下胫腓联合损伤诊治进展

下胫腓联合是由胫腓骨远端4条韧带组成的复合体,既维持着胫腓骨远端的稳定性,又使踝关节保持一定的微动特性.下胫腓联合损伤常伴发于踝关节骨折,治疗不当可能影响踝关节功能,出现踝关节不稳定、关节炎及慢性疼痛等并发症.目前下胫腓联合损伤确诊需通过临床体检、影像学检查,甚至关节镜检查进行综合判断.治疗上,下胫腓联合损伤后关节不稳...     

下胫腓联合损伤手术治疗进展

下胫腓联合损伤常伴有踝关节骨折,亦可发生在无骨折的情况下,但病史及体格检查通常缺乏特异性,漏诊或误诊可能导致患者踝关节功能受损。下胫腓联合损伤分型方法不一,可按需运用。诊断下胫腓联合损伤的辅助检查有下胫腓联合分离试验、外旋试验、挤压试验、腓骨横移试验和影像学检查,关节镜为诊断下胫腓联合损伤时极为重要的检查方法,尤其在评估固定术后慢性踝关节疼痛方面。急性单纯下胫腓联合损伤可保守治疗,但严重下胫腓联合损伤推荐手术治疗。下胫腓联合损伤的手术方式可分为静态固定、弹性固定、下胫腓钩固定和韧带重建,这些方法各有其适应证及优缺点。该文对下胫腓联合损伤手术治疗进展作一综述。     

下胫腓联合损伤的分型和治疗进展

下胫腓联合是稳定踝关节的重要结构,其损伤常合并踝关节和腓骨高位骨折,少数情况可单独发生。非稳定性损伤见于非单纯性及部分单纯性下胫腓联合损伤,需早期手术治疗。稳定性损伤见于部分单纯性下胫腓联合损伤,可选择保守治疗。早期治疗和稳定下胫腓联合损伤比不治疗,延迟治疗能取得更好的临床疗效。目前单纯性下胫腓联合损伤的稳定性及急慢性诊断一直存在争议,下胫腓联合损伤的稳定性、损伤时间、固定类型可影响下胫腓联合损伤的临床疗效。手术治疗可选择螺钉固定和弹性固定。螺钉固定是治疗下胫腓联合损伤的金标准,但其螺钉是否拔除、置入位置等技术细节一直是争议的焦点,其缺点是可限制下胫腓联合微动等。保留下胫腓联合微动机制日益受到重视,弹性固定可作为一种螺钉替代治疗方式,已经取得较好的短期疗效,但长期临床疗效和是否需要加压固定等方面需进一步研究确定。下胫腓联合损伤的治疗需要根据其稳定性、损伤时间、固定类型等方面进行合理选择,有利于提高临床疗效。     

下胫腓韧带联合分离的治疗进展

<正>踝关节骨折在日常生活中非常常见,据统计,在所有踝关节骨折和需要手术治疗的踝关节骨折的病例中,伴有下胫腓韧带联合损伤的比例分别占10%和20%[1]。临床中由于对踝关节下胫腓韧带联合损伤认识的不足,导致诊疗方面存在很多误区。下胫腓韧带损伤常导致距骨外移和踝关节不稳,尸体研究发现:当距骨向侧方移动1 mm时,胫距关节连接区域减少42%[2]。下胫腓韧带联合损伤会导致踝关节稳定性下降、踝关节疼痛,而治疗不当或漏诊常会导致疼痛、关     

急性上胫腓关节脱位1例报告

目的探讨上胫腓关节脱位的发病机制及诊治。方法手术治疗上胫腓关节脱位1例,采取2枚克氏针固定,术后管型长腿石膏于膝关节屈曲10°-15°固定3周,术后6周拆除克氏针。结果随访1年,无运动后膝关节疼痛及不稳。结论上胫腓关节脱位应依不同的脱位类型及时期采取不同的治疗策略。     

慢性下胫腓联合损伤的诊治进展

慢性下胫腓联合损伤是急性损伤诊治不当而迁延不愈的结果。急性下胫腓联合损伤通常合并踝关节骨折,当骨折开始愈合后,慢性下胫腓联合损伤的症状逐渐表现出来,此时结合其体征、X线片,必要时拍摄外旋或外翻应力位X线片、踝关节CT或MRI,其诊断稍显复杂但并不困难。踝关节镜检查为诊断慢性下胫腓联合损伤提供直接证据。由于认识不足,其治疗手段五花八门,目前尚无金标准。下胫腓韧带重建术与下胫腓融合术是两大类理念不同的治疗方法,尽管从短期随访来看,二者都取得了不错的临床结果,但后者仍颇具争议。本文将系统阐述慢性下胫腓联合损伤的诊断方法,并通过文献综述,批判性地总结现有的治疗理念。     

胫腓骨开放粉碎性骨折合并上胫腓关节脱位

胫腓骨开放粉碎性骨折合并上胫腓关节脱位袁天祥，赵文宽胫腓骨粉碎性骨折合并上胫腓关节脱位很少见。我院曾总结２４３例胫腓骨开放粉碎骨折亦未见合并上胫腓关节脱位者。我科近期治疗２例。例１男，４０岁。于１９９３年１１月２８日因交通事故致左胫腓骨中上１／３开放...     

外踝钢板加拉力螺钉治疗踝关节骨折

踝关节骨折是临床常见的骨折,常伴有下胫腓联合损伤和胫距关节脱位。以往采用内踝螺钉固定,外踝手法复位加石膏固定。疗效往往不能令人满意。自2000年4月～2002年6月采用内踝拉力螺钉固定,外踝钢板固定治疗60例踝关节骨折,取得满意疗效。     

Maisonneuve骨折的治疗

Maisonneuve骨折是一种少见的踝关节骨折伴高位腓骨骨折。容易造成误诊、误治 ,1999年 12月以来共收治 7例 ,误诊 1例 ,其余 6例均得到正确诊断 ,合理治疗。现报告如下。1　临床资料本组 7例 ,男 5例 ,女 2例 ,年龄 2 5～ 5 5岁 ,平均 3 7.5岁 ,损伤为滑倒足外翻扭伤踝部 ,受伤到就诊时间为 2h～ 7d ;查体发现内踝及小腿肿胀 ,下胫腓前韧带、腓骨上段压痛 ,摄膝踝全长X线片均有高位腓骨骨折 ,位于腓骨上 1/ 4部位 ,下胫腓间隙增宽。 1例误诊原因是由于开始对此受伤机理认识不足。以上病例采用手术治疗 ,固定内踝或修复三角韧带 ,修复下胫腓…     

合并前胫腓韧带损伤的WeberB型踝关节骨折的手术治疗

目的:评价合并前胫腓韧带损伤的WeberB型踝关节骨折手术治疗效果。方法:对32例合并前胫腓韧带损伤的WeberB型骨折进行手术治疗。结果:32例病人均获得随访(1.2～3.9年),平均2.8年,根据Meyer和Kumler的临床评价标准以及Leeds和Ehrlich的X线片诊断标准进行评价,优良率达94％。结论:合并前胫腓韧带损伤,特别是伴前胫腓韧带撕脱性骨折的WeberB型骨折,手术治疗能获得满意疗效。     

Proximal tibiofibular joint: Rendezvous with a forgotten articulation

The proximal tibiofibular joint (PTFJ) is a plane type synovial joint. The primary function of the PTFJ is dissipation of torsional stresses applied at the ankle and the lateral tibial bending moments besides a very significant tensile, rather than compressive weight bearing. Though rare, early diagnosis and treatment of the PTFJ dislocation are essential to prevent chronic joint instability and extensive surgical intervention to restore normal PTFJ biomechanics, ankle and knee function, especially in athletes prone to such injuries. PTFJ dislocations often remain undiagnosed in polytrauma scenario with ipsilateral tibial fracture due to the absence of specific signs and symptoms of PTFJ injury. Standard orthopedic textbooks generally describe no specific tests or radiological signs for assessment of the integrity of this joint. The aim of this paper was to review the relevant clinical anatomy, biomechanics and traumatic pathology of PTFJ with its effect on the knee emphasizing the importance of early diagnosis through a high index of suspicion. Dislocation of the joint may have serious implications for the knee joint stability since fibular collateral ligament and posterolateral ligament complex is attached to the upper end of the fibula. Any high energy knee injury with peroneal nerve palsy should immediately raise the suspicion of PTFJ dislocation especially if the mechanism of injury involved knee twisting in flexion beyond 80° and in such cases a comparative radiograph of the contralateral side should be performed. Wider clinical awareness can avoid both embarrassingly extensive surgeries due to diagnostic delays or unnecessary overtreatment due to misinformation on the part of the treating surgeon.     

Dislocation of the proximal tibiofibular joint in association with a tibial shaft fracture: two case reports and a literature review

Dislocation of the proximal tibiofibular joint (PTFJ) in association with a displaced tibial shaft fracture and an intact fibula is an exceedingly rare injury. We present 2 cases of tibia fractures associated with an intact fibula and a PTFJ dislocation. The first case involves a man who sustained a closed spiral fracture of the distal tibial shaft, with an intact fibula, an anterolaterally dislocated PTFJ, and a partial tear of the lateral collateral ligament. The tibia was percutaneously plated, and the PTFJ was reduced and then stabilized with temporary screw fixation. The second case involves a woman who sustained a closed fracture of the tibia in association with a PTFJ dislocation. The tibia was fixed with an intramedullary nail, and the PTFJ was similarly reduced and fixed with a temporary screw. We also provide a brief literature review focusing on classification of PTFJ dislocations, mechanism of injury, associated injuries, and treatment options.     

Dislocation of the proximal tibiofibular joint in association with a tibial shaft fracture: two case reports and a literature review.

Dislocation of the proximal tibiofibular joint (PTFJ) in association with a displaced tibial shaft fracture and an intact fibula is an exceedingly rare injury. We present 2 cases of tibia fractures associated with an intact fibula and a PTFJ dislocation. The first case involves a man who sustained a closed spiral fracture of the distal tibial shaft, with an intact fibula, an anterolaterally dislocated PTFJ, and a partial tear of the lateral collateral ligament. The tibia was percutaneously plated, and the PTFJ was reduced and then stabilized with temporary screw fixation. The second case involves a woman who sustained a closed fracture of the tibia in association with a PTFJ dislocation. The tibia was fixed with an intramedullary nail, and the PTFJ was similarly reduced and fixed with a temporary screw. We also provide a brief literature review focusing on classification of PTFJ dislocations, mechanism of injury, associated injuries, and treatment options.     

Proximal tibiofibular joint dislocation associated with tibial shaft fractures – 7 Cases

ObjectiveLower leg fractures of the tibia with or without fracture of the fibula are very common. Proximal tibiofibular joint (PTFJ) dislocation is a very rare injury that can occur together with a tibia shaft fracture. As there is only scarce literature about this injury available, we would like to present our experience with the treatment of this entity.MethodsWe present a small case series of seven patients. In most cases, the tibia fracture was nailed in a closed technique. After distal locking the proximal fibula was exposed by a lateral approach exposing and preserving the peroneal nerve. After anatomical reduction into the corresponding articular facet of the proximal tibia, the fibula was transfixed to the tibia with a positioning screw. This indirectly provided a correct length and rotation of the tibia, which could finally be locked to the nail by inserting the proximal locking bolts. The positioning screw was removed after six weeks prior to full loading. Six of seven patients had been followed up by at least 7 months post-treatment.ResultsOut of 663 prospectively collected tibia shaft fractures treated at our institution from 1/2001 to 7/2014, we found seven patients with associated PTFJ dislocation. All except one had been caused by a high energy trauma. After one year, five patients showed excellent results with full range of motion and returning to their sporting activities as before the accident. Two patients have impaired function due to associated injuries. None complained of persistent pain or instability of the PTFJ.ConclusionPTFJ dislocation with tibia shaft fracture can easily be overlooked if one is not familiar with this injury. It is important to diagnose and treat this uncommon dislocation anatomically to achieve good results. Otherwise, as the literature shows, it can lead to chronic instability of the proximal fibula with snapping, proximal fibular pain and even peroneal nerve palsy. Furthermore in complex tibial fractures correct length and rotation only can be restored after referencing with the fibula. We recommend a high index of suspicion of this injury with high energy tibia shaft fractures especially in cases with intact fibula.     

The abnormal proximal tibiofibular joint

Abnormalities of the proximal tibiofibular joint are infrequently encountered. Mostly instability occurs as a result of trauma. Four types of instability are distinguished: subluxation, anterolateral, posteromedial and superior dislocation. Four radiological methods designed to visualize abnormalities of the proximal tibiofibular joint are discussed. Special notice is given to the clinical relevance of a new method. Instability was demonstrated in 19 patients; 16 of these were treated by an operation. History, data obtained by physical examination and ways of treatment are discussed.     

Successful Fusion of the Proximal Tibiofibular Joint with Osteogenic Protein-1 (OP-1) Augmentation

Proximal tibiofibular joint (PTFJ) instability is rare, but when encountered can be difficult to manage. Previously reported forms of treatment, including cast immobilization, soft tissue repairs and reconstructions, and fibular head resection have met with limited success. Another option is PTFJ arthrodesis—however, fusion can be difficult and ankle pain after surgery is not uncommon. In this report, we present a novel surgical technique used to treat PTFJ instability. It is a form of PTFJ arthrodesis that utilizes the osteoinductive agent recombinant human osteogenic protein (rhOP-1) to help achieve fusion, in conjunction with a fibular osteotomy to unload the PTFJ and to preserve normal rotator mobility of the distal fibula during ankle motion. We have used this technique in two patients with successful results; one of whom required revision after two previous failed attempts at PTFJ fusion and the other who had a previous diagnosis of underlying collagen disorder. Their case studies are presented in detail in this report.     

Traumatic instability of the proximal tibiofibular joint

Proximal tibiofibular instability, seems to be an infrequently diagnosed abnormality, which occurs in isolation or in combination with fractures of the leg and ankle. Four types of instability are distinguished: subluxation, anterolateral dislocation, posteromedial dislocation and superior dislocation.The method of treatment depends on the type of dislocation and on the presence or absence of dysfunction of the peroneal nerve.The methods of treatment are described. Ten patients treated for this instability are presented. The use of radiographs to define the lesion is discussed. Radiographs, taken at follow-up, showed degenerative changes in the proximal tibiofibular joint in 8 of the 10 patients.     

上胫腓关节三维有限元模型的建立及对两型关节脱位的生物力学分析

背景：上胫腓关节是一个容易让人忽视的关节,临床上许多膝部的顽疾是由上胫腓关节的外伤或病变引起,研究其生物力学很重要。目前,新型高效的有限元研究方法尚未应用于上胫腓关节脱位的生物力学研究中。 目的：通过正常人的上胫腓关节CT扫描图像,建立两型（水平型和倾斜型）上胫腓关节的三维有限元模型,分析躯体受到由远端向近端的纵向作用力下,上胫腓关节处的应力分布,提供对活体上胫腓关节评估的新方法。 方法：选择2名（水平型和倾斜型各1名）均无上胫腓关节及膝关节外伤史的正常健康志愿者,进行64排CT扫描其上胫腓关节,运用逆向工程原理,通过三维有限元建模软件建立两型三维有限元模型。以上胫腓关节最常受力--沿纵轴受力,分别在两型三维有限元模型上进行力学加载,研究上胫腓关节处的应力分布,记录胫骨和腓骨出现明显相对位移（脱位）的作用力大小。 结果：成功建立了两型上胫腓关节的三维有限元模型,其加载后的应力主要分布于两型上胫腓关节的腓骨内侧部分及腓骨头中部偏外上的区域,沿纵轴作用力引起两型关节脱位的作用力为：倾斜型关节1250 N,水平型关节1850 N。 结论：倾斜型上胫腓关节较水平型上胫腓关节更易发生脱位,与文献的结果相一致。研究所用的两型上胫腓关节的三维有限元模型具有有效性,可作为力学分析的基础模型。     

Inferior dislocation of the proximal tibiofibular joint: a report on four cases

The authors report four cases of inferior dislocation of the proximal tibiofibular joint. A literature search disclosed reports on superior, anterolateral and posterolateral dislocation, but none on inferior dislocation of the proximal tibiofibular joint. The latter was associated in these four cases with fracture of the tibia, as also noted in cases of superior dislocation, and with severe neurovascular lesions.     

Early detection of peroneal neuropathy by ultrasound

A 12 year old boy presented with ankle sprain. The physical examination revealed mild weakness of ankle dorsiflexion. An ultrasound was done for the soft tissues of the ankle. In addition to relative atrophy of the peroneus longus muscle, a compressive common peroneal nerve (CPN) lesion with a synovial cyst at the level of the proximal tibiofibular joint (PTFJ) was accidently found. Since there were features of CPN compression by the synovial cyst, total excision of the cyst was performed. After the operation, muscle strength improved and the neurological deficit subsided. Therefore, the early diagnosis of PTFJ synovial cyst with nerve injury was crucial in order to achieve a better result. The obscure nature of clinical presentations can delay the diagnosis, which may potentially lead to a poor prognosis after treatment in such cases. This report highlights the fact that ankle sprain do need a thorough clinical work up in some cases.