经外踝入路胫距跟关节融合术治疗踝关节并距下关节严重关节炎的临床疗效

目的探讨经外踝入路胫距跟关节融合术治疗踝关节合并距下关节严重关节炎的临床疗效。方法采用经外踝入路胫距跟关节融合术治疗踝关节合并距下关节严重关节炎18例。结果 18例术后均获随访5-36个月,平均20个月。X线片显示踝关节及距下关节获得骨融合,未见神经血管损伤、感染、骨不连、骨质及内固定物外露等并发症。AOFAS评分从术前平均45(40-53)分提高到术后的76(70～89)分。结论经外踝入路胫距跟关节融合术是临床治疗踝关节和距下关节严重关节炎的一种安全、有效、简便的方法,能有效缓解踝与后足疼痛,提高生活质量。     

不同体位下肘关节镜常用入路与周围神经的解剖关系

目的 比较不同体位下各种肘关节镜入路与毗邻神经血管的解剖关系,评价肘关节镜操作中各种标准入路的安全性及应用价值.方法 选用新鲜尸体肘关节10个进行解剖,测量9种标准肘关节镜入路与毗邻神经血管的最近距离,并根据各入路下关节镜检的镜下视野及操作灵活性评价其应用价值. 结果肘关节镜人路与毗邻神经距离受注水膨胀关节、肘关节伸直或屈曲及前臂旋前或旋后体位变化影响.肘关节屈曲90°前臂旋后、中立、旋前位,前外侧入路关节镜套管与桡神经距离分别为(2.9±1.1)mm、(4.5±1.5)mm、(5.8 ±1.7)mm,穿刺造成神经损伤风险大;肘关节伸直前臂旋后位2例肘关节中套管与桡神经直接接触.近端前内侧或近端前外侧人路观察肘关节前间室、后正中人路观察后间室视野良好且穿刺风险小.后方入路均安全. 结论近端前内侧或近端前外侧入路优于前内侧或前外侧人路,与后正中入路结合应用可基本满足多数肘关节镜手术的要求,是一组安全、有效的人路点.     

跟骨骨折的损伤机制与治疗新进展

大部分跟骨骨折是关节内骨折,主要为高能量损伤所致。跟骨解剖结构复杂,有4个关节面,跟骨后部包括距下关节面和载距突的中关节面。跟骨前部包括距下关节小的前关节面和跟骰关节鞍状关节面。跟骨的前后部分由跗骨窦和跗骨管分开。治疗以恢复跟骨的高度、宽度、轴向长度、Bo。hle     

SandersⅡ型跟骨骨折不同入路切开复位内固定疗效及对距下关节活动度的影响

背景：跟骨是骨折常见部位,解剖学结构复杂,复位难度较大。手术是关节内骨折治疗的主要策略,既可恢复骨折部位形态,又可达到关节面重建的效果。目前选择何种入路治疗SandersⅡ型跟骨骨折尚存在争议。目的：探讨不同入路切开复位内固定在SandersⅡ型跟骨骨折治疗中的效果及其对距下关节活动度的影响。方法：回顾分析本院2011年2月至2013年9月接受跗骨窦间隙入路切开复位内固定治疗的26例SandersⅡ型跟骨骨折患者治疗情况（观察组）,收集手术相关指标（手术时间、术中失血量、切口长度、术后引流量及VAS评分）,测量术前、术后3个月的跟骨长、宽、高度及B？hler和Gissane角,采用Maryland评分及AOFAS评分评价术后6个月的恢复情况, Morrey法评价术后6个月的距下关节活动度并记录末次随访的并发症情况。选取同期的28例接受“L”形外侧扩大入路切开复位内固定的SandersⅡ型跟骨骨折患者作为对照（对照组）。结果：两组的手术时间、术中失血量的差异无统计学意义（P＞0.05）。观察组的切口长度小于对照组,术后引流量及术后VAS评分均低于对照组,差异均有统计学意义（P＜0.05）。两组术后跟骨长、宽、高度及B？hler和Gissane角均优于术前,但两组的差异无统计学意义（P＞0.05）。观察组术后6个月的Maryland评分和AOFAS评分均高于对照组,且距下关节的重度受限率及评分均较低,而轻度受限率较高,以上差异均有统计学意义（P＜0.05）。而两组并发症发生率的差异无统计学意义（P＞0.05）。结论：经跗骨窦间隙入路切开复位内固定治疗SandersⅡ型跟骨骨折患者的效果较好,促进术后恢复并减少对距下关节功能的影响。     

俯卧位踝关节镜下前后外联合入路治疗后足大范围病变的临床应用

【摘要】目的 探讨采用俯卧位,踝关节镜下前后外联合入路治疗后足大范围病变的临床疗效。方法 回顾性分析2019年3月至2020年7月于我院骨科就诊的13名后足大范围病变病人（13足）的临床资料,按病种划分：踝关节滑膜炎合并距下关节炎5例,踝关节滑膜炎3例,距下关节炎合并跗骨窦综合征3例,踝关节感染2例。所有患足的病变范围均涉及后足的前方及后方,单纯前路或后路关节镜无法完全处理。所有病人术中采取俯卧位,先屈膝状态完成前路镜,如有必要,屈膝“4”字体位行跗骨窦清理,最后伸膝状态完成后路关节镜操作,其中行距下关节融合3例。观察并记录病人的手术时间,术中灌注水量,术后住院天数,术后并发症,手术前后的疼痛视觉模拟量表（visual analogue scale, VAS）评分。结果 病人手术时间为（46.8±12.6）min,灌注水量为（6807.7±3827.2）ml,术后住院日为（3.8±0.8）d。所有切口均一期愈合,1例发生跗骨窦血肿,加压包扎后按时愈合拆线,并发症总体发生率为7.7%（1/13）。VAS评分由术前（8.2±1.0）分降至术后（2.8±0.9）分,差异具有统计学意义（P<0.05）。随访期间未见感染,骨不连、畸形愈合等并发症。结论 俯卧位关节镜可同时处理后足多个部位的病变,包括踝关节,距下关节,及跗骨窦,微创化个性化治疗的同时,减少手术时间,缩短病人住院天数,节省病人治疗经费,是后足大范围病变可以选择的治疗方式之一。     

后路关节镜距下关节融合治疗终末期关节病

[目的]探讨后侧入路关节镜距下关节融合术治疗终末期关节病的临床疗效。[方法]回顾性分析2016年8月—2019年6月采用后侧入路关节镜距下关节融合术的31例严重距下关节炎患者资料。总结围手术期资料及随访临床和影像资料。[结果]所有患者均顺利完成手术，无术中并发症，随访时间平均（19.1±2.9）个月。随时间推移，31例患者VAS评分显著降低（P<0.05）;AOFAS评分显著增加（P<0.05）。影像方面，末次随访时30例后足对线正常，仅1例存在轻度内翻（<5°），与术前相比后足对线显著改善（P<0.05）。末次随访时X线片显示融合率为100%。[结论]后侧入路关节镜距下关节融合术治疗终末期距下关节病疗效显著，术后融合率高。     

距下关节融合对中后足周围关节活动度影响的生物力学实验研究

目的分析研究正常新鲜足标本在正常情况下进行距下关节融合后对跟骰、距舟关节和踝关节的三维运动度的影响程度。方法采用新鲜足标本12例，将距下关节融合后，通过加载使足产生某种形式的运动，用三维数字化坐标仪测量跟骰、距舟关节和踩关节各关节组成骨在某种运动状态下的相对三维坐标位移，通过矩阵转换和求解非线性函数方程计算其三维旋转角度，了解跟骰、距舟关节和踝关节在距下关节融合前后2种状态下的相对运动范围，确定距下关节融合后对于周围足踝关节运动的影响程度。结果距下关节融合前后跟骰、距舟关节和踝关节在背屈一跖屈、内翻一外翻、内收一外展轴的三维运动范围之间的统计学分析显示存在显著性差异（P＜0．01），各关节平均三维运动范围受限程度分别为36．14％、38．36％、21．84％。结论距下关节融合后对跟骰、距舟关节和踝关节的活动度存在一定的限制作用，降低了前足与后足的协同性，可能增加足跗关节间退行性关节炎发生，但保留了距舟、跟骰关节的大部分活动。     

跟距骨桥分型与治疗的研究进展

跟距骨桥多发生于跟距关节内侧,在足跗骨畸形中占比最高,绝大多数患者无明显症状,发病时多表现为疼痛、距下关节活动障碍。跟距骨桥的分型多种多样,不同的分型对于临床的指导意义不同。目前临床上应用最广的是Rozansky分型,对临床治疗有一定指导意义;Lim分型则更为简单全面,而对于合并足部畸形或者骨关节炎推荐使用Blitz分型。在治疗方面,轻微症状患者建议保守治疗;保守治疗失败的患者可以选择关节镜下手术切除骨桥,而面积较大(>50%距下关节面)、多关节面骨桥、畸形严重的患者可选择切开手术,Ⅰ期或Ⅱ期处理合并平足畸形;对于多次关节镜或切开手术失败,合并严重骨关节炎或者复杂的跟距骨桥患者可选距下关节或三关节融合术,并矫正畸形。     

关节镜下手术松解治疗跟骨骨折后距下关节僵硬

目的 探讨关节镜下手术松解治疗跟骨骨折后距下关节僵硬的临床效果.方法 2004年9月至2006年12月共治疗跟骨骨折后距下关节僵硬患者10例,其中男性8例,女性2例.年龄18～48岁,平均36岁.除2例为双足受累外,其余均为单足病变.根据AOFAS后足活动度分级标准,手术前10足为Ⅲ级,2足为Ⅱ级;AOFAS后足功能评分术前为71.4分.术中患者取侧卧位,分别建立外侧、前外侧、后外侧3种入路,逐步松解前方关节囊、距下关节外侧间隙、跟腓韧带、后方及后内侧关节囊.最后进行手法松解.结果 所有患者均获随访,随访时间12～36个月,平均24.5个月.末次随访时, AOFAS后足活动度分级标准9足后足活动度提高到Ⅰ级,3足提高到Ⅱ级,未见Ⅲ级病例.AOFAS后足功能评分术后为90.6分,与术前比较差异具有统计学意义(P<0.01).所有患者均在术后1～3个月(平均1.8个月)恢复原工作. 结论 关节镜下手术松解治疗跟骨骨折后距下关节僵硬具有微创、操作简单、疗效确切的优点.     

踝后正中入路锁定钢板内固定行胫距跟关节融合术

目的评估踝后经跟腱正中入路植骨锁定钢板内固定行胫距跟关节融合术的手术技巧和临床效果。方法从2008年1月至2012年12月,共收治123例踝关节合并距下关节创伤性关节炎,其中13例因踝周软组织条件不佳而选用踝关节后方入路胫距、距下关节清理、植骨、4.5 mm干骺端锁定钢板内固定行胫距跟关节融合术。其中男9例,女4例,平均年龄47.8岁（30~65岁）;平均病程7年（1~15年）。术后定期随访复查X线片以明确骨愈合情况,并采用直观模拟量表（Visual Analog Scale,VAS）评估术后疼痛改善情况,美国骨科足踝外科（American Orthopaedic Foot and Ankle Society,AOFAS）踝关节与后足评分及简明健康量表SF-36评分评估恢复效果,并记录相关并发症。结果术后所有患者伤口均一期愈合,未见感染、皮肤坏死等软组织并发症。11例获得最终随访,平均随访时间24个月（12~36个月）。随访复查X线片示术后平均12周融合端骨性愈合（10~15周）。末次随访时,AOFAS踝与后足评分及SF-36评分均较术前明显改善,疼痛症状明显缓解。随访期间未见内固定失效、融合失败等并发症,2例患者术后出现距舟关节骨关节炎,伴轻度疼痛,口服药物对症治疗后缓解。结论经踝后正中入路锁定钢板内固定行胫距跟关节融合安全、有效,特别适合于踝周软组织条件不佳的病例。     

Ankle arthroscopy with patient in prone position

Anterior ankle arthroscopy is the most commonly performed foot and ankle arthroscopy. By means of the anterolateral and anteromedial portals, the anterior compartment of the ankle joint can be approached easily. Different posterior portals had been described to reach the posterior ankle compartment. With the patient in prone position and the combination of anterior and posterior portals, the medial and lateral gutters of the ankle joint can be reached together with the anterior and posterior compartment. This is useful for complete synovectomy of the ankle joint.     

Arthroscopy of the subtalar joint: an experimental approach

Talocalcaneal articulations are relatively complex and functionally very important because they play a major role in the movements of inversion and eversion of the foot. Few reports on arthrography of the subtalar joints are available in the literature, and, similarly, little attention has been paid by arthroscopists to these joints. This preliminary study briefly defines the normal anatomy of the subtalar joints and describes a new technique of arthroscopic examination of the posterior subtalar joint. The distal lower extremities of six fresh cadavers were used in these experiments. All the subtalar joints were supple. A 2.7-mm arthroscope was used to carry out arthroscopic and anatomic examinations. A technique of examination with one anterior portal and one posterior portal is described in detail. When the anterior portal was used, the egress needle was placed posteriorly; when the posterior portal was used, the converse was true. By using the two portals, the following intraarticular structures could be visualized: a major part of the convex posterior calcaneal facet of the talus and the posterior talar facet of the calcaneus; the synovial lining laterally and posteriorly; the posterior aspect of the interosseous talocalcaneal ligament; and the posterior recess of the joint. The results of this experimental study indicate that arthroscopy of the posterior subtalar joint is technically feasible. Clinically, the possible indications for arthroscopy would include state of the articular cartilage in suspected cases of degenerative arthritis, rheumatoid arthritis, and infection; visualization of the joint after intraarticular fracture to evaluate chronic pain syndrome in the hindfoot; biopsy; management of sinus tarsi syndrome; loose body removal.     

Considerations of a Midline Posterior Approach to the Ankle and Subtalar Joints

The standard incisional approaches for ankle and subtalar joint surgery include the medial, lateral, or anterior. However, in patients with a history of traumatic injuries or previous surgery, in which the soft tissues of the foot and ankle have been compromised, a direct midline posterior approach might be preferable. The approach offers unparalleled exposure, provides excellent frontal plane visualization, and reduces the risk of vascular compromise by preserving the surrounding angiosomes. We report on 2 separate cases in which a midline posterior approach to the ankle and subtalar joints was used successfully for fusion procedures of the tibiocalcaneal and subtalar joints.     

Arthroscopy and Endoscopy of the Foot and Ankle: Indications for New Techniques

The scope of arthroscopy and endoscopy of the foot and ankle is expanding. New techniques are emerging to deal with diverse ankle pathology. Some of the conditions that can be dealt with arthroscopically are as follows: hallux valgus deformity, lesser toe deformity, first metatarsophalangeal instability, cock-up deformity of the big toe, peroneal tendon instability, lateral ankle and subtalar instability, hindfoot deformity or arthrosis, first metatarsocuneiform hypermobility, Lisfranc joint arthrosis, various stages of posterior tibial tendon insufficiency, foot and ankle arthrofibrosis, late complications after calcaneal fracture, acute and chronic Achilles tendon rupture, insertional Achilles tendinopathy, entrapment of the first branch of the lateral plantar nerve, Freiberg’s infarction, flexor digitorum longus tenosynovitis, flexor hallucis longus pathology, calcaneonavicular coalition or “too-long” anterior process of the calcaneus, and ganglions. With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery.     

The distance between the sural nerve and ideal portal placements in lateral subtalar arthroscopy: a cadaveric study

BACKGROUND: There have been limited studies assessing the relative safety of lateral portals for subtalar arthroscopy in terms of their distance from the sural nerve and its branches. The aim of this cadaveric study was to assess and compare the distance of lateral subtalar arthroscopy portal sites to the sural nerve and its branches. MATERIALS AND METHODS: Twenty embalmed cadaveric lower limbs were dissected exposing the nerves and tendons and subtalar arthroscopy portals were replicated using pins. The anatomically important distances were measured with a digital caliper. Statistical analysis of the data was performed using SPSS for Windows 11.5 (SPSS Inc, Chicago, IL) using Friedman Tests and Wilcoxon Signed Ranks tests. RESULTS: The median distance of the anterior and middle subtalar portals to the nearest nerve was 21.3 mm and 20.9 mm, respectively, and 11.4 mm for the posterior portal. There was no statistically significant difference between anterior and middle portals (p=0.87) but there was statistically significant difference between anterior versus posterior and middle versus posterior portals (p=0.001 in each comparison). CONCLUSION: The anterior and middle subtalar portals were both less likely to damage important structures than the posterior subtalar portal. CLINICAL RELEVANCE: The results of this study can be of value to the surgeon when planning arthroscopic procedures to the subtalar joint from the lateral approach.     

Synovitis of the Tarsal Canal: An Uncommon Cause of Lateral Heel Pain After Triple Arthrodesis

Lateral heel pain after triple arthrodesis can have numerous causes, including nonunion of the fusion site, hindfoot malalignment, degenerative arthritis in adjacent joints, and deep infection. We present a case of lateral heel pain after triple arthrodesis due to synovitis of the tarsal canal that was successfully treated with anterior subtalar arthroscopy.     

Subtalar joint preparation using the Two Portal posterior arthroscopic technique versus the sinus tarsi Open approach: A cadaver study

BackgroundSubtalar fusion is the treatment of choice for subtalar arthritis when conservative management fails. The procedure can be performed arthroscopically or through the open lateral sinus tarsi (LST) approach. The arthroscopic technique is less invasive and is associated with rapid recovery, but it is more technically challenging. One of the most important aspects of fusion is adequate preparation of the joint via denudation of articular cartilage. This study compares the efficacy of subtalar joint preparation between the lateral sinus tarsi approach and the posterior two-portal arthroscopic technique using cadaveric specimens.Materials and MethodsNineteen below-knee fresh-frozen cadaver specimens were used. The subtalar joints of nine specimens were prepared through the LST approach, while ten were prepared arthroscopically. After preparation, all ankles were dissected at the subtalar joint and photographs were taken of the posterior facets of the calcaneus and talus. Total and prepared surface areas of the articular surfaces for both approaches were measured using ImageJ software and compared.ResultsThe LST technique resulted in significantly greater percent preparation of the posterior facet of the calcaneus, as well as of the subtalar joint as a whole. Overall, 92.3% of the subtalar joint surfaces (talus and calcaneus combined) were prepared using the LST technique, compared to 80.4% using the arthroscopic technique (p = 0.010). The posterior facet of the calcaneus was 94.0% prepared using the open technique, while only 78.6% prepared using the arthroscopic technique (p = 0.005).ConclusionThe LST approach for subtalar arthrodesis provides superior articular preparation compared to the two-portal posterior arthroscopic technique. Given that joint preparation is a critical component of fusion, maximizing prepared surface area is desirable and the open approach may be more efficacious for fusion. When using the arthroscopic approach, it may be advisable to use an accessory portal if there is poor visualization or limited access to the joint space secondary to severe arthritis.Level of EvidenceV     

Arthroscopy of the posterior subtalar joint

The subtalar joint is a complex and functionally important joint of the lower extremity. It plays a major role in the movement of inversion and eversion of the foot. With the development of small-joint arthroscopes and instrumentation, surgeons became interested in posterior subtalar joint arthroscopy. Diagnostic and therapeutic indications for this technique have increased; however, arthroscopic subtalar surgery is technically difficult and should be performed by an experienced arthroscopist. The number of reports dealing with posterior subtalar arthroscopy remains relatively small.     

Arthroscopic treatment of osteochondral lesions of the talar dome

Nine osteochondral lesions of the talar dome were treated arthroscopically. Two patients (a 16-year-old boy) had two recent osteochondral fractures, anterior and superior lateral, with a free fragment detached in the joint. The lesions were treated with simple ablation of the loose body. Seven old lesions were found in four men and three women, aged 18-32 years, with an osteocartilaginous, partially loose body with necrosis of the underlying bone. The lesion was posterior medial in these seven cases. Technically, arthroscopy is usually performed using an anterior approach. However, it is sometimes necessary to place the foot in the talipes equinus position to achieve articular distraction for diagnosis and treatment of posterior lesions. Treatment consisted of removal of the loose body, with curettage of the necrotic bone. The nine patients were clinically and radiologically reviewed with a follow-up period of 10-24 months. For the two osteochondral fractures, clinical results following the removal of free loose bodies in the joint were spectacular, with complete pain relief and osseous rehabilitation almost radiologically complete after 2 years. In the seven patients with an old necrotic lesion, the result was very good or good in six cases, and poor in one case. Radiologically, osseous rehabilitation occurred progressively, but remained incomplete at 2 years. This technique provides multiple advantages: minimal morbidity, 48-h hospitalization, and rapid functional recuperation without immobilization. Our results confirm the recent data in the literature (1-4).