人工腓骨棒的研究与临床应用

目的：观察部分腓骨切除后植入腓骨棒对踝关节的中期影响。方法：对62例腓骨部分切除后植入自行研制的腓骨棒的患者在3～5年后对其踝关节功能、正位C线片和踝关节肌力、活动度进行测量，与对侧对照。结果：未出现踝关节功能紊乱现象，X线片示踝穴宽度与对侧无显著性差异．无外踝上移现象。4例出现腓骨棒断离。结论：腓骨支撑棒在腓骨切除植入3～5年后效果良好，无明显副作用．     

踝关节骨折外踝畸形愈合的重建手术

目的总结腓骨旋转延长截骨术治疗踝关节骨折后外踝畸形愈合的临床疗效。方法对19例踝关节骨折外踝畸形愈合患者行腓骨旋转延长截骨术治疗。15例获得完整随访,应用美国足踝外科协会(AOFAS)评分系统评分。结果 15例获12~50个月随访,平均33个月。骨折均愈合,力线恢复良好,无感染、内固定失败、骨不连、畸形复发等。结论踝关节骨折外踝畸形愈合采用腓骨旋转延长截骨术治疗,可使踝关节功能获得较大的改善。     

踝关节骨折中的腓骨损伤

腓骨的外踝参与踝关节的组成 ,而在踝关节的骨折中 ,由于力的传导 ,会引起腓骨不同部位的损伤 ,现就这一问题谈谈认识 :1　腓骨的作用　　为了踝关节有良好的功能 ,腓骨必须有 :①正常的长度 ;②腓骨在胫骨沟内有正常的位置 ;③通过胫腓下韧带有效的固定于胫骨[1] 。在维持踝关节的功能上 ,是整个腓骨参与 ,而不仅仅是外踝 ,腓骨通过杠杆作用维持着外踝的位置 ,腓骨的损伤会引起踝关节功能的改变。有实验证明单独切断三角韧带不引起踝关节的不稳定[2 ] ,当切断内踝及上胫腓联合前后韧带在应力试验下 ,对踝关节的影响也不大 ,当切断外踝及下…     

踝关节外侧不稳定的生物力学研究进展

<正>外踝作为踝关节的重要组成部分,对于踝关节结构和功能的完整以及人的正常行走和活动有着至关重要的意义和作用。踝关节的外侧不稳定是临床上比较常见的症状,它的发生与腓骨长度的改变,韧带、下胫腓联合及腓骨长短肌的损伤等因素     

《中国骨伤》2007年第2期继续教育试题

以下是有关足踝损伤与疾病的选择题,有单选题和多选题,请选出正确答案的序号填在答题卡中。1·内翻暴力引起的踝关节损伤可有:A.内踝斜形骨折B.距骨向外脱位C.外踝撕脱性骨折D.下胫腓韧带断裂E.三角韧带断裂2·踝穴是由哪些构成的:A.前踝B.内踝C.外踝D.后踝E.距骨体3·踝关节骨折脱位常见的并发症:A.骨折不愈合B.骨坏死C.骨折畸形愈合D.创伤性关节炎E.以上都不是4·关于Pilon骨折的概念,不正确的是:A.腓骨完整,胫骨远端爆裂骨折波及踝关节面的骨折B.腓骨骨折,胫骨远端嵌压骨折未波及踝关节面的骨折C.腓骨完整,胫骨远端爆裂骨折未波…     

外踝缺损的手术治疗进展

目的综述外踝缺损的手术治疗进展。方法查阅国内外外踝缺损手术治疗方法及疗效的相关文献,并进行总结分析。结果外踝缺损常由创伤以及肿瘤切除导致,发生率虽不高但处理较棘手,治疗要求恢复踝关节的稳定性,避免创伤性关节炎的发生。目前治疗外踝缺损的手术方法主要有骨移植术、腓骨延长术、踝关节融合术。结论外踝缺损修复术式多种多样,但各有利弊,术者需根据自身水平、患者伤情及年龄等因素选择恰当术式,以求达到最佳疗效。     

腓骨退旋延长术治疗外踝畸形愈合二期创伤性踝关节炎的疗效观察

目的 观察腓骨退旋延长术治疗伴外踝畸形愈合的踝关节二期创伤性关节炎的疗效.方法 对41例踝关节二期创伤性关节炎行踝上截骨术治疗,对其中21例伴外踝畸形愈合的患者行腓骨退旋延长术治疗,17例获得完整的随访资料.应用美国骨科足踝外科协会AOFAS踝关节功能评分系统进行评分.结果 17例获得14～43个月(平均21.5个月)随访.骨折全部愈合,平均临床愈合时间13.3周(11～16周).完全负重时间平均为12周(11～15周).术前踝关节AOFAS评分为23～46分(平均27分),术后12个月评分为55～91分(平均80分),其中优5例,良8例,一般3例,差1例,优良率76.5%.术后1例发生切口皮缘部分坏死,经保守治疗痊愈.2例术后出现足外侧皮肤感觉麻木,2例患者在最近X线片显示关节炎有轻微进展.无螺钉松动、断裂及内固定失效等其他并发症.结论 伴外踝畸形愈合的踝关节二期创伤性关节炎采用腓骨退旋延长术治疗,近期可获得满意效果.     

腓骨缺损造成踝关节不稳定的研究

腓骨缺损造成踝关节不稳定的研究陆宸照，周泰仁，张海生，郭强苏，沈金根我们在１９８３年发现腓骨中段缺损导致踝关节损伤性关节炎，下肢肌力减退，踝关节疼痛，但不知其原因。后经生物力学测试，发现腓骨缺损造成踝关节不稳定，且与外踝不稳定有密切关系，现报道如下。...     

骨膜下切除术治疗腓骨远端动脉瘤样骨囊肿

腓骨远端很少发生动脉瘤样骨囊肿,手术治疗的主要目的是彻底切除囊肿,避免局部复发;防止损伤骨骺,避免外翻畸形,维持踝关节稳定性[1-3].全切外踝可产生踝关节畸形并损伤踝关节稳定性.刮除植骨术是治疗骨囊性变最常用的方法,但复发率较高,易损伤骨骺,出现肢体不等长和踝关节不稳.应用切除腓骨远端方法治疗骨肿瘤时,必须重建远侧胫腓关节,仅适用于有进展和易于复发的骨骺周围病变,且重建方法复杂,需多次手术,内固定和制动时间也相对较长[4,5].Abuhassan等[6]近期介绍的骨膜下切除腓骨远端动脉瘤样骨囊肿方法,不需要植骨,治疗效果满意.现介绍如下.     

腓骨切除后对踝关节稳定性的影响

临床上涉及腓骨切除（fibular resection）的手术并不少见，常用于腓骨肿瘤、慢性骨髓炎和严重创伤等治疗，尤其是腓骨移植一直是临床研究的热点。但是腓骨切除后对供区功能的影响日益受到重视。腓骨部分切除后造成患侧踝关节不同程度的活动受限，肌力下降，对儿童甚至产生踝关节外翻畸形，近年来都有不少相关报道，对腓骨功能的重要性也有了进一步的认识，本文就此作一综述。     

腓骨切除后踝关节损害

作者随访了腓骨切除病人15例,随访时间最短1年半,最长26年。发现腓骨切除<8cm7例,患肢症状、体征均较轻;切除至中及下1/38例,除症状较重外,还出现不同程度的下胫腓关节分离,腓骨上移,距骨向外移位,患肢的负重应力向外转移,严重者出现踝关节创伤性关节炎。认为胫腓骨远端融合可减轻或逆转病理变化。     

Examination of the pathologic anatomy of ankle fractures.

A prospective study of the translational and rotational displacement of the lateral malleolus in ankle fractures was carried out utilizing roentgenographic techniques. Twenty-six ankle fractures in 25 patients were studied using both routine plain films and CT scanning with two- and three-dimensional multiplanar reconstruction. Eighty-one percent were Lauge-Hansen supination-external rotation type injuries. Overall, 21 fractures did not involve the medial malleolus. Initial talar shift was less than or equal to 2 mm in 15 fractures. Although all patients exhibited external rotation deformities of the lateral malleolus on plain films, only one fracture was found to possess any degree of external rotation relative to the talus. The proximal fibula was seen on CT scans to have increased internal rotation with respect to the tibia in 19 cases. One patient had a slightly externally rotated proximal fibula; the remainder appeared normally aligned. The displacements measured by the CT scans at the talofibular articulation were compared with the standard plain film measurements. The displacements at the distal lateral malleolus were consistently overestimated by the plain roentgenograms, presumably because the capsular and ligamentous attachments to the distal fibula limit malleolar displacement. The talocrural angle, determined on both plain films and CT scans, was also not found to be a sensitive measure of fibular shortening nor of the severity of the fracture. The results of this study suggest that, in an isolated lateral malleolar ankle fracture, the apparent external rotation of the fracture fragment is relative only to the proximal fibula and is not associated with derangement of the talofibular articulation. Based on these mechanical considerations, surgical intervention for such fractures may not be necessary. This hypothesis is consistent with previous long-term clinical studies.     

Separate centre of ossification of the lateral malleolus with instability of the ankle joint

Summary Four cases of recurrent instability of the ankle joint are reported. The instability was associated with a separate centre of ossification of the lateral malleolus and abnormal movement between the ossicle and the distal fibula. All patients were successfully treated by surgery: two underwent internal fixation and ligamentous reconstruction and two, ligamentous reconstruction after removal of the ossicle.     

Effects of isolated Weber B fibular fractures on the tibiotalar contact area

Fractures of the lateral malleolus can occur without rupture of the deltoid ligament or fracture of the medial malleolus. Controversy exists regarding the necessity of surgery on supination-external rotation stage II ankle fractures. Theoretically, as long as the medial structures are intact, the talus cannot displace enough to cause degenerative arthritis of the ankle joint. The purpose of this study was to measure changes in contact area between the tibial plafond and the talar dome with serial displacement of the distal fibula in both a lateral and a superolateral direction. Twelve cadaver lower extremities were used. Distal fibular fractures were replicated by creating an osteotomy. Displacement was accomplished with a customized apparatus that displaced and held the distal fibula in a malaligned position. Tibiotalar contact area was measured with pressure sensitive film at the following intervals of fibular displacement: 0 mm, laterally 2 mm and 4 mm, and then posteriorly and superiorly 2 mm and 4 mm. A servohydraulic testing apparatus was used to apply the same physiologic load to all limbs while measuring contact area. Key independent variables included the direction and amount of displacement of the distal fibula. Mean tibiotalar contact area decreased from baseline (no displacement) 361.1 mm2 (SD +/- 49.0) to 162.2 mm2 (SD +/- 81.3) and 82.6 mm2 (SD +/- 30.6) for 2 mm and 4 mm lateral displacement of the distal fibula respectively. With posterior/superior displacement of 2 mm and 4 mm mean tibiotalar contact decreased to 219.3 mm2 (SD +/- 56.7) and 109.2 mm2 (SD +/- 39.0), respectively. Statistical significance was found (P <.001) when comparing normal ankle alignment with displaced fractures at all levels of displacement.     

Reconstruction of the form and function of lateral malleolus and ankle joint

Soft-tissue reconstruction alone cannot obtain normal ankle function in patients with large defects in the area of the lateral malleolus. The authors report a functional reconstructive method for the lateral malleolus, utilized in a male patient whose osteosarcoma in the fibula was resected with surrounding soft tissue. In order to reconstruct the lateral malleolus, the remaining half of the fibula at the knee was removed, and the fibular head was fixed with the tibia at the ankle joint. Ligaments were reconstructed with tendon grafts. Skin and soft-tissue defects were reconstructed with a combined composite flap comprised of a latissimus dorsi myocutaneous flap and a serratus anterior muscle flap. Dead space around the bone graft was filled with the serratus anterior muscle flap that was divided into two portions. The surface was covered with the latissimus dorsi myocutaneous flap. The patient regained almost normal function of the ankle joint. This technique would be a useful functional reconstructive method for patients with large defects in the area of the lateral malleolus.     

Is Fibular Fracture Displacement Consistent with Tibiotalar Displacement?

We believed open reduction with internal fixation is required for supination-external rotation ankle fractures located at the level of the distal tibiofibular syndesmosis (Lauge-Hanssen SER II and Weber B) with 2 mm or more fibular fracture displacement. The rationale for surgery for these ankle fractures is based on the notion of elevated intraarticular contact pressures with lateral displacement. To diagnose these injuries, we presumed that in patients with a fibular fracture with at least 2 mm fracture displacement, the lateral malleolus and talus have moved at least 2 mm in a lateral direction without medial displacement of the proximal fibula. We reviewed 55 adult patients treated operatively for a supination-external rotation II ankle fracture (2 mm or more fibular fracture displacement) between 1990 and 1998. On standard radiographs, distance from the tibia to the proximal fibula, distance from the tibia to the distal fibula, and displacement at the level of the fibular fracture were measured. These distances were compared preoperatively and postoperatively. We concluded tibiotalar displacement cannot be reliably assessed at the level of the fracture. Based on this and other studies, we believe there is little evidence to perform open reduction and internal fixation of supination-external rotation II ankle fractures.     

Altered fibular growth patterns after tibiofibular synostosis in children

BACKGROUND: Iatrogenic synostosis of the tibia and fibula following an operation on the leg in a child has been reported rarely in the literature, and the effects of this complication on future growth, alignment, and function are not known. This is a retrospective case series, from one institution, of crossunions of the distal parts of the tibia and fibula complicating operations on the leg in children. The purpose is to alert surgeons to this possible complication. METHODS: The senior author identified eight cases of iatrogenic tibiofibular synostosis seen in children since 1985. The patients had various diagnoses and were from the practices of four pediatric orthopaedic surgeons. Synostosis developed in six patients after osteotomies of the distal parts of the tibia and fibula, in one after internal fixation of distal tibial and fibular metaphyseal fractures through a single incision, and in one after posterior transfer of the anterior tibialis tendon through the interosseous membrane combined with peroneus brevis transfer to the calcaneus. Medical records were reviewed, and preoperative and follow-up radiographs were analyzed for changes in the relative positions of the proximal and distal tibial and fibular physes and in the alignment of the ankle. RESULTS: Five patients were symptomatic after crossunion; they presented with prominence of the proximal part of the fibula, ankle deformity, or ankle pain. Three patients were asymptomatic, and a synostosis was identified on routine follow-up radiographs. Intraoperative technical errors caused two of the crossunions; the cause of the others was unknown. Following tibiofibular synostosis, growth disturbances were noted radiographically in every patient. The normal growth pattern of distal migration of the fibula relative to the tibia was reversed, resulting in a decreased distance between the proximal physes of the tibia and fibula as well as proximal migration of the distal fibular physis relative to the distal part of the tibia. Shortening of the lateral malleolus led to greater valgus alignment of the ankle. CONCLUSIONS: Tibiofibular synostosis can complicate an operation on the leg in a child. After crossunion, the normal distal movement of the fibula relative to the tibia is disrupted, resulting in shortening of the lateral malleolus and ankle valgus as well as prominence of the fibular head at the knee. The synostosis also interferes with the normal motion that occurs between the tibia and fibula with weight-bearing, potentially leading to ankle pain.     

胫骨pilon骨折受伤机制的有限元分析

目的 探讨胫骨pilon骨折发生过程中胫腓骨及远端关节面的应力分布规律。方法 选择1名健康男性志愿者建立胫腓骨及距骨的三维有限元模型,根据骨折发生特点设定工况,在中立位、背伸、跖屈、内翻、外翻5种不同工况下从距骨远端向近端进行静力加载,并将模型与地面进行碰撞。结果 在静载荷下,中立位应力主要分布于踝间线以前的内踝、胫骨踝穴顶前缘及外踝,背仲位应力主要分布于外踝及胫骨踝穴顶前部,跖屈位应力分布于胫骨踝穴顶后部,内翻位应力主要分布于外踝关节面及胫骨踝穴顶外侧部,外翻位应力主要分布于外踝关节面。在碰撞情况下,中立位应力分布与静载荷下一致,背伸立应力主要分布于踝间线以前,跖屈位应力主要分布于胫骨踝穴顶之踝间线后部及外踝关节面,内翻立应力主要分布于胫骨踝穴顶外部及外踝,外翻位应力主要分布于内踝、外踝及踝间线前部。腓骨关节面存静载荷作用下均处于高应力分布状态,在碰撞过程中亦最早接受应力分布。结论 腓骨是胫骨pilon骨折发生中最早受累且受累较重的部位。胫腓骨远端关节面在骨折发生中存在4个主要应力分布区,此4个应力区向近端延伸为内、外、前、后4个柱。     

Osteotomy of the Distal Fibula for Correction of Posttraumatic Malunion

Objective Restoration of anatomic alignment of the lateral malleolus to delay or prevent development of posttraumatic osteoarthritis of the ankle joint. Indications Posttraumatic malunion of the distal fibula with shortening, often combined with external rotation and abduction of the lateral malleolus. Osteoarthritic changes may be absent, mild or moderate. Contraindications Severe, preexisting osteoarthritis of the ankle. Presence of a remote lateral pilon fracture with articular depression. Poor soft tissue conditions after infection or sympathetic reflex dystrophy. Surgical Technique Lateral approach respecting former incisions or wounds, if at all possible. Osteotomy of the fibula (horizontal, oblique or Z-shaped), resection of scar tissue, osteophytes and bony fragments in the fibular notch and freeing of the distal part of the fibula. Correction of any obstacle around the medial malleolus if indicated. Correction of length, rotation and abduction of the lateral malleolus, and fixation with a reconstruction or LC-DC plate. Fixation of the fibula in the fibular notch with two Kirschner wires. Results After a follow-up of 3.9 years, all eight patients were satisfied. In five of six patients, there was only a slight progression of arthritic changes radiologically already present before osteotomy. Two patients without any arthritic changes before the osteotomy did not develo such changes thereafter. Our results, confirmed by previous reports, indicate that the most important factor determining the final outcome is the presence of degenerative changes at the time of osteotomy. Lengthening of the fibula slowed down or even stopped progression of arthritis.     

The stability of the tibio-fibular syndesmosis following rigid internal fixation for type C malleolar fractures: an experimental and clinical study

In 5 cadavers, type C malleolar fractures of the pronation-eversion rotation type, were produced. The stability of the ankle mortice under stress was tested before and after rigid internal fixation of the fracture in the fibula. The intact interosseous membrane above the fracture in combination with the internal fixation of the fibula was sufficient to keep the lateral malleolus in place. A clinical series of 8 equivalent fractures treated with rigid internal fixation without suture of the syndesmodesis was collected and evaluated clinically and radiologically 3 years after the injury. None of the patients had significant complaints and all ankle joints were stable.