Reconstrucción de esquina posteromedial: reporte de 30 casos

Resumen

Objetivo Reportar la experiencia, después de 1 año de seguimiento, de una serie de 30 pacientes sometidos a reconstrucción de la esquina posteromedial (EPM) con la técnica descrita por La Prade.

Método Cohorte retrospectiva de 30 pacientes con lesión de EPM operados por el mismo equipo quirúrgico. Criterios de inclusión: diagnóstico clínico, radiografía con estrés y resonancia magnética compatibles con lesión de EPM, inestabilidad grado III luego de 3 meses de tratamiento ortopédico, técnica de reconstrucción de La Prade, al menos 12 meses de seguimiento. Criterios de exclusión: discordancia entre clínica e imagenología, inestabilidad grado I o II, y otra técnica quirúrgica. Evaluación con IKDC y Lysholm antes de la cirugía, a los 6 y 12 meses de seguimiento postcirugía.

Resultados 30 pacientes cumplieron los criterios de inclusión. Promedio de edad 43 años (24–69). Veintiocho pacientes presentaron lesiones de alta energía, 20 pacientes fueron diagnosticados en agudo, mientras que 10 fueron diagnosticados luego de malos resultados en reconstrucción de otros ligamentos. Veintiocho presentaron lesiones asociadas: 11 casos asociados a lesión de ligamento cruzado anterior, 3 casos asociados a lesión de ligamento cruzado posterior, 3 casos en asociación con lesiones meniscales, 9 casos con lesión asociada de ligamento cruzado anterior y posterior, y 2 casos en asociación con ligamento cruzado anterior, posterior y ligamento colateral lateral. Promedio de tiempo hasta la reconstrucción de EPM fue de 5 meses (rango 2–32). Puntuación en Lysholm e IKDC (preoperatorio 18,2 y 24,3 respectivamente), mejoraron a 76,7 y 70,7 después de 1 año de seguimiento. Al fin del seguimiento, el rango articular promedio era 113° (90–140), la mayoría de los pacientes (24) tuvieron estabilidad tipo A según IKDC.

Conclusión La reconstrucción de lesiones de EPM mejora los resultados clínicos en pacientes con inestabilidad crónica posteromedial de rodilla. Se observó mejoría en la estabilidad y scores funcionales de todos los pacientes.

Abstract

Objetive Report the experience, after 1-year follow-up, of 30 patients with La Prade's anatomical reconstruction of posteromedial corner (PMC) injuries.

Methods Retrospective cohort study. 30 patients with PMC injuries operated by the same surgical team. Inclusion criteria: clinical presentation, stress radiographs and MRI compatible with PMC injury, grade III chronic instability in spite of at least 3 months of orthopedic treatment, La Prade's anatomical technique reconstruction, 12 months follow-up at least. Exclusion criteria: discordance between clinical and image studies, grade I or II medial instability, any other surgical technique. IKDC and Lysholm at the preoperative evaluation, 6 and 12 months after surgery.

Results Thirty patients met the inclusion criteria. Mean age 43 years (24–69). 28 patients presented high-energy mechanism of injury. Twenty patients were diagnosed in the acute setting, while 10 had a delayed diagnosis after poor results of other ligament reconstruction. Majority (28) had associated injuries: 11 cases PMC + anterior cruciate ligament (ACL) injury, 3 PMC + posterior cruciate ligament (PCL) injury, 3 PMC + meniscal tears, 9 PMC + ACL + PCL injuries, and 2 PMC + ACL + PCL + lateral collateral ligament injuries. Mean time for PMC reconstruction was 5 months (range 2–32). Preoperative Lysholm and IKDC scores (18,2 and 24,3 respectively) improved to 76,7 and 70,7 after 1-year follow-up. At the end of follow-up, average ROM was 113° (90–140), most patients (24) had type A IKDC stability.

Conclusion Acceptable results were achieved following reconstruction of PMC injuries in patients with chronic posteromedial knee instability. We observed instability and functional scores improvement in all patients.

Palabras Clave

rodilla - ligamento colateral medial - lesión multiligamentaria - reconstrucción

Keywords

knee - medial collateral ligament - multiligament injury - reconstruction

Nota

Este estudio no ha sido publicado en otra revista científica.

Todos los autores han leído el manuscrito y están de acuerdo con su contenido.

• Referencias

• 1 Lind M, Jakobsen BW, Lund B, Hansen MS, Abdallah O, Christiansen SE. Anatomical reconstruction of the medial collateral ligament and posteromedial corner of the knee in patients with chronic medial collateral ligament instability. Am J Sports Med 2009; 37 (06) 1116-1122
• 2 Kannus P. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clin Orthop Relat Res 1988; (226) 103-112
• 3 Indelicato PA. Non-operative treatment of complete tears of the medial collateral ligament of the knee. J Bone Joint Surg Am 1983; 65 (03) 323-329
• 4 Phisitkul P, James SL, Wolf BR, Amendola A. MCL injuries of the knee: current concepts review. Iowa Orthop J 2006; 26: 77-90
• 5 Larson RL. Combined instabilities of the knee. Clin Orthop Relat Res 1980; (147) 68-75
• 6 Robins AJ, Newman AP, Burks RT. Postoperative return of motion in anterior cruciate ligament and medial collateral ligament injuries. The effect of medial collateral ligament rupture location. Am J Sports Med 1993; 21 (01) 20-25
• 7 Sims WF, Jacobson E. The posteromedial corner of the knee: medial-sided injury patterns revisited. KAm J Sports Med 2004; 32 (02) 337-345
• 8 Jacobson KE, Chi FS. Evaluation and treatment of medial collateral ligament and medial-sided injuries of the knee. Sports Med Arthrosc Rev 2006; 14 (02) 58-66
• 9 Robinson JR, Bull AM, Amis AA. Structural properties of the medial collateral ligament complex of the human knee. J Biomech 2005; 38 (05) 1067-1074
• 10 Robinson JR, Sanchez-Ballester J, Bull AM, Thomas RdeW, Amis AA. The posteromedial corner revisited. An anatomical description of the passive restraining structures of the medial aspect of the human knee. J Bone Joint Surg Br 2004; 86 (05) 674-681
• 11 Hughston JC, Eilers AF. The role of the posterior oblique ligament in repairs of acute medial (collateral) ligament tears of the knee. J Bone Joint Surg Am 1973; 55 (05) 923-940
• 12 Gorin S, Paul DD, Wilkinson EJ. An anterior cruciate ligament and medial collateral ligament tear in a skeletally immature patient: a new technique to augment primary repair of the medial collateral ligament and an allograft reconstruction of the anterior cruciate ligament. Arthroscopy 2003; 19 (10) E21-E26
• 13 O'Donoghue DH. Reconstruction for medial instability of the knee. J Bone Joint Surg Am 1973; 55 (05) 941-954
• 14 Slocum DB, Larson RL. Rotatory instability of the knee. Its pathogenesis and a clinical test to demonstrate its presence. J Bone Joint Surg Am 1968; 50 (02) 211-225
• 15 Nicholas JA. The five-one reconstruction for anteromedial instability of the knee. Indications, technique, and the results in fifty-two patients. J Bone Joint Surg Am 1973; 55 (05) 899-922
• 16 Fanelli GC, Edson CJ. Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy 2002; 18 (07) 703-714
• 17 Cooper DE, Stewart D. Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2- to 10-year follow-up. Am J Sports Med 2004; 32 (02) 346-360
• 18 Petersen W, Loerch S, Schanz S, Raschke M, Zantop T. The role of the posterior oblique ligament in controlling posterior tibial translation in the posterior cruciate ligament-deficient knee. Am J Sports Med 2008; 36 (03) 495-501
• 19 Yoshiya S, Kuroda R, Mizuno K, Yamamoto T, Kurosaka M. Medial collateral ligament reconstruction using autogenous hamstring tendons: technique and results in initial cases. Am J Sports Med 2005; 33 (09) 1380-1385
• 20 Laprade RF, Wijdicks CA. Surgical technique: development of an anatomic medial knee reconstruction. Clin Orthop Relat Res 2012; 470 (03) 806-814
• 21 Liu H, Wang F, Kang H, Chen B, Zhang Y, Ma L. Anatomical reconstruction of the medial collateral ligament and the posterior oblique ligament of the knee. Acta Orthop Belg 2012; 78 (03) 400-404
• 22 Dong JT, Chen BC, Men XQ. , et al. Application of triangular vector to functionally reconstruct the medial collateral ligament with double-bundle allograft technique. Arthroscopy 2012; 28 (10) 1445-1453
• 23 Canata GL, Chiey A, Leoni T. Surgical technique: does mini-invasive medial collateral ligament and posterior oblique ligament repair restore knee stability in combined chronic medial and ACL injuries?. Clin Orthop Relat Res 2012; 470 (03) 791-797
• 24 Kitamura N, Ogawa M, Kondo E, Kitayama S, Tohyama H, Yasuda K. A novel medial collateral ligament reconstruction procedure using semitendinosus tendon autograft in patients with multiligamentous knee injuries: clinical outcomes. Am J Sports Med 2013; 41 (06) 1274-1281
• 25 Dong J, Ji G, Zhang Y, Gao S, Wang F, Chen B. Single allograft medial collateral ligament and posterior oblique ligament reconstruction: a technique to improve valgus and rotational stability. Eur J Orthop Surg Traumatol 2014; 24 (06) 1025-1029
• 26 Zhang H, Bai X, Sun Y, Han X. Tibial inlay reconstruction of the medial collateral ligament using Achilles tendon allograft for the treatment of medial instability of the knee. Knee Surg Sports Traumatol Arthrosc 2014; 22 (02) 279-284
• 27 Hefti F, Müller W, Jakob RP, Stäubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993; 1 (3-4): 226-234
• 28 Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982; 10 (03) 150-154
• 29 Chen L, Kim PD, Ahmad CS, Levine WN. Medial collateral ligament injuries of the knee: current treatment concepts. Curr Rev Musculoskelet Med 2008; 1 (02) 108-113
• 30 Azar FM. Evaluation and treatment of chronic medial collateral ligament injuries of the knee. Sports Med Arthrosc Rev 2006; 14 (02) 84-90
• 31 Woo SL, Vogrin TM, Abramowitch SD. Healing and repair of ligament injuries in the knee. J Am Acad Orthop Surg 2000; 8 (06) 364-372
• 32 Shirakura K, Terauchi M, Katayama M, Watanabe H, Yamaji T, Takagishi K. The management of medial ligament tears in patients with combined anterior cruciate and medial ligament lesions. Int Orthop 2000; 24 (02) 108-111
• 33 Borden PS, Kantaras AT, Caborn DN. Medial collateral ligament reconstruction with allograft using a double-bundle technique. Arthroscopy 2002; 18 (04) E19
• 34 Wahl CJ, Nicandri G. Single-Achilles allograft posterior cruciate ligament and medial collateral ligament reconstruction: a technique to avoid osseous tunnel intersection, improve construct stiffness, and save on allograft utilization. Arthroscopy 2008; 24 (04) 486-489
• 35 Kim SJ, Lee DH, Kim TE, Choi NH. Concomitant reconstruction of the medial collateral and posterior oblique ligaments for medial instability of the knee. J Bone Joint Surg Br 2008; 90 (10) 1323-1327
• 36 Pressman A, Johnson DH. A review of ski injuries resulting in combined injury to the anterior cruciate ligament and medial collateral ligaments. Arthroscopy 2003; 19 (02) 194-202
• 37 Petersen W, Laprell H. Combined injuries of the medial collateral ligament and the anterior cruciate ligament. Early ACL reconstruction versus late ACL reconstruction. Arch Orthop Trauma Surg 1999; 119 (5-6): 258-262
• 38 Harris I, Mulford J, Solomon M, van Gelder JM, Young J. Association between compensation status and outcome after surgery: a meta-analysis. JAMA 2005; 293 (13) 1644-1652