Twin Cities Orthopedics, Edina-Crosstown. Edina, Minnesota, U.S.A.; Georgetown University School of Medicine, Washington, District of Columbia, U.S.A.
Twin Cities Orthopedics, Edina-Crosstown. Edina, Minnesota, U.S.A.; TrainingHaus, Twin Cities Orthopedics, Viking-Lakes, Eagan, Minnesota, U.S.A.
Arthroscopy. 2021 May;37(5):1378-1380. doi: 10.1016/j.arthro.2021.03.033.
Patients with multiligament knee injuries require a thorough examination (Lachman, posterior-drawer, varus, valgus, and rotational testing). Diagnoses are confirmed with magnetic resonance imaging as well as stress radiographs (posterior, varus, and valgus) when indicated. Multiple systematic reviews have reported that early (<3 weeks after injury) single-stage surgery and early knee motion improves patient-reported outcomes. Anatomic-based reconstructions of the torn primary static stabilizers and repair of the capsular structures and any tendinous avulsions are performed in a single-stage. Open anteromedial or posterolateral incisions are preferentially performed first to identify the torn structures and to prepare the posterolateral corner (PLC) and medial knee reconstruction tunnels. Next, arthroscopy allows preparation of the anterior cruciate ligament (ACL) and double-bundle (DB) posterior cruciate ligament (PCL) tunnels. Careful attention to tunnel trajectory minimizes the risk for convergence. Meniscal tears are preferentially repaired (root and ramp tears are commonly seen in this patient group). Graft passage is performed after all tunnels are reamed. The graft tensioning and fixation sequence is as follows: anterolateral bundle of the PCL to restore the central pivot, posteromedial bundle of the PCL, ACL, PLC (including fibular [lateral] collateral ligament), and posteromedial corner (including medial collateral ligament). Graft integrity and full knee range of motion should be verified before closure. Physical therapy commences on postoperative day 1 with immediate knee motion (flexion from 0°-90°; prone for DB-PCL reconstruction) and quadriceps activation. Patients are nonweightbearing for 6 weeks. Patients with ACL-based reconstructions wear an immobilizer for 6 weeks then transition to a hinged ACL brace. Patients with PCL-based reconstructions transition into a dynamic PCL brace once swelling subsides and wear it routinely for 6 months. Functional testing and stress radiography are performed to validate return to sports.
患者有多发性膝关节韧带损伤需要进行全面检查（包括前抽屉试验、Lachman 试验、内翻试验、外翻试验和旋转试验）。诊断需要通过磁共振成像和有指征的应力位 X 线片（后位、内翻、外翻位）来确认。多项系统评价报告称，早期（受伤后<3 周）行单阶段手术和早期膝关节活动可改善患者的报告结局。对撕裂的主要静态稳定结构进行解剖重建，并修复囊状结构和任何腱性撕脱，在单阶段手术中完成。首先优先采用前内侧或后外侧入路，以识别撕裂结构，并准备后外侧角（PLC）和内侧膝关节重建隧道。然后，关节镜允许准备前交叉韧带（ACL）和双束（DB）后交叉韧带（PCL）隧道。仔细注意隧道轨迹可最大程度降低汇聚风险。半月板撕裂通常优先修复（该患者群中常可见到半月板根部和半月板前角撕裂）。所有隧道扩孔后进行移植物穿过。移植物的张力和固定顺序如下：PCL 的前外侧束以恢复中心旋转轴，PCL 的后内侧束，ACL，PLC（包括腓侧[外侧]副韧带）和后内侧角（包括内侧副韧带）。在关闭前应验证移植物的完整性和膝关节的全范围活动度。术后第 1 天开始进行物理治疗，立即进行膝关节活动（从 0°-90°屈曲；DB-PCL 重建时为俯卧位）和股四头肌激活。患者 6 周内不负重。ACL 重建患者佩戴支具 6 周，然后过渡到铰链式 ACL 支具。PCL 重建患者一旦肿胀消退，过渡到动态 PCL 支具，并常规佩戴 6 个月。进行功能测试和应力位 X 线片检查，以验证重返运动。
