膝关节前外侧结构加强及重建专家共识(2021年版)

膝关节前交叉韧带重建术有一定的失败风险,对于有高危因素的患者,其失败率更高。随着对膝关节前外侧结构在维持膝关节旋转稳定中作用的发现与认知,在前交叉韧带重建的同时可以进行膝关节前外侧结构的加强或重建以降低伴有高危因素的前交叉韧带损伤患者的治疗失败率。因此,专家组在循证医学的基础上,对膝关节前外侧结构的定义、术前评估、手术适应证、手术技术和策略、术后康复及并发症预防与处理原则等方面进行了文献总结和讨论,制定了膝关节前外侧结构加强及重建专家共识规范。本共识将提供一套临床诊疗方法与路径参考,以便医生在为具有较高失效风险患者进行前交叉韧带重建和翻修手术时选择前外侧结构加强或者重建。     

前交叉韧带重建骨道定位观念演变及技术发展

股骨骨道定位是决定前交叉韧带重建术成败的关键因素。随着对前交叉韧带解剖结构及生物力学功能的深入研究,前交叉韧带重建经历了从等长重建到解剖重建观念的演变。前交叉韧带解剖重建是当前主流观点,在此基础上发展起来的功能解剖重建是新的研究热点。前交叉韧带重建骨道定位技术复杂多样,各有特点。经典的过顶点位置技术目前仍适用于前交叉韧带翻修术;时钟面定位法操作简单,但需要术者具有丰富的临床经验;骨性标志定位法和导向器辅助下残端定位法定位准确,是目前临床常用的方法;透视下Bernard四格法操作复杂,主要用于科学研究;计算机辅助导航定位技术是新兴的定位方法。该文就前交叉韧带重建骨道定位观念演变及技术发展进行综述。     

膝关节后外侧结构研究进展

膝关节后外侧结构主要有外侧副韧带、胭肌腱和胭腓韧带。随着对其解剖学、运动学、动力学以及与后交叉韧带重建关系的研究不断深入,出现了影像学及关节镜下的诊断方法。解剖重建膝关节后外侧结构刚刚起步,现已出现同时重建3个主要结构的技术。     

膝关节前外侧旋转不稳定的诊断与治疗研究进展

前交叉韧带、前外侧复合体和外侧半月板共同维持膝关节的前外侧旋转稳定性, 控制胫骨内旋。临床上膝关节前外侧旋转不稳定并不少见, 其主要损伤机制是非接触性损伤。轴移试验、胫骨内旋试验可提示前外侧旋转不稳定。X线片、CT、磁共振成像及超声检查可辅助诊断及鉴别诊断。对于急性前外侧旋转不稳定, 良好的前交叉韧带重建技术是避免术后残留前外侧旋转不稳定的基础, 前外侧韧带重建及关节外腱固定术可酌情选择;而对于慢性前外侧旋转不稳定, 采用前外侧韧带重建或关节外腱固定术治疗均有效。本文对膝关节前外侧旋转不稳定的诊断与治疗研究进展进行综述, 以期为临床诊治提供参考。     

膝关节前交叉韧带解剖单束重建的研究进展

近年来,随着对膝关节前交叉韧带解剖的深入研究,发现前交叉韧带并不是以往所认知的双束椭圆结构,而是单束带状的。该发现引起了关于双束重建是否符合前交叉韧带解剖的热论,也促使越来越多的研究者开始关注解剖单束前交叉韧带重建的技术改进。本文通过查阅近几年国内外与成人膝关节解剖单束前交叉韧带重建相关文献,对该技术的骨隧道定位和建立,移植物的选择和固定,术后并发症及术后康复和临床效果等进行总结分析,综述成人膝关节解剖单束前交叉韧带重建的研究进展。     

前外侧韧带的认识进展

膝关节的前外侧韧带最近在骨科界引起了广泛关注。自1879年第一次描述这个结构以来,它很长一段时间仅限于解剖描述和猜测,到最近尽管已认识了其生物力学特性和功能,但尚不全面。这个结构主要在内旋时对膝关节起到限制作用,而尚无明确理论解释其可能存在的本体感受。鉴于其在轴移现象中起到的作用,因此有人认为在严重的膝关节韧带损伤中,前外侧稳定术和前交叉韧带重建术的结合可以预防术后不稳定,然而其临床效果还有待检验。本文将从前外侧韧带不同时期的名称、解剖形态、组织学、生物力学和前外侧不稳的外科治疗方法五个方面进行概述。     

前交叉韧带解剖学研究进展

前交叉韧带(anterior cruciate ligament, ACL)是膝关节运动学和生物力学的重要结构,主要约束和限制胫骨前移,对外翻和内翻应力也有一定作用,除此之外,它还限制了胫骨平台向内旋转。前交叉韧带存在2个功能束且目前争议不大,即前内侧束(anteromedial bundle, AM)及后外侧束(posterolateral bundle, PL)。然而,ACL正常解剖止点究竟在哪里、ACL损伤后需要重建几束等问题,还存在不少争议,由于测量方式及研究对象的不同,研究者测得数据差距较大。但无论在重建ACL时如何定位,使用单束还是双束重建,都取决于外科医生对ACL解剖和功能关系的认识。本文将回顾前交叉韧带的神经、血管、外科标志、解剖特点,为外科医师在前交叉韧带重建手术中使用标志物确定股骨侧及胫骨侧止点提供解剖学依据。     

前外侧韧带重建术的应用与争议的研究进展

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...     

关节镜下常规入路联合后内侧入路重建后交叉韧带

后交叉韧带（PCL）是维持膝关节稳定的一条重要韧带，随着对后交叉韧带的生理解剖功能及其损伤后继发的膝关节病变研究的深入，越来越倾向于对PCL进行积极的外科重建，以达到维持膝关节后向稳定性和防止骨性关节炎发生的目的。但由于后交叉韧带的解剖位置深在，重建中制作胫侧骨道时其后交叉韧带下位止点显露困难，给韧带重建带来难题。2003-2005年在关节镜下联合后内侧入路重建后交叉韧带15例，取得满意效果，报告如下。     

Müller法重建膝关节后外侧结构

目的：探讨Muller法重建膝关节后外侧结构的临床疗效。方法：2005年6月至2007年6月治疗13例膝关节后外侧损伤,7例伴有后交叉韧带损伤,4例伴有前后交叉韧带损伤,1例伴前交叉韧带损伤,1例伴前交叉韧带止点骨折,其中5例为陈旧损伤。先关节镜下重建交叉韧带,采用髂胫束前侧约10mm宽腱束经胫骨骨隧道至后侧胭肌腱通道,与胭肌腱平行返回胭肌腱上止点,挤压螺钉固定重建胭肌腱。采用股二头肌腱前1／3腱束及挤压螺钉固定重建外侧副韧带,术后早期进行CPM锻炼及股四头肌锻炼,6-8周扶拐下地。结果：术后随访6-27个月,平均13个月,无屈伸活动障碍,外旋稳定性和对侧相比无明显差别。术后1年,有2例在屈膝30。位存在内翻I度松弛。术后膝关节功能评分（Lysholm）77～94分,平均86分。结论：Miiller法重建治疗膝关节后外侧结构损伤临床操作简便,不受重建材料限制,重建效果满意。     

Editorial Commentary: Ligamentous Hyperlaxity: A Decisive Factor for the Indication of a Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction?

Indications for combined anterior cruciate ligament (ACL) and anterolateral ligament (ALL) reconstruction are not well defined, and the role of ligamentous hyperlaxity on anterolateral rotatory instability in an ACL-deficient knee remains unclear. Possible indications for combine ACL and ALL reconstruction might be a high-grade pivot shift, revision ACL reconstruction, patients with proven anterolateral knee pathology on preoperative imaging, and young patients participating in high-demand sport, and perhaps, finally, patients with ligamentous hyperlaxity as above.     

Editorial Commentary: Anterior Cruciate Ligament Reconstruction Alone Is Not Sufficient in Anterolateral Complex Injury: Extra-Articular Augmentation (Lateral Extra-Articular Tenodesis [LET] or Anterolateral Ligament [ALL] Reconstruction) Allows Surgeons to Indicate Tight (LET) or Just Right (ALL) on a Case-by-Case Basis

Extra-articular augmentation has become an essential consideration in contemporary anterior cruciate ligament reconstruction (ACL) surgery. The verdict is still out on the extra-articular augmentation procedure of choice to accompany ACL surgery in the treatment of anterolateral rotatory instability. Anterolateral ligament reconstruction and lateral extra-articular tenodesis) are 2 common methods with clinical outcome data to support their use. Both procedures have demonstrated clinical effectiveness in reducing the rate of recurrent ACL tear/recurrent knee instability. Biomechanics studies to date have reached varied conclusions; however, a growing body of research including the study discussed here suggests both procedures enhance stability in the setting of surgical treatment of anterolateral rotatory instability, whereas ACL reconstruction alone is not sufficient in the setting of anterolateral complex injury. I suggest surgeons carefully consider when to augment ACL surgery with an extra-articular procedure and feel there is a place for both procedures. When extra constraint is indicated, I recommend lateral extra-articular tenodesis. When patient athletic demands may be lesser and a less-invasive procedure is indicated, anterolateral ligament augmentation of ACL reconstruction is my preference.     

Editorial Commentary: During Anterior Cruciate Ligament Reconstruction,Lateral Extra-Articular Procedures Have Risks and Should be Reserved for Proper Indications: Do Not LET ALL Revision Anterior Cruciate Ligament Reconstructions Be the Same

Recently, there has been renewed interest in performing a lateral extra-articular procedure (LEAP), either an anterolateral ligament (ALL) reconstruction or a LET (lateral extra-articular tenodesis) to address a deficiency of the anterolateral complex (ALC) of the knee during anterior cruciate ligament (ACL) reconstruction. The ALC consists of the superficial and deep aspects of the iliotibial band with its Kaplan fiber attachments on the distal femur, along with the ALL, a structure within the anterolateral capsule. The ALC functions to provide anterolateral rotatory stability as a secondary stabilizer of the ACL. The evidence to date is that the addition of a LEAP to a revision ACL reconstruction may reduce the risk of repeat graft failure and rotatory laxity. However, in some cases, performing a LEAP may not confer any additional benefit and add unwarranted risk including lateral pain, reduced quadriceps strength, longer time to recovery, and overconstraint of the lateral compartment with associated cartilage damage. Perhaps LEAP is best indicated for high-risk patients (young, active in pivoting sports, high-grade pivot-shift, generalized ligamentous laxity or knee hyperextension, Segond fracture, chronic ACL lesion, lateral femoral notch sign, lateral coronal plane laxity, concurrent meniscus repair, or ALC injury on magnetic resonance imaging). Other modifiable risk factors should not be ignored (graft choice, graft size, tunnel position, graft fixation, associated injuries such as a lateral meniscal root tear, or anatomic factors such as an increased posterior tibial slope). Do not LET ALL revision anterior cruciate ligament reconstructions be the same! A lateral extra-articular procedure may sometimes, but not always, reduce the risk of further failure.     

Combined Anterior Cruciate Ligament and Lateral Extra-Articular Reconstruction

The anterolateral complex (ALC) of the knee has received renewed research interest because of the potential role of this anatomic region in anterior cruciate ligament (ACL) tear biomechanics and surgical treatment outcomes. The primary structures of the ALC include the iliotibial band deep (Kaplan) fibers, the anterolateral ligament (ALL), and the capsulo-osseous layer (COL) of the iliotibial band, although there remains disagreement on the precise anatomic locations and biomechanical relevance of these structures. Sectioning studies in the ACL-deficient knee have revealed a contribution of the ALC in restraining tibial internal rotation and anterior translation. Biomechanical studies have revealed a potential role for lateral extra-articular reconstruction as an augmentation to ACL reconstruction in knees with combined ACL and ALC sectioning. Clinical studies have reported a reduced ACL reconstruction failure rate with both ALL reconstruction and lateral extra-articular tenodesis procedures.     

Anterolateral Ligament of the Knee Shows Variable Anatomy in Pediatric Specimens

Background

Anterior cruciate ligament (ACL) reconstruction failure rates are highest in youth athletes. The role of the anterolateral ligament in rotational knee stability is of increasing interest, and several centers are exploring combined ACL and anterolateral ligament reconstruction for these young patients. Literature on the anterolateral ligament of the knee is sparse in regard to the pediatric population. A single study on specimens younger than age 5 years demonstrated the presence of the anterolateral ligament in only one of eight specimens; therefore, much about the prevalence and anatomy of the anterolateral ligament in pediatric specimens remains unknown.

Questions/purposes

We sought to (1) investigate the presence or absence of the anterolateral ligament in prepubescent anatomic specimens; (2) describe the anatomic relationship of the anterolateral ligament to the lateral collateral ligament; and (3) describe the anatomic relationship between the anterolateral ligament and the physis.

Methods

Fourteen skeletally immature knee specimens (median age, 8 years; range, 7–11 years) were dissected (12 male, two female specimens). The posterolateral structures were identified in all specimens, including the lateral collateral ligament and popliteus tendon. The presence or absence of the anterolateral ligament was documented in each specimen, along with origin, insertion, and dimensions, when applicable. The relationship of the anterolateral ligament origin to the lateral collateral ligament origin was recorded.

Results

The anterolateral ligament was identified in nine of 14 specimens. The tibial attachment point was consistently located in the same region on the proximal tibia, between the fibular head and Gerdy’s tubercle; however, the femoral origin of the anterolateral ligament showed considerable variation with respect to the lateral collateral ligament origin. The median femoral origin of the anterolateral ligament was 10 mm (first interquartile 6 mm, third interquartile 13) distal to the distal femoral physis, whereas its median insertion was 9 mm (first interquartile 5 mm, third interquartile 11 mm) proximal to the proximal tibial physis.

Conclusions

The frequency of the anterolateral ligament in pediatric specimens we observed was much lower than other studies on adult specimens; future studies might further investigate the prevalence, development, and functional role of the anterolateral ligament of the knee.

Clinical Relevance

This study expands our understanding of the anterolateral ligament and provides important anatomic information to surgeons considering anterolateral ligament reconstruction concomitantly with primary or revision ACL reconstruction in pediatric athletes.

     

Anterolateral Ligament of the Knee: Diagnosis,Indications, Technique,Outcomes

In the context of anterior cruciate ligament reconstruction surgery, anterolateral ligament reconstruction is now recognized as a reliable option to control rotatory instability and should be considered in the knee surgeon's modern armamentarium. By highlighting its daily practical application, this infographic presents the indications for this specific additional lateral augmentation, the anatomic and biomechanical principles that underline its rationale, and the clinical outcomes from recent large series.In 2013, Claes et al. updated the anterolateral ligament (ALL) concept, and numerous subsequent studies detailed its precise anatomy. It is now accepted that the femoral insertion is located proximal and posterior to the epicondyle. The biomechanical behavior of the ALL during the knee flexion path has been reported to provide control of tibial internal rotation during the pivot shift and with increasing knee flexion angles (>35). Clinically, when a patient presents with an anterior cruciate ligament (ACL) injury, clinical examination (pivot shift test), radiography (Segond fracture), ultrasound, and 3-dimensional magnetic resonance imaging are useful to assess a combined ALL injury.The following indications for ALL reconstruction are now well established: ACL revision, high-grade pivot shift test, chronic ACL rupture, young patients, pivoting activities, and patients undergoing medial meniscus repair. It has been reported that anatomic and minimally invasive surgical techniques that control anterolateral rotatory instability can achieve successful outcomes without specific complications. Finally, the addition of ALL reconstruction does not delay postoperative rehabilitation, and no modification is required for an early rehabilitation protocol.     

Editorial Commentary: This Is the Way: Extra-Articular Augmentation Is an Essential Consideration in Contemporary Anterior Cruciate Ligament Surgery

Since the rediscovery of the anterolateral ligament, extra-articular augmentation (EA) has evolved from controversial to an essential consideration in contemporary anterior cruciate ligament reconstruction surgery. Anterolateral ligament (ALL) reconstruction and lateral extra-articular tenodesis are 2 common methods. Indications among early adopters pioneering anterolateral ligament reconstruction at anterior cruciate ligament surgery included revision anterior cruciate ligament (ACL) case, chronic ACL tear, high-grade pivot shift, and patients with hyperlax, hypermobile knees. Newer indications include young patient age, pivoting sport/high-demand/high-risk athlete, and concurrent medial meniscus repair. Questions remain regarding best practices as indications continue to evolve regarding technique, graft choice, angle/position of reconstruction fixation, and whether EA should be reconstructed routinely. This fast-moving surgical evolution serves as a reminder of 2 key concepts; first, that anterior cruciate ligament tears occur more fundamentally in the setting of anterolateral rotatory instability, in which concurrent soft tissue injuries are common, and, second, that even our best “anatomic” reconstructions do not fully recapitulate the native ACL, both of which give impetus to reconstructing the ALL.     

Editorial Commentary: Major Technical Advances in Knee Anterior Cruciate Ligament Reconstruction Address Anatomy,Biomechanics, and Healing

The surgical techniques in knee anterior cruciate ligament (ACL) reconstruction continue to evolve significantly. Improved understanding of the anatomy, biomechanics, and healing of the ACL has offered the foundation for several advances. The goal of these innovations is to successfully restore the native anatomy and biomechanical function of the native ligament, provide a stable and pain-free knee joint, allow return to prior level of activity, prevent rerupture, and prevent osteoarthritis. Taken in sum, these are lofty goals. The shift toward anatomic ACL reconstruction, development of diverse graft options and configurations, and the addition of reinforcement techniques, such as the anterolateral ligament reconstruction and lateral tenodesis techniques, are major advancements in ACL reconstruction.     

Extra-articular techniques in anterior cruciate ligament reconstruction: a literature review

This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique. The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.