关节镜技术治疗前外侧踝关节撞击综合征

[目的]探讨前外侧踝关节撞击综合征的病因及关节镜治疗效果。[方法]回顾分析踝关节镜技术治疗的22例前外侧踝关节撞击综合征患者。所有患者均行关节镜清理,清除撞击组织,修整损伤的软骨。采用AOFAS评分系统和Meislin标准对疗效进行评估。[结果]22例患者术后均获得随访(随访时间12~24个月,平均16.8个月),镜下发现均存在前外侧踝撞击,撞击物类型:外侧滑膜组织撞击12例,半月板样组织撞击3例,下胫腓前韧带远侧束撕裂撞击3例,距腓前韧带损伤瘢痕组织增生撞击4例。AOFAS评分由术前的(46.27±12.50)分提高到末次随访时的(85.14±10.20)分,手术前后差异具有统计学意义(P<0.05)。采用Meislin标准进行疗效评估,优8例,良10例,可4例,差0例,优良率81.82%。[结论]踝关节前外侧撞击综合征多发生在踝关节反复损伤后,撞击物多为增生瘢痕组织,可合并出现关节软骨损伤。关节镜是诊断和治疗踝关节前外侧软组织撞击综合征的有效手段,具有创伤小、恢复快、疗效好等优点。     

关节镜治疗后踝撞击征的临床观察

目的 :观察后踝关节镜治疗后踝撞击征的临床效果。方法 :自2013年1月至2014年12月,采用后方双入路后踝关节镜治疗34例后踝撞击征患者,其中男20例,女14例;年龄29~62岁,平均42.2岁。采用VAS视觉模拟评分比较治疗前及治疗后12个月关节疼痛情况,并采用AOFAS踝后足评分进行踝关节功能评价。结果:所有病例获12个月随访,切口愈合良好,无伤口并发症。术中发现34例骨性撞击和19例软组织撞击。手术时间20~35 min,平均(25.6±5.2)min;术后2、6和12个月后踝撞击征呈阴性。术后12个月的VAS视觉模拟评分1.2±1.3明显优于术前的4.6±1.0(P0.05)。术后12个月的AOFAS踝后足评分84.7±6.5明显高于术前的62.7±8.9。结论:采用关节镜治疗后踝撞击征可以缓解疼痛,改善功能,手术时间较短,取得了良好的临床效果。     

踝关节镜前后联合入路治疗踝关节撞击综合征

目的 :分析踝关节镜前后联合入路对踝关节撞击综合症患者镜下行清理的临床疗效及术中注意事项。方法:回顾性分析自2011年4月至2015年4月采用踝关节镜治疗并获得完整随访的17例踝关节撞击综合症患者,其中男12例,女5例;手术时年龄22~47岁,平均32.4岁。结合患者临床症状和影像学评估予踝关节镜清理,并去除引起症状的撞击部位,术后常规予非甾体消炎药和关节内注射透明质酸钠治疗。采用AOFAS(美国足踝外科协会)后足-踝评分,Ogilvie-Harris踝关节评分对术前情况及术后末次随访情况进行评分。结果:17例手术中情况:关节镜下显示前外踝撞击征8例,前内踝撞击征2例,前踝撞击征2例,后踝撞击征2例,3例为同时合并前后踝撞击。术中清除增生的骨赘,引起撞击的下胫腓前韧带远侧束,距腓前韧带,滑膜组织和疤痕组织。4例同时合并关节软骨损伤,软骨损伤面积约1 mm×3 mm至1.5 mm×4 mm大小。术中同时采用直径1.2 mm的克氏针行钻孔微骨折处理。17例术后随访时间8~24个月,平均14.3个月。AOFAS评分由手术前的62.30±5.20增加至术后的87.60±5.40。Ogilvie-Harris踝关节评分由手术前的6.70±0.98增加至术后的12.80±1.21。术后患者均无神经血管损伤,无伤口感染,愈合不良等并发症。患者有不同程度的踝关节肿胀,于术后4~8周逐步消失。结论:对踝关节撞击综合症患者,前后联合入路可以有效清除引起踝关节撞击的骨性撞击和软组织撞击,结合术后非甾体消炎药和关节内注射透明质酸钠治疗,可以有效缓解踝痛症状,达到较好的治疗效果。     

Arthroscopic treatment for impingement of the anterolateral soft tissues of the ankle

We treated 52 patients with impingement of the anterolateral soft tissues of the ankle by arthroscopic debridement. All had a history of single or multiple inversion injuries, without instability. One half had negative stress radiographs (stable group), while the others were positive (unstable group). Their mean age was 31 years and there were 35 men and 17 women. The results were assessed at a mean follow-up of 30 months. Three patients (6%) had a fair result, while 49 (94%) had an excellent or good outcome. No difference was found in the final results between the two groups (p > 0.05). We conclude that anterolateral impingement of the ankle should be considered in a patient with chronic anterolateral pain after an injury, regardless of the stability of the ankle.     

三入路关节镜技术治疗踝关节前外侧撞击征

目的探讨三入路关节镜技术治疗踝关节前外侧撞击征的临床疗效。方法常规建立前内侧、前外侧入路,然后建立前下外入路,通过这3个入路进行关节镜手术治疗踝关节前外侧撞击征26例。术后随访采用Meislin评分和美国足踝外科协会(AOFAS)踝关节评分系统。结果每例踝关节前外侧撞击征关节镜下可以发现以下1~5个病变:局限性滑膜炎、瘢痕组织增生、半月板样病变、距腓前韧带(ATFL)部分撕裂、前下胫腓联合韧带(AITFL)远侧束、骨赘、游离体、附属小骨、软骨损伤。其中最多的是软骨损伤(18例),其次是瘢痕组织增生(17例)和局限性滑膜炎(14例)。所有患者均获得18~36个月(平均24.5个月)随访,AOFAS评分术前为(70.3±8.2)分,末次随访时(92.0±5.3)分,t=11.3,P<0.01;采用Meislin评分:优10例,良11例,可5例,优良率80.8%。结论三入路关节镜技术能够到达前外侧沟的任何部位,可以明确诊断踝关节前外侧撞击征的病因,同时具有手术操作简单、安全性好、疗效佳的优点。     

前踝撞击征的关节镜下诊断与治疗

目的探讨前踝撞击征的关节镜下诊断与治疗。方法2000年1月至2006年1月，关节镜下治疗前踝撞击征患者28例，男18例，女10例；年龄18-51岁，平均32岁；左踝12例，右踝16例。17例有长期运动史，5例有踝关节背伸劳作史，6例有踝部骨折脱位史及反复损伤史；病史最短6个月，最长7年。踝关节检查时胫骨前缘或前内侧有固定压痛，背伸活动均不同程度受限，部分踝关节僵硬。根据Scranton和McDermott的放射学分级标准，Ⅰ级6例，Ⅱ级15例，Ⅲ级5例，Ⅳ级2例。术前采用McGuire踝关节评分系统进行评分，13例可（65-70分），15例差（〈65分）。最低41分，最高67分，平均52分。踝关节镜下用刨削器、磨钻、组织汽化仪等清理增生肥厚及炎性的滑膜、退变的软骨和骨赘等。结果所有患者均获随访，随访时间11-48个月，平均27个月。术后McGuire评分显示：Ⅰ级6例，均为优良。Ⅱ级15例，12例优良，3例可。Ⅲ级5例，2例优良，2例可，1例差；其中无间隙狭窄者2例，1例为优良，有间隙狭窄者3例，1例为优良。Ⅳ级2例，均为差。优良率为71．4％。术后最低59分，最高94分，平均76分，较术前平均提高24分。无一例发生并发症。1例Ⅳ级患者术后27个月复发。结论关节镜下治疗Ⅰ、Ⅱ级及部分无关节间隙狭窄的Ⅲ级前踝撞击征患者疗效肯定，而对于部分有关节间隙狭窄的Ⅲ级及Ⅳ级前踝撞击征患者疗效欠佳。     

Distraction for ankle arthroscopy

Distraction has proven to be usefull for arthroscopic visualisation and instrumental access to some ankle pathology. A distraction technique using a single calcaneal pin combined with the installation of the patient on a fracture table is described. The method has already been used by the authors in more than 100 ankle arthroscopy procedures without distraction-related complications.     

The safety of the posterior ankle arthroscopy in management of posterior ankle impingement: A cadaveric study

BackgroundArthroscopic management of the posterior ankle impingement with the patient in supine position has the advantage of dealing with anterior ankle pathology at the same time without the need to change position of the patient. This study aims at evaluation of the safety of portal establishment and instrumentation of this technique.MethodsSixteen fresh-frozen cadaver specimens were used. The relationships of the posteromedial and posterolateral portals to the adjacent tendons and nerves and the relationship of the coaxial portal tract with the posterior ankle capsule and the flexor hallucis longus tendon were studied.ResultAngle θ₁ between the intermalleolar line and the posterior ankle coaxial portal tract averaged 1° (−10° to 22°). Angle θ₂ between the intermalleolar line and the metal rod where the neurovascular bundle started to move averaged 19° (10° to 30°). Angle θ₃ between the intermalleolar line and the metal rod where it reached the lateral border of the Achilles tendon was larger than angle θ₂ in all specimens. The angle of safety (θ_s) averaged 18° (−1° to 26°).ConclusionsInjury to the tendon, nerves or vessels is possible during establishment of the portals and resection of the os trigonum.     

踝关节撞击征的关节镜治疗分析

目的 探讨关节镜下治疗踝关节撞击衍的疗效.方法 对2005年3月至2008年9月收治的23例关节镜下确诊为踝关节撞击征患者进行关节镜下治疗,其中男16例,女7例;年龄16～49岁,平均29岁.比较手术前后美国足踝外科协会(AOFAS)踝与后足评分.结果 本组23例患者均获随访,时间9～36个月,平均25个月.术后AOFAS平均评分[(81.6±8.1)分]明显高于术前评分[(54.2±6.4)分],差异有统计学意义(t=2.015,P=0.000).13例患者可恢复至其之前的活动水平;6例患者自诉运动水平稍差,但不影响日常生活;3例患者在步行超过30 min以上时仍可出现踝关节疼痛及肿胀;1例自觉症状与术前无好转.结论 踝关节镜是诊断踝关节撞击征的良好手段,同时也是踝关节撞击征的一种微创治疗对策,可取得较高的满意率.     

Anterior ankle impingement

The anterior ankle impingement syndrome is a clinical pain syndrome that is characterized by anterior ankle pain on (hyper) dorsiflexion. The plain radiographs often are negative in patients who have anteromedial impingement. An oblique view is recommended in these patients. Arthroscopic excision of soft tissue overgrowths and osteophytes is an effective way of treating anterior impingement of the ankle in patients who have no narrowing of the joint space. For grade II lesions (osteophytes secondary to arthritis with joint space narrowing) arthroscopic treatment is a good option, because no other therapeutic option is available with the exception of an arthrodesis or prothesis.     

Coaxial portals for posterior ankle arthroscopy

Purpose: The authors performed a cadaveric study on 10 ankles and retrospectively reviewed 29 arthroscopic synovectomies to determine the trajectory, minimal safe distances, and complications using a new approach for posterior ankle arthroscopy. Type of Study: Anatomic study and case series. Materials and Methods: A posterolateral portal was established immediately posterior to the peroneal tendon sheath. While staying within the posterior ankle capsule, an inside-out technique was then used to establish the posteromedial portal directly behind the medial malleolus adjacent to the posterior tibial tendon. The cadaveric ankles were frozen, sectioned, and photographed to measure the proximity of neurovascular structures to these coaxial portals. From 1988 to 1994, arthroscopic synovectomy was performed on 23 patients (29 ankles) with hemophilia using these modified portals. Results: Results of the anatomic study showed that the posterior tibial nerve and posterior tibial artery were located a mean distance of 5.7 mm (SEM, 0.6 mm) and 6.4 mm (SEM, 0.7 mm) from the edge of the cannula, respectively. Neither penetration nor contact of nerve or vessel was observed at either posterior portal. In the 29 clinical cases, posterior capsular synovectomy was achieved arthroscopically with no detectable complications at an average 45-month follow-up. Conclusions: Our anatomic data show that the coaxial portals described here are essentially equidistant to the neurovascular structures compared with conventional portals. Our clinical results suggest that his technique for posteromedial and posterolateral portals is safe, effective, and reproducible.     

Posterior ankle impingement syndrome

Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.     

踝关节慢性前外侧不稳的手术治疗

目的: 探讨治疗踝关节慢性前外侧不稳定 (踝关节外侧不稳定合并距下关节不稳定) 的合理而有效的手术方式。方法: 自 1999 ~2003年, 应用Chrisman Snook术式, 以腓骨短肌腱前半部分重建距腓前韧带、跟腓韧带和距跟外侧韧带,治疗踝关节慢性前外侧不稳 8例患者,共 13例关节。结果: 术后随诊 6个月~5年, 平均 19个月。术后所有踝关节均达到功能稳定, 关节活动度基本恢复正常, 没有复发性踝关节不稳发生。以Good评级标准作为疗效评价, 10例关节 (77% ) 为优, 2例关节 (15% ) 为良, 1例关节为中 (7% ), 优良率达 92%。结论: Chrisman Snook术式重建了距腓前韧带、跟腓韧带和距跟外侧韧带, 有效地矫正了踝关节外侧不稳定和距下关节不稳定, 是治疗踝关节慢性前外侧严重不稳定的合理而有效的治疗方法。     

Techniques of ankle arthroscopy

Although arthroscopic instrumentation varies widely, the technique for use is quite similar. Surgeon preferences vary but most arthroscopists agree that it is technique that makes the procedure. Discussed in this presentation is the author's method for preparing the patient for arthroscopic surgery, as well as techniques for using the arthroscope, hand instruments, and power instrumentation.