前外侧韧带重建术的应用与争议的研究进展

Advances in anterolateral ligament reconstruction: clinical practice and controversy

对前十字韧带(anterior cruciate ligament,ACL)损伤目前普遍采用ACL重建术进行治疗以恢复患者的旋转稳定性。但部分高危患者ACL重建后仍有持续性的前外侧旋转不稳,导致患者术后满意度下降与重返运动受阻,是患者预后不佳的重要原因。ACL重建后旋转不稳定促使学者关注髂胫束和前外侧韧带(anterolateral ligament,ALL)等膝关节前外侧结构。其中,ALL自1879年被发现以来已有百余年历史,但一直未受到重视。尽管仍有争议,但近年来多数研究确认ALL为独立的韧带,是维持膝关节旋转稳定性的重要解剖结构。膝关节前外侧结构加强术以损伤小、并发症发生率低的解剖性ALL重建为代表。目前,多数学者认为存在术前高度轴移、ACL翻修手术等严重旋转不稳定、年龄不足25岁以及需要参与旋转运动等对旋转稳定性要求较高,是ACL重建时需要联合ALL重建的重要参考因素。国内外的权威共识中也提出了相应的建议标准,但不同专家基于自身经验选取的手术指征并不统一。由于ALL重建改善旋转稳定性的实际作用以及是否会过度限制内旋功能的文献报道并不一致,不同学者对ACL重建中是否应联合ALL重建仍持不同的意见。目前常用的ALL重建术包括ALL单束重建和倒"Y"型ALL双束重建,其中倒"Y"型ALL双束重建对原始解剖结构的恢复更佳,也是共识中推荐的手术方式;但目前仍缺乏两种术式的随机对照试验,因此ALL重建术式尚不统一。近年来对ACL重建后容易失败的患者,也有学者采用ACL重建术中联合ALL重建术,但也存在许多争议。

Rupture of the anterior cruciate ligament(ACL)is one of the most frequent forms of knee sports injuries.Nowadays,ACL reconstruction is commonly performed to help patients restore their rotational stability.However,in patients with high risk factors,the risk of ACL reconstruction failure remains high,primarily because of continuous postoperative anterolateral rotational instability.This rotational instability after ACL reconstruction has prompted researchers to focus on the anterolateral complex of the knee,such as iliotibial tract and anterolateral ligament(ALL).Among them,ALL has remained largely unappreciated for more than a century since its discovery in 1879.Even though it is still controversial,most studies in recent years have supported the anterolateral ligament as an independent ligament and a crucial anatomical component for preserving the rotational stability of the knee joint.Although augmentation of the anterolateral complex has experienced twists and turns,the anatomic ALL reconstruction,which can be performed minimally invasively and has a low risk of complications and minimal injury,is reappearing as a key strategy to address this problem.Currently,the majority of scholars believe that the need for combined ALL reconstruction during ACL reconstruction should be taken into account when there is severe rotational instability present,such as high-grade pivot shift test preoperatively,ACL revision surgery,and high requirements for rotational stability,such as age less than 25 years and the need to participate in pivoting sports.The corresponding suggested criteria are also put forth in the authoritative consensus of both domestic and foreign sources.However,the surgical indications chosen by different experts based on their individual experiences are not all consistent.Due to conflicting reports on the actual impact of ALL reconstruction on improving rotational stability and whether it will excessively restrict knee's internal rotation function,there is still much debate among researchers regarding whether ALL reconstruction and ACL reconstruction should be combined.Currently,there are two main reconstruction techniques:ALL single bundle reconstruction and Y-construct ALL double bundle reconstruction.Y-construct ALL double bundle reconstruction has a better ability to restore the original anatomy and is recommended in the consensus,but there is still a lack of randomized controlled trials between the two techniques.Therefore,the combination of ALL reconstruction at the time of ACL reconstruction has been clinically started in recent years for patients who are susceptible to failure after ACL reconstruction,which also raises many controversies.