Dizin Çoklu Bağ Yaralanmlarına Yaklaşım
Özet
Dizin çoklu bağ yaralanmaları (ÇBY), genellikle trafik kazaları gibi yüksek enerjili travmalar veya spor yaralanmaları gibi düşük enerjili etkenler sonucu en az iki büyük bağın hasar görmesiyle oluşur. Bu ciddi yaralanmalara peroneal sinir ve popliteal arter hasarları gibi akut nörovasküler komplikasyonlar eşlik edebilir. Tanı aşamasında klinik şüphe ile birlikte Lachman, arka çekmece ve Dial gibi spesifik fizik muayene testleri uygulanır; radyografi, bilgisayarlı tomografi ve MR görüntülemeleri yapısal hasarları netleştirir. Tedavi yaklaşımında, nörovasküler bütünlüğün bozulduğu durumlarda acil kapalı/açık redüksiyon ve eksternal fiksatör uygulaması hayati önem taşır. Güncel literatürde artrofibrozis ve instabiliteyi önlemek amacıyla konservatif yöntemler yerine erken dönem cerrahi girişimler tercih edilmektedir. Artroskopik rekonstrüksiyonda allogreft veya otogreft kullanımıyla tüm bağların eş zamanlı veya aşamalı onarımı gerçekleştirilirken, ilk olarak arka çapraz bağın rekonstrükte edilmesi altın kuraldır. Başarılı bir fonksiyonel sonuç elde etmek için kişiye özel cerrahi planlama, greft tünellerinin çakışmasının önlenmesi ve postoperatif üçüncü haftada başlanan erken hareket açıklığı egzersizlerini içeren agresif bir rehabilitasyon süreci zorunludur.
Multiligament knee injuries (MLKI) typically result from high-energy traumas such as traffic accidents or low-energy factors like sports injuries, causing damage to at least two major ligaments. These severe injuries can be accompanied by acute neurovascular complications, including peroneal nerve and popliteal artery damage. During the diagnosis stage, specific physical examination tests such as Lachman, posterior drawer, and Dial tests are applied along with clinical suspicion, while radiography, computed tomography, and MRI investigations clarify structural damages. In the treatment approach, emergency closed/open reduction and external fixator application carry vital importance in cases where neurovascular integrity is compromised. In current literature, early surgical interventions are preferred over conservative methods to prevent arthrofibrosis and instability. In arthroscopic reconstruction, simultaneous or staged repair of all ligaments is performed using allografts or autografts, with the reconstruction of the posterior cruciate ligament being the gold standard first step. To achieve a successful functional outcome, personalized surgical planning, prevention of graft tunnel convergence, and an aggressive rehabilitation process including early range of motion exercises starting at the postoperative third week are mandatory.
Referanslar
Wyatt RWB, Inacio MCS, Bellevue KD, et al. Isolated ACL versus multiple knee ligament injury: associations with patient characteristics, cartilage status, and meniscal tears identified during ACL reconstruction. Phys Sportsmed. 2017;45(3):323-28.
Lynch AD, Chmielewski T, Bailey L, et al. Current concepts and controversies in rehabilitation after surgery for multiple ligament knee injury. Curr Rev Musculoskelet Med. 2017;10(3):328-45.
Levy BA, Dajani KA, Whelan DB, et al. Decision making in the multiligament-injured knee: an evidence-based systematic review. Arthroscopy. 2009;25(4):430-8.
Hua X, Tao H, Fang W, et al. Single-stage in situ suture repair of multiple-ligament knee injury: a retrospective study of 17 patients (18 knees). BMC Musculoskelet Disord. 2016;17:41.
33. Lane CG, Warren R, Pearle AD. The pivot shift. J Am Acad Orthop Surg 2008;16(12):679–88.
34. Kim SJ, Kim HK. Reliability of the anterior drawer test, the pivot shift test, and the Lachman test. Clin Orthop Relat Res 1995;(317):237–42.
Mermerkaya, M. U., Polat, M., Tanrıöver, A., Tandoğan, R., & Kayaalp, A. Dizin travmatik çıkıkları.
Merritt AL, Wahl C. Initial assessment of the acute and chronic multiple-ligament injured (dislocated) knee. Sports Med Arthrosc 2011;19(2):93–103.
Lane CG, Warren R, Pearle AD. The pivot shift. J Am Acad Orthop Surg 2008;16(12):679–88
Kim SJ, Kim HK. Reliability of the anterior drawer test, the pivot shift test, and the Lachman test. Clin Orthop Relat Res 1995;(317):237–42.
Clancy WG Jr, Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg Am 1983;65(3):310–22.
Sekiya JK, Whiddon DR, Zehms CT, Miller MD. A clinically relevant assessment of posterior cruciate ligament and posterolateral corner injuries. Evaluation of isolated and combined deficiency. J Bone Joint Surg Am 2008;90(8):1621– 7.
Gollehon DL, Torzilli PA, Warren RF. The role of the posterolateral and cruciate ligaments in the stability of the human knee. A biomechanical study. J Bone Joint Surg Am 1987;69(2):233–42.
Hughston JC, Andrews JR, Cross MJ, Moschi A. Classification of knee ligament instabilities: I. The medial compartment and cruciate ligaments. J Bone Joint Surg Am 1976;58(2):159–72.
Clancy WG Jr, Shelbourne KD, Zoellner GB, Keene JS, Reider B, Rosenberg TD. Treatment of knee joint instability secondary to rupture of the posterior cruciate ligament. Report of a new procedure. J Bone Joint Surg Am 1983;65(3):310–22
0. Ranawat A, Baker CL 3rd, Henry S, Harner CD. Posterolateral corner injury of the knee: evaluation and management. J Am Acad Orthop Surg 2008;16(9):506–18
Cooper DE. Tests for posterolateral instability of the knee in normal subjects: Results of examination under anesthesia. J Bone Joint Surg Am 1991;73(1):30–6.
Escobedo EM, Mills WJ, Hunter JC. The “reverse Segond” fracture: association with a tear of the posterior cruciate ligament and medial meniscus. AJR Am J Roentgenol 2002;178(4):979–83
Helgeson MD, Lehman RA Jr, Murphy KP. Initial evaluation of the acute and chronic multiple ligament injured knee. J Knee Surg 2005;18(3):213–9.
Levy BA, Fanelli GC, Whelan DB, Stannard JP, MacDonald PA, Boyd JL, Marx RG, Stuart MJ; Knee Dislocation Study Group. Controversies in the treatment of knee dislocations and multiligament reconstruction. J Am Acad Orthop Surg 2009;17(4):197–206
Dwyer T, Marx RG, Whelan D. Outcomes of treatment of multiple ligament knee injuries. J Knee Surg 2012;25(4):317– 26. Crossref
Wong CH, Tan JL, Chang HC, Khin LW, Low CO. Knee dislocations --a retrospective study comparing operative versus closed immobilization treatment outcomes. Knee Surg Sports Traumatol Arthrosc 2004;12(6):540–4.
Bonanzinga T, Zhang H, Song GY, Zhang J, Signorelli C, Feng H. Is PLC repair of a peel-off femoral lesion an effective option in a multiligament setting? Knee Surg Sports Traumatol Arthrosc 2015;23(10):2936–42.
Sabat D, Jain A, Kumar V. Displaced posterior cruciate ligament avulsion fractures: a retrospective comparative study between open posterior approach and arthroscopic single-tunnel suture fixation. Arthroscopy 2015;32(1):44–53.
Cook S, Ridley TJ, McCarthy MA, Gao Y, Wolf BR, Amendola A, Bollier MJ. Surgical treatment of multiligament knee injuries. Knee Surg Sports Traumatol Arthrosc 2015;23(10):2983–91.
Stannard JP, Black BS, Azbell C, Volgas DA. Posteromedial corner injury in knee dislocations. J Knee Surg 2012;25(5):429–34.
Rochecongar G, Plaweski S, Azar M, Demey G, Arndt J, Louis ML, Limozin R, Djian P, Sonnery-Cottet B, Bousquet V, Bajard X, Wajsfisz A, Boisrenoult P; French Society for Arthroscopy (Société Française d’Arthroscopie, SFA). Management of combined anterior or posterior cruciate ligament and postero-lateral corner injuries: a systematic review. Orthop Traumatol Surg Res 2014;100(8 Suppl):S371–8.
Hirschmann MT, Iranpour F, Müller W, Friederich NF. Surgical treatment of complex bicruciate knee ligament injuries in elite athletes: what long-term outcome can we expect? Am J Sports Med 2010;38(6):1103–9.
Howells NR, Brunton LR, Robinson J, Porteus AJ, Eldridge JD, Murray JR. Acute knee dislocation: an evidence based approach to the management of the multiligament injured knee. Injury 2011;42(11):1198–204.
Goebel, Collin Patrick, and Christopher Domes. "Classifications in brief: The Schenck classification of knee dislocations." Clinical Orthopaedics and Related Research 478.6 (2020): 1368.
