同种异体肌腱及自体腓骨短肌重建踝关节外侧副韧带的比较

背景：目前临床多采用自体腓骨短肌或同种异体肌腱移植重建踝关节外侧副韧带,但两种材料的组织学和生物力学特性不同。 目的：对比自体腓骨短肌与同种异体肌腱重建踝关节外侧副韧带的临床疗效。 方法：纳入66例陈旧性踝关节外侧副韧带损伤引起的慢性外踝不稳患者,年龄15-63岁,其中34例采用自体腓骨短肌腱重建踝关节外侧韧带,32例采用深冻同种异体肌腱重建踝关节外侧韧带,重建后随访观察两组腓骨肌反应时间、距骨倾斜角和距骨前移距离,以及目测类比评分和美国足踝外科协会踝-后足功能评分。 结果与结论：两组末次随访的目测类比评分、距骨倾斜角和距骨前移距离均低于治疗前(P < 0.05),美国足踝外科协会踝-后足功能评分均高于治疗前(P < 0.05);自体腓骨短肌腱组末次随访腓骨肌反应时间高于治疗前(P < 0.05),同种异体肌腱末次随访腓骨肌反应时间低于治疗前(P < 0.05);末次随访时,两组间目测类比评分、美国足踝外科协会踝-后足功能评分、距骨倾斜角、距骨前移距离及腓骨肌反应时间比较差异均无显著性意义。表明同种异体肌腱重建踝关节外侧副韧带后的踝关节功能、稳定性及运动水平与自体腓骨短肌腱重建效果相当,但具有创伤小、手术时间短、保留完整腓骨短肌的优点。 中国组织工程研究杂志出版内容重点：生物材料;骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性;组织工程     

踝外侧副韧带损伤对踝关节稳定性及软骨接触应变影响的有限元分析

背景：在踝关节扭伤和踝关节韧带损伤中近85%涉及外侧副韧带,损伤的机制为足跖屈时踝关节内翻。急性踝关节外侧扭伤的患者中有20%-40%会出现持续疼痛和慢性踝关节外侧不稳,导致距骨平移和旋转过大,加速软骨磨损,导致关节退化。目的：通过有限元建模探究不同类型的踝外侧副韧带损伤模型对踝关节稳定性以及距骨穹窿软骨接触应变的影响。方法：将1名27岁志愿者足踝CT扫描数据DICOM文件导入有限元软件中,进行三维重建及曲面拟合,再进行网格划分,建立含有骨骼、关节软骨和韧带的完整踝关节有限元模型,对比正常、距腓前韧带损伤、跟腓韧带损伤和距腓前韧带+跟腓韧带损伤4种不同工况下的踝关节稳定性和距骨软骨接触应变的改变。结果与结论：(1)在前抽屉试验中,距腓前韧带损伤和距腓前韧带+跟腓韧带损伤距骨前移距离明显大于正常和跟腓韧带损伤(P <0.05),而距腓前韧带损伤和距腓前韧带+跟腓韧带损伤之间、正常和跟腓韧带损伤之间差异无显著性意义(P> 0.05);(2)在距骨倾斜试验中,跟腓韧带损伤和距腓前韧带+跟腓韧带损伤距骨倾斜角度明显大于正常和距腓前韧带损伤,而跟腓韧带损伤和距腓前韧带+跟腓韧带损伤之...     

踝关节外侧韧带和距下关节韧带修复重建的应用解剖

目的 :为踝关节外侧韧带和距下关节韧带损伤修复重建提供解剖学基础。方法 :在 3 2侧经防腐固定、8侧冷藏新鲜标本上解剖观测踝关节外侧韧带和距下关节韧带及小趾趾长伸肌腱、第 3腓骨肌腱、腓骨短肌腱、伸肌下支持带 ,在新鲜标本上摹拟修复术。结果 :小趾趾长伸肌腱、第 3腓骨肌腱、腓骨短肌腱、伸肌下支持带解剖位置恒定 ,与踝关节外侧韧带和距下关节韧带相毗邻 ,具有一定的长、宽、厚度 ,可形成移植供体。结论 :①陈旧性踝关节外侧韧带和距下关节韧带的损伤 ,原位修复较难 ,用肌腱转位修复是一种可行的方法 ;②可用腓骨短肌腱修复距腓前和跟腓韧带损伤 ,小趾趾长伸肌腱和第 3腓骨肌腱转位修复距下关节韧带 ,伸肌下支持带可用作加强缝合 ,术式经标本摹拟具有可行性。     

手术治疗距腓前韧带距骨侧止点撕脱骨折的疗效观察

目的 探讨开放性修复手术治疗距腓前韧带距骨侧止点撕脱骨折的临床疗效。方法 回顾性研究。纳入2017年11月—2021年4月徐州仁慈医院足踝外科确诊为距腓前韧带距骨侧止点撕脱骨折的患者4例（4足）。其中男3例、女1例,年龄15~45岁（平均30.3岁）,右足2例、左足2例。患者均采用外踝前外侧小切口开放性修复手术治疗距腓前韧带的距骨侧止点撕脱骨折,术后石膏制动。观察项目：（1）记录患者骨折愈合的时间、末次随访时踝关节疼痛视觉模拟评分法（VAS）评分,美国足踝外科协会（AOFAS）踝-后足功能评分、踝关节功能评价Karlsson-Peterson评分。（2）术前及末次随访时测量距骨前移距离（ATT）、距骨倾斜角（TT）。结果 4例患者手术均顺利完成,术后均获随访8~25个月。（1）患者骨折愈合均良好,愈合时间3~5个月（平均3.8个月）。末次随访时,患者疼痛VAS评分为0~2分（平均1.3分）,AOFAS踝-后足评分为89~95分（平均92.8分）,Karlsson-Peterson评分为89~94分（平均91.5分）;患者1例踝关节疼痛消失,其余3例仅有轻微酸胀不适,不影响日常行走。（2）末次随访时ATT为（2.4±0.3）mm、TT为2.8°±0.8°,较术前（8.4±0.8）mm和10.0°±1.4°明显改善,差异均有统计学意义（t=14.40、19.62,P值均<0.001）。结论 采用开放性小切口结合2枚锚钉修复距腓前韧带的距骨侧撕脱骨折,可有效恢复患者踝关节的稳定性。手术创伤小,操作简便,有临床推广价值。     

全踝关节镜下距腓前韧带一期修复术治疗新鲜外踝撕脱骨折

目的 探讨全踝关节镜下距腓前韧带一期修复术治疗新鲜外踝撕脱骨折的临床疗效。方法 回顾性分析2016年1月—2017年3月徐州市中心医院手足显微外科全踝关节镜下治疗的36例36足新鲜外踝撕脱骨折患者的临床资料。其中男22例、女14例,年龄18～57(29.24±10.37)岁;右侧20例,左侧16例。患者均采用全踝关节镜下距腓前韧带带线锚钉一期修复治疗,术后定期门诊随访,观察踝关节外观、踝关节稳定性及行走步态等;末次随访采用视觉模拟评分(VAS)、美国骨科足踝外科协会(AOFAS)评分及足踝部Olerud-Molander评分对手术治疗效果进行评价。患者术前VAS为5～8(6.35±1.17)分,AOFAS评分为60～85(74.67±8.36)分,Olerud-Molander评分为57～80(68.89±10.70)分。结果 所有患者手术切口一期愈合,无一例出现神经、血管、肌腱损伤等并发症。36例患者获得随访,随访时间12～25(14.63±6.80)个月。末次随访时,患侧踝关节外观恢复满意,无感觉过敏现象及瘢痕触痛,踝关节恢复正常活动,无关节痛及关节不稳情况,均恢复正常行走步态;末次随访时VAS、AOFAS及Olerud-Molander评分分别为(0.31±0.14)、(90.40±9.62)、(88.71±7.38)分,与术前比较差异均有统计学意义(t=30.755、7.405、9.149,P值均＜0.05)。结论 采用全踝关节镜下一期修复距腓前韧带,具有安全可靠、疗效确切、创伤小等优点,是新鲜外踝撕脱骨折的有效治疗方法。     

腘腓韧带解剖观察及其临床意义

目的　为临床腘腓韧带损伤的诊治提供解剖学基础。 方法　对61侧成人膝关节标本进行解剖，观察腘腓韧带形态及与周围结构关系。 结果　腘腓韧带出现恒定，位于腘肌腱与腓骨头之间。　88.5%（54）的腘腓韧带为明显增厚的韧带，前宽后窄；11.5%（7）则呈筋膜形态。腘腓韧带前缘长（10.47±2.38）mm，后缘长（6.24±1.71）mm，宽（8.90±3.12）mm，厚（1.23±0.48）mm。其与腘肌腱的夹角为（120.2±　15.2）°，距腓侧副韧带距离为（9.67±3.87）mm。 结论　腘腓韧带是组成膝关节后外侧重要结构之一，但其形态变异较大；了解其解剖特点，对腘腓韧带损伤诊断及解剖重建有重要意义。     

腘腓韧带的解剖生物力学特点及其临床意义

目的：研究腘腓韧带的解剖学特点,及其在膝关节运动中的生物力学稳定机制.方法：在15具成人尸体30例膝关节标本上,于膝关节后外侧区域,解剖观察腘腓韧带的位置、组成和形态学特点.以自制夹具固定标本,观察并记录选择性切断腘腓韧带前后的不同工况下,膝内翻加载移位和胫骨上端的后外侧旋转加载移位的变化.结果：①腘腓韧带位于膝关节后外侧区域,邻近上胫腓关节,是连接腓骨头后上方与腘肌腱的韧带样结构.根据腘腓韧带在腘肌腱上附着点的区别,分为前、后两束.②离断腘腓韧带后,应力加载下,膝内翻移位不明显,胫骨上端后外侧旋转移位明显增大.结论：①腘腓韧带是膝后外侧重要的稳定结构;②腘腓韧带具有明显对抗膝后外侧旋转不稳定的作用;③腘腓韧带损伤严重导致膝关节后外侧旋转不稳的,应手术重建腘腓韧带以维持膝关节的稳定性.     

56例关节镜下同种异体肌腱重建膝关节前后交叉韧带的临床观察

膝关节前后交叉韧带是稳定膝关节的重要结构.交叉韧带损伤后,不仅会造成膝关节不稳,且能造成继发性损害,造成半月板损伤和继发性关节炎,交叉韧带自愈困难,通常需要重建修复.同种异体肌腱移植修复前后交叉韧带损伤越来越受到关注[1].我科56例前后韧带断裂患者采用同种异体肌腱重建治疗,取得了较为满意的临床效果,现报告如下.     

自体髌骨膜-髌韧带-骨瓣重建踝外侧韧带的应用解剖

目的　为自体髌骨膜-髌韧带-骨瓣重建踝关节外侧韧带提供解剖学基础。 方法　在6侧经防腐固定的成人下肢标本及6侧新鲜标本上观测踝关节外侧韧带起止点及走行径路、髌韧带的解剖形态与起止点,在新鲜标本上摹拟重建手术。  结果　髌韧带位置恒定,解剖层次表浅,切取方便,髌骨膜-髌韧带-骨瓣的髌韧带长度(4.1±0.4) cm,距腓前韧带长度(2.4±0.5) cm,跟腓韧带长度(3.1±0.4) cm。 结论　(1)髌骨膜-髌韧带-骨瓣的髌韧带具有足够的长度,可形成移植供体;(2)髌骨膜-髌韧带-骨瓣复合体两端分别与骨及软骨创面固定,容易成活和恢复功能;(3)采用自体髌骨膜-髌韧带-骨瓣重建踝外侧韧带具有可行性。     

踝关节外侧副韧带的解剖研究及对重建手术的意义

目的 对人体踝关节外侧副韧带的定量解剖及与周围骨性标志的解剖学测量,为踝关节外侧副韧带的重建手术提供理论参考.方法 选取30具经福尔马林处理好的正常成人踝关节标本,对外侧副韧带进行精细解剖并对其起止点至周围骨性标志的距离进行定量测量,对其测量结果进行统计学分析.结果 本实验30具踝关节标本中,前距腓韧带(ATFL)大致...     

腓骨骨膜-筋膜瓣移位治疗慢性踝关节不稳的临床应用

目的：报道自体腓骨骨膜—筋膜瓣移位治疗慢性踝关节不稳的方法及疗效。方法：5例慢性踝关节外侧不稳患者接受手术治疗，将腓骨骨膜—筋膜的中下1／3向下游离至近关节囊部，保留下端血供，分成两瓣，分别修复距腓前韧带和跟腓韧带。结果：随访6～18个月，5例患者临床症状明显改善，摄X线片检查踝关节稳定性恢复良好，临床疗效满意。结论：采用自体腓骨骨膜—筋膜瓣移位治疗慢性踝关节不稳方法简便，疗效确切。     

太极拳搂膝拗步动作的踝关节生物力学分析

本文旨在分析太极拳搂膝拗步中踝关节软骨和主要韧带的生物力学响应。采集1名太极拳练习者搂膝拗步及正常行走时的运动学和动力学数据,作为有限元分析的载荷和边界条件,计算关节接触应力和韧带受力。研究结果表明,搂膝拗步动作时踝关节接触应力普遍小于步行时接触应力。但是,在搂膝拗步动作中距腓前韧带、跟腓韧带和距腓后韧带的最大拉力分别为130、169、89 N,对应在步态中仅分别为57、119、48 N。因此,踝关节炎的患者可以适当练习太极拳,但是踝关节外侧韧带扭伤的练习者在搂膝拗步时应适当减小足踝动作幅度。     

A novel 9-region systematic assessment tool for separated ossicle at the fibular tip effects on lateral ankle ligament complex integrity: a cadaveric study

Purpose

Fibular tip ossicle separation can cause ligament injury leading to chronic lateral ankle instability. A cadaveric study was conducted to preliminarily assess the effects of fibular tip separated ossicle location and size on lateral ankle ligament complex integrity.

Methods

X-ray examinations and dissection of the anterior talofibular and calcaneofibular ligaments were conducted in ten radiographically confirmed normal below-knee cadaveric specimens extracted from donated fresh cadavers. Ossicle and bone fragment location and size were recorded, and distal fibula, articular surface, and adjacent ligament effects were determined by a novel 9-region matrix.

Results

Ligament risk varied by region. Anterior talofibular ligament width, perpendicular distance to fibular tip, sagittal width of distal fibula, and coronal width of distal fibula at attachment were 7.45 ± 0.22, 11.75 ± 1.03, 20.56 ± 1.54, and 8.68 ± 0.12 mm, respectively. Sagittal distal fibula and calcaneofibular ligament maximum widths at fibular attachment articular surfaces were 16.81 ± 0.96 and 3.50 ± 0.44 mm, respectively. Anterior talofibular to calcaneofibular ligament distance was 2.35 ± 0.14 mm. Separated ossicles >10 mm in regions 1–3 affected anterior talofibular ligaments, calcaneofibular ligaments, and fibular ankle joints; while those in regions 4, 8, and 7 or 9 affected anterior talofibular or calcaneofibular ligaments or were without impact.

Conclusions

At the fibular tip, separated ossicles sized >10 mm impact collateral ligaments and articular surfaces, while those 5–10 and <5 mm impact anterior talofibular or calcaneofibular ligaments, potentially impairing the lateral ankle ligament complex. Thus, systematic matric-based assessment of ossicle size and location can potentially improve and standardize ankle fracture care.     

Anatomy of lateral ankle ligaments and their relationship to bony landmarks

This study was designed to determine and describe precise anatomy of the lateral ankle ligaments and their relationship to adjacent osseous structures. This study was performed on 42 legs of 22 adult human embalmed cadavers. The lateral ankle ligaments were carefully dissected using a 2.5× surgical loupe. Mean values for the length, width and angle of the individual lateral ankle ligaments were measured. The precise location of insertion points and course of each ligament was observed and noted with ankle placed in neutral position. The anterior talofibular and calcaneofibular ligaments were coated with radio-opaque material. Radiographs were then taken in the anteroposterior, mortise and lateral projections. The anterior talofibular ligament (ATFL) was a flat, quadrilateral ligament and it made mean angle of 25° (range 5°–45°) with horizontal plane, and a mean angle of 47° (range 45°–56°) with sagittal plane. The posterior talofibular ligament was oriented in a nearly horizontal plane. Calcaneofibular ligament (CFL) was a flat oval ligament. It made a mean angle of 40° (range 30°–58°) with horizontal plane, and mean angle of 51° (range 32°–60°) with sagittal plane. The angle between CFL and ATFL was approximately 132° (range 118°–145°). These data provides important information for diagnosing injury and reconstructing lateral ankle ligaments.     

外踝韧带张力测定与踝关节不稳定性实验

本实验应用改良扣带式张力传感器测定了32侧完整成人下肢踝关节骨—韧带标本,并模拟腓骨部分切除和外踝韧带断裂后,进行了踝关节不稳定性试验,发现这些结构的损伤可造成相应的踝关节不稳定,腓骨切除后胫腓前后韧带张力增加,而距腓前后韧带与跟腓韧带张力减小(P<0.05),并出现踝关节不稳,内旋、内收和前抽屉运动分别增加4.3°,4.6°和2.3mm(P<0.05)。     

The anterior talofibular and calcaneofibular ligaments: an anatomic study

Inversion injuries of the ankle are the most common sport injuries. Extreme inversion of the ankle affects frequently lateral ankle ligaments, especially the anterior talofibular and calcaneofibular ligaments. The aim of this study is to investigate the ligaments in detail to contribute to accurate evaluation of radiological investigations and more precise surgical interventions by clarifying the anatomic structure of the ligaments by considering their functional importance. In the study, length between the attachment points and width at the midpoint of the anterior talofibular and calcaneofibular ligaments, length and width of the bands of anterior talofibular ligament, and connecting ligaments extending from the talus to calcaneus exchanging from the both ligaments were measured on the 46 ankles. In addition, angles between these ligaments and between longitudinal axis of the fibula and both ligaments were measured. Relationship between determined variables on the right and left sides was statistically analyzed. In diagnosis and treatment methods, the clinical importance of the anatomy of the lateral collateral ligaments of the ankle, especially the anterior talofibular and calcaneofibular ligaments, was frequently reported in the literature. Angular measurements benefit in determination of the ligament injury. Therefore, knowledge about normal anatomic angles between each other and angles between longitudinal axis of the fibula and both ligaments was certainly important for the correct diagnosis. Nowadays, surgical reconstructions of the ligaments are frequently used. During the surgical invention, length and width of the ligaments are necessary to determine quantity of ligament loss. Nonetheless, knowledge of ligament attachments contributes to more accurate reconstructions.     

Surgical Considerations in the Treatment of Ankle Instability

OBJECTIVE: To review the surgical indications, techniques, biomechanical testing, and clinical results reported for the most common surgical techniques used to treat ankle instability. DATA SOURCES: We searched MEDLINE from 1960-2001 using the terms ankle instability, functional ankle instability, mechanical ankle instability, ankle ligament surgery, Brostr?m, Chrisman-Snook, and Evans. DATA SYNTHESIS: Although 80% to 85% of acute ankle sprains are successfully treated with a functional ankle-rehabilitation program, the remaining 15% to 20% have recurrent ankle instability and reinjury, necessitating surgical intervention. The fundamentals of the surgical approach to lateral ankle instability are based on the anatomy of the lateral ankle ligaments, the anterior talofibular ligament, and the calcaneofibular ligament. Ankle-instability surgery has been broadly divided into an anatomic repair consisting of an imbrication of the lateral ligamentous complex and an ankle-ligament reconstruction. An ankle-ligament reconstruction weaves a harvested tendon graft, most commonly the peroneus brevis, to augment the lateral ligaments of the ankle. Goals of surgery are to reestablish ankle stability and function without compromising motion and without complications. Anatomic repair and imbrication of the lateral ligament complex with the Gould modification has an 85% to 95% success rate, and the risk of associated nerve injuries is low. This approach provides increased stability by reinforcing local host tissue, preserving subtalar and talocrural motion, eliminating the comorbidity associated with tendon-graft harvest, and offering a quicker functional recovery. One concern in using the anatomic approach is the resultant strength of the repair, although the literature does not support this concern. Ankle-reconstruction procedures that sacrifice tendons are thought to provide a stronger construct, and hence, more stability. This increased stability results in loss of talocrural and subtalar range of motion, prolonging recovery and decreasing sport performance. Adjacent nerve injury is more common with ankle-ligament reconstruction. CONCLUSIONS/RECOMMENDATIONS: Based on the literature, we believe that a modified Brostr?m lateral-ligament repair should be considered the first choice for persistent ankle instability refractory to a functional ankle-rehabilitation protocol. Ankle reconstruction with tendon augmentation should be reserved for patients with generalized ligamentous laxity or long-standing ligamentous insufficiency or as a salvage procedure in a patient with a failed modified Brostr?m lateral-ligament repair.