KCI등재
만성 후방십자인대의 치료 = Treatment of Chronic Posterior Cruciate Ligament Injury
저자
정영복 (중앙대학교 의과대학 정형외과학교실)
발행기관
학술지명
권호사항
발행연도
1990
작성언어
Korean
KDC
514.98305
등재정보
KCI등재
자료형태
학술저널
발행기관 URL
수록면
19-29(11쪽)
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Posterior cruciate ligament (PCL) is the msot important of the knee ligament because of its cross section area, tensiie strenth and location in the central axis of the knee joint (Hugston et al. 1976, Kennedy & Gringer 1967) Butler el al. (1980) demonstrated that it provides 95 % of the total restraint to posterior displacement of the tibia.
Chronic disabling PCL instability has not been demonstrated to have a satisfactory solution. There are many reconstructive procedures since Hey-Groves reported in 1917. Surgical reconstruction of the PCL has a low success rate for several reasons. First, the PCL is more commonly damaged by severe trauma resulting in extensive damage to other structures including nerves, vessels, ligaments, and cartilage surfaces. Secondly, the PCL has few secondary restraints in which to help prevent posterior tibial sag. Therefore, tissues selected for reconstruction of the PCL must maintain exceptional strength during and after healing. Third, posterior drawer forces occur constantly during daily living activities resulting in cyclic loading of the reconstruction. Fourth, because of posterior tibial sag, a $quot;functional$quot; Patella Baja is created which leads to progressive patellofemoral arthrosis. For these reasons and more, a knee which demonstrates posterior cruciate insufficiency presents a formidable challenge. Imperative to the successful outcome of any PCL reconstruction, is the selection of a replacement which has proper biomechanica1 properties with secure fixation to bone at accurate, isometric attachment sites. There are no controversy in operative treatment of the combined injury of the PCL but stilll controversy in surgical treatment of the isolated PCL injury, Because of PCL instability alone is infrequently disabling and rarely requires reconstruction. Dandy and Pusey (1982) recommended non-operative treatment in isolated PCL injury. Torg et al.(1988) reported that unidirectional instability due to PCL deficiency do not require repair or reconstruction. However, in view of the much less favorable prognosis for PCL-deficient knees with multidirectional instability, consideration should be given to surgical stabilization. In contrast to the findings of Dandy and Pusey, Kennedy et al. (1867) reported that in twenty-five of fifty-seven knecs with untreated insufficiency of thc posterior cruciate ligament significant degenerateive changes developed within an average of sixty-one months. Clancy et al. (1983) reported that moderate to severe articular injury of the medial femoral condyle was found at operation in 48 percent of the patients with chronic injury of the PCL. Seventy-one percent of the patients for whom the interval between injury and ligament reconstruction was two to four years, and 90 percent of those for whom the interval was more than four years, showed articular injury of the medial femoral condyle. From the data contained in these reports, it appears that in at least some individuals with isolated insufficiency of the PCL functional disability will develop.
To repair or reconstruction a torn PCL successfully, the surgeon must fully appreciate its anatomie structure and its function. The angle between the ligament and the long femoral axis in extension was 43 ± 3 degree. The distance between the central points of the ligament insertion area (ligament length) was 38 ± 4 mm. The thickness was 6 ± 1 mm and the width 14 ± 2 mm measured in the middle third of the ligament.
When surgeon try to reconstruction of PCL to make sure that the distance between the insertion points is isometric during flexion and extension of the knee (Odensten & Gillquist 1988). When correctly placed and held that the graft will not allow posterior sag af the tibia and the knee can be flexed to 90 degree and the knee extended to 20 degree of flexion without in-out movement of the graft by Hugston. The new replacement should be seen to tighten sligtly as the knee proceeds from 20 degrees to 100 degrees of flexion within 3 mm excursion on the isometer. Isometric placement of the graft is present if ligament tension is maintained through the range of motion. And also flexion and extension is not impeded. If the femoral attachment site has been placed too distal, the new ligament will tighten and impede motion as the knee is taken into flexion. If the femoral attachment site is too proximal, then the substitute will tighten excessively as the knee is extended. There should be no impingement of the medial femoral notch, and there should be minimal crimping of the ligament fibers over the pasterior edge of the femoral tunnel. At moment the isometric point of the PCL is near the center of posteromedial part of the ligament where is the most favorable site. It should be noted that obtaining an isometric PCL replacement is very difficult and variability from patient to patient is much greater than with isometric anterior cruciate replacements. The use of a guide wire and isometric positioner is encourage. The major indication for surgical reconstruction is unpredictable instability that occurs during the course of everyday activity and dose not improve with adequate program of rehabilitation exercise. Bracing is inapporopriate for these patients, as the brace whould have to be worn continuously. Insall and Hood (1982) estimate that about one-third of their patients who were diagnoged as having posterior cruciate insufficiency have required reconstruction. Over 10 mm laxity in posterior drawer test of the PCL insufficiency should be surgical reconstruction by Tricky (1980). I recommend that surgical reconstruction is over 10 ∼ 15 mm laxity in poIterior drawer test and 2 ∼ 3 degree of the laxity in reverse pivotshift test and reverse Lachman test of the young patients who has discomfort and some symptoms in daily life. Otherwise non-operative treatment should be considered, To have good functional posterior cruciate stability, the greatest possible power and function in the extensor mechanism is necessary. In surgical reconstructed or non-operated cases of the PCL insufficiency, good quadriceps power is very important for normal function of the knee. Quadriceps rehabilitation is a quite worthwhile goal and is associated with good results. Good rehabilitation save bad sugery, bad rehabilitation compromise good surgery. The rehabilitation must be indivisualized acording to patients circumstance. As soon as apossible early mobilization of the knee is very important of the PCL insufficiency.
We must remember that the worst knee is the result of poor sugically treated case (Hughston).
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