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首页> 外文期刊>Orthopaedic Journal of Sports Medicine >Elimination of the Pivot-Shift Sign After Repair of an Occult Anterolateral Ligament Injury in an ACL-Deficient Knee
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Elimination of the Pivot-Shift Sign After Repair of an Occult Anterolateral Ligament Injury in an ACL-Deficient Knee

机译：修复ACL缺陷型膝关节隐性前外侧韧带损伤修复后的枢轴移位标志

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Several biomechanical studies have demonstrated the importance of the anterolateral ligament (ALL) in rotational instability of the knee.~( 1 , 10 , 12 , 14 )Despite this, the precise role of the ALL in eliminating the pivot shift remains controversial.~( 9 , 11 , 13 )This disparity exists secondary to the nature of cadaveric research and the subsequent creation of artificial injury patterns that are not a true representation of in vivo characteristics. This case report provides clinical evidence of the important role that the anterolateral structure plays in anterolateral rotational instability, as demonstrated by the pivot-shift sign. Case Presentation A 17-year-old female volleyball player presented to the emergency department after a noncontact injury of the left knee sustained during the impact of landing from a jump. She reported that she heard a “crack” and experienced immediate pain and swelling in the knee. Physical examination revealed a moderate effusion, a 0° to 80° range of motion, and a grade 2 Lachman test. The pivot-shift test could not be reliably performed due to pain and subsequent muscular contraction. Plain radiographs showed no evidence of a bony injury. The patient underwent 1.5-T magnetic resonance imaging (MRI), which confirmed the clinical diagnosis of anterior cruciate ligament (ACL) rupture and revealed characteristic bone bruising of the lateral femoral condyle. Even though no ALL or anterolateral capsule lesion was reported by the radiologist, it was possible to identify abnormalities of the ALL according to previously reported imaging parameters of this structure~( 5 )( Figure 1A ). Figure 1. Magnetic resonance imaging (MRI) and clinical images of the left knee. (A) Coronal (proton-density, fat-suppressed) MRI demonstrating a tear of the anterolateral ligament/capsule (arrow). (B-D) Clinical photographs of the lateral aspect of the same knee (all images are oriented with the most distal part of the limb to the left). (B) Intact iliotibial band (ITB) (*). (C) Tear of the anterolateral capsule identified after ITB split in line with its fibers (*). (D) Repaired anterolateral capsule. The patient was admitted to the hospital for an ACL reconstruction, which was performed 5 days after the injury. Examination under general anesthesia revealed a full range of motion, positive Lachman test, and grade 2 pivot shift (see the online Video Supplement). Varus and valgus stress tests were both negative at 0° and 30° of flexion. The semitendinosus and gracilis tendons were harvested for the ACL graft. Due to the presence of a grade 2 pivot shift and suspicion of injury to the anterolateral structures, the lateral compartment was approached by a hockey stick incision. After skin flaps were lifted, the fascia lata was confirmed to be completely normal, with no visible tear, bruise, or hematoma ( Figure 1B ). It was then incised, in line with its fibers, to reveal heavily blood-stained synovial fluid exiting the joint via a 1-cm-wide lesion of the anterolateral capsule ( Figure 1C ). The lesion was repaired by 3 parallel stitches with square knots (No. 2 Vicryl; Ethicon) in tension with the knee at 90° of flexion and neutral rotation ( Figure 1D ). Physical examination was repeated prior to ACL reconstruction and revealed the continued presence of a positive Lachman test but a complete resolution of the pivot shift, in contrast to the grade 2 pivot shift present prior to repair of the anterolateral capsule and ligament. Arthroscopic evaluation showed normal medial and lateral menisci and a grade 3, midlevel ACL rupture. ACL reconstruction was then performed with a doubled hamstring tendon graft (size 8 mm). An 8-mm tibial tunnel was drilled at the center of the native footprint with a guide set at 60°. An 8 × 25–mm femoral socket was drilled with an outside-in technique (flip cutter; Arthrex). The center was located at the anatomic insertion of the ACL, midway between the “resident’s ridge” and the posterior wall of the femoral condyle. The graft was passed through the joint via a suture loop, retrieved through the tibial tunnel, and fixed on the femoral side with a TightRope RT adjustable-loop cortical button (Arthrex) and on the tibial side with an absorbable biocomposite 9 × 28-mm interference screw (Arthrex) fixed in 30° of flexion with a posterior drawer applied. After ACL reconstruction, the physical examination was repeated. Both Lachman and pivot-shift tests were negative. The fascia lata was sutured, and the skin was closed. No drain was used. A long leg brace was applied with the limb placed in extension, and the brace remained in situ for 2 weeks. On postoperative day 2, isometric exercises for quadriceps contraction and muscular strengthening were commenced. Progression to weightbearing as tolerated was encouraged. After 2 weeks, the brace was removed and full active range of motion was encouraged. Activities were increased in physical therapy and progressed to resistance isotonic
机译：几项生物力学研究表明，前外侧韧带（ALL）在膝关节旋转不稳中具有重要意义。〜（1，10，12，14）尽管如此，ALL在消除枢轴位移方面的确切作用仍然存在争议。 9、11、13）这种差异存在于尸体研究的本质以及随后的人为伤害模式的创建中，这些行为并不是体内特征的真实表现。该病例报告提供了前外侧结构在前外侧旋转不稳定性中发挥重要作用的临床证据，如枢转移位迹象所示。案例介绍一名17岁的女排球运动员因跳跃着陆而遭受的左膝非接触式受伤后，被送往急诊科。她报告说她听到“ a”的声音，并立即感到膝盖疼痛和肿胀。体格检查发现有中等程度的积液，0°至80°的运动范围以及2级Lachman测试。由于疼痛和随后的肌肉收缩，无法可靠地执行枢轴移动测试。普通X光片未显示骨损伤的证据。患者接受了1.5-T磁共振成像（MRI），证实了前交叉韧带（ACL）破裂的临床诊断，并揭示了股外侧lateral的特征性瘀伤。即使放射科医生没有报告ALL或前囊膜病变，也可以根据先前报道的该结构的成像参数确定ALL的异常[5]（图1A）。图1.左膝的磁共振成像（MRI）和临床图像。 （A）冠状（质子密度，脂肪抑制的）MRI显示前外侧韧带/胶囊的撕裂（箭头）。 （B-D）同一膝关节外侧的临床照片（所有图像的朝向都指向四肢的最远端）。 （B）完整的胫束带（ITB）（*）。 （C）在ITB与其纤维（*）对齐后分裂的前外侧囊的撕裂。 （D）修复前外侧囊。该患者入院接受ACL重建，该手术在受伤后5天进行。在全身麻醉下进行的检查显示出全方位的运动，阳性的Lachman测试和2级枢轴移位（请参见在线视频补充资料）。内翻和外翻应力测试在0°和30°屈曲时均为阴性。收获半腱肌和肌腱肌腱用于ACL移植。由于存在2级枢轴移位和怀疑前外侧结构受伤的情况，曲棍球棒切口切入了外侧室。提起皮瓣后，确认筋膜完全正常，无可见的泪痕，瘀伤或血肿（图1B）。然后将其切开，并与其纤维对齐，以显示血液污染严重的滑液通过前外侧囊的1厘米宽病变离开关节（图1C）。病变通过正方形结（编号2 Vicryl; Ethicon）的3个平行缝线在膝盖屈曲90度和中性旋转的张力下进行修复（图1D）。在进行ACL重建之前，重复进行了体格检查，结果发现继续存在阳性Lachman测试，但枢轴位移完全解决，这与修复前外侧囊和韧带之前的2级枢轴位移相反。关节镜评估显示内侧和外侧半月板正常，中度ACL 3级破裂。然后用双股绳肌腱移植物（尺寸8 mm）进行ACL重建。在原始脚印的中心钻了一个8毫米的胫骨隧道，并设置了60°的导向装置。用一种由内而外的技术（翻转刀; Arthrex）钻了一个8×25mm的股骨窝。中心位于ACL的解剖部位，位于“患者脊”和股骨dy后壁之间的中间位置。移植物通过缝合环穿过关节，通过胫骨隧道取回，并使用TightRope RT可调环皮层纽扣（Arthrex）固定在股骨侧，并使用9×28-mm可吸收生物复合物固定在胫骨侧干涉螺钉（Arthrex）固定在30°屈曲位置，并装有后抽屉。 ACL重建后，重复体格检查。拉赫曼测试和枢轴位移测试均为阴性。缝合了筋膜，皮肤闭合。没有使用排水。应用长腿支架，四肢伸直，支架保持原位2周。术后第2天，开始进行股四头肌收缩和肌肉增强等距练习。鼓励发展到可以忍受的负重。 2周后，取下支架，并鼓励进行完整的活动范围。在物理治疗中活动增加，并发展为等渗性抵抗

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