螺旋CT三维重建和MRI在踝关节骨折合并急性三角韧带损伤诊断中比较

目的对比螺旋CT三维重建(3DCT)和磁共振成像(MRI)在踝关节骨折合并急性三角韧带损伤中诊断价值。方法选取温州医科大学附属台州医院收治的76例踝关节骨折合并急性三角韧带损伤患者,均采用3DCT、MRI检测。结果三角韧带浅层或深层Ⅲ度损伤、深浅层同时Ⅲ度损伤内侧踝穴宽度(MCS)均高于Ⅰ、Ⅱ度损伤,深浅层同时Ⅲ度损伤MCS值高于浅层或深层Ⅲ度损伤(P0.05)。浅层、深层三角韧带区域,随着MRI显示损伤程度升高,MCS值逐渐升高(P0.05)。MCS与浅层、深层三角韧带MRI损伤程度均呈正相关(r=0.728,P=0.000;r=0.681,P=0.000)。MCS预测三角韧带浅层断裂、深层断裂及浅、深层同时断裂最佳临界值分别为6.34mm、7.64mm、7.81mm。结论3DCT可用于踝关节骨折合并急性三角韧带损伤诊断,MRI更适用于损伤程度评估。     

踝关节骨折X线与MRI诊断下胫腓联合损伤的相关性分析

[目的]评估急性踝关节骨折X线测量与MRI诊断下胫腓联合损伤的相关性,为临床诊治下胫腓联合损伤提供建议和方法.[方法] 56例急性踝关节骨折均行Denis-weber分型和Lauge-Hansen分型,骨折分型结合X线测量评定下胫腓联合损伤,MRI作为参照标准来评估下胫腓联合的完整性,以此来统计分析X线检查发现下胫腓损伤相对于MRI的敏感性和特异性,并对X线测量值与韧带损伤进行Spearman等级相关分析.[结果]Denis-weber分型中结合测量值,发现下胫腓联合损伤的敏感性为49％,特异性为100％,Lauge-Hansen分型的敏感性为93％,特异性为94％,下胫腓间隙和下胫腓重叠阴影不与下胫腓联合损伤成完全对应关系,增宽的距骨内踝间隙不与三角韧带损伤成对应关系.[结论]根据Lauge-Hansen骨折分型判断下胫腓联合损伤与MRI表现更接近;与X线检查相比,MRI能更准确地评估下胫腓联合损伤的严重程度.     

全层修复三角韧带与下胫腓联合内固定治疗Lauge-Hansen旋后外旋型Ⅳ度踝关节骨折

目的探讨全层修复三角韧带联合下胫腓联合螺钉固定治疗Lauge-Hansen旋后外旋型Ⅳ度踝关节骨折的临床疗效。方法回顾性分析自2013-03—2018-03手术治疗的31例Lauge-Hansen旋后外旋型Ⅳ度踝关节骨折,先取仰卧位内侧入路探查三角韧带并评估损伤程度,在三角韧带深层止点预置锚钉,再取侧卧位后外侧入路复位腓骨、后踝固定或不固定,再取仰卧位前外侧小切口探查清理下胫腓联合并行下胫腓联合螺钉固定,最后依次修复三角韧带深层、浅层。结果 31例均获得随访,随访时间平均31(18~48)个月。骨折完全愈合时间为12~48周,无骨折延迟愈合、下胫腓螺钉断裂发生。末次随访时踝-后足AOFAS评分平均91(72~97)分,优27例,良3例,可1例。结论全层修复三角韧带联合下胫腓联合螺钉内固定治疗合并下胫腓联合及三角韧带损伤的Lauge-Hansen旋后外旋型Ⅳ度踝关节骨折可降低踝关节复位不良发生率,恢复踝关节稳定性,有利于患者进行早期功能锻练,达到快速康复的目的。     

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。     

踝关节三角韧带损伤的诊疗进展

 踝关节不稳的患者中40%存在不同程度的三角韧带损伤［1-5］，并且三角韧带对踝关节稳定起重要作用［3，6-8］。三角韧带损伤分为急性与慢性损伤两类，两者在损伤机制及治疗方式上均存在很大差异。急性三角韧带损伤主要由外踝骨折造成，特别是Lauge-Hansen分型中的旋后-外旋型损伤。慢性三角韧带损伤主要是慢性内踝不稳及平足引起的慢性三角韧带功能不全。
一、三角韧带的解剖
1998年，Milner和Soames［9］明确指出三角韧带分为浅层和深层。目前，对于组成三角韧带浅层与深层的具体纤维束数目、命名、变异、是否可以分离等在多项研究中始终无法统一。Stufkens等［5］认为组成三角韧带的纤维束数为3～6束；而多数研究却认为其纤维束数目为6束［1，5，9-11］，浅层4束，深层2束［9-11］。浅层纤维束从前至后分别为胫舟韧带、胫跳跃韧带、胫跟韧带及胫距后韧带浅层，深层纤维束为胫距前韧带及胫距后韧带深层，也有学者将三条胫距韧带均归为深层［1，5］。浅层的胫跳跃韧带及深层的胫距后韧带深层变异最少，在相关研究的所有标本中均可找到［9-12］。Milner和Soames［9］在其研究的40具标本中均可分离观察到胫舟韧带，而Boss和Hintermann［10］却认为胫舟韧带是加强踝关节囊的纤维束，不属于三角韧带。其他韧带按其在多篇研究中的发现比例由多至少依次为胫跟韧带(15%～100%)、胫距后韧带浅层(37.5%～75%)、胫距前韧带(10%～50%)［9-12］。     

踝关节骨折三角韧带损伤修复与否的文献综述

踝关节三角韧带损伤占踝关节损伤的10%~15%,其中单独三角韧带损伤较为少见,常合并有踝关节骨折及下胫腓联合韧带的损伤[1-3],踝关节也是体育活动中最常受伤的关节之一[4]。预计到2030年踝关节受伤的发生率将增加3倍[5]。在Lauge-Hansen[6]描述的踝关节骨折分型中,三角韧带损伤或内侧踝骨折,是以环形方式围绕踝关节而发生。三角韧带的损伤最常发生在旋前外和旋后外上,旋后外损伤是最常见的骨折类型。三角韧带结构的命名和解剖形态一直存在争议,它是一个坚强的多层复合体,由浅层和深层组成,是踝关节内侧重要稳定结构[7]。浅层的三角韧带包括胫舟韧带、胫跟韧带和胫距后韧带浅层,跨过踝关节和距下关节[8-9]。最近发表的有关于三角韧带组成的解剖学研究显示,弹簧韧带被认为是三角韧带浅层的一个组成部分[10-11]。三角韧带深层包括胫距前韧带深层和胫距后韧带深层,仅与踝关节相连[8-9](见图1~2)。     

外踝骨折合并三角韧带断裂一期手术治疗临床疗效观察

目的观察外踝解剖钢板内固定外踝骨折后同时采用带线锚钉缝合修复三角韧带断裂的临床疗效。方法回顾性分析自2016-08—2018-08诊治的16例外踝骨折合并三角韧带断裂,先作内侧踝关节弧形切口探查损伤的三角韧带,将嵌顿在踝关节间隙内的三角韧带断端牵出,标记三角韧带的浅层和深层。再作外踝纵形切口进行外踝骨折切开复位解剖钢板内固定,置入1枚空心钉稳定下胫腓联合,垂直距骨体中心部置入2枚Anchor带线锚钉缝合固定三角韧带深层,用2枚Anchor带线锚钉于内踝尖前部及下部缝合固定三角韧带浅层。结果 16例术后均获得随访,随访时间平均13.2(10～20)个月。随访期间外踝骨折愈合良好,无内固定失败、骨折不愈合、感染等并发症发生,前抽屉试验阴性,无距骨倾斜。末次随访时疼痛VAS评分、踝与后足功能AOFAS评分、内侧踝关节间隙较术前明显改善,差异有统计学意义(P0.05)。结论明确三角韧带断裂后一期行外踝骨折切开复位内固定与带线锚钉缝合修复三角韧带可以明显缩小内侧踝关节间隙,增加踝关节稳定性,减少因三角韧带损伤导致的踝关节不稳及其他并发症的发生。     

加深对足踝部损伤的认识,提高手术治疗水平

本期发表了多篇有关足踝部骨折与疾患的文章,对进一步提高这方面的诊治水平十分有益。目前,对踝关节骨折的分型多采用Lauge-Hansen和AO分型方法,这两种分型方法不仅重视骨折的特点,而且强调韧带损伤的重要性及是否存在下胫腓分离。踝关节内侧结构完整可保证距骨在踝穴内不发生外移,因此在对内踝骨折和腓骨骨折行内固定后,一部分病例可获得踝穴的稳定。对以下几种情况应行下胫腓固定:(1)固定后腓骨仍有外移或在外旋、外翻应力下踝穴增宽、距骨向外侧移动;(2)伴有三角韧带断裂;(3)内踝骨折较小,可能仅波及前结节(anteriorcolliculus),但同时…     

不同方式治疗踝关节骨折伴三角韧带完全断裂的临床效果观察

目的观察踝关节旋后外旋型Ⅳ度骨折伴三角韧带完全断裂经切开复位内固定后采用不同方式修复三角韧带的临床效果。方法回顾性分析我院2008年1月至2016年1月收治的踝关节旋后外旋型Ⅳ度骨折伴三角韧带完全断裂患者80例,均行切开复位内固定治疗踝关节骨折,共分四组,A组20例,不进行三角韧带修复,作为对照组;B组20例,仅修复浅层韧带;C组20例,仅修复深层韧带;D组20例,修复深层和浅层韧带。记录并比较四组患者的手术时间、骨折完全愈合时间、术前和术后的内踝间隙,采用美国足踝外科协会(AOFAS)中的踝-后足评分系统比较各组患者的优良率。结果四组患者手术时间差异显著,D组手术时间最长,为(153.5±10.4)min,A组手术时间最短,为(98.2±8.1)min,P0.05;在AOFAS踝-后足评分中,B组患者优良率85%,C组优良率90%,D组优良率95%,均明显高于A组,P0.05。结论踝关节旋后外旋型Ⅳ度骨折伴三角韧带完全断裂除需进行解剖复位外,还应修复三角韧带,尤其是深层韧带。     

距骨侧锚钉联合内踝部金属垫片修复踝关节骨折合并的三角韧带深层断裂

目的探讨采用距骨侧锚钉联合内踝部金属垫片修复踝关节骨折合并的三角韧带深层断裂的效果。方法回顾性分析自2012-06—2015-08诊治的27例踝关节骨折合并三角韧带深层断裂。三角韧带断裂部位:距骨止点处断裂18例,体部断裂5例,内踝止点处断裂4例。对三角韧带深层断裂者用锚钉在距骨侧置钉,进行重建或修补,并于内踝内侧放置垫片以防止切割及松脱。末次随访时采用踝关节功能AOFAS评分评估疗效。结果 25例术后获得随访,随访时间平均14.2(8~23)个月。未出现神经血管损伤及感染,切口及骨折愈合良好。末次随访时踝关节功能AOFAS评分平均92.4(88~96)分,未出现踝关节内侧不稳定。结论采用距骨侧锚钉联合内踝部金属垫片修复踝关节骨折合并的三角韧带深层断裂的效果满意,操作相对简单,值得临床推广应用。     

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.     

MRI与术中外旋应力试验在旋后-外旋踝关节骨折中的应用价值比较

背景：旋后-外旋骨折占所有踝关节骨折的40%~75%。其治疗方式的选择主要依赖对内侧结构损伤程度的判断,特别是内侧三角韧带是否有损伤。循证医学的资料表明,术前MR扫描与术中外旋应力试验是判断三角韧带损伤的方法。那么,术前MR扫描是否可以替代术中应力试验,明确三角韧带损伤的情况并指导踝骨折采用保守治疗或手术治疗。本文试图通过手术验证两者的敏感性是否一致。目的：探讨MRI与术中外旋应力试验在判断踝关节旋后-外旋型损伤程度中的应用价值。方法：2008年1月至2012年12月,我院收治的Lauge-Hansen分型旋后-外旋型踝关节骨折患者,共计30例,术前常规行X线、MR扫描,记录踝关节内侧三角韧带损伤情况。麻醉后行踝关节外旋应力位摄片,依据踝关节内侧间隙是否正常判定三角韧带损伤情况。再比较外旋应力试验与MR结果。结果：MR扫描对三角韧带损伤情况判定,等同于术中外旋应力试验。结论：MRI对于判断三角韧带是否损伤有一定价值,可以指导旋后-外旋型踝关节骨折不同程度损伤的鉴别与治疗方法的选择。     

Compatibility of Lauge-Hansen Classification Between Plain Radiographs and Magnetic Resonance Imaging in Ankle Fractures

We evaluated the accuracy of the predictive injury sequences of the Lauge-Hansen (L-H) classification using magnetic resonance imaging (MRI) in patients with ankle fractures and determined the possible causes of mismatch. Sixty-five patients with ankle fractures who had a complete series of anteroposterior, lateral, and oblique radiographs and ankle MRI studies available were included. The fracture pattern was assigned by 2 senior orthopedic surgeons according to the L-H classification system. The syndesmotic ligaments, lateral collateral ligaments, and medial deltoid complex ligaments were evaluated on the preoperative MRI scans. Comparisons were performed between the predicted ankle ligamentous injury based on the radiographic L-H classification and preoperative MRI analysis. Of the 65 feet in 65 patients, 50 feet (76.9%) were classified as having a supination-external rotation (SER) fracture, 6 feet (9.2%) as having a pronation-external rotation fracture, 4 feet (6.2%) as having a supination adduction fracture, and 2 feet (3.1%) as having a pronation abduction fracture. The overall compatibility of the radiologic classification with the MRI classification was 66.1%. In the evaluation of 50 feet with the MRI SER designation, maximum compatibility was found for stage 4 (77.3%). The main cause for the discrepancy in the SER designation was missing the presence of deltoid ligament disruption on the plain radiographs, especially in the stage 2 and 3 SER fracture pattern. In the evaluation of deltoid complex injuries, all injuries were localized to the anterior part of the medial deltoid complex. The validity of the L-H classification system was low. A new classification system is needed to address the medial malleolus fracture or deltoid complex injuries without posterior injury. Also, stress radiographs could be added to standard radiographs for the classification to address deltoid complex injuries.     

The diagnosis and treatment of deltoid ligament lesions in supination–external rotation ankle fractures: a review

The supination-external rotation or Weber B type fracture exists as a stable and an unstable type. The unstable type has a medial malleolus fracture or deltoid ligament lesion in addition to a fibular fracture. The consensus is the unstable type and best treated by open reduction and internal fixation. The diagnostic process for a medial ligament lesion has been well investigated but there is no consensus as to the best method of assessment. The number of deltoid ruptures as a result of an external rotation mechanism is higher than previously believed. The derivation of the injury mechanism could provide information of the likely ligamentous lesion in several fracture patterns. The use of the Lauge-Hansen classification system in the assessment of the initial X-ray images can be helpful in predicting the involvement of the deltoid ligament but the reliability in terms of sensitivity and specificity is unknown. Clinical examination, stress radiography, magnetic resonance imaging, arthroscopy, and ultrasonography have been used to investigate medial collateral integrity in cases of ankle fractures. None of these has shown to possess the combination of being cost-effective, reliable and easy to use; currently gravity stress radiography is favoured and, in cases of doubt, arthroscopy could be of value. There is a disagreement as to the benefit of repair by suture of the deltoid ligament in cases of an acute rupture in combination with a lateral malleolar fracture. There is no evidence found for suturing but exploration is thought to be beneficial in case of interposition of medial structures.     

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.     

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.     

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.

     

Anatomical Basis of Variability in Injuries of the Medial Malleolus and the Deltoid Ligament: II. Clinical Studies

The anatomical concept of the deltoid ligament as being attached to the anterior colliculus of the medial malleolus by its superficial portion, and to the posterior colliculus by its deep portion has been applied to a clinical material. A number of singular and concurrent lesions of the medial malleolus and the deltoid ligament were recognized: fracture of the anterior colliculus, concurrent fracture of the anterior colliculus and rupture of the deep posterior talotibial ligament, fracture of the posterior colliculus, supracollicular fracture, rupture of the deltoid ligament, and chip fracture of the anterior colliculus. The clinical implications of these lesions are discussed.     

Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. II. Clinical studies.

The anatomical concept of the deltoid ligament as being attached to the anterior colliculus of the medial malleolus by its superficial portion, and to the posterior colliculus by its deep portion has been applied to a clinical material. A number of singular and concurrent lesions of the medial malleolus and the deltoid ligament were recognized: fracture of the anterior colliculus, concurrent fracture of the anterior colliculus and rupture of the deep posterior talotibial ligament, fracture of the posterior colliculus, supracollicular fracture, rupture of the deltoid ligament, and chip fracture of the anterior colliculus. The clinical implications of these lesions are discussed.