Floyd Edward R, Carlson Gregory B, Monson Jill K, LaPrade Robert F
Twin Cities Orthopedics, Minneapolis, Minnesota, USA.
School of Medicine & Health Sciences, University of North Dakota, Fargo, North Dakota, USA.
Video J Sports Med. 2021 Nov 11;1(6):26350254211039223. doi: 10.1177/26350254211039223. eCollection 2021 Nov-Dec.
Multiple ligament injuries of the knee occur in a variety of settings, often from athletic activities. Multiple cruciate and collateral ligament injuries may be associated with hamstring tendon rupture, common peroneal nerve (CPN) injury, meniscus, bone, and cartilage damage.
After evaluation for concomitant life-threatening and vascular injuries (especially of the popliteal artery), the knee is assessed through a thorough physical examination and imaging series, including varus, valgus, and posterior stress radiography, and magnetic resonance imaging (MRI). Research over the last 30 years has suggested that operative treatment in the acute setting (<3 weeks) in a single-stage procedure may have improved results to delayed/staged reconstruction. Early range of motion starting on postoperative day 1 is important to prevent development of arthrofibrosis.
We describe the technique used to surgically manage a patient suffering from anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and complete posterolateral corner (PLC) rupture. Neurolysis of the CPN is performed to free the irritated nerve from scar tissue, along with biceps femoris tendon and lateral capsular repairs. Anatomic-based reconstructions are performed. The ACL reconstruction is with a single bundle using a patellar tendon autograft, PCL reconstruction is a double bundle with Achilles and tibialis anterior tendon allografts, and PLC reconstruction is accomplished with a split Achilles tendon allograft. The correct orientation of tunnel placement must be planned to avoid tunnel convergence; these angles have been determined through 3D modeling. The optimal sequence for graft tensioning has been established and follows the pattern: PCL, ACL, PLC, and then medial-sided structures if necessary.
Successful outcomes have been reported for both medial and lateral based injuries, and follow-up studies have also shown equivalent results between acute and chronic outcomes, and for multiligament injuries involving the ACL and PCL if anatomic reconstructions with appropriate tunnel angles, passage and tensioning sequence of grafts, and rehabilitation regimens are performed.
DISCUSSION/CONCLUSION: Single-stage anatomic reconstruction is the gold standard for managing multiple ligament injuries in the knee. Commencement of early 0° to 90° knee range of motion and PCL-supporting bracing are critical to prevent arthrofibrosis and protect the grafts from attenuation.
膝关节多发韧带损伤发生于多种情况，常源于体育活动。多条交叉韧带和侧副韧带损伤可能伴有腘绳肌腱断裂、腓总神经（CPN）损伤、半月板、骨骼和软骨损伤。
在评估是否伴有危及生命的损伤和血管损伤（尤其是腘动脉损伤）后，通过全面的体格检查和影像学检查系列评估膝关节，包括内翻、外翻和后应力X线摄影以及磁共振成像（MRI）。过去30年的研究表明，在急性期（<3周）进行单阶段手术治疗可能比延迟/分期重建有更好的效果。术后第1天开始早期活动范围对于预防关节纤维化的发生很重要。
我们描述了用于手术治疗一名患有前交叉韧带（ACL）、后交叉韧带（PCL）和完全后外侧角（PLC）断裂患者的技术。对CPN进行神经松解，以将受刺激的神经从瘢痕组织中游离出来，同时进行股二头肌肌腱和外侧关节囊修复。进行基于解剖的重建。ACL重建采用单束自体髌腱移植，PCL重建采用双束同种异体跟腱和胫骨前肌腱移植，PLC重建采用劈开的同种异体跟腱移植。必须规划隧道放置的正确方向以避免隧道汇聚；这些角度已通过三维建模确定。已确定移植物张紧的最佳顺序，遵循以下模式：PCL、ACL、PLC，如有必要，然后是内侧结构。
对于基于内侧和外侧的损伤均报告了成功的结果，随访研究还表明，在急性和慢性结果之间以及对于涉及ACL和PCL的多韧带损伤，如果进行具有适当隧道角度、移植物通道和张紧顺序以及康复方案的解剖重建，则结果相当。
讨论/结论：单阶段解剖重建是治疗膝关节多发韧带损伤的金标准。早期开始0°至90°膝关节活动范围以及使用PCL支撑支具对于预防关节纤维化和保护移植物免于松弛至关重要。
