膝关节对角线损伤的评估诊断与手术策略探讨和疗效分析

Evaluation and diagnosis of knee joint diagonal lesion and surgical strategy and effectiveness

目的 探讨膝关节对角线损伤的评估诊断依据及手术策略,并观察其临床疗效。方法 回顾分析2011年11月—2019年11月收治的9例膝关节对角线损伤患者,其中男7例,女2例;年龄18~61岁,平均38.3岁。根据膝关节多发韧带损伤临床分期标准,急性期损伤(≤3周)患者6例,受伤至手术时间5~16 d,平均9.3 d;陈旧期损伤(>3周)患者3例,受伤至手术时间分别为7、12、144个月。对角线损伤中后外侧复合体损伤根据Fanelli分型均为C型,后交叉韧带损伤依据美国医学会(AMA)分级均为3级损伤;骨折根据胫骨平台骨折三柱分型:零柱骨折2例,内侧柱骨折7例。急性期损伤患者手术采用后交叉韧带重建,后外侧复合体修复和/或加强重建,胫骨平台骨折采取保守治疗或骨折复位内固定;陈旧期损伤患者胫骨平台畸形愈合骨折行局限性关节内截骨矫形复位、植骨加内固定,术中进一步评估膝关节稳定性情况,根据需要行后交叉韧带重建和/或后外侧复合体修复与重建。手术前后通过Lysholm评分、国际膝关节评分委员会(IKDC)评分评价膝关节功能及治疗效果。结果 9例患者均获随访,随访时间24~119个月,平均51.7个月。患者手术切口均Ⅰ期愈合,均未发生切口感染、下肢深静脉血栓形成等并发症,随访期间无再次手术者。术后6个月及1、2年复查双下肢全长X线片示双下肢力线均恢复正常,应力位X线片示各向稳定性恢复良好。术后6个月复查膝关节X线片示胫骨平台骨折愈合良好。术后1年复查MRI示修复重建韧带信号良好,未出现韧带吸收、断裂等重建失效情况。术后1年评估患肢肌力均达Ⅴ级,膝关节主被动活动度恢复至0°~130°。术后2年急性期和陈旧性损伤患者Lysholm评分、IKDC评分均较术前显著改善(P<0.05)。结论 膝关节对角线损伤是以后交叉韧带、后外侧复合体损伤为主伴胫骨平台前内侧份劈裂塌陷骨折的一种特殊类型;医生需要进行正确评估并诊断该类损伤的结构,并制定详细的手术和康复方案,才能获得较好临床效果。

Objective To investigate the evaluation,diagnosis,and surgical treatment of knee joint diagonal lesion and to observe its effectiveness.Methods A retrospective analysis was performed on 9 patients with knee joint diagonal lesion admitted between November 2011 and November 2019,including 7 males and 2 females,aged 18-61 years,with an average age of 38.3 years.According to the clinical staging criteria of multiple ligament injury of knee joint,6 patients with acute stage injury(≤3 weeks),the time from injury to operation was 5-16 days,with an average of 9.3 days;3 patients with old stage injury(>3 weeks),the time from injury to operation was 7,12,144 months,respectively.Posterolateral complex injuries were all type C according to Fanelli classification,and the posterior cruciate ligament injury was grade 3 according to American Medical Association(AMA)classification.According to the three columns classification of tibial plateau fracture,there were 2 cases of zero column fracture and 7 cases of medial column fracture.Patients with acute injury were treated with posterior cruciate ligament reconstruction,posterolateral complex repair and/or reinforcement reconstruction,and tibial plateau fracture was treated with conservative treatment or internal fixation.Patients with malunion of tibial plateau in old stage were treated with limited osteotomy,bone grafting,and internal fixation;the stability of the knee joint was further evaluated during operation,then the posterior cruciate ligament reconstruction and/or posterolateral complex repair and reconstruction were performed as needed.Lysholm score and the International Knee Documentation Committee(IKDC)score before and after operation were used to evaluate knee function and effectiveness.Results All patients were followed up 24-119 months,with an average of 51.7 months.All the incisions healed by first intention,and no complication such as incision infection,deep venous thrombosis of lower extremities occurred,and there was no reoperation during follow-up.The full-length X-ray films of both lower extremities at 6 months and 1,2 years after operation showed that the alignment of both lower extremities returned to normal,and the stress position X-ray films showed that the stability in all directions recovered well.The X-ray films of the knee joint at6 months after operation showed that the fracture of the tibial plateau healed well.At 1 year after operation,MRI showed that the signal of the repaired and reconstructed ligament was good,and there was no reconstruction failure such as ligament absorption or rupture occurred.At 1 year after operation,the muscle strength of the affected limbs was all rated as gradeⅤ,and the active and passive range of motion of the knee joint recovered to 0°-130°.At 2 years after operation,the Lysholm score and IKDC score significantly improved when compared with those before operation(P<0.05).Conclusion Knee joint diagonal lesion is a special type of posterior cruciate ligament and posterolateral complex injury with anteromedial split and collapse fracture of tibial plateau,which requires correct evaluation and diagnosis of the injured structure,and detailed surgical and rehabilitation programs to achieve better effectiveness.