全踝关节镜下免打结锚钉修复距腓前韧带的疗效分析

目的：探讨全踝关节镜下采用免打结锚钉修复距腓前韧带治疗慢性踝关节外侧不稳的临床疗效。方法：自2018年4月至2021年8月,对24例采用全踝关节镜下免打结锚钉修复距腓前韧带治疗的慢性踝关节外侧不稳患者进行回顾性分析,其中男16例,女8例;年龄22~42(28.6±5.8)岁;受伤至手术时间6~10(7.7±1.3)个月。比较手术前后美国踝与足关节协会(American Orhopaedic Foot and Ankle Society,AOFAS)踝与后足功能评分、视觉模拟疼痛评分(visual analogue scale,VAS)、距骨倾斜角及距骨前移距离变化情况。结果：所有患者获得随访,时间8~12(10.20±1.14)个月。伤口均Ⅰ期愈合,未出现伤口感染,神经损伤及踝关节外侧不稳等其他并发症。AOFAS评分由术前(52.79±8.96)分提高到术后6个月(93.00±4.01)分,其中优23例,良1例;VAS由术前(5.50±0.98)分下降到术后6个月(1.04±0.80)分(P<0.05);距骨倾斜角由术前(9.16±2.09)°下降到术后3个月(3.10±1.72)°(P<0.05);距骨前移距离由术前(8.80±2.55) mm下降到术后3个月(2.98±1.97) mm (P<0.05)。末次随访24例患者行踝关节抽屉试验及内翻试验均为阴性。结论：全踝关节镜下采用免打结锚钉技术修复距腓前韧带治疗慢性踝关节外侧不稳创伤小,并发症少,安全可靠,踝关节功能恢复好。     

Five-year functional outcome analysis of ankle fracture fixation

This study examines retrospectively the functional outcome of patients at 5 years following their ankle fracture surgery using the Olerud-Molander Ankle Score (OMAS) and SF-12 questionnaire. Of 69 patients, 43 were females and 26 males. The mean age was 50.7 years. There were 74 and 26% of Weber 'B' and 'C' fractures, respectively. The mean OMAS was 75.2. About 63% of the patients were still complaining of stiffness, around 45% patients were still complaining of ankle swelling, 50% of patients still had some sort of pain, 39% still thought that they had not fully recovered and 38% did not return to their pre-injury sporting activity. Apart from the age, no significant difference was seen in the OMAS due to gender, fracture type or timing of surgery. Our findings show that many patients who have had surgery for ankle fractures will still have some functional limitations even 5 years after the injury.     

Posterior tibial nerve lesions in ankle arthroscopy

Ankle arthroscopy provides a minimally invasive approach to the diagnosis and treatment of certain ankle disorders. Neurological complications resulting from ankle arthroscopy have been well documented in orthopaedic and podiatric literature. Owing to the superficial location of the ankle joint and the abundance of overlying periarticular neurovascular structures, complications reported in ankle arthroscopy are greater than those reported for other joints. In particular, all reported neurovascular injuries following ankle arthroscopy have been the direct result of distractor pin or portal placement. The standard posteromedial portal has recognized risks because of the proximity of the posterior neurovascular structures. There can be considerable variability in the course of these portals and their proximity to the neurovascular structures. We found one report of intra-articular damage to the posterior tibial nerve as a result of ankle arthroscopy in the English-language literature and we report this paper as a second case described in the literature.     

Pseudoaneurysm as a complication of ankle arthroscopy

We present a case of a pseudoaneurysm of the anterior tibial artery following ankle arthroscopy with synovectomy, an extremely rare complication when standard anteromedial and anterolateral portals are used. The patient was diagnosed and treated with appropriate interventions which led to an uneventful recovery. Nevertheless, the potential sequelae of delayed diagnosis or misdiagnosis of the complication are dangerous; therefore, a high index of suspicion for a pseudoaneurysm must be maintained in the postoperative period.     

踝关节慢性前外侧不稳的手术治疗

目的: 探讨治疗踝关节慢性前外侧不稳定 (踝关节外侧不稳定合并距下关节不稳定) 的合理而有效的手术方式。方法: 自 1999 ~2003年, 应用Chrisman Snook术式, 以腓骨短肌腱前半部分重建距腓前韧带、跟腓韧带和距跟外侧韧带,治疗踝关节慢性前外侧不稳 8例患者,共 13例关节。结果: 术后随诊 6个月~5年, 平均 19个月。术后所有踝关节均达到功能稳定, 关节活动度基本恢复正常, 没有复发性踝关节不稳发生。以Good评级标准作为疗效评价, 10例关节 (77% ) 为优, 2例关节 (15% ) 为良, 1例关节为中 (7% ), 优良率达 92%。结论: Chrisman Snook术式重建了距腓前韧带、跟腓韧带和距跟外侧韧带, 有效地矫正了踝关节外侧不稳定和距下关节不稳定, 是治疗踝关节慢性前外侧严重不稳定的合理而有效的治疗方法。     

关节镜联合韧带缝合治疗外踝不稳的短期疗效

目的随访采用关节镜手术联合小切口辅助下缝合距腓前韧带缝合术式治疗的患者,分析此术式治疗慢性外踝不稳的近期疗效,为进一步推广应用提供依据。 方法回顾性随访自2016年1月至2018年5月,选择保守治疗无效的踝关节机械性不稳患者,排除功能性不稳、足踝部畸形等其他病史的患者。共纳入了西南医院关节外科63例应用关节镜手术联合韧带缝合术治疗慢性外踝不稳的患者。记录围手术期并发症,采用配对t检验分析术前与术后1年以上末次随访的踝关节视觉模拟疼痛(VAS)评分、美国足踝骨科协会踝与后足(AOFAS)评分。 结果患者末次随访较术前踝关节VAS评分、AOFAS评分明显改善,差异有统计学意义(t＝17.8、20.8,两者均P<0.01)。关节镜手术探查发现：合并软组织撞击征47例,撕脱性骨折24例,前踝骨性撞击征11例,距骨软骨损伤8例,关节游离体8例,腓骨肌腱脱位1例。患者术后均无严重并发症。 结论关节镜手术联合韧带缝合术治疗慢性外踝不稳,可以获得较理想的近期疗效。该联合方案,既可以应用关节镜微创术处理踝关节内合并损伤,又可以使用锚钉技术缝合距腓前韧带,具有操作相对简单,并发症低的优势。     

Ankle position affects dorsalis pedis artery exposure in anterior ankle arthroscopy

BackgroundIn anterior ankle arthroscopy, the anterior working area (AWA) is restricted by the presence of the dorsalis pedis artery (DPA) and tendons. Pseudoaneurysms caused by iatrogenic damage to the DPA are difficult to identify intraoperatively. In knee arthroscopy, risk of popliteal artery damage is reduced in the flexed position [1]. This study investigates how DPA movement is affected by dorsiflexion and plantarflexion with the aim of identifying the positions providing the greatest AWA.MethodsTwelve cadaveric ankles were dissected to access the DPA. While distracted, ankles were progressively dorsiflexed at 5° intervals from maximum plantarflexion. DPA and tibialis anterior tendon (TA) movement at each 5° interval was measured by their respective distances from the inferior border of the medial malleolus.ResultsMean ankle dorsiflexion was 24.58 ± 1.30° with all specimens showing anterior DPA and TA movement as dorsiflexion increased. Mean DPA and TA movement at maximum dorsiflexion was 3.58 ± 0.29 mm and 2.92 ± 0.34 mm respectively. A ratio of 1:1.23 relates TA and DPA movement (in mm), and a ratio of 10:1.46 relates dorsiflexion angle to DPA movement (in mm).ConclusionAnterior movement of the dorsalis pedis artery during dorsiflexion increases the AWA for anterior arthroscopy. Increasing the AWA with maximal dorsiflexion may prove to be a valuable method for lowering the risk of iatrogenic DPA damage. Additionally, increased AWA may allow the use of larger diameter surgical instruments allowing greater control and a reduction in operation time.     

慢性踝关节不稳诊断与治疗的研究进展

慢性踝关节不稳常由急性踝关节扭伤漏诊或者治疗不当所致,可以导致局部长期疼痛,继发踝关节创伤性关节炎甚至功能障碍等一系列问题,是种常见但治疗相对棘手的疾病。但是对于其诊断与治疗尚没有统一的标准。应力下X线、MRI及超声等检查方式众多,哪种才是疾病诊断过程中的首选或是金标准。在疾病的治疗过程中,手术是治疗严重踝关节不稳的主要手段,但现有的手术方式疗效差别较大,理念也不尽一致,使临床医师选择手术方式时存在较大的困惑。近年来文献报道的手术治疗方式已由原有的非解剖重建逐渐向原位解剖重建转变。     

一期韧带修复联合拉力螺钉固定治疗踝关节不稳的疗效观察

目的：探讨一期韧带修复联合拉力螺钉固定治疗踝关节不稳的临床疗效。方法回顾性分析2011年1月至2013年6月间我科收治的34例急性踝关节外侧扭伤患者,男18例,女16例,年龄28.0~69.0岁,平均(49.3±1.9)岁。随机分为螺钉固定组和外固定组,每组各17例,分别采用一期带线铆钉原位修补联合拉力螺钉固定(螺钉固定组)和石膏或支具外固定治疗(外固定组)。所有患者术后患肢不负重,随访3个月,观察两组住院费用及并发症发生情况,根据美国足踝外科协会( American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足功能评分及视觉模拟评分法( visual analogue score, VAS)评价两种方法的治疗效果。结果螺钉固定组住院费用为(1.72±0.30)万元,外固定组为(0.68±0.20)万元,差异有统计学意义(P<0.05)。术后1、2、3个月随访AOFAS踝与后足评分,螺钉固定组为(66.2±1.3)分、(88.5±2.1)分、(97.2±1.9)分,外固定组为(46.8±1.6)分、(53.5±2.7)分、(75.6±1.2)分,差异有统计学意义(P<0.05)。采用VAS评分：螺钉固定组为(3.2±0.8)分、(2.5±0.6)分、(1.2±0.2)分,外固定组为(4.0±0.7)分、(3.1±0.6)分、(2.6±0.4)分,差异有统计学意义(P<0.05)。螺钉固定组所有患者术后未发生螺钉切出、断钉、创伤性关节炎、下胫腓不稳等并发症,外固定组中2例出现踝关节僵硬,经功能锻炼和物理疗法后有所缓解,4例术后3个月因疼痛和踝关节不稳二期行韧带重建术,恢复可。结论一期韧带修复联合拉力螺钉固定治疗急性踝关节不稳虽然住院费用较高,但并发症少,术后踝关节功能佳,是临床治疗踝关节扭伤的一种可行术式。     

前踝撞击征的关节镜下诊断与治疗

目的探讨前踝撞击征的关节镜下诊断与治疗。方法2000年1月至2006年1月，关节镜下治疗前踝撞击征患者28例，男18例，女10例；年龄18-51岁，平均32岁；左踝12例，右踝16例。17例有长期运动史，5例有踝关节背伸劳作史，6例有踝部骨折脱位史及反复损伤史；病史最短6个月，最长7年。踝关节检查时胫骨前缘或前内侧有固定压痛，背伸活动均不同程度受限，部分踝关节僵硬。根据Scranton和McDermott的放射学分级标准，Ⅰ级6例，Ⅱ级15例，Ⅲ级5例，Ⅳ级2例。术前采用McGuire踝关节评分系统进行评分，13例可（65-70分），15例差（〈65分）。最低41分，最高67分，平均52分。踝关节镜下用刨削器、磨钻、组织汽化仪等清理增生肥厚及炎性的滑膜、退变的软骨和骨赘等。结果所有患者均获随访，随访时间11-48个月，平均27个月。术后McGuire评分显示：Ⅰ级6例，均为优良。Ⅱ级15例，12例优良，3例可。Ⅲ级5例，2例优良，2例可，1例差；其中无间隙狭窄者2例，1例为优良，有间隙狭窄者3例，1例为优良。Ⅳ级2例，均为差。优良率为71．4％。术后最低59分，最高94分，平均76分，较术前平均提高24分。无一例发生并发症。1例Ⅳ级患者术后27个月复发。结论关节镜下治疗Ⅰ、Ⅱ级及部分无关节间隙狭窄的Ⅲ级前踝撞击征患者疗效肯定，而对于部分有关节间隙狭窄的Ⅲ级及Ⅳ级前踝撞击征患者疗效欠佳。     

The safety of the posterior ankle arthroscopy in management of posterior ankle impingement: A cadaveric study

BackgroundArthroscopic management of the posterior ankle impingement with the patient in supine position has the advantage of dealing with anterior ankle pathology at the same time without the need to change position of the patient. This study aims at evaluation of the safety of portal establishment and instrumentation of this technique.MethodsSixteen fresh-frozen cadaver specimens were used. The relationships of the posteromedial and posterolateral portals to the adjacent tendons and nerves and the relationship of the coaxial portal tract with the posterior ankle capsule and the flexor hallucis longus tendon were studied.ResultAngle θ₁ between the intermalleolar line and the posterior ankle coaxial portal tract averaged 1° (−10° to 22°). Angle θ₂ between the intermalleolar line and the metal rod where the neurovascular bundle started to move averaged 19° (10° to 30°). Angle θ₃ between the intermalleolar line and the metal rod where it reached the lateral border of the Achilles tendon was larger than angle θ₂ in all specimens. The angle of safety (θ_s) averaged 18° (−1° to 26°).ConclusionsInjury to the tendon, nerves or vessels is possible during establishment of the portals and resection of the os trigonum.     

踝关节外侧不稳的手术修复

目的探讨踝关节外侧不稳手术治疗的效果。方法自1994年6月至2007年7月采用Watson—Jones手术和改进的Chrisman—Snook手术治疗踝关节不稳24例（踝）,其中11例采用Watson—Jones手术,13例采用Chrisman—Snook手术。结果除8例失访外,余16例获平均5年9个月（2．5—9年）随访,踝关节功能采用踝关节稳定度（50分）、踝关节内翻试验（25分）和踝关节抽屉试验（25分）等来评价,疗效优（85～100分）14例,良2例（70—84分）,无失败（〈69分）。还比较了Watson—Jones法与改进的Chrisman—Snook法疗效。术前、术后稳定度、踝内翻试验和抽屉试验两组数据的统计学分析（P〈0．01）有显著意义。本组无并发症发生。结论踝关节外侧不稳采用Watson-Jones手术和改进的Chrisman—Snook手术修复踝关节外侧韧带有良好疗效。     

踝关节外侧结构重建治疗踝关节外侧不稳

目的：探讨踝关节外侧结构重建在治疗慢性踝关节外侧不稳中的作用。方法：回顾分析2005年7月至2008年1月收治的13例慢性踝关节不稳患者,男10例,女3例;年龄24～45岁,平均33岁。13例均采用自体半束腓骨短肌腱解剖重建距腓前韧带和跟腓韧带（Sammarco法）,手术前后按踝关节评分系统进行评分,评分项目包括稳定性、疼痛、活动能力、X线表现。结果：13例均获随访,时间6～32个月,平均16.4个月,患者踝关节评分在稳定性、疼痛、活动能力等方面均有所改善,踝关节评分由术前的平均（43.54±7.04）分提高至术后的（73.38±4.17）分,手术前后差异有统计学意义（P〈0.01）。全部患者对手术表示满意。结论：采用半束自体腓骨短肌腱解剖重建距腓前韧带及跟腓韧带的方法治疗踝关节外侧不稳,操作便利,对于以关节不稳为主要表现的患者,疗效确切。     

注重慢性踝关节不稳的诊断和治疗

<正>踝关节不稳指踝关节内外侧及下胫腓联合等维持踝关节稳定的重要结构受损,导致踝关节频繁内翻或外翻性损伤所引发的踝关节长期慢性疼痛和创伤性关节炎以及功能障碍,也称为踝关节不稳综合征。踝关节不稳主     

Operative arthroscopy of the ankle

The long-term results of 30 operative arthroscopies of the ankle performed from 1983 to 1989 are the basis of this study. The most frequent lesions are synovitis and osteochondral defects of the talus. The treatment consists of lavage, synovial debridement, osteochondral debridement, and the removal of loose bodies. Of the 30 cases, 86.7% obtained excellent or good results and 88% of the athletes returned to their sport.     

The feasibility of point-of-care ankle ultrasound examination in patients with recurrent ankle sprain and chronic ankle instability: Comparison with magnetic resonance imaging

ObjectiveTo evaluate the feasibility of point-of-care ankle ultrasound compared with magnetic resonance imaging (MRI) for diagnosing major ligaments and Achilles tendon injuries in patients with recurrent ankle sprain and chronic instability, and to evaluate inter-observer reliability between an emergency physician and a musculoskeletal radiology fellow.Material and methodsA prospective cross-sectional study was conducted in an emergency department. Patients with recurrent ankle sprain and chronic instability were recruited. An emergency physician and a musculoskeletal radiology fellow independently evaluated the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), distal anterior tibiofibular ligament (ATiFL), deltoid ligament, and Achilles tendon using point-of-care ankle ultrasound. Findings were classified normal, partial tear, and complete tear. MRI was used as the reference standard. We calculated diagnostic values for point-of-care ankle ultrasound for both reviewers and compared them using DeLong's test. Intra-class correlation coefficients (ICCs) were calculated for agreement between each reviewer and the reference standard, and between the two reviewers.ResultsEighty-five patients were enrolled. Point-of-care ankle ultrasound showed acceptable sensitivity (96.4–100%), specificity (95.0–100%), and accuracy (96.5–100%); these performance markers did not differ significantly between reviewers. Agreement between each reviewer and the reference standard was excellent (emergency physician, ICC = 0.846–1.000; musculoskeletal radiology fellow, ICC = 0.930–1.000), as was inter-observer agreement (ICC = 0.873–1.000).ConclusionPoint-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries; it could be used for immediate diagnosis and further pre-operative imaging. Moreover, it may reduce the interval from emergency department admission to admission for surgical intervention, and may save costs.     

French translation and validation of the Cumberland Ankle Instability Tool,an instrument for measuring functional ankle instability

BackgroundAnkle sprains are one of the most common musculoskeletal injuries, and can lead to chronic ankle instability (CAI). The Cumberland Ankle Instability Tool (CAIT) measures a subset of CAI, functional ankle instability (FAI). Because no French version existed, we set out to translate and validate the CAIT in French.MethodsThe CAIT was translated using a forward-backward methodology. We examined its psychometric properties and calculated a cut-off score for FAI in a sample of 102 subjects (median age 22 years).ResultsThe CAIT was translated without significant problems. The CAIT-F can discriminate between those with and without FAI (p < 0.001), with a cut-off score of ≤ 23 points. The test-retest reliability is excellent (ICC = 0.960), as is the internal consistency (α = 0.885). Construct validity was confirmed. No floor or ceiling effects were detected among subjects with FAI.ConclusionsThe CAIT is now available in French, and is a valid and reliable instrument.     

Anterior tibiotalar impingement associated with chronic ankle instability

The authors describe the surgical treatment of 13 cases of chronic ankle instability and concomitant anterior bony impingement of the ankle in professional and recreational athletes. All patients had symptoms and signs of lateral instability and a painful block to dorsiflexion. Two patients presented with recurrence of impingement after a previous debridement alone without an ankle stabilization. The anterior osteophytes were debrided arthroscopically and a Brostrom-Gould open stabilization was performed. After a mean follow-up period of 12 months (range 4-23 months), all 13 patients had mechanically and functionally stable ankles. The mean improvement in range of dorsiflexion was 12.4 degrees and all but one had improvement with respect to a subjective and functional outcome assessment. There have been no recurrences of impingement to date. These results suggest that ankle stabilization performed in conjunction with debridement of osteophytes may reduce the recurrence of exostoses as well as improving the outcome.     

踝关节镜检在治疗急性踝关节骨折中的作用

目的探讨应用关节镜探查急性踝关节骨折时关节内合并病变,并辅助进行踝关节骨折的复位及固定的可能性及优缺点。 方法回顾性分析中山大学孙逸仙纪念医院骨科2016年3月至2017年11月诊断为"急性踝关节骨折"的患者,共78例。所有患者在行踝关节镜检＋切开复位内固定,记录关节镜下软骨损伤、三角韧带损伤、下胫腓联合损伤及游离碎片,采用卡方检验分析关节内病变与骨折类型的相关性。 结果在所有患者中,Weber A型骨折6例,Weber B型骨折45例,Weber C型骨折27例。骨软骨损伤共51例,其中Weber A/B/C分别0/33/18例;胫腓联合损伤39例,其中Weber A/B/C分别0/18/21例;三角韧带损伤27例,其中Weber A/B/C分别0/21/6例;关节腔游离碎片7例,其中Weber A/B/C分别0/4/3例。Weber B型骨折与Weber C骨折距骨软骨损伤发生无统计学差异(χ²＝0.363,P >0.05),但软骨损伤程度,Weber B型骨折更重(Fisher确切检验,P ＝0.007)。胫腓联合损伤,Weber B型骨折与Weber C骨折两组之间相比无统计学差异(χ²＝ 2.4 ,P >0.05);在Weber C骨折中,后踝骨折与胫腓联合不稳明显相关(Fisher确切检验,P ＝0.02)。三角韧带损伤,Weber B型骨折与Weber C骨折两组之间相比有统计学差异(χ²＝4.302, P<0.05);但当将内踝骨折与三角韧带损伤定义为内侧不稳时,两组之间无统计学差异(Fisher确切检验,P ＝0.07)。 结论在急性踝关节骨折时,关节镜探查可同时发现并处理合并的踝关节内病变,并辅助进行踝关节骨折的复位及固定,是提高切开内固定手术疗效的有益辅助工具。