距下关节脱位

本文就近年来关于距下关节的稳定、脱位机制及脱位后复住失败的原因和对策作一综述,以便能为临床正确诊断和处理该类损伤,减少并发症提供理论指导。     

距下关节脱位6例报告

距下关节脱位俗称距骨下关节脱位，是距骨与跟骨、舟骨之间的脱位，临床较少见，且易与踝关节脱位相混淆。我院自2002年6月至2007年12月诊治距下关节脱位6例，其中内翻脱位4例，外翻脱位2例，现报告如下。     

关节镜下距下关节融合术治疗创伤性距下关节炎

目的探讨关节镜下距下关节融合术治疗创伤性距下关节炎的效果。方法2003年1月～2007年2月,对8例距下关节创伤性关节炎行关节镜下距下关节融合术,交替使用三个入路。结果8例术后随访20～55个月,平均30个月。未见皮肤坏死、麻木、感染等手术并发症。8例X线片均示骨性融合,平均愈合时间10.8周（9～12周）。改良美国足踝外科协会（AOFAS）评分从术前的（51.0±11.7）分提高到（82.0±10.9）分,差异具有显著性（配对t检验,t=19.69,P〈0.01）。结论关节镜下距下关节融合术创伤小,理论上不损伤跟骨距骨的血供,患者痛苦小,操作简单,避免切开,早期适当活动及负重,有助于恢复本体感觉,有利于骨性愈合,效果确切。     

环锯切骨融合距下关节治疗距下关节痛

目的介绍环锯切骨融合距下关节治疗距下关节痛的方法及临床效果。方法1997年6月～2001年10月,利用环锯(Φ11.5mm、12mm、13mm)对18例距下关节痛患者进行环锯切骨融合,男12例,女6例;年龄35～59岁,平均47岁;右足11例,左足7例;创伤性距下关节炎8例,退变性关节炎5例,先天性跟距骨桥2例,类风湿性关节炎2例,顽固性跗骨窦炎1例。应用100mm视觉模糊疼痛量表VAS测试,80～91分,平均83.8分。踝关节后外侧入路14例,踝关节前外侧入路4例;14例行原锯心骨旋转90°回植融合,4例取髂骨骨柱植骨融合。术后踝关节中立位石膏固定12～16周。结果18例均获得随访,随访时间5个月～4年,平均25个月。术后2周切口一期愈合,4周有骨痂形成,12周应用100mm视觉模糊疼痛量表VAS测试,22～49分,平均32.5分,较术前降低30～59分,平均降低51.3分。均摄X线片示距下关节牢固融合。1例出现轻度足下垂,1例出现行走或长时间站立后足跟部酸胀痛。结论采用环锯切骨融合距下关节的方法治疗距下关节痛,切口小,易显露,不影响后足的生物力学结构。在距下关节原位状态下融合,对距下关节高度及距舟关节稳定性影响不大;应用锯心骨旋转回植不需另植骨。     

距下关节运动的探讨

距下关节运动的探讨杨星光，毛宾尧，刘明廷，刘洪涛，李保文距下关节属鞍状关节，是由距骨和跟骨形成的关节。有些学者认为，它是复合关节，即有距跟关节和距跟舟关节组成。我们通过对４０副距跟骨标本和４尸７足的测定，观察了距下关节面的构成以及运动，从运动解剖学来...     

距下关节完全性脱位二例治疗体会

距下关节脱位由高能量创伤所致,发生率低,仅占全身关节脱位的1%,国内外报道较少[1].笔者于2010年1月收治2例,其治疗过程及结果差别较大,经过对比,认为早期手法复位是治疗的关键.1病例报告例1,男,42岁.于2010年1月5日驾驶小轿车时发生车祸致右足踝受伤,右足踝呈极度内翻状,肿胀,疼痛,活动受限,即送某医院住院治疗,摄片检查显示右跟距关节完全性脱位,跟骨向内侧完全错位,距舟关节半脱位,右距骨内后缘撕脱性骨折.     

粗钻头法距下关节融合术治疗距下关节炎

目的探讨粗钻头法行距下关节融合术治疗距下关节炎的临床疗效。方法 2006年10月至2009年1月采用粗钻头法行距下关节融合术治疗11例严重距下关节炎患者。男7例,女4例;年龄22～63岁,平均42.5岁。右足6例,左足5例。其中陈旧性跟骨骨折后创伤性关节炎9例,骨关节炎1例,类风湿关节炎1例。采用跟骨外侧切口,以4.5 mm粗钻头于距下关节处开出骨道,取髂骨植入。结果所有患者随访9～42个月,平均22个月,均达到骨性融合。按视觉模拟法对疼痛评分,术前和末次随访分别为5.9～7.5分（平均6.7分）及1.1～2.0（平均1.5分）。根据美国足踝外科协会足-踝评分系统评分,从术前41～67分（平均55.6分）至末次随访72～94分（平均83.7分）。优5例,良4例,可2例,优良率81.8%。结论应用粗钻头行距下关节融合术,创伤小、临床操作简便、易行、融合率高,值得临床推广应用。     

微创距下关节融合术治疗距下关节创伤性关节炎

目的探讨微创距下关节融合术治疗跟骨陈旧性骨折导致的距下关节创伤性关节炎的手术疗效。方法C型臂透视引导下定位距下关节,采用跟腱后外侧切口,透视引导下于距下关节内打人导针,并以阶梯钻沿导针方向扩开通道,破坏距下关节两侧关节面,后取自体髂骨移植或以同种异体骨填充关节间隙,并自足跟打人空心拉力螺钉1～2枚给予固定。结果本组17例患者均获随访,随访时间7～13个月,平均10个月。采用Maryland足部功能评分Ⅲ,优10例,良6例,可1例,优良率94．12％。结论微创距下关节融合术治疗跟骨陈旧骨折距下关节创伤性关节。炎,手术操作简单、创伤小、术后恢复快、疗效满意、值得推广。     

距跟骨骨小梁与距下关节

对４０副距跟骨和７具尸体足的解剖，剖面积和Ｘ线检查，发现距骨和跟骨间的骨小梁有严格的顺应性，其分布，疏密度与距下关节和其它相邻关节的运动应力有密切关系，纵横骨小梁互相交错，形成桁架样结构。跟骨四束骨小梁构成类球状网络，是跟骨对抗各种应力的高承载运动结构和良好的应力转化系统。     

微创距下关节融合术治疗距下关节创伤性关节炎的实验研究

目的 探讨应用阶梯钻微创距下关节融合治疗距下关节创伤性关节炎的可行性,以及不同阶梯钻角度获得的距下关节融合面积及所占后关节面百分比对疗效的影响.方法 选取成人足标本22具,随机分为A、B两组(每组11具).C型臂X线机透视下向距下关节方向打入1枚导针,A组用空心钻沿导针向距下关节钻取隧道,再以动力髋螺钉阶梯钻扩大隧道;B组在A组基础上将阶梯钻于内、外侧各倾斜20°～25°钻入,以增加融合面积.取髂骨松质骨并剪成碎骨块向隧道内打压植骨,空心螺钉固定距下关节.比较两组中距骨、跟骨相对关节面的轴向融合面积及其占后关节面面积的百分比.结果 距下关节融合隧道内关节软骨完全清除,未伤及内外侧关节囊韧带等软组织.植骨块充分填充于融合隧道,未遗留空腔.A组距骨侧轴向融合面积为(293±34)mm2,跟骨侧轴向融合面积为(321±56)mm2,占后关节面面积的百分比分别为43.3%和47.4%,B组中距骨侧轴向融合面积为(433±19)mm2,跟骨侧轴向融合面积为(515±37)mm2,占后关节面面积的比例分别为64.3%和76.1%.两组距骨、跟骨轴向融合面积差异均有统计学意义(P＜0.05).结论 阶梯钻微创距下关节融合术操作安全、方便,对周围软组织影响小,适当调整阶梯钻角度后再次钻入可获得满意的距下关节融合面积,从而提高融合率.

Abstract：

Objective To evaluate feasibility of the minimally invasive subtalar arthrodesis for subtalar traumatic arthritis with a subland drill for dynamic hip screw (DHS),and effects of different fusion areas and their proportions to the posterior articular facet on the treatment. Methods Twenty-two frozen cadaveric specimens of adult feet were randomly assigned into 2 equal groups.In group A,after a guide pin was inserted into the subtalar joint,atunnel was made with a hollow drill along the guide pin.Next the tunnel was expanded with a DHS subland drill.In group B,the tunnel was enlarged to increase the fusion area by driving the DHS subland drill medially and laterally about 20° to 25° respectively,in addition to all the steps of group A.In both groups,morselized spongy bone of ilium was impacted into the tunnel before the subtalar joint was fixed with a hollow screw at last.The axial fusion areas of the talus and calcaneus and their proportions to the posterior articular facet were calculated respectively for both groups and compared. Results The articular cartilage in the tunnel was removed completely and the surrounding soft tissue was not disturbed.The grafted bone was impacted in the tunnel fully and no vacant space left.In group A,the axial talar and calcaneal fusion areas were 293 ± 34 mm2 and 321 ± 56 mm2,which accounted for 43.3％ and 47.4％ of the posterior articular facet respectively.In group B,the axial talar and calcaneal fusion areas were 433 ± 19 mm2 and 515 ±37 mm2,which accounted for 64.3％ and 76.1％ of the posterior articular facet respectively.The differences in the fusion areas were significant between the 2 groups ( P ＜ 0.05 ). Conclusions The procedure of minimally invasive subtalar arthrodesis with a DHS subland drill is safe because the damage to the surrounding soft tissue is minimal.Furthermore,this simple method has a benefit of achieving a broader fusion area,which can facilitate subtalar fusing and reduce complications theatrically.     

Dorsal dislocation of the first metatarso-phalangeal joint

Summary A case of dorsal dislocation of the first metatarso-phalangeal joint is reported because it is a very unusual injury, and the literature is reviewed.

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Résumé Nous présentons un cas de luxation dorsale de l'articulation métatarso-phalangienne du premier orteil, lésion très rare, ainsi qu'une révision de la courte bibliographie consacrée à ce sujet, en soulignant l'anatomie et la pathogénie de la lésion.

     

肩锁关节外固定器治疗肩锁关节脱位的临床观察

目的 观察自行研制的肩锁关节外固定器治疗肩锁关节脱位的临床疗效及其优势。方法 29例Ⅱ-Ⅲ度锁关节脱位的患者,采用闭合手法复位后再行经皮肩锁关节外固定器固定,固定时间4－6周,全部患者随访3－24个月。结果 根据Lazzcana的判定标准,24例优,5例良。结论 肩锁关节外固定器针对肩锁关节的解剖与功能特点,设计成肩钾冈与锁骨远端间固定,能克服肩锁关节脱位后的病理应力,结构简单、操作方便,固定可靠,较之肩肘加压及穿针等固定方式均有优势。     

距下关节前脱位合并距骨颈骨折1例

患者李某,男，34岁,农民。2001年8月20日上午11时许，被石块砸伤右踝部，伤后右髁部肿胀疼痛学期工作总结活动受限，0.5h内来院就诊。检查：右小腿下段前侧至踝前皮肤擦伤，右踝部肿胀压痛、畸形，活动受限。足背动脉博动良好，足趾血运及感觉良好。X线侧位片显示距下关节前脱位，足趾颈骨折。正位片显示距舟关节脱位。诊断：距下关节前脱位全并距骨颈骨折。     

踝关节骨折脱位的治疗分析

踝关节骨折脱位是严重的关节内损伤,处理不当,容易发生并发症和后遗症。我院治疗踝关节骨折脱位106例,现报告如下。1临床资料本组男72例,女34例;年龄13~81岁,平均42岁。左侧50例,右侧56例。致伤原因:坠落伤16例,扭伤42例,压砸伤38例,挤压伤10例。骨折分类:参照Lauge-Hansen分型     

关节镜辅助下治疗髌骨复发性脱位

目的 探讨关节镜辅助下行髌外侧支持带松解、内侧支持带紧缩及部分加行Goldthwait-Roux(改良)术治疗髌骨复发性脱位的疗效.方法 2003年1月至2008年12月共收治78例髌骨复发性脱位患者,男23例,女55例;年龄11～45岁,平均20.3岁;平均脱位次数为5次.所有患者均在关节镜监视下行髌外侧支持带松解、内侧支持带紧缩(12例行内侧髌股韧带重建)术,其中13例加行Goldthwait-Roux术,26例加行改良Goldthwait-Roux术.观察患者的主观症状和客观体征,髌骨脱位复发情况,膝关节正位、髌骨轴位X线片,评价膝关节功能康复情况.结果 65例患者术后获19～76个月(平均47.3个月)随访,患者对治疗均满意,无再脱位.7例膝关节活动过多有酸痛感,5例膝关节有10°～15°的屈曲度减少,6例偶有髌股轻微错动感.65例患者按髌骨损伤Bostman评分:术前(18.5±4.5)分,术后(27.5±2.5)分,差异有统计学意义(t=9.223,P=0.018).按Lysholm膝关节功能评分:术前(42.3±6.1)分,术后(91.4±4.3)分,差异有统计学意义(t=46.801,P=0.026).结论 根据病情行髌骨术外侧支持带松解、内侧支持带紧缩,部分加行Goldthwait-Roux(改良)术治疗髌骨复发性脱位是一种行效的方法,且创伤小、恢复快.

Abstract：

Objective To evaluate arthroscopy-assisted release of the lateral retinaculum and reefing of the interior retinaculum for treatment of recurrent patello-femoral joint dislocation.Methods From January 2003 to December 2008, 78 cases of recurrent patello-femoral joint dislocation were treated under arthroscopy.They were 23 men and 55 women, with a mean age of 20.3 years (range, 11 to 45 years).Their recurrence of dislocation averaged 5 times.Operative release of the lateral retinaculum and reefing of the interior retinaculum were performed under arthroscopy for all the patients.Auxiliary Goldthwait-Roux procedures were conducted in addition in 13 cases, and auxiliary improved Goldthwait-Roux procedures in 26 cases.We evaluated their subjective symptoms and objective signs, recurrence of patello-femoral joint dislocation, X-ray examinations and functional rehabilitation of the knee joint during the first 3 months, and at 6 and 12 months postoperation.Results Of the 78 cases, 65 were followed up for a mean of 47.3 months (from 19 to 76 months).All the patients were satisfied with the therapeutic effect.Recurrence of dislocation was no longer observed.Seven cases experienced slight pain after excessive motion.The flexion was slightly limited in 5 cases.Six cases reported a sense of patello-femoral malposition.By the Bostman evaluation system, the 65 cases scored 18.5 ±4.5 and 27.5 ±2.5 before and after surgery respectively, showing a statistically significant difference(P=0.018).By the Lysholm evaluation system, they scored 42.3±6.1 and 91.4±4.3 before and after surgery respectively, also showing a statistically significant difference (P = 0.026).Conclusion For treatment of recurrent patello-femoral joint dislocation, arthroscopy-assisted release of the lateral retinaculum and reefing of the interior retinaculum, as well as the auxiliary Goldthwait-Roux or improved Goldthwait-Roux procedures for necessary cases, has the merits of minimal invasion and rapid recovery.     

Neglected dorsolateral dislocation of the first metatarsophalangeal joint: A case report

IntroductionAlthough the first metatarsophalangeal (MTP) joint is frequently injured, Complete dislocation of the first MTP joint represents a relatively rare traumatic injury.Presentation of caseA 46-year-old gentleman presented with a traumatic first MTP joint dislocation resulting from an automobile accident. Due to coronavirus outbreak in the hospital at that time, patient was referred to another hospital. Six months later, reduction was achieved surgically and fixation of the MTP with K-wires was done.DiscussionOnly few case reports have described the injury, and the ideal treatment along with the long-term result of the injury has yet to be further studied because reports are rare in this regard.ConclusionFunctional range of motion may result even after 6 months of delayed treatment with ORIF and osteopenia may result.     

应用人工碳纤维治疗肩锁关节脱位

目的：观察人工碳纤维治疗肩锁关节脱位的临床疗效并作出评估。方法：25例肩锁关节脱位患者，包括Ⅱ度7例，Ⅲ度18例，均采用人工碳纤维和张力带双丝线捆扎喙突和锁骨，并用克氏针固定肩锁关节。结果：术后无一例伤口感染和再脱位发生，其疗效评定按黄公怡标准；优17例，良8例，X线检查：术后喙突一锁骨间距较术前明显减小，与健侧间距基本一致，随访时间6－20个月（平均12个月），结论：人工碳纤维治疗肩锁关节脱位是一种有效可靠的手术方法，适用于Ⅲ度完全脱位和部分II度不完全脱位患者，有利于早期功能锻炼。     

Conservative treatment of closed subtalar dislocation: A case report and 2 years follow-up

We report a case of a closed subtalar dislocation without any related fractures treated with closed reduction and conservative treatment with a cast immobilization. Pure subtalar dislocation without any fractures is extremely rare and hardly reported in the literature. Such injuries are more likely to be open and associated with fractures of the surrounding foot bones such as malleoli, talus or fifth metatarsal fractures. In the examined case, closed reduction was followed by cast immobilization for 3 weeks. Six months post-injury, the patient had a full range of motion without any pain while there were no signs of residual instability or early post-traumatic osteoarthritis. Subjective clinical testing using a valid health instrument revealed an excellent outcome. We discuss in details the mechanism of such an injury and highlight the importance of prompt closed reduction and early mobilization to ensure a satisfactory long term outcome.     

肩锁关节脱位治疗的热议与冷思考

肩锁关节脱位是一种常见的肩部运动损伤,约占全身关节脱位的3.2%[1]。由于肩锁关节的特殊解剖特点,对肩锁关节脱位的治疗一直受到国内外学者的重视,其治疗方法有上百种之多。     

难复位性肩关节脱位的手法治疗

我科自2001—2004年对7例难复性肩关节脱位采用改良足蹬法复位，取得满意效果，介绍如下：