全膝关节置换术中膝关节内侧副韧带损伤的处理

Treatment of intraoperative injury of medial collateral ligament during total knee arthroplasty

目的 探讨全膝关节置换术（TKA）中膝关节内侧副韧带（MCL）损伤的处理方法。方法 回顾性分析2013年6月-2014年6月上海交通大学附属第六人民医院骨科687例（714膝）行初次TKA术中10例（10膝）MCL损伤患者的病例资料，其中1例为MCL股骨侧止点撕脱，另9例为MCL体部断裂。MCL股骨侧止点撕脱患者采用带缝线锚钉方法进行止点重建，体部损伤患者均采用断端直接缝合方法进行修复。除2例体部断裂的患者因修复后仍无法恢复内侧稳定性而使用限制性衬垫之外，其余8例患者均使用非限制性后稳定型膝关节假体。术后康复过程中有5例患者使用膝关节支具进行保护。观察患者手术前后美国膝关节协会评分（KSS）和膝关节活动度。结果 10例患者随访3—15个月（平均9个月）。患者均无膝关节不稳定的主诉，末次随访时，膝关节伸直位及屈膝30°位外翻应力试验未发现内侧松弛。患者KSS由术前平均76．8分（37—100分）改善到153．3分（126～170分），膝关节平均活动度由术前的92°（70°～110°）改善到108°（90°-120°）。结论 对TKA中的MCL损伤应当进行积极的手术修复。在采用正确的方法进行MCL修复、重建并且获得良好下肢力线的前提下，非限制性膝关节假体能够获得理想的治疗结果。

Objective To investigate the proper treatment of intraoperative injury of medial collateral ligament （MCL） during total knee arthroplasty （TKA）. Methods A total of 10 patients （ 10 knees） with intraoperative MCL injury among 687 patients （714 knees） who received total knee arthroplasty at the department of orthopaedic surgery in Shanghai Sixth People＇s Hospital Affiliated to Shanghai Jiao Tong University from June 2013 to June 2014 were retrospectively analyzed. One of these cases was avulsion of the femoal origin of MCL in which suture anchor was used for its reattachment. The rest were midsubstance disruption which was treated with direct suture repair. Medial stability could not be reconstructed despite meticulous repair of the MCL in 2 of these cases, and constrained liner was used in these 2 cases. Non- constrained posterior stabilized prosthesis was implanted for the other 8 cases. A hinged knee brace was applied to 5 of these cases as part of the postoperative rehabilitation program. American knee society score and range of motion of the knee joint before and after the surgery were recorded and analyzed. Results The mean duration of follow-up was 9 months （range, 3-15 months）. No patient had complaint of instability of the knee joint at latest follow-up visit. The mean American knee society score was improved from 76.8 （ range, 37 - 100） pre-operatively to 153.3 （ 126 - 170） postoperatively. The mean range of motion of the knee joint was improved from 92° （range, 70° - 110°） pre-operatively to 108° （range 90° - 120°） postoperatively. Conclusions Intraoperative injury of MCL during TKA should be properly repaired. Good clinical results can be achieved with the use of non-constrained knee prosthesis in these situations if the injured MCL has been repaired and the mechanical axis of the lower extremity has been realigned.