PCL之间的平均距离显著增加至6.9 mm（P <.001），且未观察到隧道汇聚。PCL与后外侧角隧道之间以及ACL与PCL隧道之间未观察到隧道汇聚。
在多韧带膝关节重建过程中，胫骨近端存在较高的隧道汇聚风险。将POL隧道对准Gerdy结节内侧15 mm处，将sMCL隧道横向穿过胫骨（位于腓骨前方）并与水平面成30°向远端倾斜，可降低隧道汇聚风险。
在多韧带膝关节重建过程中，应调整胫骨上POL和sMCL的隧道方向，以避免与PCL隧道汇聚。
