Diz Bağ Yaralanmaları Tedavi ve Rehabilitasyonu
Özet
Diz bağ yaralanmalarının (Ön Çapraz Bağ - ÖÇB, İç Yan Bağ - İYB, Arka Çapraz Bağ - AÇB ve Dış Yan Bağ - DYB) tedavi ve rehabilitasyon süreçleri, hastanın işlevsel seviyesine ve yaralanmanın derecesine göre planlanan dinamik bir yaklaşım gerektirmektedir. ÖÇB rekonstrüksiyonunda preoperatif hazırlık cerrahi başarıyı doğrudan etkilerken, postoperatif dönemde greft türüne bağlı olarak kanıta dayalı ve bireyselleştirilmiş evreler izlenir. İYB yırtıklarında öncelikli seçenek RICE protokolünü içeren konservatif tedavi olsa da komplet instabilite ve çoklu bağ hasarlarında cerrahi endikasyonlar doğmaktadır. AÇB yaralanmaları, bağın yüksek intrinsik iyileşme kapasitesi sayesinde çoğunlukla ameliyatsız yöntemlerle yönetilir; ancak arka tibial translasyonu engellemek için dinamik atelleme ve kuadriseps güçlendirme hayati önem taşır. İzole DYB yaralanmaları nadir görülmekle birlikte, rehabilitasyon sürecinde peroneal sinir hasarı riskine karşı kriyoterapinin süresine dikkat edilmelidir. Tüm bağ yaralanmalarında spora veya tam aktiviteye dönüş; ağrısız eklem hareket açıklığı, efüzyon olmaması ve kas kuvvetinin sağlam tarafın en az %90'ına ulaşması gibi objektif kriterler ile fiziksel performans testlerine dayanır.
Treatment and rehabilitation protocols for knee ligament injuries (Anterior Cruciate Ligament - ACL, Medial Collateral Ligament - MCL, Posterior Cruciate Ligament - PCL, and Lateral Collateral Ligament - LCL) require a dynamic approach tailored to the patient's functional level and injury severity. In ACL reconstruction, preoperative preparation directly impacts surgical success, while postoperative care follows evidence-based, individualized phases depending on the graft type. For MCL tears, conservative management incorporating the RICE protocol is the primary option, though surgical interventions are indicated in cases of complete instability or multi-ligament damage. PCL injuries are mostly managed non-operatively due to the ligament's high intrinsic healing capacity, where dynamic bracing and quadriceps strengthening are crucial to prevent posterior tibial translation. Although isolated LCL injuries are rare, the duration of cryotherapy during rehabilitation must be carefully monitored to avoid the risk of peroneal nerve damage. Across all ligament injuries, returning to sports or full activity relies on physical performance tests and objective criteria, such as pain-free range of motion, absence of effusion, and restoring muscle strength to at least 90% of the uninjured limb.
Referanslar
Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British journal of sports medicine. 2016;50(13):804-8.
Van Grinsven S, Van Cingel R, Holla C, Van Loon C. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2010;18(8):1128-44.
van Melick N, van Cingel RE, Brooijmans F, Neeter C, van Tienen T, Hullegie W, et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. British journal of sports medicine. 2016;50(24):1506-15.
Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British journal of sports medicine. 2016;50(13):804-8.
Grindem H, Granan LP, Risberg MA, Engebretsen L, Snyder-Mackler L, Eitzen I. How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry. British journal of sports medicine. 2015;49(6):385-9.
van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2010;18(8):1128-44.
Shaerf DA, Pastides PS, Sarraf KM, Willis-Owen CA. Anterior cruciate ligament reconstruction best practice: A review of graft choice. World journal of orthopedics. 2014;5(1):23-9.
Yosmaoglu HB, Baltaci G, Kaya D, Ozer H. Tracking ability, motor coordination, and functional determinants after anterior cruciate ligament reconstruction. Journal of sport rehabilitation. 2011;20(2):207-18.
Yosmaoğlu HB, Baltacı G, Kaya D, Ozer H, Atay A. Comparison of functional outcomes of two anterior cruciate ligament reconstruction methods with hamstring tendon graft. Acta orthopaedica et traumatologica turcica. 2011;45(4):240-7.
Yosmaoglu HB, Baltaci G, Ozer H, Atay A. Effects of additional gracilis tendon harvest on muscle torque, motor coordination, and knee laxity in ACL reconstruction. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2011;19(8):1287-92.
Wilk KE, Arrigo CA. Rehabilitation Principles of the Anterior Cruciate Ligament Reconstructed Knee: Twelve Steps for Successful Progression and Return to Play. Clin Sports Med. 2017;36(1):189-232.
De Carlo M, Armstrong B. Rehabilitation of the knee following sports injury. Clin Sports Med. 2010;29(1):81-106, table of contents.
Indelicato PA. Isolated Medial Collateral Ligament Injuries in the Knee. The Journal of the American Academy of Orthopaedic Surgeons. 1995;3(1):9-14.
Hanson CA, Weinhold PS, Afshari HM, Dahners LE. The effect of analgesic agents on the healing rat medial collateral ligament. Am J Sports Med. 2005;33(5):674-9.
Zhang X, Schwarz EM, Young DA, Puzas JE, Rosier RN, O'Keefe RJ. Cyclooxygenase-2 regulates mesenchymal cell differentiation into the osteoblast lineage and is critically involved in bone repair. The Journal of clinical investigation. 2002;109(11):1405-15.
Creighton RA, Spang JT, Dahners LE. Basic science of ligament healing: medial collateral ligament healing with and without treatment. Sports Medicine and Arthroscopy Review. 2005;13(3):145-50.
Dexter W, Fields K, Grayzel J. Medial collateral ligament injury of the knee. Monografía en Internet] Walthman (MA): UpToDate. 2014.
Bagwell MS, Wilk KE, Colberg RE, Dugas JR. The use of serial platelet rich plasma injections with early rehabilitation to expedite grade iii medial collateral ligament injury in a professional athlete: a case report. Int J Sports Phys Ther. 2018;13(3):520-5.
Ada AM, Yavuz F. Treatment of a medial collateral ligament sprain using prolotherapy: a case study. Alternative therapies in health and medicine. 2015;21(4):68-71.
Wheatley WB, Krome J, Martin DF. Rehabilitation programmes following arthroscopic meniscectomy in athletes. Sports medicine (Auckland, NZ). 1996;21(6):447-56.
Memarzadeh A, Melton JT. Medial collateral ligament of the knee: anatomy, management and surgical techniques for reconstruction. Orthopaedics and Trauma. 2019;33(2):91-9.
Derscheid GL, Garrick JG. Medial collateral ligament injuries in football. Nonoperative management of grade I and grade II sprains. Am J Sports Med. 1981;9(6):365-8.
Fanelli GC, Harris JD. Surgical treatment of acute medial collateral ligament and posteromedial corner injuries of the knee. Sports Med Arthrosc Rev. 2006;14(2):78-83.
Jacobson KE, Chi FS. Evaluation and treatment of medial collateral ligament and medial-sided injuries of the knee. Sports Med Arthrosc Rev. 2006;14(2):58-66.
Irarrázaval S, Yaseen Z, Guenther D, Fu FH. Clinical Management of Ligament Injuries of the Knee and Postoperative Rehabilitation. Regenerative Strategies for the Treatment of Knee Joint Disabilities: Springer; 2017. p. 323-48.
Weber AE, Kopydlowski NJ, Sekiya JK. Nonsurgical management and postoperative rehabilitation of medial instability of the knee. Sports Med Arthrosc Rev. 2015;23(2):104-9.
Marchant MH, Jr., Tibor LM, Sekiya JK, Hardaker WT, Jr., Garrett WE, Jr., Taylor DC. Management of medial-sided knee injuries, part 1: medial collateral ligament. Am J Sports Med. 2011;39(5):1102-13.
Indelicato PA, Hermansdorfer J, Huegel M. Nonoperative management of complete tears of the medial collateral ligament of the knee in intercollegiate football players. Clinical orthopaedics and related research. 1990(256):174-7.
Kannus P. Long-term results of conservatively treated medial collateral ligament injuries of the knee joint. Clinical orthopaedics and related research. 1988(226):103-12.
Shelbourne KD, Clark M, Gray T. Minimum 10-year follow-up of patients after an acute, isolated posterior cruciate ligament injury treated nonoperatively. Am J Sports Med. 2013;41(7):1526-33.
Agolley D, Gabr A, Benjamin-Laing H, Haddad FS. Successful return to sports in athletes following non-operative management of acute isolated posterior cruciate ligament injuries: medium-term follow-up. The bone & joint journal. 2017;99-b(6):774-8.
Parolie JM, Bergfeld JA. Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med. 1986;14(1):35-8.
LaPrade CM, Civitarese DM, Rasmussen MT, LaPrade RF. Emerging Updates on the Posterior Cruciate Ligament: A Review of the Current Literature. Am J Sports Med. 2015;43(12):3077-92.
Jacobi M, Reischl N, Wahl P, Gautier E, Jakob RP. Acute isolated injury of the posterior cruciate ligament treated by a dynamic anterior drawer brace: a preliminary report. The Journal of bone and joint surgery British volume. 2010;92(10):1381-4.
Ahn S, Lee YS, Song YD, Chang CB, Kang SB, Choi YS. Does surgical reconstruction produce better stability than conservative treatment in the isolated PCL injuries? Archives of orthopaedic and trauma surgery. 2016;136(6):811-9.
Sanders TL, Pareek A, Barrett IJ, Kremers HM, Bryan AJ, Stuart MJ, et al. Incidence and long-term follow-up of isolated posterior cruciate ligament tears. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2017;25(10):3017-23.
Wang SH, Chien WC, Chung CH, Wang YC, Lin LC, Pan RY. Long-term results of posterior cruciate ligament tear with or without reconstruction: A nationwide, population-based cohort study. PloS one. 2018;13(10):e0205118.
Gwinner C, Weiler A, Denecke T, Rogasch JMM, Boeth H, Jung TM. Degenerative changes after posterior cruciate ligament reconstruction are irrespective of posterior knee stability: MRI-based long-term results. Archives of orthopaedic and trauma surgery. 2018;138(3):377-85.
Pierce CM, O'Brien L, Griffin LW, Laprade RF. Posterior cruciate ligament tears: functional and postoperative rehabilitation. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2013;21(5):1071-84.
de Paula Leite Cury R, Kiyomoto HD, Rosal GF, Bryk FF, de Oliveira VM, de Camargo OP. Rehabilitation protocol after isolated posterior cruciate ligament reconstruction. Revista brasileira de ortopedia. 2012;47(4):421-7.
Lephart SM. Proprioception and neuromuscular control in joint stability. Human kinetics. 2000:405-13.
Neal S, Lawson D. Rehabilitation of common knee injuries and conditions.
LaPrade RF, Terry GC. Injuries to the posterolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med. 1997;25(4):433-8.
Babwah T. Common peroneal neuropathy related to cryotherapy and compression in a footballer. Research in sports medicine (Print). 2011;19(1):66-71.
