1、InjuriestotheMedialCollateralLigamentandAssociatedMedialStructuresoftheKnee膝關節(jié)內(nèi)側(cè)副韌帶及相關內(nèi)側(cè)結(jié)構(gòu)的損傷CoenA.Wijdicks,PhDl,ChadJ.Griffith,MD2,SteinarJohansen,MD3,LarsEngebretsen,MD,PhD3andRobertF.LaPrade,MD,PhD4InvestigationperformedattheDepartmentofOrthopaedicSurgery,UniversityofMinnesota,Minneapolis,Minneso

2、ta,andtheOsloUniversityHospitalandFacultyofMedicine,UniversityofOslo,Oslo,NorwayThesuperficialmedialcollateralligamentandothermedialkneestabilizersi.e.,thedeepmedialcollateralligamentandtheposteriorobliqueligamentarethemostcommonlyinjuredligamentousstructuresoftheknee.Themainstructuresofthemedialasp

3、ectofthekneearetheproximalanddistaldivisionsofthesuperficialmedialcollateralligament,themeniscofemoralandmeniscotibialdivisionsofthedeepmedialcollateralligament,andtheposteriorobliqueligament.Physicalexaminationistheinitialmethodofchoiceforthediagnosisofmedialkneeinjuriesthroughtheapplicationofavalg

4、usloadbothatfullkneeextensionandbetween20and30ofkneeflexion.Becausenonoperativetreatmenthasafavorableoutcome,thereisaconsensusthatitshouldbethefirststepinthemanagementofacuteisolatedgrade-IIIinjuriesofthemedialcollateralligamentorsuchinjuriescombinedwithananteriorcruciateligamenttear.Ifoperativetrea

5、tmentisrequired,ananatomicrepairorreconstructionisrecommended.口內(nèi)側(cè)副韌帶淺層及其他內(nèi)側(cè)的膝關節(jié)穩(wěn)定結(jié)構(gòu)一一即內(nèi)側(cè)副韌帶深層和后斜韌帶一一是損傷最為多見的膝關節(jié)韌帶結(jié)構(gòu)。口膝關節(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?？谠谙リP節(jié)完全伸直以及屈曲20。-30。時施加外翻應力進行體格檢查是診斷膝關節(jié)內(nèi)側(cè)損傷的首要方法。口由于非手術治療通常可獲得良好的療效，一般認為新鮮的單純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才考慮一期進行處理?？谌绫匦柽M行手術治療則推薦進行解剖修

6、復或重建。Theunderstandingoftheanatomy,biomechanics,andtreatmentofmedialkneeinjuriescontinuestoevolve.Quantitativetechniquesforthemeasurementofanatomicstructuresandbiomechanicaltestinganddigitalradiographyhaveimprovedanatomicdefinitionoftheseverityofinjuries.Thedevelopmentofnewreconstructiontechniquesmay

7、leadtoimprovedsurgicaloutcomes.Thesuperficialmedialcollateralligamentandothermedialkneestabilizersi.e.,thedeepmedialcollateralligamentandtheposteriorobliqueligamentarethemostcommonlyinjuredligamentousstructuresofthekneel-4.Theincideneeofinjuriestothesemedialkneestructureshasbeenreportedtobe0.24per10

8、00intheUnitedStatesinanygivenyear5andtobetwiceashighinmales(0.36comparedwith0.18infemales)5.Themajorityofmedialkneeligamenttearsareisolated.Theseinjuriesoccurpredominantlyinyoungindividualsparticipatinginsportsactivities,withthemechanismofinjuryinvolvingvalguskneeloading,externalrotation,oracombined

9、forcevectoroccurringinsuchsportsasskiing,icehockey,andsoccer，whichrequirekneeflexion6-8.對膝關節(jié)內(nèi)側(cè)損傷的解剖、生物力學和治療的探索仍在不斷推進，采用定量的方法測定解剖結(jié)構(gòu)以及相關的生物力學試驗和數(shù)字X線攝影(DR)使得損傷的嚴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一步改善手術結(jié)果。內(nèi)側(cè)副韌帶淺層及其他內(nèi)側(cè)的膝關節(jié)穩(wěn)定結(jié)構(gòu)一一即內(nèi)側(cè)副韌帶深層和后斜韌帶一一是損傷最為多見的膝關節(jié)韌帶結(jié)構(gòu)1-4。據(jù)報道5,在美國每年這樣的膝關節(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

10、則是女性的兩倍(0.36/0.18)。大多數(shù)膝關節(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動的年輕患者中尤其多見，受傷機制主要包括膝關節(jié)外翻暴力，外旋或者在需要屈膝的運動中，如滑雪、冰球、足球等，多個方向的應力聯(lián)合作用導致?lián)p傷6-8。AnatomySuperficialMedialCollateralLigamentThesuperficialmedialcollateralligament,commonlycalledthetibialcollateralligament,isthelargeststructureofthemedialaspectoftheknee(Fig.1,A).Th

11、isstructureconsistsofonefemoralattachmentandtwotibialattachments9.Quantitativeassessmenthasshownthefemoralattachmenttobeovaland,ontheaverage,3.2mmproximaland4.8mmposteriortothemedialepicondyle.Asthesuperficialmedialcollateralligamentcoursesdistally,ithastwotibialattachments.Theproximaltibialattachme

12、ntisprimarilytosofttissueovertheterminationoftheanteriorarmofthesemimembranosustendonandislocatedanaverageof12.2mmdistaltothetibialjointline9.Thedistaltibialattachmentofthesuperficialmedialcollateralligamentisbroadandisdirectlytoboneatanaverageof61.2mmdistaltothetibialjointline;itislocatedjustanteri

13、ortotheposteromedialcrestofthetibia9.Thetwodistinettibialattachmentshavebeenreportedtoresultintwodistinctfunctioningdivisionsofthesuperficialmedialcollateralligament10.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)在股骨有一個附著點，在脛骨有兩個附著點9,定量研究顯示股骨附著點為卵圓形，平均距離內(nèi)上髁上方3.2mm后方4.8mm。內(nèi)側(cè)副韌帶淺層向遠端延伸，在脛骨有兩個止點，近端止

14、點主要以一層軟組織覆蓋半膜肌腱前頭的止點，位于脛骨關節(jié)線下方平均12.2mm處9；遠端止點較寬，直接附于骨上，距脛骨關節(jié)線遠端平均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獨立的附著點使其成為了兩個不同的功能組分10。sMCL(proximal)POLsMCL(distal)snsoumqEaEE10mm,respectively,whencomparedwiththeuninjured,contralateralside3,21-24.Clinicianscanutilizethissystemtodefinetheinitialgradeofinjury,

15、toplantreatment(nonoperativeoroperative),andtodetermineevideneeofhealingwithnonoperativetreatment.分型通過體格檢查來了解膝關節(jié)內(nèi)側(cè)韌帶損傷的程度，主要依賴于兩個方面：患者放松的程度以及醫(yī)生在患膝屈曲20。至30時加載外翻負荷后檢出其終點(endpoint)的能力。如果患者由于疼痛而進行保護或者醫(yī)生不愿給患者造成更嚴重的疼痛，外翻應力試驗或外翻應力位X線攝影則可能會低估膝關節(jié)內(nèi)側(cè)的松弛程度。檢查過程中可以對側(cè)為基準進行對比。膝關節(jié)內(nèi)側(cè)損傷有一個被廣泛應用的等級評價方法，參照美國醫(yī)學會運動損傷命名法標

16、準而制定(圖2,表1)20。按照該評價系統(tǒng)，單純I度：少量纖維撕裂，伴有局限性壓痛無松弛；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)為外翻應力下可見完全斷裂及松弛。單純膝關節(jié)內(nèi)側(cè)損傷也可以按照施加外翻應力時松弛的程度進行分級。等級分為1+、2+和3+,相當于對內(nèi)側(cè)關節(jié)間隙進行主觀評價，并與未受傷的對側(cè)相比較，分別增寬3-5mm、6-10mm及10mm以上3,21-24。臨床醫(yī)生可以參照這一評價系統(tǒng)確定其最初的損傷等級，制定治療計劃(手術或非手術)，并可作為非手術治療愈合與否的驗證手段。PosteriorObliq

17、ueLigamentsuperficialMedialCollateralLigamentGradeIG日血IIFig.2Anteromedialviewoftheleftknee,showingtheinjurygradingscaleestablishedbytheAmericanMedicalAssociationStandardNomenclatureofAthleticInjuries20.Isolatedgrade-Iinjuriespresentwithlocalizedtendernessandnolaxity.Isolatedgrade-IIinjuriespresentwi

18、thabroaderareaoftendernessandpartiallytornmedialcollateralandposteriorobliquefibers.Isolatedgrade-IIIinjuriespresentwithcompletedisruption,andthereislaxitywithanappliedvalgusstress.圖2左膝前內(nèi)側(cè)面觀，所示為參照美國醫(yī)學會運動損傷命名法標準制定的損傷等級評價標準20。單純I度損傷表現(xiàn)為局限性壓痛無松弛；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，在外翻應力下可

19、見松弛。表1膝關節(jié)內(nèi)側(cè)損飭尊級評定標準分世運義I度當局限性壓疝無不誌II度局限性壓痣內(nèi)鯉副韌港纖維及后斜纖維剖分撫裂III度2&完全斷裂.外翻應力下存在不穩(wěn)皿度量化標準上觀性臨床評價蘋131+松弛3-5mm2+松弛6-lOiniii3+松弛lOmui以.應力位X線片單純內(nèi)側(cè)副韌帝攝傷膝關節(jié)師勵0時內(nèi)啊關節(jié)間20時增寬3.2mm膝關節(jié)內(nèi)刪絡構(gòu)完仝攬傷（內(nèi)側(cè)副韌帯法層、后膝關節(jié)師曲儼時內(nèi)啊關節(jié)問20斜韌帶、內(nèi)側(cè)詡韌帶深層、時增寬9.8nun*所例數(shù)值為項研究中的平均值，而非分空系統(tǒng)的評價標準DXVCHealingThesuperficialmedialcollateralligamenthasbe

20、enreportedtohaveanabundantvascularsupply.Healingofthisligamentfollowstheclassicmodelofhealinginvolvinghemorrhage,inflammation,repaii;andremodeling25.Studiesofthevariablesinvolvedinthehealingofthesuperficialmedialcollateralligamentinanimalshaveshownthatthehealingislocationdependent.Inonestudyofarabbi

21、tsuperficialmedialcollateralligamentinjurymodel,theligamenttooklongertohealwhenitwasinjuredneareitherattachmentsitethanwhenithadamidsubstaneeinjury26.Thebiologicaleffectsofimmobilizationhavealsobeenwidelystudiedinsuperficialmedialcollateralligamentinjurymodels.Inarabbitmodel,areductionofcollagenmass

22、andincreasedcollagendegradationwereobservedaftertwelveweeksofimmobilization27.Thesenegativeeffectsofimmobilizationwerenotedtobecausedbycollagenmatrixreorganizationandcatabolicbehaviorwithinthemedialcollateralligamentafterinjury28,29.Inanotherstudy,dogsthathadundergonesurgicaltransectionofthesuperfic

23、ialmedialcollateralligamentweredividedintothreetreatmentgroups:earlymotion,immobilizationforthreeweeks,andimmobilizationforsixweeks30.Theauthorsconcludedthatearlymotionprotocolsleadtoenhancedhealingandimprovedbiomechanicalpropertiesofthesuperficialmedialcollateralligament.Thisinformationwassubsequen

24、tlyusedtopromoteandreinforcesimilarnonoperativerehabilitationprotocolsfortheseinjuriesinhumans.愈合據(jù)研究報道，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、修復和重建25。但也有與之不同的報道，動物實驗顯示內(nèi)側(cè)副韌帶淺層的愈合與損傷的位置密切相關。有學者研究了兔子內(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，兩個附著點附近的損傷愈合時間更長26。在內(nèi)側(cè)副韌帶淺層損傷的模型中制動的生物學作用也是一個被廣泛研究的內(nèi)容。在一個兔子模型中，制動12周以后觀察到膠原的含量減少，膠原的退

25、變明顯增加27。人們注意到制動帶來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。在另一項研究中，狗的內(nèi)側(cè)副韌帶淺層經(jīng)手術橫行切斷，然后分成3個處理組：早期活動、制動3周和制動6周30。作者的結(jié)論認為早期活動可促進內(nèi)側(cè)副韌帶淺層損傷的愈合，改善其生物力學性能。這一結(jié)論后來也常常被引用，作為類似的非手術康復計劃在人類相關損傷中應用的理論依據(jù)。ClinicallyRelevantBiomechanicsAcompleteunderstandingofmedialkneebiomechanicsisvaluablefortheassessmentofwhichinjure

26、dstructuresshouldberepairedorreconstructed.Anunderstandingofthedegreeofabnormaljointmotionthatoccurswhenastructureisinjuredgreatlyassistswiththeinterpretationoftheresultsoftheclinicalexaminationandhelpstodeterminethepresenceofconcurrentligamentinjury.Withthetrendtowardmoreanatomicreconstruction,itis

27、importanttounderstandthefunctionof,andthedifferencesbetween,theindividualcomponentsofthesemainmedialknee-stabilizingstructures.Biomechanicalstudieshaveshownthatthesuperficialmedialcollateralligamentistheprimaryrestrainttovalguslaxityoftheknee1,31-34.Onestudy,inwhichbuckletransducerswereused,quantita

28、tivelydemonstrateddifferencesbetweenthetwodivisionsofthesuperficialmedialcollateralligamentintermsoftheirresponsestoappliedloads10.Theimplicationsoftheseobservationsarethat,althoughthesuperficialmedialcollateralligamenthaspreviouslybeenbiomechanicallytestedandoperativelyreconstructedundertheassumpti

29、onthatitisonecontinuousstructure1,33,35-40,thetwodivisionsoftheligamentactuallyfunctionasconjoinedbutdistinctstructures.Thus,thebiomechanicalstudy10suggeststhattheaimofanoperativerepairorreconstructionofthesuperficialmedialcollateralligamentshouldbetorestorethedistinctfunctionsofbothdivisionsbyreatt

30、achingthetwotibialattachmentsinanattempttoreproducetheoverallfunctionofthesuperficialmedialcollateralligamentconstruct.臨床生物力學深入了解膝關節(jié)內(nèi)側(cè)結(jié)構(gòu)的生物力學性能對于明確哪些結(jié)構(gòu)損傷必須進行修復或重建意義重大。認識清楚某一結(jié)構(gòu)損傷后導致關節(jié)異?；顒拥某潭龋瑢τ诮忉屌R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。隨著越來越提倡解剖重建，理解膝關節(jié)內(nèi)側(cè)穩(wěn)定結(jié)構(gòu)各個組分的功能及其相互之間的差異則顯得尤為重要。生物力學研究顯示內(nèi)側(cè)副韌帶淺層主要起到限制膝關節(jié)過度外翻的

31、作用1,31-34。其中有一項研究，應用環(huán)扣傳感器進行了定量分析，結(jié)果顯示了內(nèi)側(cè)副韌帶淺層在加載負荷后兩個部分之間的反應不同10。這一研究提示，盡管以前的生物力學試驗和手術重建都將內(nèi)側(cè)副韌帶淺層當作一個連續(xù)的結(jié)構(gòu)來處理1,33,35-40,而事實上該韌帶的兩個組分雖然協(xié)同作用但卻是兩個相互獨立的結(jié)構(gòu)。因此，有生物力學研究10主張在對內(nèi)側(cè)副韌帶淺層進行手術修復或重建時，應以恢復其兩個組分不同的功能為目的，分別重建兩個脛骨附著點以求還原內(nèi)側(cè)副韌帶淺層的所有功能。Theposteriorobliqueligamentreinforcestheposteromedialaspectofthecapsu

32、le,whichcoursesoffthedistalaspectofthesemimembranosustendon2,9,14.Fromabiomechanicalperspective,theposteriorobliqueligamentfunctionsasaninternalrotatorandvalgusstabilizeratbetween0and30ofkneeflexion1,2,10,35,37,38,41,42.Ithasalsobeenreportedthat,withappliedinternalrotationtorquesat0ofkneeflexion,the

33、loadsontheposteriorobliqueligamentaresignificantlyhigherthanthoseoneitherdivisionofthesuperficialmedialcollateralligament10.Inaddition,ithasbeenreportedthatthereisareciprocalloadresponsetointernalrotationtorquebetweentheposteriorobliqueligamentandthesuperficialmedialcollateralligamentasthedegreeofkn

34、eeflexionincreases,withahigherloadresponseinthesuperficialmedialcollateralligamentat90ofkneeflexion.Thisobservationdemonstratesthatthereisacomplementaryrelationshipbetweentheposteriorobliqueligamentandthesuperficialmedialcollateralligamentwithregardtotheresistanceofinternalrotationtorquesthatdepends

35、onthekneeflexionangle.Asubsequentstudyofloaddistributionwithbuckletransducersshowedthatsectioningofthecomponentsofboththedeepmedialcollateralligamentandthesuperficialmedialcollateralligamentresultedinsignificantincreases,comparedwiththeintactstate,intheforcesexperieneedbytheposteriorobliqueligamentu

36、ndervalgusloadsat0,20,and30ofkneeflexion42.Thisobservationcorrelatesbothwithpreviousreportsthattheposteriorobliqueligamentinintactkneesexperiencestensileloadwithvalgusforces,especiallyclosetokneeextension10,42,andthattheposteriorobliqueligamenthasasecondaryroleinprovidingvalgusstabilityoftheknee35,4

37、3,44.后斜韌帶遠離半膜肌腱遠端走行，加強后內(nèi)側(cè)關節(jié)囊2,9,14。從生物力學角度而言，在膝關節(jié)屈曲0至30。時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。也有報道在膝關節(jié)屈曲0并加載內(nèi)旋扭矩時，后斜韌帶承受的負荷要明顯高于內(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，隨著膝關節(jié)屈曲的度數(shù)增加，后斜韌帶與內(nèi)側(cè)副韌帶淺層的負荷變化趨勢相反，屈膝90時內(nèi)側(cè)副韌帶淺層的負荷反應較高。這一觀測顯示根據(jù)膝關節(jié)屈曲的角度不同，后斜韌帶與內(nèi)側(cè)副韌帶淺層對內(nèi)旋扭矩的抵抗存在互補關系。隨后的研究應用環(huán)扣傳感器對負荷的分配進行了探討，結(jié)果顯示膝關節(jié)屈曲0、2

38、0及30。時，切斷內(nèi)側(cè)副韌帶深層和淺層都可觀測到后斜韌帶承載的負荷明顯增加42。這一觀測結(jié)果與上文提到的兩方面的研究都是密切相關的，在完整的膝關節(jié)中加載外翻應力時后斜韌帶承載張力負荷，膝關節(jié)接近于伸直時尤其明顯10,42；后斜韌帶對膝關節(jié)的外翻穩(wěn)定有輔助作用35,43,44。Comparedwiththenumberofstudiesonthefunctionofthesuperficialmedialcollateralligament,therearefewerreportsontheisolatedfunctionofthedeepmedialcollateralligament.The

39、authorsofprevioussequentialsectioningstudiesdonetoevaluatethefunctionofthedeepmedialcollateralligamentdescribeditasasecondaryrestrainttovalgusloads41-43.Morespecifically,theyfoundthatvalgusstabilizationwasprovidedbythemeniscofemoralportionofthedeepmedialcollateralligamentatalltestedflexionanglesandb

40、ythemeniscotibialportionofthedeepmedialcollateralligamentat60ofkneeflexion.Thedeepmedialcollateralligamentwasalsoreportedtoproviderestraintagainstexternalrotationtorqueinkneesflexedbetween30and9041,43.有關內(nèi)側(cè)副韌帶淺層功能的研究很多，與之相比，單純研究內(nèi)側(cè)副韌帶深層相關功能的報道則相對較少。上文提到的順序切斷的研究對內(nèi)側(cè)副韌帶深層的功能進行了評估，作者將其描述為一個對抗外翻負荷的輔助結(jié)構(gòu)41-4

41、3。更確切地說，他們發(fā)現(xiàn)外翻穩(wěn)定性的維持在膝關節(jié)的各個屈曲角度，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節(jié)屈曲30至90時內(nèi)側(cè)副韌帶深層也可對抗外旋扭矩41,43。Theseresultsdemonstratethatinjuriestotheindividualcomponentsofthemedialaspectofthekneealtertheintricateload-sharingrelationshipsthatexistamongallofthemedialkneestructuresand,ifleftuntre

42、ated,couldpotentiallyincreasetheriskoffurtherinjury42,45.Therefore,onthebasisofthesynthesisofinformationfromtheliteratureandourpersonalperspective,webelievethat,incasesinwhichanoperativerepairorreconstructionisindicated,considerationshouldbegiventorepairingorreconstructingallinjuredmedialkneestructu

43、restorestorethenormalload-sharingrelationshipsamongthosestructuresatthetimeofoperativetreatment.Ananatomicmedialkneereconstructiontechnique(Fig.3)46,basedonpreviousquantitativeanatomic9andbiomechanicalstudies10,42,wasdevelopedinanattempttorestorenormalstabilitytoakneefollowingcompletesectioningofthe

44、superficialmedialcollateralligamentandposteriorobliqueligament.Itwasreportedthatthisreconstructionrestorednearlynormalstabilitytothekneeandthat,followinganappliedload,thereconstructedligamentsdidnothaveagreaterforceresponsethanintactligamentsatanypointduringtesting46.Thissuggeststhatoverconstraintof

45、thekneeandoverloadingofthereconstructiongrafts,whichcouldleadtograftfailure,waspreventedbytheuseofthistechnique.這些研究結(jié)果提示，膝關節(jié)內(nèi)側(cè)單一結(jié)構(gòu)的損傷，可改變膝關節(jié)內(nèi)側(cè)所有相關結(jié)構(gòu)之間存在的負荷分擔關系，如果不進行妥善處理的話，可能會增加進一步損傷的風險42,45。因此，綜合文獻中的信息及我們個人的觀點，我們認為，對于具備手術修復或重建指征的病例，進行手術治療時應考慮修復或重建所有受損的膝關節(jié)內(nèi)側(cè)結(jié)構(gòu)，以恢復這些結(jié)構(gòu)相互間正常的負荷分擔關系。以上述定量解剖和生物力學研究為基礎創(chuàng)立

46、的膝關節(jié)內(nèi)側(cè)解剖重建方法（圖3）46,通過完全切開暴露內(nèi)側(cè)副韌帶淺層和后斜韌帶，以期恢復膝關節(jié)正常的穩(wěn)定性。有研究認為該重建方法可恢復幾近于正常的膝關節(jié)穩(wěn)定性，此外，在試驗過程中加載負荷后，重建的韌帶任一點上的應力反應都不大于正常完整的韌帶46o這表明通過應用這一方法可防止出現(xiàn)膝關節(jié)過緊，并可避免重建的移植物承受過大的負荷，而這些都是導致移植物失效的常見原因。Fig.3Illustrationofamedialkneereconstructonprocedure(medialviewofaleftknee).Thesuperficialmedialcollateralligament(sMCL

47、)andposteriorobliqueligament(POL)arereconstructedwithuseoftwoseparategraftsandfourreconstructiontunnels.Notethattheproximaltibialattachmentofthesuperficialmedialcollateralligament,whichisprimarilytosofttissuesandislocatedjustdistaltothejointline,wasrecreatedbysuturingthesuperficialmedialcollateralli

48、gamentgrafttotheanteriorarmofthesemimembranosusmuscle.(Reproduced,withpermission,from:CoobsBR,WijdicksCA,ArmitageBM,SpiridonovSI,WesterhausBD,JohansenS,EngebretsenL,LaPradeRF.Aninvitroanalysisofananatomicalmedialkneereconstruction.AmJSportsMed.2010;38:339-47.)圖3圖示為膝關節(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

49、帶(POL)分別應用兩條移植腱經(jīng)4個骨隧道進行重建。注意內(nèi)側(cè)副韌帶淺層的近側(cè)脛骨附著點主要通過軟組織附于關節(jié)線稍下方，術中可將內(nèi)側(cè)副韌帶淺層的移植物縫合到半膜肌的前頭進行重建。(經(jīng)惠允引自：CoobsBR,WijdicksCA,ArmitageBM,SpiridonovSI,WesterhausBD,JohansenS,EngebretsenL,LaPradeRF.Aninvitroanalysisofananatomicalmedialkneereconstruction.AmJSportsMed.2010;38:339-47.)DiagnosisHistoryPatientsoftende

50、scribeamechanismofinjuryinvolvingacontactornoncontactvalgusforcetotheknee.Theyalsoreportpainandswellingalongthemedialaspectoftheknee.Whenaskedtoexplainthetypeofinstabilitythattheyfeelwithactivities,individualswithmedialkneeinjuriesinvolvingthesuperficialmedialcollateralligament,posteriorobliqueligam

51、ent,anddeepmedialcollateralligamentoftendescribedaside-to-sidefeelingofinstability,especiallywhentheywereathleteswhoperformedcuttingandpivotingmaneuvers.診斷病史患者自述的受傷機制通常包括膝關節(jié)接觸性或非接觸性的外翻暴力，主訴通常為膝關節(jié)內(nèi)側(cè)面的疼痛和腫脹。而為了判斷不穩(wěn)的類型而進一步詢問其活動時的感受時，膝關節(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，一般都會訴邊對邊動作(sidetoside)時有不穩(wěn)的感覺，尤其患者

52、是運動員，做斜切及扭轉(zhuǎn)動作時則更為明顯。ClinicalEvaluationPhysicalexaminationofthekneeremainsthemostsuitabletoolforobtainingadiagnosisofinjurytoitsmedialstructures.Beginningwithvisualinspection,cliniciansmayobservelocalizedswellingorecchymosisoverthefemoralortibialattachmentofthesuperficialmedialcollateralligament9.The

53、seareascanbepalpatedtohelptoidentifytendernessofthesuperficialmedialcollateralligament.Itisimportanttounderstandtheanatomyofthemedialsideofthekneetoappropriatelypalpateandassessthestructuresinvolved9.Avalgusloadappliedat20to30ofkneeflexionisusedtodetectmedialjointopening(Fig.4,A).Applyingthevalgusst

54、ressatboth0and30ofkneeflexioncanfurtherassistinthediagnosisoftheinjurypatternbecausewhenakneehasincreasedmedialjointspaceopeningat30offlexionbutnotat0theposteriorobliqueligamentismostlikelystillintact.Anadditionalassessmentperformedatthistimeofvalgusmomentapplicationisevaluationoftheintegrityoftheso

55、-calledendpoint.Ifthemedialkneestructuresarecompletelyruptured,therewillbenodefinitiveendpointandtheanteriorcruciateligamentmaybeprovidingasecondaryrestrainttothevalgusstress41.ItisthereforeimportanttoverifythisobservationwiththeLachman47,anteriordrawei,andpivotshifttestsandassesstheintegrityofthean

56、teriorcruciateligamentinassociationwithmedialkneeinjury.臨床評估膝關節(jié)的體格檢查仍然是診斷相關內(nèi)側(cè)結(jié)構(gòu)損傷最為合適的手段。首先進行視診，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周圍的皮下瘀斑等情況9。對這些區(qū)域進行觸診，明確內(nèi)側(cè)副韌帶淺層是否存在壓痛。深入了解膝關節(jié)內(nèi)側(cè)的解剖對于準確地觸診和評估受累的結(jié)構(gòu)都是非常重要的9。膝關節(jié)屈曲20。至30，加載外翻負荷以檢查膝關節(jié)內(nèi)側(cè)間隙的寬度（圖4-A）。在膝關節(jié)屈曲0。和30。時施加外翻應力可作為進一步診斷損傷類型的輔助手段，因為膝關節(jié)屈曲30。時內(nèi)側(cè)關節(jié)間隙增寬而屈曲0。時無明

57、顯增寬則意味著后斜韌帶很有可能仍保持完整。此時，加載外翻力矩后還須要評估其是否具有明顯的終點。如果膝關節(jié)內(nèi)側(cè)結(jié)構(gòu)完全斷裂，則可能沒有明確的終點，此時前交叉韌帶可能對外翻應力提供一定的對抗作用41。因此，通過Lachman試驗、前抽屜試驗、軸移試驗等對這一檢查進行驗證，并檢查膝關節(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.4A:Avalgusloadisappliedat20to30ofkneeflexiontodetectmedialjointopening.Thepatientsthighisallowedtorestontheexaminationtableinorderto

58、relaxthethighmuscles.Whilethevalgusforceisbeingappliedthroughthefootandankle,theexaminerpalpatesthemedialjointareatodeterminetheamountofmedialjointlinegapping.B:Completeinjurytothemedialstructuresincreasesexternalrotationatboth30and90ofkneeflexion,resultinginapositivedialtest41,48.Asdemonstrated,the

59、patientslowerlimbisplacedin9O5ofkneeflexionandtheamountofexternalrotationiscomparedwiththatofthenormal,contralateralknee.圖4A：屈膝20。至30施加外翻應力檢查膝關節(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。通過足踝部對膝關節(jié)施加外翻應力，然后進行觸診檢查膝關節(jié)內(nèi)側(cè)間隙的寬度，以確定關節(jié)間隙是否存在增寬。B：內(nèi)側(cè)結(jié)構(gòu)完全損傷在膝關節(jié)屈曲30。和90時都可使外旋異常增加，導致脛骨外旋試驗(dialtest)陽性41,48。如圖所示，患者的下肢置于90屈膝位，并與

60、對側(cè)正常的膝關節(jié)比對其外旋的程度。Palpationofthefemur-basedandtibia-basedportionsofthemedialkneestructurescanoftendelineatethelocationoftheligamentinjury.Theanteromedialdrawertest,performedbyflexingthekneeapproximately90whileexternallyrotatingthefoot10to15andapplyingananteromedialrotationalforcetotheknee,shouldalsob