骨科英文书籍精读（307）｜膝关节韧带损伤的并发症
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CHRONIC LIGAMENTOUS INSTABILITY
Instability (‘giving way’) of the knee may be obvious soon after the acute injury has healed, or it may only become apparent much later. It is usually progressive (a partial meniscectomy for a meniscal tear is likely to make it worse and create new tears) but, except in people engaged in strenuous sport, dancing or certain work activities, the disability is often tolerated without complaint. In more severe and longstanding cases, osteoarthritis may eventually supervene. Functional pathology Unstable tibiofemoral relationships may result in abnormal sideways tilt (varus or valgus), excessive glide (forwards, backwards or even in an oblique direction), unnatural rotation (internal or external), or combinations of these.
Seldom is only one ligament at fault. As described at the beginning of this chapter, stability is normally maintained by both primary and secondary stabilizers (not to mention the dynamic forces of surrounding muscles). In different positions, different structures come into play as primary stabilizers. Therefore, when testing for medial and lateral stability, valgus and varus stresses should be applied with the knee first in 30 degrees of flexion and then in full extension.
Abnormal translation or rotation of the tibia on the femur is even more complex. A positive anterior drawer sign is the result of a torn ACL, but a solitary cruciate injury is unusual. More commonly there is anterolateral rotatory instability where, in addition to a torn ACL, the lateral capsule and LCL are torn or ‘stretched’. In this instance, not only will the anterior drawer test be positive, but the lateral tibial condyle can be made to sublux forwards as the tibia rotates abnormally around an axis through the medial condyles; this is the basis of the pivot shift phenomenon (Galway and MacIntosh, 1980).
A positive posterior tibial sag and drawer sign means that the posterior cruciate ligament is torn (Fig. 30.5).
Soon after injury, however, this sign is difficult to elicit unless the ligaments of the arcuate complex and popliteus also are torn. Chronic deficiency of the arcuate ligament complex causes a type of posterol-ateral rotatory instability that is a counterpart of the pivot shift phenomenon (Bahk and Cosgarea, 2006; Ranawat et al., 2008). Complete tears of all the posterior structures also allow the knee to hyperextend.
---from 《Apley’s System of Orthopaedics and Fractures》
重点词汇整理：
engaged in strenuous sport从事激烈的运动
osteoarthritis may eventually supervene. 骨关节炎最终可能发生。
supervene /ˌsuːpərˈviːn/v. （尤指意外）发生并带来重大影响；随后发生；由另一事实导致
Functional pathology Unstable tibiofemoral relationships 功能性病理学不稳定的胫股关系
abnormal sideways tilt (varus or valgus), excessive glide (forwards, backwards or even in an oblique direction), unnatural rotation (internal or external), or combinations of these.异常侧倾(内翻或外翻)，过度滑动(向前、向后甚至斜向)，不自然旋转(内部或外部)，或这些的组合。
glide /ɡlaɪd/vi. 滑翔；滑行；悄悄地走；消逝vt. 使滑行；使滑动n. 滑翔；滑行；滑移；滑音
first in 30 degrees of flexion and then in full extension.首先是30度的屈曲，然后是完全伸展。
A positive anterior drawer sign前抽屉试验阳性（+）
the lateral tibial condyle can be made to sublux forwards as the tibia rotates abnormally around an axis through the medial condyles; 当胫骨通过内侧髁异常旋转时，可使外侧髁半向前移位;
elicit /ɪˈlɪsɪt/vt. 抽出，引出；引起
arcuate complex弓形聚合体
Complete tears of all the posterior structures also allow the knee to hyperextend.所有后部结构的完全撕裂也会导致膝盖过伸。
百度翻译：
慢性韧带不稳
急性损伤愈合后不久，膝关节的不稳定（“退让”）可能会很明显，或者只会在很久之后才变得明显。它通常是渐进性的（半月板撕裂的部分半月板切除术可能会使病情恶化并产生新的眼泪），但是，除了从事剧烈运动、舞蹈或某些工作活动的人外，残疾通常可以毫无怨言地被容忍。在更严重和长期的情况下，骨关节炎最终可能会再次发生。功能病理学不稳定的胫股关系可能导致异常的侧倾（内翻或外翻）、过度的滑动（向前、向后甚至倾斜）、不自然的旋转（内部或外部）或这些的组合。
很少只有一条韧带有毛病。如本章开头所述，稳定性通常由主要和次要稳定器维持（更不用说周围肌肉的动力）。在不同的位置，不同的结构作为主要的稳定剂发挥作用。因此，在测试内侧和外侧稳定性时，外翻和内翻应力应首先在膝关节屈曲30度时施加，然后在完全伸展时施加。
胫骨在股骨上的异常平移或旋转更为复杂。前交叉韧带撕裂导致前抽屉征阳性，但单交叉韧带损伤并不常见。更常见的是前外侧旋转不稳，除前交叉韧带撕裂外，侧囊和LCL撕裂或“拉伸”。在这种情况下，不仅前抽屉试验是阳性的，而且当胫骨绕着穿过内侧髁的轴异常旋转时，可以使外侧胫骨髁向前下垂；这是轴心移位现象的基础（Galway和MacIntosh，1980）。
胫骨后凹和抽屉征阳性表示后交叉韧带撕裂（图30.5）。
然而，受伤后不久，除非弓状复合体和腘窝的韧带也被撕裂，否则很难发现这种征象。弓状韧带复合体的慢性缺陷会导致一种后外侧旋转不稳定，这是轴心移位现象的对应物（Bahk和Cosgarea，2006；Ranawat等人，2008）。所有位置结构的完全撕裂也允许膝盖过度伸展。