关节镜下行踝关节融合术治疗晚期创伤性关节炎11例临床报告

目的:评估关节镜下行踝关节融合术治疗晚期创伤性关节炎的疗效。方法:2006年1月～2009年10月,11例(男8例,女3例)晚期创伤性关节炎患者,年龄45～67岁,平均56岁;9例为外伤引起,2例为习惯性扭伤。均采用关节镜行踝关节融合术,镜下清除踝关节内增生肥厚滑膜,磨削胫骨及距骨表面的关节软骨及其硬化骨,取出游离体,并以两枚松质骨螺钉固定踝关节于屈曲0°,外翻5°～10°,外旋5°～10°及距骨轻度后移位。术后平均随访26周(20周～32周),分别采用Mazur评分系统及Angus and Cowell评价标准比较手术前后评分。结果:11例患者术前Mazur评分平均49.5分,术后平均86.7分(P<0.05)。11例患者术前Angus and Cowell评价标准为差,术后8例优,2例良,1例差(即踝关节未融合患者)。术后患者完全融合时间为11.2周(8周～16周)。融合率为90.9%。1例未达到骨性融合,进行对症治疗未见骨质融合倾向遂取下螺钉并清理钉道溶解骨行自体骨植骨外固定架固定。术后14周时达到骨性融合。结论:关节镜下行踝关节融合术是治疗晚期创伤性关节炎行之有效的方法。     

关节镜治疗创伤后踝关节炎52例

目的 观察关节镜治疗创伤后踝关节炎的效果.方法 共选择52例患者,均有踝关节扭伤或骨折史,创伤修复后仍有患踝疼痛、活动受限,踝关节X线片无异常.伤后平均病程5.6个月.局部麻醉下,建立标准踝关节前内、前外侧入路,进行踝关节镜检查、清理.采用踝-后足评分系统对术前、术后1个月患踝进行评分.结果 术后随访平均3.6个月.患者对术后效果非常满意12例,满意38例,不满意2例.关节镜下可见单纯滑膜炎,滑膜炎+距骨软骨损伤及纤维组织增生.踝-后足评分术前为53.23分,术后1个月为86.46分. 结论踝关节镜创伤小,术后恢复快,经过关节镜下的对症治疗,可以明显缓解踝关节创伤后的不适症状,是一种有效的治疗手段.     

关节镜技术在治疗运动创伤性踝关节炎中的应用

目的 介绍应用关节镜技术治疗踝关节不同类型运动创伤性踝关节炎的方法和体会.方法 对2008年1月-2010年10月采用踝关节镜下治疗运动创伤性踝关节炎25例,手术前后以美国足踝外科协会(AOFAS)踝-后足评分系统进行评价功能,以前抽屉应力位X线片评估关节稳定性.25例患者进行关节镜检查并进行相应滑膜瘢痕组织切除、软骨面修整、微骨折处理治疗,5例1期行外踝韧带缝合修补术.结果 关节镜下可见单纯滑膜炎4例,滑膜炎合并纤维瘢痕组织增生形成撞击综合征10例,胫骨和(或)距骨软骨损伤11例,腓骨端新鲜损伤淤血4例.23例患者获随访,随访时间6～24个月,平均13.5个月.踝-后足评分术前(54.3±6.2)分,术后1个月为(81.5±7.9)分,3个月为(82.9±2.5)分,半年为(83.1±2.1)分,1年为(83.5±3.9)分,差异均有统计学意义(t=13.01,20.58,21.10,19.11,P＜0.05);术前前抽屉应力位X线片示距骨前移为(15.2±2.5)mm,术后为(3.5±0.2)mm,差异有统计学意义(t=9.33,P＜0.05).患者前抽屉试验和距骨倾斜试验均为阴性.结论 踝关节镜创伤小、恢复快,通过关节镜技术对症治疗,踝关节运动创伤后的不适症状可明显得到缓解.     

改良进钉方式行交锁髓内钉踝关节融合术13例

使用交锁髓内钉进行踝关节融合术已较为普遍。2004年以来，我们采用改良进钉方式行踝关节融合术13例，疗效满意。现分析报告如下。 1 临床资料 1．1 一般情况 13例中，男8例，女5例；年龄46～58岁，平均53．6岁。左侧7例，右侧6例；创伤性踝关节炎12例，陈旧性距骨体粉碎性骨折1例。均表现为患踝负重行走时疼痛，伴跛行步态。     

自体髂骨植骨治疗距骨软骨损伤17例

目的:探讨经内踝截骨、取髂骨植骨治疗距骨骨软骨损伤的手术技巧及预后疗效。方法:回顾性分析2012年7月至2015年10月,采用取同侧髂骨松质骨植骨术治疗且获得完整随访的内侧距骨软骨损伤17例(17足)的病历资料。男10例;女7例;左足7例,右足10例;年龄16-50岁;平均年龄35岁;14例患者病灶位于内侧,3例患者病灶位于外侧,病灶平均面积为为60±52.8 mm2;按照MRI的Hepple距骨软骨损伤分型,Ⅲ型8例;Ⅳ型6例;Ⅴ型3例;所有患者术前及术后均行CT及MRI检查。采用美国足与踝协会踝与后足评分(AOFAS)及视觉疼痛量表(VAS)对术后踝关节的功能及疼痛评定治疗效果。结果:17例患者术后随访4~39个月;平均18.6个月。AOFAS评分由术前的77.32±6.67分提高到术后的93.10±8.24分,VAS评分由术前的7.80±1.38分降低到术后的1.96±1.67分,差异均具有统计学意义(P<0.001)。术后随访未见伤口感染、皮肤坏死、内固定失效、截骨端不愈合或畸形愈合等并发症。结论:对于HeppleⅢ、Ⅳ、Ⅴ型的距骨软骨损伤,经内踝截骨、髂骨植骨术治疗距骨软骨损伤是有效的治疗方式;手术治疗可以改善踝关节的功能、缓解踝关节的疼痛。     

踝关节镜下切除疼痛性距后三角骨临床疗效分析

目的:探讨经后方入路踝关节镜下切除疼痛性距后三角骨的临床疗效及安全性。方法:2002年1月～2007年10月,我所采用踝关节后内侧与后外侧入路、在关节镜下切除疼痛性距后三角骨22例。22例患者均表现为踝关节后侧疼痛,主动及被动跖屈时疼痛加重。术后21例患者获得随访,平均年龄为23.7岁(13～47岁),平均随访时间为33个月(8～75个月)。根据主观和客观评分判断疗效。结果:术后患足的美国足踝外科(AOFOS)踝关节与后足评分(94.8±5.1分)显著高于术前(73.3±3.6分)(t=19.66,P<0.001);术后主观疼痛程度评分(0.62±0.59分)显著低于术前(4.90±0.77分)(t=25.06,P<0.001);疗效优良率为95.2%。结论:经后方入路踝关节镜下切除疼痛性距后三角骨临床效果良好,手术安全。     

逆行髓内钉胫距跟关节融合治疗胫距、距下关节创伤性关节炎

目的 探讨应用逆行髓内钉行胫距跟关节融合术治疗合并胫距、距下关节严重创伤性关节炎的临床疗效.方法 自2003年6月至2006年6月,应用逆行髓内钉行胫距跟关节融合术治疗合并胫距、距下关节创伤性关节炎患者17例,术后疗效评估采用美国足踝外科协会(AOFAS)踝-后足功能评分标准.结果 14例术后获得随访,时间6～23个月,平均14.6个月.12例(86%)功能在术后平均11.6周(8～19周)达到骨性愈合,2例(14%)出现延迟愈合(17～19周),其中早期手术的2例(12%)诉足跟进针点疼痛;AOFAS踝-后足功能评分从术前的47分(43～55分)提高到术后的75分(69～86分).结论 逆行髓内钉胫距跟关节融合术是临床治疗踝关节和距下关节严重创伤性关节炎的一种有效方法,能有效缓解踝与后足疼痛,提高生活质量.     

闭合性右距舟关节和跟骰关节半脱位1例

1临床资料患者,男,31岁,下车时右足尖先着地扭伤,右足疼痛1h来诊。查体示:右足屈曲内翻畸形,踝前外侧皮肤张力较大,但未见骨性突起,未见明显皮肤破损。临床拟诊踝关节脱位拍右踝关节正侧位X线片(见图1),平片发现右踝关节未见异常。遂行右足正斜位片进一步检查。右足平片示(见图2):右距-舟关节丧失部分对合关系,舟骨向内侧移位1.0cm;跟-骰关节间隙增宽,骰骨向内侧移位约0.5cm。根据右足距-舟关节、跟-骰关节半脱位,X线诊断为:右足距骨周围关节半脱位。临床以闭合性足距骨周围关节半脱位收入骨科,在硬膜外麻醉下手法复位,X线平片复查示解剖…     

自体胫骨带骨膜骨移植治疗距骨内侧骨软骨损伤

目的:探讨经内踝截骨、胫骨带骨膜骨移植治疗距骨内侧骨软骨损伤的临床疗效。方法:总结第三军医大学西南医院2014年1月至2015年8月,采用内踝截骨、病灶清理、胫骨带骨膜骨移植治疗距骨内侧骨软骨损伤28例。术中经内踝截骨,显露内侧距骨顶,清理碎裂软骨,去除病灶及囊肿,自同侧胫骨钻取带骨膜骨柱,采取打压固定技术将骨柱植入受区钻好的孔中,固定内踝截骨块。观察患者术前术后踝关节X线片、MRI,在PACS系统测量比较距骨骨软骨损伤水肿区域的左右径、前后径及深度变化,比较术前及术后末次随访时美国足踝外科协会(AOFAS)踝与后足评分。结果:本组共23例患者获最终随访,随访时间15个月(10~28月),X线片证实术后平均11周(9~14周)内踝截骨端愈合,MRI检查显示患者术后病灶骨髓水肿区域较术前明显减小,差异具有统计学意义(P<0.01),1例患者形成软骨组织稍高于周围关节软骨,2例患者软骨下骨囊肿未完全消失,6例取内固定时行关节镜检,其中5例移植物与周围关节软骨愈合良好,表面被软骨样组织覆盖,其色泽、光滑度等与周围软骨面差异较小,患者AOFAS踝与后足评分均较术前明显改善(P<0.05),随访期间未见供区疼痛、伤口感染、内固定失效等并发症。结论:对于Ⅲ~Ⅴ期距骨骨软骨损伤,经内踝截骨、病灶清理、胫骨带骨膜骨移植可修复软骨缺损,减轻疼痛,改善关节功能,是一种有效的治疗方法。     

足三关节融合术并发症的预防

足三关节融合术是矫正马蹄内、外翻畸形的有效手术 ,然而由于操作失误等原因 ,常可致术后并发皮肤坏死、原畸形复发 ,骨缺血坏死等并发症。本院近 5年来开展足三关节融合术 6 4例。现将预防并发症的体会介绍如下。1　临床资料本组共 6 4例 ,其中男 46例 ,女 18例 ,年龄 :最小 15岁 ,最大 46岁。右足 38例 ,左足 2 6例。单纯下垂 15例 ,马蹄内翻 35例 ,马蹄外翻 10例。术后随访最短 8个月 ,最长 4年。 1例发生假关节 (距舟关节 ) ,3例行走过久时感到踝关节疼痛 ,Ｘ片示胫距关节有外伤性关节炎征象。2　体会2 1　适应证选择　对年龄偏小者 ,…     

Radionuclide bone scanning in subtalar coalitions: differential considerations

The radionuclide bone scan is a noninvasive screening procedure which can help in identifying or confirming subtalar coalitions in patients with foot and/or ankle pain of unknown origin in whom routine plain film studies are inconclusive. Five patients (seven symptomatic feet) with clinical and plain film findings suggesting a subtalar coalition are presented. The radionuclide bone scans in four patients (six feet) with documented subtalar coalitions demonstrated augmented uptake in the subtalar joint in all six feet and a secondary area of augmented concentration in the superior aspect of the talus or talonavicular joint in five feet. The radionuclide bone scan was normal in the one patient who was later proved not to have a coalition. The scans of 100 patients with foot pain of other etiologies were reviewed, and in no instance did the scan demonstrate the combination of subtalar and talus or talonavicular uptake observed in the patients with coalitions.     

距骨骨折后缺血性坏死与功能预后的关系

目的 分析距骨骨折后缺血性坏死的发生率及功能预后.方法 回顾性分析2004年7月-2009年11月收治12例13足得到随访的距骨骨折的坏死发生率、足踝功能及致残率.按Hawkins分型:Ⅰ型2足,Ⅱ型4足,Ⅲ型5足,Ⅳ型2足.结果 12例随访11～52个月,平均19.6个月.8足出现距骨坏死,3足需处理,其中1足行踝关节融合,1足行距下关节融合,1足行减压植骨;另5足踝关节、距下关节功能良好,无距骨塌陷、骨关节炎表现.根据Maryland足部评分标准,优8足,良2足,可1足,差2足,优良率为77%.结论 距骨骨折脱位后缺血性坏死的发生率与骨折的部位及创伤能量相关,但其功能预后与缺血坏死并不相关.     

Diagnostic and Therapeutic Foot and Ankle Injections

For patients with disabling foot or ankle pain, medical or surgical treatment decisions can be difficult to make when multiple joints show changes of osteoarthritis or if the patient's pain clinically is related to a joint or tendon that is normal by other imaging studies. For these patients, injection of anesthetic, steroid, or both, into joints or tendon sheaths of the foot and ankle provides important diagnostic information and therapeutic relief. Diagnostic injections may show that the joints noted by other imaging studies have osteoarthritis that are not responsible for a patient's pain or that a normal joint is responsible. When multiple joints show changes of arthritis, anesthetic injections can help decide which and how many joints could benefit from surgical arthrodesis. Relief of pain after anesthetic joint injection correlates well with postoperative pain relief subsequent to arthrodesis. This article discusses the indications and the contraindications for performing diagnostic and therapeutic joint injections, and also presents the techniques for performing these studies.     

旋后内收型Ⅱ度踝关节骨折的治疗策略

目的 探讨及总结旋后内收型Ⅱ度踝关节骨折的治疗策略及经验.方法 2003年3月-2008年9月,对32例旋后内收型Ⅱ度踝关节骨折进行手术治疗,其中男21例,女11例;年龄21～76岁,平均44.5岁.其中3例为开放性骨折.采取前内侧入路暴露内踝垂直骨折线及胫骨远端内侧关节面,探查胫骨远端关节面及距骨软骨受损情况,对塌陷受损的胫骨远端关节面进行植骨以恢复其高度,内踝直视下解剖复位,清除关节内脱落的软骨碎片;外侧韧带撕裂损伤根据稳定性情况决定是否修复,外踝移位骨折根据骨折块的大小及移位程度选择内固定.X线片观察术后骨折愈合、内固定及是否伴骨性关节炎情况,测量踝关节活动度恢复情况,同时按Maryland后足评分系统对踝关节功能进行评估.结果 32例中23例获随访,时间6-47个月,平均27.9个月.1例术后5个月出现2枚螺钉突出皮下予取出,余X线片显示无内固定松动、断裂,骨折2.3～5.1个月(平均2.9个月)后均愈合,随访时间内未出现骨性关节炎表现,踝关节活动度背伸为6°～17°,平均13°;跖屈27°～46°,平均36°.按Maryland后足评估标准,评定优19例,良4例,优良率为100%.结论 了解及重视旋后内收型Ⅱ度踝骨折受伤机制,加强对胫骨远端内侧关节面高度、软骨及距骨关节面软骨受损情况的诊断及处理可有效减少骨关节炎等并发症的发生1前内侧纵行切口更有利于骨折及受损关节软骨面的暴露、关节腔脱落软骨片的清除、胫骨远端植骨关节面高度的恢复及内固定的放置.

Abstract：

Objective To explore the treatment strategies for grade Ⅱ supination adduction ankle fracture. Methods From March 2003 to September 2008, 32 patients with grade Ⅱ supination adduction ankle fractures were treated surgically. There were 21 males and 11 females, at a mean age of 44.5 years (range, 21-76 years). Three patients had open ankle fractures. Anteromedial approach to the medial malleolus was taken to expose the vertical medial malleolus fractures and tibial plafond for exploring damage to distal articular surface of the tibia and that to cartilage of the talus. Open reduction and internal fixation with impaction of the articular fragment and possible bone grafting were applied to restore the height of the collapsed tibia. Medial mallcolus fractures were anatomically reduced and the intra-articular cartilage debris removed under direct vision. Repair of the lateral ligament injuries was decided acoording to the stability of the ligament. Different internal fixation was chosen according to fracture displacement of the block size and degree of lateral malleolus fractures. Fracture union, internal fixation and osteoarthritis were detected by X-ray examination. The range of ankle motion was measured. Maryland foot score was taken to assess the ankle function.Results Twenty-three patients were followed up postoperatively for a mean period of 27.9 months ( range, 6-47 months). Two prominent screws were removed from one patient five months after operation because of loosening. Bony fusion was achieved in all patients after an average period of 2.9 months ( range, 2.3-5.1 months). X-ray examination revealed no other internal fixation loosening or osteoarthritis. The average range of motion was 13 degrees of dorsiflexion (range, 6-17 degrees) and 36 degrees of plantarflexion (range, 27-46 degrees). According to Maryland foot score, ankle function was excellent in 19 patients and good in four, with excellence rate of 100%.Conclusions Understanding injury mechanism of supination adduction ankle fracture, strengthening the diagnosis and treatment of damage of tibial plafond articular surface height, cartilage and talar articular surface cartilage can effectively reduce the incidence of complications such as osteoarthritis. Anteromedial incision allows excellent exposure of the medial tibial plafond for clearance of intra-articular cartilage pieces, recovery of distal tibial articular surface height and placement of internal fixation.     

基于free-style理念探讨穿支螺旋桨皮瓣在修复踝关节周围软组织缺损的应用

目的 运用free-style理念设计穿支螺旋桨皮瓣修复踝关节周围软组织缺损,探讨其可靠性与临床疗效.方法 回顾性分析2017年9月—2019年6月陕西中医药大学附属医院创伤二科收治的踝关节周围软组织缺损患者34例,男性21例,女性13例;年龄21～69岁,平均47.3岁;道路交通伤10例,重物砸伤6例,高处跌落伤7例...     

Lisfranc injury--surgical fixation facilities an early return to work

BACKGROUND: Lisfranc injury is rare and the diagnosis maybe easily missed. This study reviews the experience of a single centre. METHODS: A prospective review of patients with Lisfranc injuries presenting to a single surgeon with a specialist interest in foot and ankle surgery over a one year period. RESULTS: Five patients were identified--four men and one woman with a median age of 31 years (range 22-50 years). Presentation was a mean of 25 days after injury (range 3-56 days). The left foot was affected in three cases and the right in two. There was joint diastasis in four patients and fracture-dislocation in one. Three patients presented early and were treated by internal fixation and two presented late and were managed conservatively. Mean follow-up was eight months (range 4.5-12 months). Surgery resulted in a return to work by 6 months with no symptoms. The two patients managed conservatively continued to experience pain at 12 months and were unable to return to their original occupations. CONCLUSION: Injury to the Lisfranc joint should be excluded in any foot injury. Early diagnosis and internal fixation appears to result in an earlier return to work when compared to non-operative management.     

闭合复位经皮空心螺钉内固定与切开复位内固定治疗踝关节骨折的疗效比较

目的 探讨闭合复位经皮空心螺钉内固定(MINI)与传统切开复位内固定(ORIF)治疗踝关节骨折的疗效.方法 对2004年3月～2009年8月收治的98例非粉碎性内外踝双骨折临床资料进行回顾性分析,根据内固定方法不同分为MINI组和ORIF组,MINI组53例,男性42例,女性11例;年龄23～59岁,平均37.5岁;骨...     

Post-sprain versus post-fracture post-traumatic ankle osteoarthritis: Impact on foot and ankle kinematics and kinetics

BackgroundCommon etiologies for post-traumatic ankle osteoarthritis are ankle fractures and chronic ankle instability. As the nature of trauma is different for these two etiologies, it might be expected that the two subtypes of post-traumatic ankle osteoarthritis would display different foot mechanics during gait.Research questionThe objective of this exploratory cross-sectional study was to compare the foot kinematics and kinetics of patients suffering from post-fracture ankle osteoarthritis with those of patients suffering from post-sprain ankle osteoarthritis.MethodsTwenty-nine subjects with end-stage post-traumatic ankle osteoarthritis and fifteen asymptomatic control subjects participated in this study. All patients suffered from post-traumatic ankle osteoarthritis secondary to ankle-related fracture (Group 1; n = 15) or to chronic ankle instability (Group 2; n = 14). A four-segment kinematic and kinetic foot model was used to calculate intrinsic foot joint kinematics and kinetics during gait. Vector field statistical analysis MANOVA was used to assess differences between groups for the entire three-component intrinsic foot joint angles and moments.ResultsMANOVA showed significant differences between the groups. Post-hoc analyses suggested that the differences between post-fracture ankle osteoarthritis group and controls were caused by a combination of less adducted Shank-Calcaneus position and less plantarflexion at this joint. Post-hoc analyses also suggested that both pathological groups exhibited a decreased plantarflexion moment for Shank-Calcaneus, Chopart, Lisfranc joints compared to controls. Analyses of both pathological groups versus controls for power suggested lower Shank-Calcaneus and Lisfranc power generation during pre-swing phase.SignificanceNo significant differences were found between the two pathological groups in this exploratory study. Alterations in foot kinematics and kinetics were mainly found about the dorsi-/plantarflexion axis during the pre-swing phase of the stance phase for both pathological groups compared to controls. Observed differences were not limited to the painful ankle joint, but seem also to have affected the kinetics of the neighbouring foot joints.     

Arthroscopic treatment of sports-related synovitis of the ankle.

We describe nine cases of sports-related synovitis of the ankle joint with a followup of 24 to 44 months (average, 30.9). It affects young athletes and occurs after episodes of acute or recurrent inversion ankle sprains or undisplaced ankle fractures. The patients complain of morning pain and stiffness along with increased pain and swelling with attempted athletic participation. All ankles were stable and all failed to respond to at least 6 months of conservative treatment. The technetium bone scans were positive in eight of the cases. During arthroscopy, a hypertrophic anterior-chamber synovitis was found and treated by arthroscopic partial synovectomy. The results were excellent in eight of the patients in whom symptoms resolved, allowing full return to their previous sports, and fair in one case. The only complication was one superficial wound infection.