膝关节内侧副韧带及相关内侧结构的损伤

理解膝关节内侧稳定结构各个组分的功能及其相

互之间的差异则显得尤为重要。

生物力学研究显示内侧副韧带浅 层主要起到限制膝关节过度外翻的作

用

1,31-34

。其中有一项研究，应用环扣传感器进行了定量分析，结果显示了内侧副韧带浅层在加载

负荷后两个部分之间的反应不同

10

。

这一研究提示，

尽管以前的生物力学试验和手术重建都将内侧副

韧带浅层当作一个连续的结构来处理

1,33,35-40

，而事实上该韧带的两个组分虽然协同作用但却是两

个相互独立的结构。

因此，

有生物力学研究

10

主张在对内侧副韧带浅层进行手术修复或重建时，

应以

恢复其两个组分不同的功能为目的，分别重建两个胫骨附着点以求还原内侧副韧带浅层的所有功能。

The posterior oblique ligament reinforces the posteromedial aspect of the capsule, which courses off

the distal aspect of the semimembranosus tendon2,9,14. From a biomechanical perspective, the

posterior oblique ligament functions as an internal rotator and valgus stabilizer at between 0

°

and

30

°

of knee flexion1,2,10,35,37,38,41,42. It has also been reported that, with applied internal

rotation torques at 0

°

of knee flexion, the loads on the posterior oblique ligament are significantly

higher than those on either division of the superficial medial collateral ligament10. In addition, it has

been reported that there is a reciprocal load response to internal rotation torque between the

posterior oblique ligament and the superficial medial collateral ligament as the degree of knee

flexion increases, with a higher load response in the superficial medial collateral ligament at 90

°

of

knee flexion. This observation demonstrates that there is a complementary relationship between the

posterior oblique ligament and the superficial medial collateral ligament with regard to the

resistance of internal rotation torques that depends on the knee flexion angle. A subsequent study of

load distribution with buckle transducers showed that sectioning of the components of both the deep

medial collateral ligament and the superficial medial collateral ligament resulted in significant

increases, compared with the intact state, in the forces experienced by the posterior oblique

ligament under valgus loads at 0

°

, 20

°

, and 30

°

of knee flexion42. This observation correlates both

with previous reports that the posterior oblique ligament in intact knees experiences tensile load

with valgus forces, especially close to knee extension10,42, and that the posterior oblique ligament

has a secondary role in providing valgus stability of the knee35,43,44.

后斜韧 带远离半膜肌腱远端走行，加强后内侧关节囊

2,9,14

。从 生物力学角度而言，在膝关节屈曲

0

°

至

30

°

时后 斜韧带主要起到内旋和外翻稳定作用

1,2,10,35,37,38,41,42

。

也有报道在膝关节屈曲

0

°

并加

载内旋扭矩时，

后斜韧 带承受的负荷要明显高于内侧副韧带浅层的任一部分

10

。

此外，

还有研究指出，

加载内旋扭矩时，随 着膝关节屈曲的度数增加，后斜韧带与内侧副韧带浅层的负荷变化趋势相反，屈

膝

90

°

时内侧副韧带浅层的负荷反应较高。这 一观测显示根据膝关节屈曲的角度不同，后斜韧带与内

侧副韧带浅层对内旋扭矩的抵抗存 在互补关系。随后的研究应用环扣传感器对负荷的分配进行了探

讨，结果显示膝关节屈曲

0

°

、

20

°

及

30

°

时，切断内侧副韧带深层和浅层都可观测到后斜韧带承载的

负荷明显增加

42

。

这一观测结果与上文提到的两方面的研究都是密切相关的，

在完整的膝关节中加载

外翻应力时后斜韧带承载张力负荷，膝关节接近于伸直时尤其明显

10 ,42

；后斜韧带对膝关节的外翻

稳定有辅助作用

35,43,44

。

Compared with the number of studies on the function of the superficial medial collateral ligament,

there are fewer reports on the isolated function of the deep medial collateral ligament. The authors

of previous sequential sectioning studies done to evaluate the function of the deep medial collateral

ligament described it as a secondary restraint to valgus loads41-43. More specifically, they found

that valgus stabilization was provided by the meniscofemoral portion of the deep medial collateral

ligament at all tested flexion angles and by the meniscotibial portion of the deep medial collateral

ligament at 60

°

of knee flexion. The deep medial collateral ligament was also reported to provide

restraint against external rotation torque in knees flexed between 30

°

and 90

°

41,43.

有关内侧副韧带浅层功能的研究很多，

与之相比，

单 纯研究内侧副韧带深层相关功能的报道则相对较

少。

上文提到的 顺序切断的研究对内侧副韧带深层的功能进行了评估，

作者将其描述为一个对抗外翻

负荷的辅助结构

41-43

。更确切地说， 他们发现外翻稳定性的维持在膝关节的各个屈曲角度，内侧副

韧带深层的板股韧带更为重 要，而屈膝

60

°

时内侧副韧带深层的 板胫韧带则发挥主要作用。另外也有

研究表明膝关节屈曲

30< /p>

°

至

90

°

时内侧副韧带深层也可对抗外旋扭矩

41,43

。

These results demonstrate that injuries to the individual components of the medial aspect of the

knee alter the intricate load-sharing relationships that exist among all of the medial knee structures

and, if left untreated, could potentially increase the risk of further injury42,45. Therefore, on the

basis of the synthesis of information from the literature and our personal perspective, we believe

that, in cases in which an operative repair or reconstruction is indicated, consideration should be

given to repairing or reconstructing all injured medial knee structures to restore the normal

load-sharing relationships among those structures at the time of operative treatment.

An anatomic medial knee reconstruction technique (Fig. 3)46, based on previous quantitative

anatomic9 and biomechanical studies10,42, was developed in an attempt to restore normal stability

to a knee following complete sectioning of the superficial medial collateral ligament and posterior

oblique ligament. It was reported that this reconstruction restored nearly normal stability to the knee

and that, following an applied load, the reconstructed ligaments did not have a greater force

response than intact ligaments at any point during testing46. This suggests that overconstraint of

the knee and overloading of the reconstruction grafts, which could lead to graft failure, was

prevented by the use of this technique.

这些研 究结果提示，

膝关节内侧单一结构的损伤，

可改变膝关节内侧所 有相关结构之间存在的负荷分

担关系，如果不进行妥善处理的话，可能会增加进一步损伤 的风险

42,45

。因此，综合文献中的信息

< br>及我们个人的观点，我们认为，对于具备手术修复或重建指征的病例，进行手术治疗时应考虑修复或

重建所有受损的膝关节内侧结构，以恢复这些结构相互间正常的负荷分担关系。

以上述定量解剖和生物力学研究为基础创立的膝关 节内侧解剖重建方法（图

3

）

46

，通过完全切开暴

露内侧副韧带浅层和后斜韧带，

< br>以期恢复膝关节正常的稳定性。

有研究认为该重建方法可恢复几近于

正常的膝关节稳定性，此外，在试验过程中加载负荷后，重建的韧带任一点上的应力反应都不大于正< /p>

常完整的韧带

46

。

这表明通过应用这一方法可防止出现膝关节过紧，

并可避免重建的移植物承受过大< /p>

的负荷，而这些都是导致移植物失效的常见原因。

Fig. 3 Illustration of a medial knee reconstruction procedure (medial view of a left knee). The

superficial medial collateral ligament (sMCL) and posterior oblique ligament (POL) are reconstructed

with use of two separate grafts and four reconstruction tunnels. Note that the proximal tibial

attachment of the superficial medial collateral ligament, which is primarily to soft tissues and is

located just distal to the joint line, was recreated by suturing the superficial medial collateral

ligament graft to the anterior arm of the semimembranosus muscle. (Reproduced, with permission,

from: Coobs BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S, Engebretsen

L, LaPrade RF

. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med.

2010;38:339-47.)

图

3

图示 为膝关节内侧重建方法（左膝内侧面观）

。内侧副韧带浅层（

s MCL

）和后斜韧带（

POL

）分别应

用两条移植腱经

4

个骨隧道进行重建。 注意内侧副韧带浅层的近侧胫骨附着点主要通过软组织附于关

节线稍下方，

术中可将内侧副韧带浅层的移植物缝合到半膜肌的前头进行重建。

（经惠允引 自：

Coobs

BR, Wijdicks CA, Armitage BM, Spiridonov SI, Westerhaus BD, Johansen S, Engebretsen L, LaPrade

RF

. An in vitro analysis of an anatomical medial knee reconstruction. Am J Sports Med.

2010;38:339-47.

）

Diagnosis

History

Patients often describe a mechanism of injury involving a contact or noncontact valgus force to the

knee. They also report pain and swelling along the medial aspect of the knee. When asked to explain

the type of instability that they feel with activities, individuals with medial knee injuries involving the

superficial medial collateral ligament, posterior oblique ligament, and deep medial collateral

ligament often described a side-to-side feeling of instability, especially when they were athletes who

performed cutting and pivoting maneuvers.

诊断

病史

患者 自述的受伤机制通常包括膝关节接触性或非接触性的外翻暴力，

主诉通常为膝关节内侧面 的疼痛

和肿胀。而为了判断不稳的类型而进一步询问其活动时的感受时，膝关节内侧结构 损伤的患者，包括

内侧副韧带浅层、后斜韧带、内侧副韧带深层，一般都会诉边对边动作 （

side to side

）时有不稳的感

< br>觉，尤其患者是运动员，做斜切及扭转动作时则更为明显。

Clinical Evaluation

Physical examination of the knee remains the most suitable tool for obtaining a diagnosis of injury to

its medial structures. Beginning with visual inspection, clinicians may observe localized swelling or

ecchymosis over the femoral or tibial attachment of the superficial medial collateral ligament9.

These areas can be palpated to help to identify tenderness of the superficial medial collateral

ligament. It is important to understand the anatomy of the medial side of the knee to appropriately

palpate and assess the structures involved9.

A valgus load applied at 20

°

to 30

°

of knee flexion is used to detect medial joint opening (Fig. 4, A).

Applying the valgus stress at both 0

°

and 30

°

of knee flexion can further assist in the diagnosis of the

injury pattern because when a knee has increased medial joint space opening at 30

°

of flexion but

not at 0

°

the posterior oblique ligament is most likely still intact. An additional assessment performed

at this time of valgus moment application is evaluation of the integrity of the so-called end point. If

the medial knee structures are completely ruptured, there will be no definitive end point and the

anterior cruciate ligament may be providing a secondary restraint to the valgus stress41. It is

therefore important to verify this observation with the Lachman47, anterior drawer

, and pivot shift

tests and assess the integrity of the anterior cruciate ligament in association with medial knee injury.

临床评估

膝关节的体格检查仍然是诊断相关内侧结构损伤最为合适的手段。

首先进行视诊，

医生可以观察局部

肿胀，以及内侧副韧带浅层股骨或胫骨附着点周围的 皮下瘀斑等情况

9

。对这些区域进行触诊，明确

内侧副韧带浅层是否存在压痛。

深入了解膝关节内侧的解剖对于准确地触诊和评 估受累的结构都是非

常重要的

9

。

膝关节屈曲

2 0

°

至

30

°

，加载外翻负荷以检查膝关节内侧间隙的宽度（图