Ön Çapraz Bağ Cerrahisinde Anterolateral Ligament Rekonstrüksiyonunun Yeri ve Tarihçesi
Özet
Ön çapraz bağ (ÖÇB) yaralanmaları, diz ekleminde rotasyonel instabiliteye ve tibianın anterior translasyonuna yol açan, sporcularda sık karşılaşılan fonksiyonel sorunlardandır; bu yaralanmalara sıklıkla anterolateral kapsül ve lateral menisküs hasarları eşlik etmektedir. Tibianın iç rotasyonunu kontrol ederek dizin dönme stabilitesini sağlayan anterolateral ligamanın (ALL) anatomik varlığı ve önemi, ilk kez 1879 yılında Paul Segond tarafından tanımlanmış ve 2013 yılında Claes ve arkadaşları tarafından kadavra çalışmalarıyla kesin olarak ortaya konmuştur. Yapılan biyomekanik araştırmalar, ÖÇB yetmezliğine ALL hasarının da eklenmesinin iç rotasyonel gevşekliği belirgin şekilde artırdığını göstermektedir. Bu doğrultuda, özellikle revizyon ÖÇB cerrahilerinde, yüksek dereceli pivot-shift saptanan kronik vakalarda, genç hastalarda ve yüksek performans bekleyen sporcularda kombine ÖÇB ve ALL rekonstrüksiyonu uygulanması önerilmektedir. Cerrahi teknik olarak hamstring otogreftleri (grasilis ve semitendinozus) tercih edilmekte, hazırlanan greftler diz 30 derece fleksiyonda ve nötral pozisyondayken, gelecekte oluşabilecek lateral kompartman artrozu riskini en aza indirmek için aşırı gerimden kaçınılarak fikse edilmektedir. Sonuç olarak ALL rekonstrüksiyonu, revizyon cerrahilerinde ek bir komplikasyon yaratmaksızın anterolateral rotatuar stabiliteye ciddi katkı sağlayan, rehabilitasyon sürecini olumsuz etkilemeyen, minimal invaziv ve son derece işlevsel anatomik bir cerrahi girişimdir.
Anterior cruciate ligament (ACL) injuries are common functional problems among athletes that lead to rotational instability in the knee joint and anterior translation of the tibia; these injuries are frequently accompanied by anterolateral capsule and lateral meniscus damages. The anatomical presence and importance of the anterolateral ligament (ALL), which provides rotational stability to the knee by controlling the internal rotation of the tibia, was first described by Paul Segond in 1879 and conclusively demonstrated by Claes and colleagues in 2013 through cadaveric studies. Biomechanical research shows that the addition of ALL damage to ACL insufficiency significantly increases internal rotational laxity. Accordingly, combined ACL and ALL reconstruction is recommended especially in revision ACL surgeries, chronic cases with high-grade pivot-shift, young patients, and athletes expecting high performance. As a surgical technique, hamstring autografts (gracilis and semitendinosus) are preferred; the prepared grafts are fixed while the knee is at 30 degrees of flexion and in a neutral position, avoiding over-tension to minimize the risk of future lateral compartment arthrosis. Consequently, ALL reconstruction is a minimally invasive and highly functional anatomical surgical procedure that significantly contributes to anterolateral rotatory stability in revision surgeries without creating additional complications or negatively affecting the rehabilitation process.
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