三角韧带合并下胫腓联合损伤的微创治疗进展

三角韧带也称踝关节内侧副韧带,下胫腓联合是胫腓骨远端的复合韧带结构.二者常因踝关节暴力骨折同时发生,并多伴有严重并发症.三角韧带合并下胫腓联合损伤多采用手术治疗,穿皮质螺钉多用于下胫腓联合损伤,锚钉固定多用于三角韧带断裂.随着足踝外科与运动医学的发展与更新,新的治疗方案正逐渐应用于临床之中,如穿骨皮质的可吸收螺钉、胫腓...     

Wagstaffe骨折的手术疗效评估

背景:众所周知,踝关节骨折在临床工作中经常遇到,切开复位内固定已成为其治疗的金标准,然而踝关节骨折伴有下胫腓前韧带撕脱骨折在以往文献中鲜有报道。目的:探讨Wagstaffe骨折的诊断、评估方法以及治疗措施。方法:本文收集了2009年10月至2011年11月Wagstaffe骨折患者35例,均为Weber-B型踝关节骨折。男25例,女10例。按照Wagstaffe骨折分型:Ⅰ型2例,Ⅱ型27例,Ⅲ型6例。对所有患者均采用切复内固定术,术前术后进行影像学以及功能评分。结果:平均随访18个月。WagstaffeⅡ型骨折在踝关节骨折中最为常见,本报道中有27例(77.1%)患者为此类骨折。AOFAS评分由术前(26.4±8.1)分提高到术后(83.1±5.9)分,Maryland足部评分由术前(37.1±7.5)分提高到术后(82.1±5.9)分,患者功能恢复良好,疼痛减轻。Leeds和Ehrlich的影像学标准优良率85.7%,无差病例。结论:Wagstaffe骨折Ⅱ型发生率较高,术中对Wagstaffe骨折进行准确的复位固定可以有效提高患者术后功能恢复,降低创伤性关节炎的发生率。     

Clinical characteristics and surgical experience of Type III Wagstaffe fractures: Pay attention to concomitant chondral injury of the talus

Background

The purpose of this study was to investigate clinical characteristics and surgical management of Type III Wagstaffe fracture.

A cadaveric study investigating the role of the anterior inferior tibio-fibular ligament and the posterior inferior tibio-fibular ligament in ankle fracture syndesmosis stability

BackgroundThis cadaveric study aimed to investigate the role AITFL and PITFL have on preventing talar shift in ankle fractures, as well as investigating the role of AITFL reconstruction in preventing talar shift.MethodsTwelve lower limb cadavers were used. Talar shift was measured following: Step 1- no ligaments cut; Step 2- entire deltoid ligament division; Step 3- group A (5 specimens) PITFL cut whilst group B (7 specimens) AITFL cut; Step 4- group A had AITFL divided whilst group B had PITFL cut. Reconstruction of the AITFL was performed using part of the superior extensor retinaculum as a local flap. Measurement of talar shift was then repeated.ResultsWith no ligaments divided, mean talar shift was 0.8 mm for group A and 0.7 mm for group B. When the deltoid ligament was divided, mean talar shift for group A was 4.8 mm compared to 4.7 mm in group B (P = 1.00). The mean shift in group A after PITFL division was 6.0 mm, increasing the talar shift by an average of 1.2 mm. In group B after AITFL division mean talar shift was 8.3 mm (P = 0.06), increasing talar shift by an average of 3.6 mm. After division of the second tibiofibular ligament, mean talar shift in group A measured 10.0 mm and in group B was 10.9 mm (P = 0.29). Three times more talar shift occurred after the AIFTL was divided compared to the PITFL (P = 0.06).ConclusionConsequently, repairing the PITFL in isolation (for example by fixation of a posterior malleolus avulsion fracture) may not adequately prevent talar shift; we feel consideration should also be given to reconstruction of the AITFL to augment the syndesmosis fixation, which may provide a stronger restoration of ankle stability.Level of Clinical Evidence: 5.     

Kinematics of the distal tibiofibular syndesmosis

In 11 healthy volunteers, the normal kinematics of the tibiofibular syndesmosis of the ankle during weight bearing and external rotation stress were compared to a nonweight-bearing neutral position by radiostereometry. We found very small rotations and displacements in this “normal” group, which indicated that the fibula is closely attached to the tibia, thereby preventing larger movements at the level of the ankle. We found no common kinematic pattern during weight bearing in the neutral position.

Application of a 7.5 Nm external rotation moment on the foot caused external rotation of the fibula between 2 and 5 degrees, medial translation between 0 and 2.5 mm and posterior displacement between 1.0 and 3.1 mm. These data can be used as normal reference values for studies of patients with suspected syndesmotic injuries.     

踝关节骨折伴下胫腓关节分离的治疗

目的 探讨踝关了骨折伴下胫腓关节分离的治疗方法。方法 对２０例踝关节骨折伴下胫腓韧带分离患者按Ｂｏｎｎｉｎ分度法,Ⅱ１２例,Ⅲ度８全和加压松质骨螺钉内固定术,使踝穴结构恢复正常。结果 随访８～１８个月,平均１４．５个月病人踝关节功能恢复正常,优良率达８５％。结论 对踝关节骨折伴下胫腓韧还分离的患者在治疗骨折的同时注意修补下胫腓韧带以恢复正常踝穴结构,避兔创伤生骨关节炎发生。     

三踝骨折合并下胫腓联合分离的手术治疗

目的探讨三踝骨折伴下胫腓联合分离手术治疗的疗效。方法对41例三踝骨折伴下胫腓联合分离的患者采取手术切开复位内固定治疗。结果41例均获随访,时间9—24（16．5±0．4）个月,切口愈合时间7—20d。全部获骨性愈合,平均愈合时间（4±1）个月,无下胫腓螺钉断裂发生。踝关节功能按Leedsetal临床评定标准：优17例,良22例,差2例,优良率95．1％。1例开放性骨折术后6d出现感染,经局部换药、反复冲洗2周后切口愈合。2例合并糖尿病患者分别于术后2、4周发生切口周围无菌性积液,经积极处理未并发伤口感染,关节功能无影响。结论三踝骨折伴下胫腓联合分离采用手术治疗可恢复并稳定踝穴和距骨的解剖关系,踝关节可早期功能锻炼,并可获得满意治疗效果。     

Delayed reconstruction of lateral complex structures of the ankle

Lateral ankle instability is one of the most common and well-recognized conditions presenting to foot and ankle surgeons. It may exist as an isolated entity or in conjunction with other concomitant pathology, making it important to appropriately diagnose and identify other conditions that may need to be addressed as part of treatment. These associated conditions may be a source of chronic pain, even when the instability has been appropriately treated, or may lead to failure of treatment by predisposing the patient to ankle inversion injuries. The primary goal of this editorial is to provide a brief summary of the common techniques used in the delayed reconstruction of lateral ankle ligamentous injuries and present a method we have successfully employed for over 15 years. We will also briefly discuss the diagnosis and treatment of the more common associated conditions, which are important to identify to achieve satisfactory results for the patient. We present the outcomes of 250 consecutive reconstructions performed over the last 10 years and describe our operative technique for addressing lateral ankle ligamentous injuries.     

踝关节骨折伴急性三角韧带损伤诊疗现状概述

踝关节骨折临床上发生率很高，常需手术治疗。当伴随三角韧带损伤时，则多见于旋前以及部分旋后外旋Ⅳ度的踝关节骨折。临床上此类诊断常较困难，手术修复的时机及方法目前也无统一标准。本文主要综述了近年来"踝关节骨折伴三角韧带损伤"诊疗的研究进展。三角韧带损伤的诊断常需综合各项辅助检查及症状体征来判断，其中以应力试验及磁共振检查最为重要；术中骨折复位固定后发现踝关节不稳或三角韧带嵌顿阻止复位，则建议术中探查修复，修复的方法众多，目前以带线锚钉重建三角韧带为主。     

踝关节镜下修复距腓前韧带治疗慢性踝关节不稳

目的探讨踝关节镜下改良Brostr?m法解剖修复距腓前韧带(ATFL)治疗慢性踝关节不稳的临床疗效。 方法选取2015年12月至2017年1月慢性踝关节不稳患者共12例,均采用踝关节镜辅助下改良Brostr?m法解剖修复距腓前韧带进行治疗。采用美国足踝外科学会(AOFAS)评分标准、Tegner运动水平评分及距骨倾斜角变化对手术前后疗效进行评价,随访观察并发症发生情况。治疗前后各观察指标比较采用配对t检验。 结果12例均获得15～46个月随访,平均(26±8)个月。随访期间,所有患者踝关节活动度基本达到正常水平,未出现踝关节不稳,无踝关节肿胀、疼痛等表现,末次随访AOFAS评分为(91.0±2.6)分、Tegner评分为(6.0±1.2)分,两者较术前均明显提高(t ＝10.57、12.38,均为P<0.001)。距骨倾斜角(4.5±1.0)°较术前降低(t＝7.13,P<0.001)。 结论踝关节镜下改良Brostr?m法解剖重建ATFL治疗慢性踝关节不稳,能更精准地探查韧带断端、定位韧带附着点、创伤小、疼痛轻、术后恢复快,疗效理想。     

Evans和Chrisman-Snook术式治疗踝关节外侧副韧带Ⅱ度损伤的生物力学比较

目的:测试Evans和Chrisman-Snook术式治疗踝关节外侧副韧带Ⅱ度损伤的术后稳定性,为临床治疗方法的选择及预后的判断提供依据。方法:2008年7月至2009年6月,采集18具冰冻下肢标本,男10例,女8例,平均年龄(39.3±11.2)岁,随机分为3组:正常对照组(A组),Evans术式组(B组)和Chrisman-Snook术式组(C组),每组6只标本。解冻后在B、C组中切断距腓前韧带和跟腓韧带,造成外侧副韧带Ⅱ度损伤,并采用Evans术式和Chrisman-Snook术式重建外侧副韧带,进行生物力学测试,观察胫距关节和距下关节侧方应力加载下的位移情况。结果:①胫距关节侧方应力试验显示B组对外侧副韧带损伤修复后位移大于A、C组(P<0.0001),A组与C组差异无统计学意义(P>0.05)。②距下关节侧方应力试验显示B组术后位移大于A、C组(P<0.0001),A组与C组差异无统计学意义(P>0.05)。结论:踝关节外侧副韧带损伤造成踝关节不稳,在其修复术式中Chrisman-Snook术式比Evans术式在重建踝关节术后初期稳定性上优于Evans术式,Chrisman-Snook术式更符合生物力学原理。     

自体半腱肌重建外侧副韧带治疗慢性踝关节外侧不稳的疗效分析

目的 :探讨采用自体半腱肌重建外侧副韧带治疗慢性踝关节外侧不稳的临床疗效。方法 :回顾性分析2014年9月至2016年11月采用自体半腱肌肌腱重建踝关节外侧副韧带治疗28例踝关节外侧不稳患者的临床资料,其中男20例,女8例;平均年龄28.6岁(18~47岁)。记录围术期并发症,并采用美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝关节评分标准评价术后功能改善情况,采用视觉模拟标尺法(Visual analogue scale,VAS)评估患者术后疼痛情况。结果 :28例患者均获得随访,时间6~28个月,平均18.2个月。围术期未出现医源性骨折及切口感染等严重手术并发症。末次随访时未出现踝关节不稳或踝关节活动受限,未出现膝部肌腱供区肌肉功能障碍。AOFAS评分由术前的53.1±6.8提高至术后的90.4±5.9,差异有统计学意义(P0.05)。VAS评分由术前的6.3±1.7提高至术后的0.8±0.5,差异有统计学意义(P0.05)。结论:采用自体半腱肌解剖重建踝关节外侧副韧带手术方式简便,术后恢复好,无严重并发症,临床疗效好,是治疗慢性踝关节外侧不稳的可靠方法之一。     

35例踝关节骨折脱位并下胫腓联合分离的治疗体会

2004年1月～2010年3月,我院采用切开复位内固定术治疗35例踝关节骨折脱位并下胫腓联合分离的患者,取得较好疗效。1材料与方法1.1病例资料本组35例,男23例,女12例,年龄17～58岁。采用Lauge-Hamen分型:18例为旋前外展型,12例为旋前外旋型,5例为旋后外旋型。     

踝关节外侧结构重建治疗踝关节外侧不稳

目的：探讨踝关节外侧结构重建在治疗慢性踝关节外侧不稳中的作用。方法：回顾分析2005年7月至2008年1月收治的13例慢性踝关节不稳患者,男10例,女3例;年龄24～45岁,平均33岁。13例均采用自体半束腓骨短肌腱解剖重建距腓前韧带和跟腓韧带（Sammarco法）,手术前后按踝关节评分系统进行评分,评分项目包括稳定性、疼痛、活动能力、X线表现。结果：13例均获随访,时间6～32个月,平均16.4个月,患者踝关节评分在稳定性、疼痛、活动能力等方面均有所改善,踝关节评分由术前的平均（43.54±7.04）分提高至术后的（73.38±4.17）分,手术前后差异有统计学意义（P〈0.01）。全部患者对手术表示满意。结论：采用半束自体腓骨短肌腱解剖重建距腓前韧带及跟腓韧带的方法治疗踝关节外侧不稳,操作便利,对于以关节不稳为主要表现的患者,疗效确切。     

下伸肌支持带重建下胫腓前韧带的解剖学基础

[目的]为下伸肌支持带重建下胫腓前韧带提供解剖学依据。[方法]8侧成人下肢标本,对下伸肌支持带上下内侧束及下胫腓前韧带的形态及解剖学数据进行观测,2侧新鲜标本进行模拟手术试验。[结果]下伸肌支持带跟骨附着点宽度(2.81±0.73)cm,自跟骨附着点至胫骨附着点的长度(8.53±0.42)cm,自趾长伸肌纤维管外侧壁至胫骨附着点的长度(5.87±0.62)cm;下胫腓前韧带的厚度(0.46±0.09)cm,在外踝附着点宽度(2.03±0.46)cm,在胫骨附着点宽度(1.35±0.27)cm,下伸肌支持带上内侧束胫骨附着点至下胫腓前韧带腓骨附着点的最短长度(5.45±1.06)cm。[结论]下伸肌支持带上内侧束潜行转位重建下胫腓前韧带具有可行性,自跟骨附着点切取下伸肌支持带全长可反折加强重建下胫腓前韧带。     

螺钉固定与Tight-rope固定治疗下胫腓前联合损伤的初步有限元分析

目的 :建立下胫腓前联合损伤(anterior inferior tibiofibular syndesmosis injuries,AITSI)螺钉固定及Tightrope固定(TR)模型,比较其受力及位移情况,为临床诊治提供依据。方法 :选取1例正常人的踝关节CT图像建立3D模型。然后建立AITSI损伤模型,对损伤模型置入螺钉得到螺钉固定模型,使用Tight-rope固定得到TR模型。分析各模型单脚站立时的中立位、踝关节内旋以及外旋3种受力情况,观察胫腓骨及距骨关节面应力变化,以及胫腓骨远端位移情况。结果:AITSI导致胫腓骨及距骨关节面受力增加,胫腓骨位移增加。使用螺钉固定及TR均能有效减少AITSI导致的胫腓骨远端过度位移,但在螺钉固定模型中,胫腓骨位移明显小于正常模型,且胫腓骨远端及距骨关节面受力增大,螺钉受力集中。螺钉固定模型中的胫骨及腓骨最大受力为TR模型的1.3倍以上,距骨关节面接触力为1.8倍,螺钉固定模型中下胫腓前韧带胫骨附着点位移约为正常模型的0.6倍,而TR模型中该数据约为正常模型的1.1倍,但TR对于腓骨位移控制欠佳。结论:严重的下胫腓前联合损伤将改变踝关节受力及位移情况,应该行内固定治疗。下胫腓联合螺钉及TR都能有效地治疗下胫腓前联合分离,Tight-rope固定相较于螺钉固定在骨骼受力、踝关节微动及内固定物断裂方面具有优势,但存在腓骨旋转控制欠佳的劣势。伴有Weber C型踝关节骨折以及肥胖的患者更适合螺钉固定。     

Triplane ankle fracture with deltoid ligament tear and syndesmotic disruption

In patients with immature skeletons, ligamentous injuries rarely accompany ankle fractures. In this article, we report about deltoid ligament tears and syndesmotic disruptions accompanying triplane ankle fractures in two children, and make recommendations as to the evaluation and treatment of children with such injuries.     

前内侧切口治疗后踝骨折

目的探讨前内侧入路治疗后踝骨折的优势及临床疗效。方法对58例涉及后踝的踝关节骨折患者采用前内侧切口治疗,予螺钉和(或)克氏针固定。术后石膏固定3～4周。结果 50例患者得到随访,时间4～38个月,骨折全部愈合。疗效按美国足踝AOFAS评分标准:优18例,良26例,中4例,差2例,优良率为88%。结论前内侧切口可以完整地观察胫距关节面,直视下对后踝进行复位固定,临床疗效较满意。