急性膝关节多发韧带损伤的早期治疗

Management of acute multiple ligamentous injuries of knee joint

目的探讨急性膝关节多发韧带损伤时十字韧带与周围韧带损伤的不同特点及早期手术的疗效,提出治疗观点.方法选择1999年8月～2002年6月经手术治疗的47例累及两组以上膝关节韧带损伤的病例,其中随访1年以上者40例,男28例,女12例;年龄22～50岁,平均33.5岁.所有病例均行关节镜下前、后十字韧带重建和(或)周围侧副韧带修补.结果IKDC评分,正常10例,接近正常25例,不正常5例.Lysholm评分:优30例,良8例,中2例.膝关节活动度:伸膝完全正常者35例,轻度受限者5例,但均小于10°.膝关节屈曲活动度:完全正常者26例,受限10°以内者10例,受限20°以内者3例,受限30°者1例.膝关节稳定性检查:28例前十字韧带手术患者中Lachman(-)16例,(+)12例;轴移试验(-)20例,(+)8例;KT-1000关节活动度＜3 mm 23例,3～5 mm 5例.22例后十字韧带手术患者中PDT(-)5例,(+)16例,(++)1例;KT-1000关节活动度＜3 mm 5例,3～5 mm11例,5～7 mm 5例,7～10 mm 1例.25例内侧副韧带手术患者中Abd 0°(-)16例,(+)9例;Abd 30°(+)10例,(+)13例,(++)2例.14例后外复合体手术患者中Add0°(-)3例,(+)10例,(++)1例;Add 30°(-)2例,(+)11例,(++)1例,其中(++)者视为失效.结论膝关节多发韧带损伤的关键是早期治疗,后外复合体及Ⅲ度周围韧带损伤应早期手术修补.后十字韧带自愈能力强,应选择Ⅱ度以上者进行手术,前、后十字韧带最好同期重建,如果条件不具备,可优先选择重建后十字韧带,术后应注意被动伸膝及CPM功能锻炼.

Objective To introduce early management of multiple ligamentou s injuries of knee joint as well as analyze their clinical results. Methods From A ugust 1999 through June 2002, 47 consecutive cases with at least 2 groups of acu te ligamentous injuries of knee joint were treated using cruciate ligament recon struction and repair of peripheral ligaments. There were 28 males and 12 females aging from 22 to 50 years with an average of 33.5 years. The causes of injury w ere traffic accident in 22, fall in 8, sport injury in 6, and crush injury in 4. The mean interval from injury to surgery was 10.6 days ranging from 6 to 28 day s. The indications of surgical treatment were as follows: completed rupture of m edial collateral ligament, rupture of anterior cruciate ligament, and posterior cruciate ligament injury with posterior tibial displacement more than 7 mm. Resu lts 40 cases were followed-up from 12 to 48 months with an average of 23.5 month s. According to the IKDC scale, there were grade A in 10, grade B in 25 and grad e C in 5; while by Lysholm evaluation, there were excellent in 30, good in 8 and fair in 2. In the ROM examination, 35 cases obtained with normal extension, 5 w ith mild limited extension less than 10°; 26 cases obtained with normal flexion , 10 with mild limited flexion less than 10°, 3 with flexion loss to 20° and 1 to 30° respectively. Of 28 ACL reconstruction, 16 were found with Lachman test (-),and 12 (+); furthermore, 20 cases were found with pivot shift(-),8 cases 1(+). On KT-1000 examination, there were < 3mm in 23, 3-5mm in 5. Of 22 PCL reco nstruction, 5 were found with PDT (-),16 (+), and 1 (++). On KT-1000 examinatio n, there were < 3 mm in 5, 3-5 mm in 11, 5-7 mm in 5, and 7-10 mm in 1. In later al stress test of 25 medial collateral ligament injuries treated with primary re pair, there were negative in 16 and (+) in 9 as the knee joint on 0° position; negative in 10, (+) in 13, and (++) in 2 as the knee joint on 30° flexion. Conc lusion By accurate identification of injured ligament and proper selection of in dication combining with active postoperative rehabilitation in acute multiple li gamentous injuries of knee joint, primary reconstruction of cruciate ligaments a nd repair of peripheral ligaments of Ⅲ degree injury are reproducible, and can obtain satisfactory clinical results.