跟骨外侧手术入路安全范围的解剖学研究

目的通过跟骨外侧解剖学重要结构研究, 归纳出"跟骨外侧手术安全范围", 并设计安全手术入路。方法通过15例跟骨尸体标本, 在跟骨外侧以腓骨尖顶点(最低点)为原点, 建立坐标系统X、Y、Z轴。在坐标第三象限(跟骨外侧主体部分)测量跟骨外侧4个重要解剖结构范围(跟腓韧带跟骨止点、腓骨肌总腱鞘、跟骨外侧动脉、跟骨外侧神经)的空间量化关系, 汇总统计各结构的走向轨迹;通过以上测量汇总, 将安全范围进行重合, 找出最小概率损伤跟骨外侧重要结构手术入路范围。结果重要结构在坐标第三象限跟骨外侧主体部分在X、Y、Z轴上距原点的距离分别是:跟骨外侧动脉(21.40±3.38)、(18.47±3.91)、(25.06±3.45)mm, 跟骨外侧神经(16.53±4.77)、(16.27±3.68)、(23.13±4.00)mm, 腓骨肌总腱鞘(9.73±1.73)、(11.47±2.13)、(10.87±1.59)mm, 跟腓韧带跟骨止点(22.33±2.84)mm。上述4个重要结构主要汇聚于原点O和至跟骨外缘切线的前1/3范围, 在该安全范围进行手术入路设计相对较为安全, 该切口位于腓骨最低点下>...     

膝关节半月板根部附着区的解剖学测量

目的:测量国人膝关节内外侧半月板前后根部附着区的解剖学数据,为临床修复半月板根部损伤提供解剖学基础。方法:选取30个国人成人尸体膝关节标本,其中男16例,女14例;死亡年龄35～68(55.6±7.8)岁。对半月板根部附着区结构进行解剖,测量内外侧半月板根部附着区中心点与胫骨内外侧髁间棘、后交叉韧带前缘、内侧胫骨平台软骨后方外侧缘及外侧胫骨平台软骨后方内侧缘等标志点的位置关系和各个附着区的面积。结果:内侧半月板后根部附着区:中心点位于胫骨内侧髁间棘后方(11.73±3.10) mm、外侧(2.77±0.86) mm,后交叉韧带前缘前(2.76±0.76) mm,内侧平台软骨外侧缘外(3.92±0.22) mm,附着区面积(31.29±5.18) mm~2。内侧半月板前根部附着区:中心点位于胫骨内侧髁间棘前方(25.40±5.27) mm、外侧(3.01±0.86) mm,附着区面积(46.18±11.60) mm~2。外侧半月板后根部附着区:中心点位于胫骨外侧髁间棘后方(4.51±1.35)mm、内侧(1.85±0.34) mm,后交叉韧带前缘前(6.91±1.11) mm,外侧平台软骨内侧缘内(3.16±0.96) mm,附着区面积(44.10±6.23) mm~2。外侧半月板前根部附着区:中心点位于胫骨外侧髁间棘前方(12.97±2.92) mm、外侧(1.31±0.22) mm,附着区面积(60.84±14.98) mm~2。结论 :该试验定量描述内外侧半月板前后根部附着区的面积以及其中心点与相应标志点的位置关系,为临床修复半月板根部损伤提供一定的解剖学参考。     

膝关节后外侧角重建术中骨隧道定位的应用解剖研究

目的测量国人膝关节后外侧角(posterolateral corner of the knee,PLC)中外侧副韧带(lateral collateral ligament,LCL)、腘肌腱(popliteus tendon,PT)和腘腓韧带(popliteofibular ligament,PFL)止点的解剖学数据,为临床PLC重建术中骨隧道的定位提供解剖学依据。方法取30个成年膝关节甲醛固定标本,其中男14例,女16例;年龄45～71岁,平均55岁。对PLC结构进行观察,测量LCL、PT和PFL附丽部中心点与股骨外上髁和腓骨茎突最近点的位置关系以及附丽部的横截面积,并将每个标本测量值进行标准化。结果股骨侧:LCL附丽部中心点在股骨外上髁近端(1.27±3.10)mm、后方(2.99±1.29)mm,PT附丽部中心点在股骨外上髁远端(8.85±3.38)mm、后方(3.83±1.95)mm。腓骨侧:LCL附丽部中心点在腓骨茎突最近点远端(10.56±2.17)mm、前方(7.51±1.81)mm,PFL附丽部中心点在腓骨茎突最近点远端(1.31±0.55)mm、前方(0.49±1.36)mm。LCL和PT在股骨上附丽部的横截面积分别为(44.96±13.29)mm2和(52.52±11.93)mm2,LCL和PFL在腓骨上附丽部的横截面积分别为(35.93±11.21)mm2和(14.71±6.91)mm2。结论 LCL、PFL及PT的附丽部中心点具有稳定性。     

双源三维CT重建前交叉韧带股骨止点的印迹技术

目的 探讨双源CT(DSCT)三维重建前交叉韧带(ACL)股骨止点的印迹技术,尝试建立适用于关节镜下ACL解剖双束重建定位及测量系统,为临床实现个体化重建提供解剖学依据.方法 30名志愿者,对其双膝关节进行DSCT扫描,64排工作站(GE,Volume Share2-AW4.4版本软件)三维重建膝关节股骨外髁内侧壁三维模型,观察、圈画、标定ACL股骨止点双束印迹,定位股骨远端与股骨外髁滑车相交点O点；尝试测量ACL印迹长、短轴,两束中心点距离与股骨干之间夹角,双束中心点距离及印迹边缘至股骨髁软骨缘的距离等. 结果 采用DSCT技术再现的ACL股骨止点印迹为一凸起、平坦、形态不规则、灰度一致但与周围不同的区域；在股骨外髁三维模型上,成功建立了适用于关节镜下ACL解剖双束重建的“三点两角”定位系统.印迹长轴平均为(16.5±1.8) mm,印迹短轴平均为(8.0±1.3)mm,印迹角度平均为8 3°±4.9°,双束中心点距离平均为(7.8±1.0) mm,印迹边缘至股骨软骨远端最近距离平均为(1.6±1.5) mm,印迹边缘至股骨软骨后缘最近距离平均为(1.7±0.9)mm. 结论 采用DSCT三维重建技术可清晰重建ACL股骨印迹；ACL股骨止点自然印迹形态、位置存在个体化差异,“三点两角”定位法更适用于关节镜下定位,实现ACL解剖个体化重建.     

前交叉韧带重建术中胫骨骨道定位的应用解剖研究

[目的]探究前交叉韧带(anterior cruciate ligament,ACL)于胫骨止点处的解剖形态以及测量髁间窝顶线与胫骨平台交汇点至后交叉韧带前缘的距离对胫骨骨道定位的解剖学意义,为ACL重建术提供理论依据。[方法]选取新鲜成人膝关节标本8例,仔细剔除关节周围肌肉、后关节囊等结构,保留前后交叉韧带及两侧侧副韧带,保证膝关节正常屈伸范围。在屈伸膝关节时按照ACL纤维张力区将其分为前内束和后外束,在胫骨附着处将ACL切断制备ACL损伤模型。用测量工具和Phontoshop软件获取ACL基本解剖参数以及髁间窝顶线与胫骨平台的交汇点、ACL前缘、ACL胫骨止点的中心点分别至后交叉韧带前缘的距离。[结果]ACL平均体部直径为(11.21±0.76)mm,ACL在胫骨止点处的平均最大横径为(11.34±0.79)mm,平均最大前后径为(16.54±0.82)mm。前内束和后外束在胫骨止点处的平均面积分别为(113.35±29.65)mm~2和(83.29±16.99)mm~2。髁间窝顶线与胫骨平台的交汇点、ACL前缘以及ACL胫骨止点的中心点至后交叉韧带前缘的距离分别为(12.13±0.96)mm,(21.14±0.83)mm和(8.82±0.77)mm。[结论]利用胫骨平台骨道定位ACL在股骨的解剖止点现实可行,在ACL重建术中具有重要意义。     

小切口解剖重建踝关节外侧韧带复合体治疗慢性外踝不稳的临床疗效

目的:探讨解剖重建踝关节外侧韧带复合体治疗慢性外踝不稳的临床疗效。方法:自2005年9月至2010年3月,采用解剖重建距腓前韧带及跟腓韧带手术治疗慢性外踝不稳29例,男24例,女5例;年龄15～35岁,平均24岁;病史7个月～10年,平均10个月。主要临床表现为踝关节反复扭伤。查体时29例均有踝关节的内翻增加以及距骨前移增加,内翻活动度比健侧平均增加(12.5±3.2)°。术中先在踝关节镜下处理关节内病变。移植物为自体股薄肌腱,距骨止点以锚钉在骨表面固定,移植物通过腓骨远端的骨隧道,跟骨止点以挤压钉在骨隧道内固定。术后通过观察患者症状的变化、距骨内翻和前移的程度改变以及影像学变化来评价疗效,并以AOFAS后足功能评分评价踝关节功能。结果:所有患者手术成功,无骨折及感染发生。所有患者获得随访,时间16～60个月,平均28个月。终末随访时无踝关节不稳定或活动受限。术后踝关节内翻角度比对侧增加值为(2.5±0.8)°,低于术前(t=12.3,P=0.012);距骨前移距离(3.5±0.8)mm,较术前(16.3±4.0)mm下降(t=18.6,P=0.002);距骨倾斜角(4.5±1.0)°,较术前(17.5±3.6)°下降(t=9.7,P=0.035);AOFAS后足功能评分(92.8±6.2)分,较术前(48.0±6.7)分升高(t=25.3,P=0.001)。所有患者无严重并发症出现,对疗效满意。结论:自体股薄肌腱移植解剖重建踝关节外侧韧带复合体的手术方式符合解剖学重建理念,手术创伤小,术后恢复快,无严重并发症。该手术临床效果可靠,术后踝关节稳定性恢复良好,踝关节功能明显改善。     

自体部分腓骨长肌腱移植重建治疗慢性踝关节外侧不稳

目的探讨自体部分腓骨长肌腱移植重建踝关节外侧韧带治疗慢性踝关节外侧不稳的疗效。方法回顾分析2014年9月—2018年11月,32例(32侧)采用自体腓骨长肌腱前半部重建踝关节外侧韧带治疗的慢性踝关节外侧不稳患者临床资料。男25例,女7例;年龄20～51岁,平均28.5岁。病程6～41个月,平均8.9个月。踝关节Karlsson-Peterson评分为(53.7±9.7)分。距骨倾斜角为(14.9±3.7)°,距骨前移距离(8.2±2.8)mm。合并距骨软骨损伤6例,骨性撞击4例。结果术后切口均Ⅰ期愈合。患者均获随访,随访时间12～53个月,平均22.7个月。末次随访时,踝关节Karlsson-Peterson评分为(85.2±9.6)分,距骨倾斜角为(4.3±1.4)°,距骨前移距离为(3.5±1.1)mm,与术前比较差异均有统计学意义(P0.05)。末次随访时,患者自评满意度为非常满意17例、满意10例、一般4例、不满意1例。7例随访期间发生踝关节扭伤,5例跟骨侧挤压钉部位有压痛,4例踝关节前外侧疼痛超过6个月。患者均无腓骨长肌腱取腱部位不适;12例末次随访时行超声检查,提示双侧腓骨长肌腱密度及直径均无明显差异。结论慢性踝关节不稳需行外侧韧带重建时,自体部分腓骨长肌腱移植重建是一种安全可靠的术式。     

双源CT三维重建前交叉韧带股骨止点印迹的研究

目的 通过双源CT(DSCT)三维重建前交叉韧带(ACL)股骨止点,测量双束止点印迹,为临床实现解剖重建提供依据.方法 对55名志愿者双侧共110个膝关节进行DSCT扫描,其中男32名,女23名；年龄20～ 50岁,平均28岁.64排工作站三维重建膝关节股骨外髁,再现股骨外髁内侧壁ACL印迹,测量并比较不同性别及不同膝关节侧别印迹角、长短轴、印迹边缘至周围软骨的距离,以及双束中心点距离等.结果 110个膝关节的印迹角平均为6.8°±4.6°,印迹长轴平均为(16.8±1.7) mm,印迹短轴平均为(7.5±1.4) mm,印迹边缘至股骨软骨后缘最短距离(DPCM)平均为(1.9±1.0) mm,印迹边缘至股骨软骨远端最短距离(DDCM)平均为(1.5±1.3) mm,双束中心距离平均为(8.0±1.0)mm.男性左、右侧膝关节印迹角、印迹长轴、印迹短轴、DPCM、DDCM及双束中心距离比较差异均无统计学意义(P＞0.05).女性左、右侧膝关节印迹角、印迹长轴、印迹短轴、DDCM及双束中心距离比较差异均无统计学意义(P＞0.05),但左、右侧DPCM比较差异有统计学意义(P＜0.05).男、女性膝关节印迹角、印迹短轴比较差异均无统计学意义(P＞0.05),但男、女性印迹长轴、DPCM、DDCM及双束中心距离差异均有统计学意义(P＜0.05).结论 DSCT对正常人群ACL股骨止点自然印迹的测量结果可靠,具有代表性.ACL股骨止点自然印迹角、双束中心点距离以及与印迹至周围软骨距离等形态、位置参数存在个体差异.     

前交叉韧带股骨止点的解剖学研究

[目的]通过股骨干性标本研究前交叉韧带(ACL)股骨止点的形态、位置及大小,提出新的形态学分类,为临床重建ACL提供解剖学依据。[方法]对67副已知性别成人股骨干性标本的ACL股骨止点进行解剖研究。测量ACL股骨附着点的面积、形态以及与周围结构的关系。应用SPSS10.0统计软件对数据进行统计学分析。[结果]ACL股骨止点面积:男(104.4±30.8)mm2,女(81.4±29.1)mm2,性别差异有显著性意义(P0.01)。ACL股骨附着区形态中椭圆形49例,占36.6%,新月形39例,占29.1%;圆形20例,占14.9%;长条形17例占12.7%,不规则形9例,占6.6%。[结论]ACL股骨止点有椭圆形、新月形、长条形、不规则形等多种形态,股骨止点面积有性别差异,重建ACL应结合股骨附着区的形态、位置、大小、性别等特点进行个体化重建。     

下胫腓联合损伤螺钉内固定治疗的影像学研究

目的通过踝关节3个不同平面CT断层影像获得下胫腓定位螺钉的最佳置入途径,为手术中正确置入螺钉提供简便的操作方法。方法对100例单侧下肢损伤患者健侧踝关节CT轴位图像进行测量分析,取踝关节中立位状态下关节面近端2、3、5 cm水平的轴位CT影像,测量胫骨及腓骨的中心点,研究胫、腓骨中心点连线与腓骨外侧脊的关系及与水平面的成角。结果 100例CT图像数据中,位于踝关节近端2 cm平面置入点位于腓骨外侧脊顶端上,与水平成角10.95°±4.52°;近端3 cm平面置入点位于腓骨外侧脊顶端后方1.15 mm±0.35 mm,与水平成角13.74°±4.42°;近端5 cm平面置入点位于腓骨外侧脊顶端后方2.65 mm±1.05 mm,与水平成角17.07°±4.96°。其中男、女性之间未见明显差异(P0.05)。结论腓骨外侧脊作为特定及恒定的解剖结构对术中操作具有重要的参考作用,可为手术提供简便有效的操作方法,能正确置入下胫腓定位螺钉,降低失误率。     

Anatomical Study on the Reconstruction of the Anterior Talofibular Ligament

The purpose of this study aimed to (1) identify the relationship between the fibula and the talus of the anterior talofibular ligament (ATFL); (2) collect detailed anatomical data and provide anatomical basis for ATFL anatomical reconstruction. We selected 27 ankle specimens of adult cadavers (9 left feet and 18 right feet in 11 males and 16 females; mean age 41.6 years) with the exception of ankle deformities, fractures, underdevelopment and degenerative diseases. In these 27 specimens,15 cases of ATFL were divided into two bundles and 12 cases of ATFL were single bundles. The average ATFL length was 20.31 ± 3.12mm. The center of the ATFL in 11 specimens was located in the calcaneofibular ligament (CFL) foot print area. The long axis of the fibula side stop point was 8.83±1.82 mm, and the short axis was 3.12±0.49 mm. The distance from the center of the ATFL fibula attachment area to the tip of the fibula was 14.22±2.87 mm, and the distance from the center of the CFL is 5.57±1.80mm. The distance from the center of the ATFL talar attachment area to the tibiotalar articular surface was (9.74±2.12) mm, and the distance from the anterior external cartilage surface of the talus was (4.87±1.82) mm. The angle between ATFL and the long axis of the fibula is 78°±12°. Our results suggest that in ATFL reconstruction, the anatomical attachment points around the ATFL or the angle between ATFL and the long axis of the fibula both can be used for bone canal positioning.     

Safe angles of ATFL and CFL anchor insertion into anatomical attachment of fibula in a lateral ankle ligament repair

BackgroundLateral ankle ligament repair for chronic lateral ankle instability is common, and arthroscopic repair of the anterior talofibular ligament (ATFL) has been widely performed. However, it is desirable to repair of calcaneofibular ligament (CFL) combined with arthroscopic ATFL repair to obtain good long term clinical outcomes. Repairing CFL through small skin incision, there is the possibility to interfere with ATFL and CFL anchors because of close attachment of ATFL and CFL at fibula. The purpose of this study is to determine the safety anchor insertion angles for ATFL and CFL on CT images and to achieve ATFL and CFL repair with minimally invasive technique.MethodsFifty ankles in 50 patients were included in this study. On a sagittal CT image, the anchor drill hole angles for ATFL and CFL were measured to avoid interference with these anchors. Then, arthroscopic ATFL repair combined with CFL repair was performed on 15 patients according to the safety insertion angles obtained by CT. CFL repair was performed through 1.5 cm length of accessory anterolateral portal. Clinical outcome was evaluated using the Japanese Society for the Surgery of the Foot (JSSF) ankle hindfoot scale and the Karlsson score before surgery and at final follow-up.ResultsOn the CT image, the mean angles between the ATFL drill hole and anterior border of the fibula was 59.4 ± 6.5°, and those between the longitudinal axis of the fibula and ATFL drill hole, and the CFL drill hole were 34.6 ± 5.0°, and 15.1 ± 5.7°, respectively. Postoperative CT after arthroscopic ATFL repair combined with CFL repair showed that no interference with 2 anchors, and JSSF scale and the Karlsson score were significantly improved from preoperative to final follow-up.ConclusionsThis study showed how safety ATFL and CFL anchor insertion angles comprise a minimally invasive anatomical repair technique.     

Isometric points in lateral ankle ligament reconstruction: A three-dimensional kinematic study

BackgroundTo optimize the biomechanical outcomes in lateral ankle ligament reconstruction, avoid stiffness or residual laxity, aiming for an isometric reconstruction of the anterior lateral talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) is mandatory. However, the localization of the optimal ligament insertion remains challenging to assess intraoperatively.MethodThree-dimensional (3D) surface models from 10 healthy ankles were generated. 30 insertion points of the CFL were defined on the lateral side of the calcaneus each 10% of its total length in the dorsal-to-ventral and proximal-to-distal plane. 6 insertion points were defined at the ventral ridge of fibula from the malleolar tip and 5 insertions were defined along the lateral talar process. The ligament length variation of ATFL and CFL was assessed after a simulation of the flexion/extension around a simulated tibiotalar axis and inversion/eversion around a simulated subtalar axis in 36 different positions.ResultsThe isometric point of CFL on the calcaneus is located at about 60% along the dorsal-to-ventral and between 60% and 70% along the proximal-to-distal plane. From maximal extension to flexion, these points present respectively a length variation of ? 0.8 to ? 1.1 mm (p = 0.46) and ? 1.1 to ? 0.8 mm (p = 0.56). A fibular insertion at 5 mm proximal to the malleolar tip present a length variation ranging from ? 0.1–1 mm (p < 0.001) for ATFL and from ? 0.7–0.5 mm (p < 0.001) for CFL. A talar insertion point of the ATFL located 5 mm proximal to the subtalar joint present the lowest variation, ranging from ? 1.1–0.7 mm (p < 0.001), however an insertion at 20- or 25-mm present isometry (+0.1 to +0.9 mm p = 0.1, and +0.4 to +0.4 mm p = 1 respectively) if the fibular insertion is located at 5 mm proximal to the malleolar tip.ConclusionThis study provides anatomical references which are reproducible in daily practice. These insertion points allow to achieve a stable reconstruction while maintaining a tension-free mobilization of the ankle.     

Independent Attachment of Lateral Ankle Ligaments: Anterior Talofibular and Calcaneofibular Ligaments - A Cadaveric Study

Anatomic knowledge of lateral ligaments around the lateral malleolus is important for repair or reconstruction of ankle instability. The detailed structure of the connective fibers between the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) is unknown. To clarify the anatomic structure of ATFL and CFL and the connective fiber between the 2 ligaments, the lateral ligament was dissected in 60 ankles of formalin-fixed cadavers, and the distance was measured between bony landmarks and fibular attachment of ATFL and CFL using a digital caliper. All ankles had connective fibers between ATFL and CFL. The structure of connective fibers consisted of a thin fiber above the surface layer of ATFL and CFL; it comprised thin fibrils of the surface layer covering the lower part of ATFL and the front part of CFL. Both ATFL and CFL were independent fibers, and both attachments of the fibula were isolated. Single bands of ATFL were noted in 14 of 60 (23.3%) ankles, double bands that divided the superior and inferior bands were observed in 42 of 60 (70.0%) ankles, and multiple bands were observed in 4 of 60 (6.7%) ankles. A cord-like and a flat and fanning type of CFL was noted in 22 (36.7%) and 38 (63.3%) of the 60 ankles, respectively. Distances between ATFL/CFL and articular and inferior tips of the fibula were 4.3 ± 1.1 mm/7.6 ± 1.6 mm and 14.3 ± 1.9 mm/7.4 ± 1.7 mm, respectively (mean ± standard deviation). The results of this study suggest that knowledge of more anatomic structures of ATFL, CFL, and connective fiber will be beneficial for surgeons in the repair or reconstruction of the lateral ligament of the ankle.     

Evaluation of anatomical axis-joint center distance and anatomical axis-joint center ratio in distal femur and proximal tibia in coronal plane of Indian population

BackgroundRadiographic evaluation of the anatomical geometry of the bone is important for executing reconstructive surgeries like deformity correction, limb lengthening and joint replacements. Various studies have been done in the past to define the anatomic placement of implant inside the bone. The aim of this study is to evaluate the distance between the anatomical axis and joint center of the distal femur (aJCD-f) and proximal tibia (aJCD-t) along with the ratio of anatomical axis-joint center distance of distal femur (aJCR-f) and proximal tibia (aJCR-t) of the skeletally mature individual of Indian population along with its application in day to day practice.MethodsData is procured from the standard radiographs of the knee on large films. The anatomical axis is drawn on both sides of tibia and femur in a standard fashion. These lines intersect the horizontal drawn line at the intercondylar notch of femur and joint orientation line of the tibia. The aJCD-f, aJCD-t, aJCR-f, aJCR-t are then measured. Also the center of the inter-spinous distance of the tibia is measured from the anatomical axis (aSCD-t).ResultsA total of 182 x-rays of skeletally mature individual were included with mean age of 46.35 ± 13.93 years. Of them 81 were males and 101 were females. There were 89 x-ray of left side and 93 x-ray of right side. The mean width of the femur at the intercondylar notch is found to be 76.78 mm (±7.40). The mean aJCD-f is found to be 3.87 mm (±2.44), aJCR-f to be 0.50 (±0.06). The mean width of the tibia is found to be 76.80 mm (±6.48). The aJCD-t is found to be 2.20 mm (±1.41), aJCR-t to be 0.50 (±0.03). The aSCD-t at the level of tibial spine is found to be −0.23 mm (±2.84). There was significant difference in the width of the femoral condyle of males 82.13 mm (±0.65) and females 72.48 mm (±0.55). Males showed mean aJCD-f of 3.59 mm (±2.42) and females showed 4.10 mm (±2.46). The aJCR-f is found to be significantly different between males 0.49 (±0.05) and females 0.51 (±0.07). There is significant difference between the width of the proximal tibia between males 80.83 mm (±0.68) and females 73.56 mm (±0.46). The aJCD-t of males and females is found to be 2.28 mm (±1.25) and 2.16 mm (±1.54) respectively. The aJCR-t is found to be significantly different between males 0.49 (±0.03) and females 0.50 (±0.04). While the mean distance of the anatomical axis from the lateral tibial spine is 0.23 mm lateral to the center of the inter-spinous distance and is found to be same in both males and females −0.23 mm (±2.84).ConclusionThe coronal plane parameter like aJCD, aJCR of femur and tibia and aSCD-t of tibia can be a useful parameter to calculate in the ‘real world’ settings for reconstructive surgeries like deformity correction, nailing through the knee for femur and tibia as well as replacement surgeries around knee.     

踝关节跖屈、背屈运动的研究

目的:研究Pilon骨折在治疗中评价踝关节功能,诊断下胫腓联合分离、踝关节前后脱位的影像学依据。方法:35例正常成人,男21例(42踝),女14例(28踝);年龄21-48岁,平均31.6岁。踝关节常规摄正、侧位X线片;测量踝关节主动跖屈、背屈运动的最大角度,下胫腓联合间隙的宽度,胫骨外侧与腓骨的胫侧重叠影宽度,距骨踝关节面几何中心偏离胫骨中轴线的距离。结果:跖屈主动运动的最大角度,男(40.8°±3.1°),女(43.9°±4.8°);背屈主动运动的最大角度,男(27.6°±5.2°),女(26.5°±6.1°)。下胫腓联合间隙的宽度平均(3.2±0.5)mm。胫骨外侧与腓骨的胫侧重叠影宽度平均(6.9±2.2)mm。踝关节的跖屈下胫腓联合有逐渐变窄的变化,平均2 mm。距骨中心中轴距:男性跖屈最大值2.4 mm、背屈2.5 mm,女性跖屈最大值1.9 mm、背屈2.0 mm,最小值均为0 mm。结论:男女之间无论是背屈还是跖屈均无显著性差异(P>0.05),即踝关节在运动灵活性上无性别差异。踝关节主动跖屈、背屈运动的最大角度为Pilon骨折术中踝关节功能评定提供参考,下胫腓联合宽度>3.5 mm为下胫腓联合分离,胫骨外侧与腓骨的胫侧重叠影宽度<5.5 mm时,有下胫腓联合分离的可能。距骨中心中轴距>2 mm提示踝关节前后脱位。Pilon骨折在恢复骨折解剖复位的同时要注意这两个指标,对于恢复踝关节的侧方稳定、前后方向稳定有重要意义,能指导踝关节骨折治疗和康复。     

关节镜下自体半腱肌肌腱解剖重建踝关节外侧副韧带

目的 探讨关节镜下自体半腱肌肌腱重建踝关节外侧副韧带治疗慢性踝关节不稳定的方法及初期临床疗效。方法 将2015年12月至2017年2月我院收治的16例慢性踝关节不稳定病人纳入研究,其中男14例,女2例,年龄为（28.1±6.4）岁;术前应力位X线片提示距骨倾斜25.5°±5.5°（18°~35°）,距骨前移（10.1±1.8） mm（7~14 mm）。采用2.7 mm 30°短踝关节镜经前外侧入路观察,经前外侧辅助入路于腓骨远端和距骨外侧面距腓前韧带足印区制作骨隧道,跟骨外侧壁跟腓韧带止点处经皮透视制作骨隧道,取自体半腱肌肌腱对折编织成“Y”型,将移植物引入骨隧道,腓骨端使用袢钢板悬吊固定,距骨及跟骨端使用5.0 mm界面螺钉固定。术后早期功能锻炼,末次随访应用美国足踝外科医师协会（American Orthopedic Foot and Ankle Society, AOFAS）踝与后足功能评分系统评价踝关节功能;采用疼痛视觉模拟量表（visual analogue scale, VAS）评估疼痛情况;采用Sefton外侧副韧带重建疗效评价系统评估踝关节稳定性。结果 本组16例病人术后随访（16.8±4.3）个月（12~24个月）,均于术后3个月恢复正常体育活动,末次随访未观察到踝关节不稳定复发。AOFAS评分为（89.2±4.8）分,VAS评分为（0.7±0.6）分。依据Sefton评价标准：优9例,良5例,可2例,优良率为87.5%。结论 关节镜下自体半腱肌肌腱解剖重建踝关节外侧副韧带治疗慢性踝关节不稳定的近期疗效理想,并发症较少。     

Angle bisector method to determine the accurate angle for tibiofibular syndesmotic fixation: A validation study with 3D-printed anatomical models

PurposeThis study aimed to validate the angle bisector method on 3D-printed ankle models to reveal whether it aids in placing syndesmotic screws at an accurate trajectory that is patient- and level-specific and also not surgeon-dependent.MethodsDICOM data of 16 ankles were used to create 3D anatomical models. Then the models were printed in their original size and two trauma surgeons performed the syndesmotic fixations with the angle bisector method at 2 cm and 3.5 cm proximal to joint space. Afterward, the models were sectioned to reveal the trajectory of the screws. The photos of the axial sections were processed in a software to determine the centroidal axis which is defined as true syndesmotic axis and analyze its relationship with the screws inserted. The angle between the centroidal axis and syndesmotic screw was measured by two-blinded observers 2 times with 2 weeks interval.ResultsThe average angle between the centroidal axis and screw trajectory was 2.4° ± 2° at 2 cm-level and 1.3° ± 1.5° at 3.5 cm-level, indicating a reliable direction with minimal differences at both levels. The average distance between fibular entry points of the centroidal axis and screw trajectory was less than 1 mm at both levels indicating that the angle bisector method can provide an excellent entry point from fibula for syndesmotic fixation. The inter- & intra-observer consistencies were excellent with all ICC values above 0.90.ConclusionThe angle bisector method provided an accurate syndesmotic axis for implant placement which is patient- & level-specific and not surgeon-dependent, in 3D-printed anatomical ankle models.     

Maisonneuve骨折的临床诊治特点及15例手术疗效分析

目的 :探讨Maisonneuve骨折(maisonneuve fractures of the fibula,MFF)的诊断和治疗特点,并评估其手术治疗的临床疗效。方法:自2017年3月至2018年6月,采用手术治疗15例MFF患者,其中男9例,女6例;年龄27～54(35.00±7.46)岁;受伤至手术时间5～8(6.33±1.04) d。所有骨折为新鲜闭合性损伤。观察患者术后骨性愈合时间及术后并发症情况,并于术后12个月采用美国足与踝关节协会(American Orthopaedic Foot and Ankle Society,AOFAS)评分评价患者术后踝关节功能恢复程度。结果:15例患者获得随访,时间12～28(17.00±3.79)个月。4例发生漏诊。所有骨折获得骨性愈合,时间4～6(4.80±0.94)个月。术后未出现切口感染、骨折延迟愈合或不愈合等并发症。术后12个月AOFAS评分为(90.23±7.27)分;其中优9例,良3例,可3例。结论:MFF是一类严重的不稳定的踝关节损伤类型,容易忽视腓骨高位骨折及下胫腓的分离而造成漏诊误诊,手术治疗可恢复下胫腓联合以及踝穴的解剖学关系,获得较满意的疗效。