膝关节创伤性多发韧带损伤中后外复合体重建的临床疗效

Posterolateral corner reconstruction in treatment of traumatic multi-ligament injury of the knee

目的探讨膝关节创伤性多发韧带损伤中后外复合体（PLC）重建的治疗方案和临床疗效。方法2003年7月至2008午11月共收治85例陈旧性膝关节多发韧带损伤且同时累及PLC损伤的患者，男63例，女22例；平均年龄34．6岁（15～52岁）。损伤类型：前交叉韧带合并PLC损伤2例，前后交叉韧带合并PLC损伤21例，后交叉韧带合并PLC损伤51例，后交叉韧带、内侧副韧带合并PLC损伤11例。PLC损伤根据Fanelli对膝关节后外不稳定的分型：A型48例，使用异体胫前肌腱重建腘腓韧带或胴肌腱；C型37例，其手术方式包括劈裂跟腱的手术技术、外侧副韧带＋腘肌腱或腘腓韧带联合重建术。患者术前和末次随访时采用国际膝关节文献委员会（IKDC）综合评分评估，麻醉下膝关节应力像检查评估膝关节后向和内翻稳定性，胫骨外旋试验评估膝关节后外旋转稳定性。结果58例患者（A型35例，C型23例）术后获1～5年（平均38．5个月）随访，27例失访。35例A型损伤患者胫骨后移程度由术前平均（16．7±5．3）mm减少为末次随访时的（5．1±3．8）mm，胫骨外旋由16．7°±4．7°减小为-1．8°±6．6°。23例C型损伤患者胫骨后移由术前平均（14．9±4．4）mm减少为末次随访时的（5．4±4．2）mm，胫骨外旋由16．2°±9．9°减小为-3．0°±8．6°，外侧关节间隙张开由（13．8±2．6）mm减小为（8．6±2．7）mm，以上术前与末次随访时数据比较差异均有统计学意义（P〈0．05）。58例患者术前IKDC综合评分分级：C级2例，D级56例；末次随访时：A级31例，B级15例，C级12例。结论对膝关节创伤性多发韧带损伤中的PLC损伤进行系统分类，根据不同的损伤类型进行相应的解剖重建，近中期临床随访结果显示：能明显改善膝关节后向和后外稳定性。

Objective To assess the clinical outcomes of posterolateral corner （PLC） reconstruction protocols in the treatment of traumatic multi-ligament injury or dislocation of the knee. Methods PLC reconstruction was performed consecutively for 85 patients with chronic posterolateral instability of the knee from July 2003 to November 2008. The inclusion criteria for surgery were multi-ligament injury and PLC injury with/without varus laxity and with tibial extorsion 10° greater than the normal. According to Fanelli classification, the popliteofibular ligament（PFL） or popliteal tendon was reconstructed for the type A PLC injury （48 eases）, while the split Achilles tendon reconstruction or lateral collateral ligament （LCL） and popliteal tendon reconstruction or X shape reconstruction were chosen for the type C injury （37 eases） . Results The average follow-up was 38.5 months. The average posterior tibial translation was reduced from preoperative 16.7 ± 5.3 mm to post-operative 5. 1 ±3.8 mm in type A group and reduced from 14.9 ±4.4 mm to 5.4 ± 4.2 mm in type C group. The tibial extorsion was decreased from an average of 16.7° ±4. 7° preoperatively to -1.8°±6.6° postoperatively in type A group and from 16.2°±9.9° to -3.0°±8.6° in type C group, as compared with the normal knee. The lateral compartment opening measured from stress view was decreased from 13.8 ± 2.6 mm to 8.6 ± 2.7 mm. These differences were statistically significant （ P 〈 0. 05）. By International Knee Documentation Committee（IKDC） grades, preoperatively 2 patients were of grade C and 56 of grade D, but postoperatively 31 were of grade A, 15 of grade B and 12 of grade C. Conclusion In the treatment of traumatic multi-ligament injury or dislocation of the knee, PLC reconstruction protocols based on the Fanelli＇ s classification can effectively correct the posterior and posterolateral instability.