后交叉韧带重建焦点问题的争论

李晗 王晓峰 陈百成

（河北医科大学第三医院关节外科，石家庄050051）

后交叉韧带重建焦点问题的争论

李晗 王晓峰 陈百成*

（河北医科大学第三医院关节外科，石家庄050051）

后交叉韧带（posterior cruciate ligament，PCL）是稳定膝关节的重要结构，限制和引导膝关节的运动。PCL断裂将直接导致膝关节不稳，从而损害其功能。随着关节镜技术的不断完善，关节镜下重建PCL已成为理想选择。较开放手术相比，关节镜手术具有康复快，创伤小等优点。然而，随着对后交叉韧带研究的不断深入，在生物力学[1-8]、手术指征[9-12]以及康复策略[13,14]等方面出现了一些争议和挑战。围绕上述问题，学者们展开了广泛的讨论。

1 后叉韧带的生物力学机制

深入了解PCL的生物力学机制有助于解剖重建[15]。早期观点认为PCL由两组功能束 组 成 ，分 别为前外侧束（AL）和后内侧束（PM）[16,17]，AL屈膝紧张伸膝松弛，PM正好相反[17,18]。这两束在膝关节活动时功能独立。

然而，最近的研究显示这两束在膝关节伸屈活动 中 是相 互 协 同 的[15,19-21]。Mauro等[19]利 用 机 器 人 系统研究发现，AL和PM两束在膝关节伸屈活动时所承受的应力并无统计学差异。Ahmad等[21]报道随着膝关节的屈曲，PM束趋于水平限制胫骨后移。Papannagari等[20]通过磁共振（MRI）扫描发现，随着膝关节屈曲，AL和PM止点的方向变化达到120°。

Race和Amis[22]比较了单双束后交叉韧带等长重建的生物力学功能；结果显示单束等长重建膝关节伸屈活动受限，而双束重建可以获得较为理想伸屈活动度。Harner等利用尸体膝关节进行后交叉韧带双束重建获得了较好的后稳定性。然而，部分学者认 为实 验 结果 虽 有统 计 学意 义[4-6,23,24]，但 是 单双 束 重建并无本质差异。

此外，股骨隧道位置的选择意见不统一。Mannor等[7]报道将股骨插入点适当前移可以更有效的限制胫骨平台后移，但高张力可能会拉长移植物。Shearn等[1]报道PM束的位置居中可以有效降低AL束的张力。但是，这会导致两束功能独立。

2 术后膝关节功能

大量的研究报道均提倡术前功能锻炼，但是术后效果与正常状态相比仍不甚理想[15]。由于移植物存在残留松弛度，韧带重建术后膝关节功能的客观评分低于主观评分，各种重建技术均存在这一现象[15]。研究显示移植物残留松弛度的范围在2～6 mm，这意味着手术医师的业务水平直接影响术后效果[25-33]。

目前，关于单双束PCL重建术后效果的比较研究正全面展开。Wang等[34]报道术后功能评分和影像学评估无明显差异。Fanelli等研究显示主观和客观功能评分无明显差异。只有Yoon等[38]报道双束重建稳定性更好，但也强调因为二者的主观功能评分无差异，尚不能确定双束重建优于单束重建。

3 后叉韧带损伤的治疗

PCL具有内源性愈合能力；相关的MRI研究显示虽然PCL具备自我愈合能力，但仍存在残留松弛度[39-41]。绝大 多数PCL损伤并未影响板股韧带。因此在急性或亚急性损伤期，PCL的愈合能力要强于ACL[25]。大 量 影像学 研 究显示 ，滑膜包 裹 和板股 韧带，可以避免PCL完全断裂[39-42]。

PCL损伤的治疗视损伤状态而定，主要包括患者的年龄、活动能力以及韧带松弛度。年轻患者应行石膏外固定局部制动，防止胫股关节错位[9,43]。若膝关节前后移动，则需要更换石膏托。石膏外固定应持续6周，继而再行支具外固定6周[9]。需要注意的是，PCL损伤保守治疗应该立即进行康复锻炼加强股四头肌力量。

我们建议PCL 2度以上的损伤需进行韧带重建[25]。残留的PCL纤维有助于移植物的血管化，同时机械感受器可以保证膝关节稳定性。股骨隧道应保证移植物距离关节软骨边缘至少2 mm。胫骨隧道应位于韧带止点中心，将移植物沿韧带内侧缘导 入 股 骨 隧 道[25,26,44]。

4 其他合并损伤

PCL损伤可以利用改良Inlay技术进行前外侧束重建，陈旧性损伤（超过12个月）的患者，同时保有残存的PCL，则重建后可以获得较为理想的稳定性。但是，这种技术创 伤较大且技 术要求高[29,30,45,46]。前外 侧束重建股骨隧道的位置应距离关节软骨边缘5～6 mm，并且垂直于软骨面。残存的PCL纤维可以作为软组织垫覆盖在胫骨和股骨隧道入口，将移植物与骨骼隔开，避免出现杀伤角效应。但应当注意的是，如果残存PCL较为稀薄，则必须进行双束重建[47]。

PCL损伤通常会伴有后外侧旋转不稳（PLRI），发生率在43%～80%[47,48]。PCL重建失败是多因素的，最常见的就是PLRI[49,50]。因此，术前及时发现合并伤是至关重要的。目前，诊断PLRI只能依据体格检查。当患者出现急性损伤时，由于肌肉拮抗轻度PLRI可能会漏诊[48]。所以，最好是在术前麻醉状态下进行体格检查[48,51]。

根据我们的经验，PCL和后外侧角损伤会造成胫骨平台向后外侧移位。在此种情况下进行旋转试验或后外侧抽屉试验，难以发现后外侧胫骨平台半脱位。因此，适当伸直膝关节后再进行旋转试验和后外侧抽屉试验，有助于诊断PLRI。俯卧位时胫骨平台后移减少，进行旋转试验诊断更为准确[51,52]。2度损伤适合使用包裹腓骨小头的后外侧角吊带保守治疗[48]。LaPrade和Wentorf认为3度损伤 应 行关节镜下解剖重建[53]。

5 术后康复

以往的观点认为，PCL重建不建议快速的术后康复训练，应采取相对保守而缓慢的康复策略[54,55]。但是，只有相对松散的康复建议，尚未建立标准化的指南[14]。例如，PCL重建通常伴有内外侧副韧带的重建，早期负重导致局部压力过大，最终出现韧带松动[54,56]。

然而，目前学者们研究发现，早期关节负重对于稳定膝关节至关重要。第一，当双腿站立时，患者可以获得更好的静态稳定性，可以降低跌倒的风险。第二，关节负重可以刺激腱骨愈合。第三，刺激关节滑液的分泌，滋养关节软骨。第四，关节负重能够加强 肌 肉 力 量 和 本 体 感 觉[54,56,59]。 最 后 ，膝 关 节 轴 向 负重可以产生前向应力，避免胫骨平台后移[14,57,58]。

快速功能康复并不意味着立即进行关节活动度训练[14]。0°～30°的膝关节屈曲髌腱角大于腘绳肌角，腘绳肌腱不会形成剪切应力[60,61]，适合进行直腿抬高和小幅度的下蹲训练。Daniel等[62]阐述了股四头肌中立角的概念，这个角度出现在膝关节屈曲60°～75°。股四头肌伸展训练小于中立角可以避免胫骨平台后移[62,63]。

综上所述，目前，后交叉韧带的研究观点已经改变，两功能束由功能独立转变为相互协同。随着重建技术的不断发展，手术方式相对于从前更为积极。同时，保残重建和PLRI备受关注。此外，术后积极而系统的功能锻炼和早期负重日益受到重视。由于生物力学观点的矛盾以及临床研究的局限性，单双束重建的优劣尚不能定论。

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*通信作者：陈百成，E-mail：981847462@qq.com