三角韧带损伤的手术治疗

[目的]探讨踝关节三角韧带损伤的手术治疗及效果。[方法]2002年4月-2005年4月治疗伴有三角韧带损伤的踝关节骨折40例，均采用切开复位和坚强内固定，并修复重建三角韧带，恢复踝关节内外侧结构的稳定性。下胫腓联合分离仍不稳定者，给予皮质骨螺钉横向内固定。[结果]全部病例得到16个月-3a随访，平均1．5a。按齐氏疗效评定标准：优良30例，可8例，差2例，优良率75％。[结论]强调踝关节骨折切开解剖复位，坚强内固定的同时，应充分重视修复重建三角韧带。     

踝关节骨折伴三角韧带断裂的手术治疗

目的:评价踝关节骨折伴三角韧带断裂的手术治疗效果。方法:对14例踝关节骨折伴三角韧带断裂的患者,采用踝关节骨折切开复位内固定并同时修复三角韧带的方法治疗,观察术后踝关节功能情况,评估临床疗效。结果:切口均Ⅰ期愈合,无内固定物松动及骨折不愈合等并发症;随访时间12~18个月,平均14.6个月;骨折愈合时间12~16周,平均13.8周;采用美国骨科足踝协会足踝评分系统评价末次随访时踝关节功能,优7例,良5例,可1例,差1例,优良率85.7%。结论:骨折切开复位内固定同时修复三角韧带治疗踝关节骨折伴三角韧带断裂,可获得良好疗效。     

手术治疗踝关节骨折伴三角韧带损伤的疗效观察

目的探讨手术治疗踝关节骨折伴三角韧带损伤的疗效。方法 2010年1月-2013年1月,收治11例踝关节骨折伴三角韧带损伤患者。其中男7例,女4例;年龄18~72岁,平均38.2岁。受伤至手术时间为6 h~7 d,平均4 d。踝关节骨折根据Lauge-Hansen分型标准:旋前-外旋型5例,旋后-外旋型4例,旋前-外展型2例。踝关节彩色多普勒超声及MRI检查证实三角韧带断裂。麻醉后行外翻应力试验、距骨外翻倾斜试验和前抽屉试验均为阳性。踝关节骨折行切开复位内固定,探查并修复三角韧带。结果术后切口均Ⅰ期愈合,无感染等手术相关并发症发生。患者均获随访,随访时间12~18个月,平均13.3个月。X线片复查示,骨折均解剖复位,内固定物位置满意,踝关节各骨对应关系无异常,下胫腓联合关系正常;骨折均愈合,愈合时间6~8周,平均7.6周。术后3~6个月复查踝关节MRI示三角韧带形态正常。按美国足踝外科协会(AOFAS)评分:获优6例,良3例,可1例,差1例,优良率81.8%。结论对于踝关节骨折伴三角韧带损伤,切开复位内固定骨折同时修补三角韧带,可最大程度恢复踝关节内侧稳定结构。     

带线锚钉修复踝关节三角韧带断裂32例体会

目的探讨带线锚钉修复踝关节三角韧带断裂的手术方法及疗效。方法选取2009年月10月至2011年月10月本院治疗伴三角韧带断裂的踝关节骨折32例,均行骨折切开复位坚强内固定,并带线锚钉修复重建三角韧带,恢复踝关节内外侧结构的稳定性。结果全部部病例术后随访1-3年,优23例,良9例,优良率100％。结论带线锚钉修复踝关节三角韧带断裂手术方式恢复了三角韧带的解剖和生物力学,固定可靠,是一种较好的修复方法。     

带线锚钉治疗踝关节三角韧带损伤的疗效分析

目的:探讨应用带线锚钉治疗踝关节三角韧带损伤的临床疗效。方法:2008年4月～2012年4月治疗伴有三角韧带损伤的踝关节骨折23例,男性14例,女性9例,年龄24～69岁,平均42.8岁,均采用切开复位和坚强内固定,并修复重建三角韧带,恢复踝关节内外侧结构的稳定性。结果:随访2～36个月,术后踝关节内侧间隙宽度较术前明显改善(P<0.01),优良率为87.0%。结论:带线锚钉治疗踝关节三角韧带损伤,较采用钢丝或丝线的传统方法具有创伤小、操作简单、固定可靠的特点,带线锚钉是治疗三角韧带损伤良好的内固定材料。     

可吸收锚钉修复三角韧带损伤在踝关节骨折术中的应用

目的观察踝关节骨折术中采用可吸收锚钉修复三角韧带损伤的临床疗效。方法回顾性分析自2017-05—2019-01采用钢板螺钉内固定治疗的36例合并内侧三角韧带损伤的踝关节骨折,术中采用可吸收锚钉修复三角韧带损伤。结果 36例均获得随访,随访时间平均16.4(5.1～26.2)个月。所有患者均未出现组织感染、排斥反应、关节再脱位、骨折不愈合等并发症。骨折愈合时间9.1～17.3周,平均12.5周。末次随访时AOFAS评分:优25例,良9例,可2例,优良率94.4%。1例踝关节活动范围减小,行走后疼痛,无静息痛,口服药物缓解。结论对于合并内侧三角韧带损伤的踝关节骨折,踝关节骨折复位固定后采用可吸收锚钉重建内侧三角韧带可获得更好的踝关节稳定性,减少并发症发生。     

带线锚钉治疗Ⅳ度旋前-外旋踝关节骨折的初步效果

目的 探讨合并三角韧带损伤的重度旋前-外旋踝关节骨折手术方法和治疗效果.方法 2005年7月-2007年4月,采用切开复位内固定,结合带线锚钉修补治疗17例合并三角韧带损伤的旋前-外旋踝关节骨折.男13例,女4例;年龄21～56岁,平均36.5岁.均为闭合性损伤,不伴软组织缺损,关节活动受限.术前X线片及CT检查均可见外踝、后踝骨折,有明显外移的距骨,不伴内踝骨折.根据Lauge-Hansen分型均为旋前.外旋型Ⅳ度损伤,根据Danis-Weber分型均为C型.受伤至手术时间4～7 d,平均5.6 d.结果 术后患者伤口均Ⅰ期愈合.17例均获随访,随访时间11～24个月,平均15.6个月.X线片示17例骨折均达骨性愈合,愈合时间11～16周,平均14.8周.按改良Baird-Jackson评分系统评价:优5例,良9例,可2例,差1例,优良率82.4%.无手术相关并发症发生.X线片测得术后内踝间隙为(3.16±0.37)mm,与术前(4.87±0.43)mm比较差异有统计学意义(P<0.01);术后患侧重力应力位下内踝间隙为(3.55±0.44)mm,与健侧(3.47±0.43)mm比较差异无统计学意义(P>0.05).结论 治疗合并三角韧带损伤的Ⅳ度旋前-外旋踝关节骨折,在骨折切开复位内固定同时应充分重视修复重建内侧韧带结构.     

带线锚钉在踝关节三角韧带损伤修复中的应用

目的 探讨踝关节骨折伴有三角韧带损伤的手术方法和临床疗效.方法 2008年8月至2011年3月,治疗伴有三角韧带损伤的踝关节骨折16 例,均采用切开复位内固定,同时应用带线锚钉修复重建三角韧带.结果 所有患者术后随访10～20个月,平均13.2个月,按Baird-Jackson评分系统评价,优5 例,良8 例,可2 例,差1 例,优良率81.3%.术后无相关并发症发生.术后1年X线片测得患侧重力应力位下内踝间隙为（3.54±0.40） mm,与健侧（3.46±0.39） mm比较,差异无统计学意义（P＞0.05）.结论 合并三角韧带损伤的踝关节骨折在行骨折切开复位内固定的同时行三角韧带的修复重建具有重要意义,应用带线锚钉修复三角韧带的效果可靠,值得推广.     

踝关节骨折伴下胫腓联合分离的手术治疗及临床意义

目的探讨治疗踝关节骨折伴下胫腓联合分离的手术方法及临床意义。方法自2002年1月～2005年12月对112例伴踝关节骨折下胫腓联合分离行腓骨内固定或不固定,内踝内固定,三角韧带探查修复术。未固定下胫腓联合。术后随访6～36个月,平均20.8个月。结果用Mazur评分系统评估手术疗效:优98例,良14例。未见骨折不愈合、关节不稳及创伤性关节炎等并发症。结论对伴下胫腓联合分离的踝关节骨折行手术治疗时,除了固定内、外踝,还要修复三角韧带损伤。恢复了内、外侧所有结构的完整性后才能真正恢复下胫腓联合及踝关节的正常生物力学环境和稳定性,这时即使不固定下胫腓联合,也可以获得下胫腓联合的稳定。固定内、外踝和下胫腓联合,而三角韧带的损伤不修复,虽然下胫腓韧带可以获得愈合,但三角韧带会愈合不佳、韧带松弛及功能不良,最终仍会导致创伤性关节炎。     

手术治疗三角韧带断裂的踝关节旋后外旋Ⅳ型骨折的疗效分析

【】 目的 探讨手术治疗三角韧带断裂的踝关节旋后外旋Ⅳ型骨折的的临床疗效。 方法 我院自2010年1月至2013年06月,根据 Lauge-Hansen分型,对21例三角韧带断裂的踝关节旋后外旋Ⅳ型骨折采用外踝切开复位钢板内固定,三角韧带锚钉修复的手术方法进行治疗,其中2例合并内踝骨折,2例合并后踝骨折,同时行空心拉力螺钉内固定,3例行下胫腓联合固定。病例中男16例,女5例;平均年龄46．1岁(32~61岁)。受伤至手术平均时间为5．1 天(3~10 天)。均为闭合性骨折,并且未合并其他部位骨折。对治疗结果进行功能及影像学方面的评估。末次随访应用Mazur踝关节评分系统。 结果 所有患者均获得随访,术后平均随访时间13．2个月(8~22个月),骨折处均获得骨性愈合,平均愈合时间4．7个月(4．2~6．9个月),踝穴正常,无创伤性关节炎。优6例,良13,可2例,优良率为90％。结论 三角韧带断裂的踝关节旋后外旋Ⅳ型骨折采用外踝切开复位钢板内固定,三角韧带锚钉修复的手术方法,能够获得满意的临床疗效。     

Ultrasonographic examination of the deltoid ligament in bimalleolar equivalent fractures

BACKGROUND: Lauge-Hansen supination-external rotation Stage IV ankle injuries may simulate a Stage II or Stage III injury radiographically if the medial disruption occurred through the deltoid ligament instead of the medial malleolus, making it difficult to determine whether an operation is indicated. MATERIALS AND METHODS: Seventeen patients presented with radiographically isolated lateral malleolar fractures at the syndesmotic level. They were examined with ultrasonography for evaluation of the integrity of the deltoid ligament. Patients in whom ultrasonography showed complete rupture of the deltoid ligament received operative fixation of the ankle fracture, with exploration and repair of the deltoid ligament at the same time. Patients without complete rupture of the deltoid ligament were treated conservatively with a short leg cast for 6 weeks followed by an ankle brace for another 6 weeks. Nine male and six female patients completed the final clinical and radiographic evaluations. RESULTS: Ultrasonography showed complete rupture of the deltoid ligament in six patients. Exploration of the deltoid ligaments confirmed the sonographic findings in all these patients. In the remaining nine patients, the deltoid ligaments were not completely ruptured on ultrasound. These fractures were treated conservatively, and all healed uneventfully. All the 15 patients had good or fair results on the final evaluation. CONCLUSION: Ultrasonography is a convenient and accurate diagnostic tool to differentiate unstable bimalleolar-equivalent ankle fractures from an isolated lateral malleolar fracture. Thus, it can be helpful in the decision process for the treatment of choice for different fracture patterns.     

Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation

BACKGROUND: The stability of the ankle joint is provided by the medial and lateral malleoli and ligaments. Recent studies of cadaveric ankles have demonstrated that injury to the medial structures of the ankle is necessary to allow lateral subluxation of the talus after fracture. However, cadaveric models are limited by the fracture pattern chosen for the model. We sought to investigate the competency of the deltoid ligament in vivo in patients with an operatively treated bimalleolar ankle fracture. METHODS: Twenty-seven patients with a bimalleolar ankle fracture were evaluated. In each patient, the medial malleolus was anatomically reduced and fixed. A radiograph of the ankle was then made with application of an external rotation load to the joint. All lateral malleolar injuries were then reduced and fixed. The radiographs were evaluated for restoration of the competence of the deltoid ligament according to established criteria. RESULTS: Seven (26 percent) of the twenty-seven patients had radiographically evident incompetence of the deltoid ligament after medial malleolar fixation. This finding was associated with a small medial malleolar fragment. CONCLUSIONS: In bimalleolar fractures, the medial injury may be an osseous avulsion, leaving the deltoid intact on the displaced fragment, or it may be a combination of ligamentous and osseous injury with disruption of the deep portion of the deltoid ligament.     

Posterior Malleolus Fracture Displacement Is Associated with Rotational Ankle Fracture Stability in Patients Without Medial Malleolar Fractures

Background

The optimal method for the determination of ankle stability remains controversial in rotational ankle fractures without medial bony injury.

Questions/Purposes

The purposes of this study were to (1) evaluate whether posterior malleolar (PM) fracture displacement is associated with deltoid ligament injury in supination-external rotation (SER) ankle fractures and (2) compare the diagnostic accuracy of PM displacement and magnetic resonance imaging (MRI) evaluation of the deep deltoid ligament in identifying fractures with deltoid ligament incompetence.

Methods

Patients with rotational bimalleolar injuries containing lateral malleolar and PM fractures without bony medial injury were included. After operative lateral and PM fixation, an external rotation stress test was performed to evaluate deltoid ligament stability. Operative dictations were reviewed to confirm injury pattern, stability on stress test, and visual inspection of the deltoid ligament. Maximum PM displacement was assessed on lateral X-ray. Pre-operative MRI of the ankle was performed following closed reduction and splinting.

Results

The final cohort consisted of 13 trimalleolar equivalent fractures (torn deltoid ligament) and 20 bimalleolar fractures (medial malleolus and deltoid ligament intact). Average PM displacement was significantly higher for SER trimalleolar equivalent patterns when measured on lateral X-ray. The sensitivity of detecting trimalleolar equivalent fracture was higher on all reported X-ray findings than the sensitivity obtained by the reported MRI findings of deltoid ligament injury.

Conclusion

PM displacement on X-ray is a useful adjuvant along with external rotation stress radiography and MRI evaluation of deep deltoid integrity to distinguish between stable and unstable fracture patterns and thus helps facilitate treatment decisions.

     

Rupture of the deltoid ligament in ankle fractures: should it be repaired?

In the 2 years after January 1984 we treated 290 fractures of the lateral malleolus in adults, 169 (58 per cent) of them operatively according to the AO-ASIF principles. In 28 fractures (10 per cent) there was also a rupture of the deltoid ligament. These patients were all operated upon, without exploring the medial side of the ankle joint. Postoperative treatment involved movements and partial weight bearing for 6 weeks. These 28 patients were reviewed after an average interval of 18 months. The Weber scoring system was used to assess the results. In 20 cases there was a very good or good result. In eight cases the result was poor. No patient had any sign of medial laxity either clinically or on eversion-stress radiographs. Some patients had signs of osteoarthritis. Clinical relevance: After anatomical reconstruction of the lateral malleolus with perfect congruity of the ankle mortise there is no need to explore and suture the ruptured deltoid ligament. After rigid internal fixation of the lateral malleolus postoperative treatment can allow full function.     

旋后-外旋型踝关节骨折中三角韧带断裂的诊断与治疗

旋后-外旋型或Weber B型踝关节骨折存在稳定型和不稳定型骨折。不稳定性骨折通常在腓骨骨折的同时存在内踝的骨折或三角韧带的撕裂。现在的共识是对于不稳定型的踝关节骨折,采取切开复位内固定的方式能达到较好的临床疗效。对于内侧韧带撕裂的诊断有很多研究,但对于评估内侧韧带撕裂的最合适方法仍未达成共识。由于外旋引起的三角韧带断裂的患者数量要远比过去想象中的多。在Lauge-Hansen分型中,根据损伤的机制可以提供可能的韧带损伤的信息。通过X线的表现,运用Lauge-Hansen分型系统在评估三角韧带是否损伤具有重要的价值,但其敏感性和特异性有待考究。体格检查、应力位X线片、MRI、关节镜、B超现在已用于踝关节骨折中内侧副韧带的完整的评估,但是这些方法没有一种是便宜、简便、可靠的。现在临床医师习惯使用重力应力试验进行评估,对于可疑的病例,行关节镜探查是非常有价值的。最新的观点认为单纯腓骨骨折,可仅行腓骨骨折切开复位内固定术,对合并外踝骨折的三角韧带撕裂进行修复是没有意义的,也没有证据证明暴露并修复三角韧带对内踝结构有影响。     

Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments

Foot and ankle surgeons often rely on the medial clear space to evaluate competency of the deep deltoid ligament when evaluating ankle fractures. This investigation assesses the integrity of the deep deltoid ligament after lateral malleolar fracture by using direct arthroscopic visualization and medial clear-space separation on plain film radiographs. The objectives of this study were to test the reliability of medial clear-space separation and the Lauge-Hansen classification scheme in predicting deep deltoid rupture in displaced lateral malleolar fractures. The medial clear space was measured on injury radiographs of 40 patients with an isolated displaced lateral malleolar fracture who underwent open reduction and internal fixation. Injury radiographs were classified according to the Lauge-Hansen scheme. Direct arthroscopic visualization was used to evaluate the deep deltoid ligament under manual stress before fracture reduction. The mean preoperative medial clear space in patients with a deep deltoid rupture (n = 13) was 6.6 +/- 2.4 mm (range, 4 to 12 mm), and in patients without a deep deltoid rupture (n = 26), it was 4.0 +/- 1.0 mm (range, 2.5 to 6 mm) (P =.002, 2-sample t test). At an injury medial clear space > or =3 mm, the false positive rate for deltoid rupture was 88.5% (P =.54, Fisher's exact test). At > or =4 mm, the false positive rate was 53.6% (P =.007). All fractures were rotational injuries according to the Lauge-Hansen system. Three fractures were not classifiable; another 3 fractures showed deltoid ligament integrity opposite the expected finding. The results indicate that, in isolated displaced fractures of the lateral malleolus, radiographic widening of the medial clear space is not a reliable indicator for deep deltoid rupture. Some fractures considered stable by the Lauge-Hansen classification may require careful scrutiny to rule out deep deltoid injury.     

Early radiographic outcomes following deltoid ligament repair in bimalleolar equivalent ankle fractures

BackgroundIndications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/? deltoid ligament repair.MethodsA retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/? deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively.ResultsOne hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 ± 0.65 mm vs. 2.26 ± 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 ± 1.20 mm vs. 4.87 ± 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups.ConclusionDeltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits.Level of clinical evidenceLevel III, retrospective cohort study.     

Radiographic effects observed in the coronal view after medial malleolar osteotomy at total ankle arthroplasty in rheumatoid arthritis cases

BackgroundWhen soft tissue balance is not acceptable at total ankle arthroplasty (TAA) for rheumatoid varus deformity, medial malleolar osteotomy has been performed. At the same time, the shape of the ankle joint changes after soft tissue balancing with such an osteotomy, however there is few information for the radiographic findings after the osteotomy. Thus, radiographic changes in the coronal view of such cases were investigated.MethodsJSSF-RA foot and ankle scale and SAFE-Q scores were determined along with pre/postoperative radiographic parameters of the ankle joint in 70 ankles (65 patients) with rheumatoid arthritis followed for a mean of 7.9 years (range, 2–16 years) after TAA. Seven ankles were excluded because those underwent lateral or lateral/medial malleolar osteotomy. Twenty-seven ankles underwent medial malleolar osteotomy, and compared with 36 ankles without osteotomy.ResultsAll ankles achieved bone union after medial malleolar osteotomy, and the tibial medial malleolus (TMM) angle was significantly decreased [30.3°–19.1°] following significant valgus correction [TC angle: −2.7° to 0.5°]. The gap due to medial soft tissue tightness was significantly improved by medial malleolar osteotomy [4.95° to 0.7°]. Lateral malleolar fractures sometimes occurred (19%: 5/27 ankles) at valgus correction, but they healed completely without any internal fixation.ConclusionMedial malleolar osteotomy was useful in rheumatoid varus ankle for not only controlling the soft tissue balance, but also providing a stabilized shape of the ankle joint. Lateral malleolar fractures were caused by valgus correction following medial malleolar osteotomy in some cases, but all fractures were completely healed without any internal fixation.     

后侧腓骨钢板内固定在踝关节骨折中的应用

目的：探讨踝关节骨折治疗的新方法并评价其疗效。方法：手术治疗踝关节骨折42例,对其中资料完整的34例进行分析,男19例,女15例。根据Weber-AO分类：B型28例,C型6例。应用Baird和Jackson评分系统对其术后疗效进行评定,并将骨折类型、骨折固定方法、术后功能锻炼时间与最终功能的关系进行分析。对34例Weber-AO分型的B型及C型踝关节骨折,采用腓骨后侧钢板内固定,以避免螺钉对关节面的损伤,对同时伴有后踝骨折的病例,同时一个切口对腓骨及后踝进行固定。结果：随访时间1.2～3.2年,平均1.8年。34例中疗效为优24例,良6例,可4例,优良率为88.2%。结论：腓骨后侧钢板内固定治疗踝关节骨折,避免了螺钉对关节面的损伤,增加了螺钉的把持力,并可一个切口同时完成外踝及后踝骨折的治疗,为踝关节骨折治疗提供了一个新方法。     

The contribution of anterior deltoid ligament to ankle stability in isolated lateral malleolar fractures

The treatment of isolated lateral malleolar fractures with deltoid ligament rupture remains controversial. We prospectively analysed 35 patients with isolated lateral malleolar fractures during 2006–2013. Radiography and magnetic resonance imaging (MRI) were performed to assess the degree of reduction, ligament damage, and stability. Internal fixation was performed for all unstable valgus fractures with unacceptable fracture parameters. Fractures with residual valgus instability after fixation underwent anterior deltoid repair. The mean anterior deltoid ligament grade based on MRI was significantly different between the high-grade unstable group and the stable and low-grade unstable groups (p = 0.037 and 0.004, respectively). Postoperative medial clear space measurements were not significantly different between groups. MRI was shown to be a useful tool in the preoperative identification of isolated lateral malleolus fractures prone to valgus instability. In the case of high-grade unstable fractures of the lateral malleolus, repair of the anterior deltoid ligament is adequate for restoring medial stability.