经皮踝外侧韧带复合体重建治疗慢性踝外侧不稳

[目的]探讨经皮功能重建踝关节外侧韧带复合体治疗慢性踝关节不稳的临床疗效。[方法]2014年1月~2018年2月,符合纳入标准的47例慢性踝关节不稳患者随机分为两组,其中,切开组23例采用常规切开术式重建距腓前韧带(ATFL)和跟腓韧带(CFL),经皮组24例采用超声定位,经皮建立骨隧道重建ATFL和CFL。比较两组间手术时间、围术期并发症、踝背伸-跖屈活动度(ROM)、AOFAS评分、VAS评分,应力位影像测量距骨前移度和倾斜度。[结果]术中切开组2例出现腓浅神经损伤。经皮组手术时间、切口总长度显著小于切开组,差异有统计学意义(P<0.001)。切开组术后4例切口边缘处坏死,而经皮组1例切口渗液。两组患者随访26~30个月,平均(27.39±2.51)个月。术后6个月时,经皮组ROM显著大于切开组(P<0.05)。随时间推移两组患者AOFAS评分均显著增加,而VAS评分显著减少(P<0.001),但是两组相同时间点AOFAS评分和VAS评分的差异均无统计学意义(P>0.05)。应力位X线测量方面,术后两组患者距骨前移距度和距骨倾斜角均较术前显著减少(P<0.001)。但是两组相同时间点在距骨前移距度和距骨倾斜角的差异均无统计学意义(P>0.05)。[结论]经皮踝关节外侧韧带复合体重建治疗慢性踝关节不稳的效果与常规开放手术相当,但具有手术时间短、创伤小、并发症少的优点。     

Chronic, recurring ligament instability in the lateral ankle

According to the literature, chronic ankle instability occurs after acute rupture of the lateral ankle ligaments in 10-20% of the cases. The etiology of the instability are ligamentous damage and functional neuromuscular disorder of the peroneal muscles. The standards of diagnostics are the history with the frequency of inversion trauma per period and the interval from the primary trauma, the clinical examination and radiological stress tests. Newer diagnostic methods, up to now not well established in clinical routine, include stabilometry, cybex-measurements of the pronator muscles, the evaluation of peroneal reaction time on a tilting platform and dynamic pedography. Conservative management of chronic ankle instability consists of wearing ankle braces and rehabilitation programs concerned with peroneal muscle strengthening and coordination training. The indication for surgical reconstruction of the ankle ligaments are a well-documented mechanical instability with the neuromuscular reflexes intact and a failed physiotherapeutic training program. The surgical procedure should be selected according to a priority list: 1. anatomical repair, eventually augmented with periosteum from the fibula, 2. Watson-Jones tenodesis, and 3. Chrisman-Snook tenodesis to treat a concomittant subtalar instability.     

Modified Brostrom-Evans-Gould technique for recurrent lateral ankle ligament instability

PURPOSE: To review the outcome of the modified Brostrom-Evans-Gould technique in patients with chronic lateral ankle ligament instability. METHODS: Between August 2003 and June 2005, 20 men aged 19 to 35 (mean, 23) years with chronic lateral instability affecting 21 ankles, underwent the modified Brostrom-Evans-Gould technique by a single surgeon. The mean follow-up period was 12 (range, 6-20) months. Patients were assessed preoperatively and postoperatively using the Kaikkonen Ankle Scoring Scale. RESULTS: Preoperatively, all patients had poor scores (<50). Postoperatively, 17 (81%) of the ankles attained excellent scores (85-100) and 4 (19%) attained good scores (70-84). CONCLUSION: The modified Brostrom-Evans-Gould technique appears effective for chronic lateral ankle ligament instability, particularly in the Asian population with a higher prevalence of generalised joint hyperlaxity.     

距腓前韧带重建联合踝关节镜术治疗慢性踝关节外侧不稳

[目的]介绍用第三腓骨肌腱转位解剖重建距腓前韧带联合踝关节镜下微骨折术治疗慢性踝关节外侧不稳合并距骨骨软骨损伤的手术技术。[方法] 2015年12月～2017年5月25例(25踝)慢性踝关节外侧不稳合并距骨软骨损伤患者行手术治疗,所有患者均采取第三腓骨肌腱转位解剖重建距腓前韧带,踝关节镜下微骨折术治疗距骨骨软骨损伤。记录术后切口愈合情况及并发症发生情况,采用疼痛视觉模拟评分(VAS)评价踝关节疼痛程度,采用美国足踝外科协会后足与踝关节评分(AOFAS HA score)评价踝关节功能,并行影像评估。[结果]所有患者术后切口I期愈合,无神经损伤等并发症发生,术后均获得随访,随访时间12～30个月,平均(17.53±5.24)个月。末次随访时踝关节MRI显示重建距腓前韧带良好,修复的距骨软骨均较术前影像改善,VAS由术前的(4.15±0.93)分降低至术后的(0.99±0.80)分,AOFAS HA评分由术前的(55.60±4.21)分提高至末次随访时的(90.32±7.62)分,差异均具有统计学意义(P0.05)。[结论]应用第三腓骨肌腱转位解剖重建距腓前韧带联合踝关节镜下微骨折术治疗慢性踝关节外侧不稳合并距骨骨软骨损伤创伤小、并发症少、效果确切。     

Idiopathic cavovarus and lateral ankle instability: recognition and treatment implications relating to ankle arthritis

Hindfoot malalignment and chronic lateral ankle instability may lead to degenerative ankle arthritis. We retrospectively analyzed 10 patients with 13 cavovarus feet. None of the patients had underlying neurologic disorders. All patients presented with a history consistent with chronic lateral ankle instability, clinically with cavovarus feet, and radiographically with varying degrees of varus talar tilt and ankle arthritis. Ankles with severe degenerative change were fused. The ankles with mild or moderate change underwent calcaneal osteotomy with lateral ligament reconstruction and/or dorsiflexion osteotomy of the first metatarsal. A quantitative radiographic Coleman block test was utilized to aid in the preoperative planning of the calcaneal and metatarsal osteotomies. All patients had correction of preoperative deformity and resolution of pain and instability. Recognition of the association between cavovarus and chronic ankle instability and degenerative ankle arthritis may be important in developing the appropriate treatment strategy in this patient population.     

Degenerative arthritis of the knee secondary to ochronosis

Alkaptonuria is a rare disease in which a deficiency in the homogentisate 1, 2-dioxygenase enzyme results in a buildup of homogentisic acid. Ochronosis, the deposition of excess homogentisic acid in connective tissue, causes brownish-black pigmentation and weakening of the tissue ultimately resulting in chronic inflammation, degeneration, and osteoarthritis. There is currently no definitive cure for alkaptonuric ochronosis, and management is usually symptomatic. However, total joint replacements in severe cases of ochronotic osteoarthritis have comparable outcomes to osteoarthritic patients without ochronosis. We report a case of a patient with ochronotic arthritis of the knee treated with total knee arthroplasty.     

关节镜下自体半腱肌肌腱解剖重建踝关节外侧副韧带

目的 探讨关节镜下自体半腱肌肌腱重建踝关节外侧副韧带治疗慢性踝关节不稳定的方法及初期临床疗效。方法 将2015年12月至2017年2月我院收治的16例慢性踝关节不稳定病人纳入研究,其中男14例,女2例,年龄为（28.1±6.4）岁;术前应力位X线片提示距骨倾斜25.5°±5.5°（18°~35°）,距骨前移（10.1±1.8） mm（7~14 mm）。采用2.7 mm 30°短踝关节镜经前外侧入路观察,经前外侧辅助入路于腓骨远端和距骨外侧面距腓前韧带足印区制作骨隧道,跟骨外侧壁跟腓韧带止点处经皮透视制作骨隧道,取自体半腱肌肌腱对折编织成“Y”型,将移植物引入骨隧道,腓骨端使用袢钢板悬吊固定,距骨及跟骨端使用5.0 mm界面螺钉固定。术后早期功能锻炼,末次随访应用美国足踝外科医师协会（American Orthopedic Foot and Ankle Society, AOFAS）踝与后足功能评分系统评价踝关节功能;采用疼痛视觉模拟量表（visual analogue scale, VAS）评估疼痛情况;采用Sefton外侧副韧带重建疗效评价系统评估踝关节稳定性。结果 本组16例病人术后随访（16.8±4.3）个月（12~24个月）,均于术后3个月恢复正常体育活动,末次随访未观察到踝关节不稳定复发。AOFAS评分为（89.2±4.8）分,VAS评分为（0.7±0.6）分。依据Sefton评价标准：优9例,良5例,可2例,优良率为87.5%。结论 关节镜下自体半腱肌肌腱解剖重建踝关节外侧副韧带治疗慢性踝关节不稳定的近期疗效理想,并发症较少。     

Follow-up results of ligament replacement by PDS in chronic lateral ligament instability of the upper ankle joint

From September 1988 till February 1989 we have operated on 14 PDS-ligament replacements of the ankle in patients with chronic lateral instability. Only one patient had an excellent clinical result with a stable ankle. Ten of twelve patients had poor results at follow-up. 2 patients had been reoperated on. We did not find biological substitute along the PDS guide line. This suggested the opinion, the PDS-ligament replacement of the ankle can't realize the expectations.     

慢性踝关节外侧不稳定

慢性踝关节外侧不稳定是一种常见的疾病,国内对于此病的研究和报告不多,一方面是由于患者本身要求不高,另一方面临床医生对它也不够重视。结合国内外有关文献报道,探讨了有关诊断问题,描述和比较了几种常见手术重建方法,以期能对慢性踝关节外侧不稳定的诊断和治疗有更深入和全面的认识。     

MRI appearance of the lateral fibulotalocalcaneal ligament complex injury in the patients with chronic lateral ankle instability

BackgroundThe anterior talofibular ligament (ATFL) comprises the superior and inferior fascicles. The inferior fascicle is connected to the calcaneofibular ligament, and forms “lateral fibulotalocalcaneal ligament (LFTCL) complex”. This study aimed to evaluate the feasibility of diagnosing LFTCL complex injuries in patients with chronic lateral ankle instability (CLAI).MethodsForty-eight ankles (35 with CLAI and 13 without CLAI) underwent arthroscopic surgery, and preoperative magnetic resonance imaging (MRI) was conducted with 0.8 mm- thick axial and oblique slices. The diagnostic accuracy of injuries to the superior fascicle and LFTCL complex was evaluated by two observers.ResultsThe sensitivity and specificity of the LFTCL complex injury were 94.7% and 92.3% for observer 1 and 84.2% and 84.6% for observer 2, respectively.ConclusionsMRI with 0.8 mm slices could detect LFTCL complex injury in patients with CLAI. Diagnosing the LFTCL complex injury on MRI will improve outcomes of an arthroscopic isolated ATFL repair.     

Chronic lateral instability of the ankle

Summary The authors present 14 cases of chronic lateral instability of the ankle in 13 patients, in whom we performed ligamentoplasty using peroneus lateral brevis.The importance of careful preoperative evaluation of clinical findings as well as stress-roentgenograms and arthrographies is emphasized and a simple surgical technique is presented.We also realize an assessment of the results obtained which are very encouraging at the present.(Head: Prof. J. M. Canadell, MD)     

Degenerative arthritis of the knee secondary to fracture malunion

Degenerative arthritis of the knee is a complication of femoral or tibial fractures potentially avoidable by the correction of various degrees of malalignment. To better clarify the malalignment problem, the records of 14 patients (15 limbs), with degenerative arthritis of the knee and a history of tibial or femoral fracture were retrospectively reviewed. The average follow-up was 31.7 years. Static biomechanical frontal plane analyses were evaluated. The calculated increased force on either the medial or lateral tibial plateau, due to the malunion, was strongly associated with presence of a varus or valgus deformity at the knee (p less than 0.0005). A normal tibial plateau force for the malaligned condition multiplied by the time since fracture correlated directly with the amount of subsequent varus or valgus deformity at the knee (p less than 0.01). Lower limb fracture alignment should be restored to as near normal as possible to reduce the likelihood of gonarthrosis.     

The anterior talo-fibular ligament reconstruction in surgical treatment of chronic lateral ankle instability

Chronic lateral ankle instability causes significant problems in physical activity and accelerates development of osteoarthritic changes. The results of treatment for chronic ankle instability are often meets controversial. A surgical reconstruction of ATFL as described in this paper was performed during the period 1997–2005 on 47 patients (26 male, 21 female), with a mean age of 29.3 years. The average follow-up period was 46.2 months. All patients had clinical examination, X-ray and MRI. The mean values of the Good score improved from an average 3.32 prior to surgery to 1.19 one year after the operation. Paired t-tests showed improvements of great significance (p < 10⁻²⁸). The Good score prior to surgery ranged from 2–4, whereas the scores one year after surgery were either 1 or 2, with a score of 1 being recorded in 38 cases (81%). In the postoperative follow-up, MRI showed a newly-formed ligament structure in all cases. The authors describe their own technique for a reconstruction of lateral ankle instability using remnants of the former ATFL. The scar tissue seems to be sufficient to form a new duplicated structure providing good stability. MRI proved to be a sensitive and specific method for identifying the extent of talo-fibular ligament injury.     

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。