Lesione del punto d’angolo postero-interno (PAPI) del ginocchio

TRAUMI DEL PAPI NEL GINOCCHIO

INTRODUZIONE

Il punto d’angolo postero interno (PAPI) del ginocchio è composto da strutture comprese tra il bordo posteriore del legamento collaterale mediale superficiale e il confine mediale del legamento crociato posteriore ed include: il legamento posteriore obliquo, il tendine semimembranoso, il legamento popliteo obliquo e il corno posteriore del menisco mediale.

Anche il capo mediale del muscolo gastrocnemio fornisce supporto al punto d’angolo postero-interno.

Questa struttura è importante per la stabilità del ginocchio ma, in letteratura ha ricevuto molta meno attenzione rispetto al punto d’angolo postero-esterno.

È importante identificare lesioni del PAPI poiché, rispetto alle lesioni isolate del legamento collaterale mediale, non tendono a guarire senza intervento chirurgico determinando pertanto instabilità del ginocchio e quindi dolore cronico.

REPERTI RM

Le singole componenti del punto d’angolo postero-interno sono difficili da visualizzare in RM a causa della loro complessaanatomia, del loro spessore sottile e della stretta associazione con altre strutture.

 Il PAPI può dunque essere identificato dalla  posizione, in quanto costituisce lo strato posteriore della 
porzione superficiale del legamento collaterale mediale (figura 4-7)

FIGURA 4: Posteriore al legamento collaterale mediale superficiale, sono presenti fibre a bassa intensità di
 segnale che rappresentano il legamento obliquo posteriore (frecce ), adiacenti all’epicondilo mediale .


FIGURA 5: l'immagine sagittale T1 pesata, dimostra l'origine normale del capo mediale del tendine
 gastrocnemio lungo la faccia postero-mediale del condilo femorale mediale (freccia). E’ evidente
 anche il tendine semimembranoso nelle vicinanze (punta di freccia).


FIGURA 6: Sopra il livello dell’articolazione , sono evidenti la porzione mediale del tendine gastrocnemio
 ( freccia) ed il tendine semimembranoso nelle immediate vicinanze (punta di freccia ).

FIGURA 7:le immagini in assiale dimostrano l’inserzione distale del semimembranoso.

Il tendine gastrocnemio mediale ed il semimembranoso possono essere in genere visualizzati direttamente sia nelle immagini sagittali che assiali. Il legamento polpiteo obliquo non è direttamente visualizzabile nelle immagini RM di routine. Molti traumi del PAPI possono essere identificati riconoscendo l’edema e l’ispessimento dei tessuti molli sottocutanei della regione postero-interna del ginocchio, posteriormente al legamento collaterale mediale, nella posizione del legamento obliquo posteriore.

Le lesioni post-traumatiche del legamento obliquo posteriore, possono essere accompagnate da edema osseo dovuto alla avulsione della inserzione prossimale del legamento obliquo posteriore al tubercolo adduttore (figure 8  9 e 10 ).

FIGURA 8: (a) L'immagine assiale dimostra la presenza di edema lungo la linea articolare nella regione posteromediale e
 centrale posteriore del ginocchio (frecce ) . L’edema è disposto in corrispondenza del legamento obliquo posteriore, del
 legamenti popliteo obliquo e della parte posteriore della capsula articolare.(b) L'immagine coronale mostra anche l'edema
 postero-mediale , posteriore al legamento collaterale mediale (frecce)

FIGURA 9: l’immagine in densità protonica a soppressione del tessuto adiposo in un ragazzo di 13 anni in seguito ad una caduta con torsione, dimostra un diffuso ispessimento ed edema tissutale nella regione della legamento posteriore obliquo (frecce).La bassa intensità di segnale del legamento collaterale mediale superficiale (punta di freccia) è visibile anteriormente nella regione del legamento posteriore obliquo. L’edema intra-spongioso (asterisco) è visibile all’interno del condilo femorale mediale.

FIGURA 10: le immagini assiali e coronali a densità protonica con soppressione del tessuto adiposo in un ragazzo di 15 anni con dolore mediale, dimostrano edema intra-osseo all’interno del condilo mediale (asterischi), a livello del sito di inserzione del legamento posteriore obliquo . Si associa edema ed ispessimento dei tessuti molli nella regione del legamento posteriore obliquo (frecce). Il tendine mediale del gastrocnemio (MG) e il tendine semimembranoso ( SM ) non presentano edema.

Il tendine gastrocnemio mediale ed il tendine semimembranoso possono essere visualizzati direttamente in RM e, le lesioni di queste strutture, possono essere specificamente diagnosticate rilevando le anomalie intrinseche delle regioni colpite (figure 11 e 12 ) .

FIGURA 11: le immagini assiali e sagittali a densità ponderata con soppressione del tessuto adiposo in una donna di 28 anni con dolore postero-mediale rivela la presenza di versamento ed edema compatibile con lesione parziale all’origine del capo mediale del tendine gastrocnemio (frecce).

FIGURA 12: l’immagine assiale a densità protonica a soppressione del tessuto adiposo in una ragazza di 25 anni che aveva avuto un trauma in iperestensione con lesione del legamento crociato posteriore. Vi è diffuso edema nella regione postero-mediale a livello del legamento obliquo posteriore (frecce), il tendine semimembranoso è ispessito ed edematoso (freccia), reperto compatibili con lacerazione parziale.

Naturalmente, non tutte le cause di edema o versamento in sede postero-mediale sono correlate alla presenza di patologie del punto d’angolo postero-interno. Altre cause di edema nella regione postero-interna includono la rottura di cisti poplitea, di cisti para-meniscale e la presenza di borsite anserina (o dei tendini della zampa d’oca) (figura 13).

FIG 13: immagine sagittale T2pesata in una donna di 43 anni con dolore e gonfiore mediale rivela raccolta fluida poli-lobata all'interno della borsa anserina (frecce), compatibile con borsite. L'origine mediale gastrocnemio (punta di freccia) e il tendine semimembranoso (SM) non mostrano alterazioni.

VALUTAZIONE CLINICA E TRATTAMENTO

 La valutazione clinica per le lesioni del PAPI comprende il test per l'apertura mediale del ginocchio in stress
 valgo con il ginocchio in completa estensione  a 30 gradi  di flessione. Nei casi di lesioni isolate del 
legamento collaterale mediale superficiale, il ginocchio sarà instabile in flessione. 
Se l'instabilità è presente anche in estensione, la lesione coinvolgerà anche la capsula e il legamento 
posteriore obliquo. Un altro tipo di instabilità che si può verificare è l’instabilità rotatoria antero-mediale in cui
 si osserva la sub-lussazione anteriore e la rotazione esterna del piatto tibiale mediale rispetto al femore.
 I pazienti che presentano questo tipo di instabilità hanno quasi sempre una lesione del legamento posteriore
 obliquo. 
Lesioni isolate del legamento collaterale mediale vengono trattate in modo conservativo. Le lesioni acute del
 legamento collaterale mediale e lesioni del punto d’angolo postero-interno sono riparate solo nel contesto di 
lesioni multi-legamentose. In questi casi viene riparata prima la lesione del legamento crociato, poi vengono
 riparate o ricostruite le strutture mediali, dalle più profonde alle più superficiali. Vengono trattati il menisco e
 la zona menisco-capsulare, seguite dal legamento collaterale mediale. 
Se si esegue una riparazione, il legamento obliquo posteriore e la capsula postero-mediale vengono poi
 suturate al legamento collaterale mediale e, il legamento semimbranoso lasso, torna in tensione insieme al
 legamento obliquo posteriore e al collaterale mediale. 
La ricostruzione è spesso eseguita utilizzando il tendine semitendinoso, lasciando intatta l'inserzione a livello
 della zampa d'oca.L'innesto viene fissato a livello dell'inserzione femorale del legamento collaterale 
superficiale con l'estremità libera, ricreando il legamento obliquo posteriore. Le complicazioni post-chirurgiche 
sono rare e comprendono la rigidità del ginocchio e la lesione del nervo safeno.

 A cura della Dott.ssa S. D'Onofrio

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