关节镜下经皮穿针空心螺钉内固定融合治疗距下关节创伤性关节炎

目的 探讨关节镜下经皮穿针空心螺钉内固定融合治疗距下关节创伤性关节炎的方法并评价其临床疗效.方法 选择2006年4月-2009年12月收治的12例严重距下关节创伤性关节炎患者,其中男5例,女7例;年龄28～68岁,平均45.6岁.均为单纯距下关节病变,经保守治疗、疼痛控制无效,选择关节镜下经皮穿针空心螺钉内固定的距下关节融合术.患者术前、术后均采用美国足踝外科协会(America Orthopedic Foot and Ankle Society,AOFAS)踝-后足功能评分表进行临床随访,同时,采用X线摄片进行影像学评估.结果 术后平均随访21.2个月(6～48个月).12例患者AOFAS术前评分(54.67±5.28)分(43～61分),术后末次随访评分(89.17±3.56)分(78～95分),优良率为93%.术后X线片显示,11例距下关节骨性融合,平均融合时间为12.4周(9～15周).1例出现骨不连,行走后外踝下方疼痛,给予石膏靴固定制动3个月后复查X线片,距下关节骨性融合.结论 关节镜下经皮穿针空心螺钉内固定融合治疗距下关节创伤性关节炎可获得良好的临床疗效,是一种值得推荐的手术方法.     

关节镜下病灶清理术治疗踝关节骨性关节炎临床疗效分析

目的:探讨关节镜下病灶清理术治疗踝关节骨性关节炎的临床效果及其影响因素。方法:回顾性研究2000年3月至2006年2月本所收治的67例踝关节骨性关节炎病例,67例均行踝关节镜下病灶清理术,54例患者获得随访,平均随访时间为36.4(12～84)个月。比较术前、术后美国足踝外科(AOFAS)踝-后足评分、改良的McGuire踝关节评分、Mazur踝关节评分,以及不同病变程度、性别和年龄组之间改良的McGuire踝关节评分的差异;并进行主观疗效评定。结果:术后患足AOFAS踝-后足评分、改良的McGuire踝关节评分及Mazur踝关节评分均明显提高,分别从术前的58.2±12.9分、59.5±15.4分、61.3±14.7分提高至84.4±11.4分、85.3±12.8分、85.1±15.3分(均P<0.01);主观疗效优良率为81.5%。小于40岁的年轻患者及病变程度较轻患者的疗效较好(P<0.05)。结论:关节镜下病灶清理术治疗踝关节骨性关节炎疗效良好,病变程度及患者年龄是影响疗效的因素。     

人工踝关节置换治疗踝关节病的临床疗效

目的探讨人工踝关节置换治疗踝关节病的疗效。方法对18例患者18踝行人工踝关节置换,其中创伤性踝关节炎9例,骨性踝关节炎6例,创伤后局限性距骨缺血坏死2例,粉碎骨折踝关节融合后1例。结果随访1～5年,按Kofoed评价系统观察疗效,优16例,良2例。患足背伸范围6°～12°,跖屈范围8°～16°,背伸和跖屈11°～23°。并发症有切口皮缘坏死2例,无足内、外翻和影像学松动。结论人工踝关节置换是改善踝关节功能的良好方法。     

关节镜辅助下足踝关节融合术

目的探讨关节镜辅助下足踝关节融合术的方法与疗效。方法2001年1月-2004年7月，采用关节镜辅助下踝关节融合术13例，距舟关节融合术8例。男15例，女6例；年龄32—68岁，平均41岁。其中踝关节粉碎性骨折伴创伤性骨关节炎6例，地方性大骨节病7例，距舟关节炎8例；左足9例，右足12例。镜下清除踝关节和距舟关节增生肥厚的滑膜和纤维瘢痕组织，磨削骨赘，切除胫骨端、距骨穹隆和内外侧踝穴的软骨和软骨下骨，进行自体骨植骨。为保证骨对骨的密切接触需进行内固定。结果术后均获得随访，时间6～38个月，平均10个月。术后关节无肿胀和疼痛，行走步态和功能明显改善，X线片显示骨性融合。结论关节镜辅助下进行踝关节和距舟关节融合，不仅创伤小、视野清晰、操作简便，而且不破坏周围结构，有利于融合并保留踝穴轮廓。     

环锯法闭合行踝关节融合术42例

踝关节创伤性骨性关节炎及部分畸形严重影响下肢运动功能,传统的关节融合术创伤大,感染率和不愈合率高。我院自1995年6月起,选用20个截肢标本作解剖学测量、研究、设计,并实施环锯法闭合行踝关节融合术,临床应用42例,取得满意疗效。标本测量及计算利用20例截肢病人,男8例,女12例。其中创伤截肢9例,糖尿病足截肢11例。解剖下端关节面:胫骨下端关节面呈凹形,据Ｈｏｌｉｎｓｈｅａｄ测量[1],胫骨下端关节面的冠状面与胫骨上端的冠状面不在同一平面上。一般正常人下端较上端向外扭转0°～45°,平均20°,笔者所测为14°～25°,平均17°;踝关节矢…     

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.     

关节镜下复位空心螺钉固定治疗股骨髁部B型骨折11例临床报道

目的:探讨关节镜引导下微创治疗股骨髁部B型骨折的临床效果及手术适应症。方法:自2009年3月～2011年3月,对11例(11膝)股骨髁部B型骨折患者进行关节镜引导下复位空心螺钉固定术,其中男7例,女4例,年龄平均34.5岁;将骨折依国际内固定研究会(AO)标准分类,B1型3例,B2型4例,B3型4例。清理关节腔后,在关节镜监视下牵引,用点式复位钳不断调整以复位骨折,镜下证实关节面分离<2 mm和骨折的软骨面平整后,打入导针,用空心螺钉固定。结果:全部11例患者均获得随访,平均17个月(10～27个月),术后复查X线片示骨折均解剖对位,术后6月骨折均达到骨性愈合,Lysholm膝关节评分平均为90分(83～95分),膝关节屈伸活动度平均为131°(120～140°)。结论:关节镜引导下复位空心螺钉固定股骨髁部B型骨折具有微创、可视、复位确切等优点,并对合并膝内损伤者具有明显诊治优势。     

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.     

锚钉修复三角韧带结合内固定治疗旋前外旋Ⅳ度踝关节骨折

目的探讨应用锚钉修复三角韧带损伤结合钢板螺钉内固定治疗旋前外旋Ⅳ度踝关节骨折的疗效。方法 2009年8月~2011年10月,对26例旋前外旋型Ⅳ度踝关节骨折行切开复位内固定,并植入锚钉修复三角韧带深层和浅层,恢复内、外侧结构的稳定性。术后观察骨折愈合及患者踝关节功能恢复情况。结果 26例随访6~30个月,平均16个月。所有骨折均愈合,时间10~16周,平均12周。1例未固定下胫腓联合的患者,负重后逐渐出现踝穴增宽、距骨外移导致创伤性关节炎而疼痛。采用Mazur踝关节症状与功能评分评定疗效:优15例,良8例,可2例,差1例,优良率为88.5%。无感染、骨折不愈合、锚钉松动等发生。结论应重建旋前外旋型踝关节骨折中三角韧带的连续性及下胫腓联合的稳定性,锚钉具有创伤小、对踝关节生理影响小等特点,是修复三角韧带损伤的有效方法。     

关节置换治疗膝关节创伤后晚期严重功能障碍

目的探讨膝关节创伤后严重功能障碍的治疗以及人工关节置换治疗这类疾病的手术适应证及手术方法。方法自1997年6月至2004年6月采用人工关节置换治疗严重创伤后晚期膝关节功能障碍18例21膝,对于其中严重创伤性关节炎无明显畸形10例12膝,采用膝关节表面置换。创伤性关节炎合并膝关节20°～40°内外翻或20°～90°固定性屈曲畸形6例7膝,膝关节完全骨性强直2例2膝,患者采用可旋转铰链式膝关节。所有患者均获得随访,时间6个月～7年,平均3.5年,采用美国特种外科医院(HospitalforSpecialSurgery,HSS)评分标准对手术疗效进行评价。结果评定膝关节术后的疼痛、活动功能、关节畸形矫正以及稳定性和肌力。术前评价均为差,术后优12膝,良7膝,可2膝,总优良率90%。患者主观满意率为100%。结论关节置换治疗膝关节创伤后晚期严重功能障碍是一种有效的方法。     

人工全踝关节置换术治疗踝关节骨关节炎的疗效分析

目的 观察人工全踝关节置换术治疗踝关节骨关节炎的疗效.方法 对1999年10月- 2006年10月所收治的42例患有严重踝关节骨关节炎并符合手术适应证的患者进行人工全踝关节置换术.并按照Kofoed评分标准,对患者的疼痛程度、踝关节功能、踝关节活动度进行评分;同时根据Mayo踝关节置换的评价标准对患者进行疗效评价.结果 根据Kofoed评分标准,术后患者在疼痛、功能和活动度方面都明显优于术前(P＜0.05),优良率为90％ (28/31);而根据Mayo踝关节置换的评价标准,优良率为87％ (27/31).结论 人工全踝置换术能有效缓解踝关节疼痛,改善踝关节活动度及功能,为需行踝关节融合术患者提供一种有效的方法.     

Arthroscopic management of septic arthritis: stages of infection and results

Seventy-six patients with septic arthritis (78 affected joints) were treated with a combination of arthroscopic irrigation, debridement, and antibiotic therapy according to the tested bacterial sensitivity. There were 62 knee, 10 shoulder, 5 ankle joints, and 1 hip joint. No antibiotics were added to the irrigating solution. The arthroscopic and radiological stage of infection, treatment, and outcome in these patients was analyzed. The patients were classified into three groups according to initial stage of joint infection (stage I: 21 patients, 22 joints; stage II: 43 patients, 44 joints; stage III: 12 patients, 12 joints). Causes of infection were: hematogenous dissemination in 54%, postoperative wound infection in 28% (17% after open, 11% after arthroscopic procedures). Other causes were: 10% intra-articular steroid injections, 3% diagnostic punctures, and 3% open traumatic injury of the joint. In 78% of the infected joints the causative organism could be identified: Staphylococcus aureus was the most common organism found (42%), followed by streptococci (15%), pneumococci (6%), Escherichia coli (4%), Staphylococcus epidermidis (3%), Borrelia burgdorferi (3%), and others in 5%. In the stage I group only one patient needed repeated arthroscopic irrigation, in the stage II group 52%, and in the stage III group 75%. Open revision for eradication of the infection was necessary in one joint with stage II and in two joints with stage III infection (3%). Two joints of the stage III group needed additional surgery after successful treatment of the infection. The combination of arthroscopic irrigation and systemic antibiotic therapy was able to cure 91% of the affected joints. Open revision was necessary in 4% of joints. The number of arthroscopic procedures and the efficacy of treatment depended on the initial stage of the infection. It is concluded that an arthroscopic staging of the initial joint infection has prognostic and therapeutic consequences.     

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.     

Treatment of anterolateral impingements of the ankle joint by arthroscopy

Impingement syndromes of the ankle joint are among the most common intraarticular ankle lesions. Soft tissue impingement lesions of the ankle usually occur as a result of synovial, or capsular irritation secondary to traumatic injuries, usually ankle sprains, leading to chronic ankle pain. The aim of this prospective study was to evaluate arthroscopic debridement of an anterolateral soft tissue impingement of the ankle. During the period between October 2000 and February 2004, 23 patients with residual complaints after an ankle sprain were diagnosed as anterolateral impingement of the ankle, and were treated by arthroscopic debridement. At a minimum of 6 months follow up, patients were asked to complete an American orthopaedic foot and ankle society (AOFAS) ankle and hind foot score. The average follow-up was 25 months (range 12–38). The average pre-operative patient assessed AOFAS score was 34 (range 4–57). At the end of follow-up the mean AOFAS score was 89 (range 60–100). In terms of patient satisfaction 22 patients said they would accept the same arthroscopic procedure again for the same complaints. At the end of follow-up, 7 patients had excellent results, and 14 patients had good results while two patients had fair results. We believe that arthroscopic debridement of the anterolateral impingement soft tissues are a good, and effective method of treatment.     

Tibiocalcaneal arthrodesis: a new arthroscopic procedure

Tibiocalcaneal arthrodesis is considered an aggressive and technically demanding procedure that can be used to treat severe deformities of the hindfoot, and it is rarely performed. The indications for ankle arthroscopy are increasing, and arthroscopic tibiotalar arthrodesis is a common and successful procedure, but arthroscopic tibiocalcaneal arthrodesis has not been previously reported in the literature. A case of extensive talus necrosis with severe hindfoot deformity treated by means of an arthroscopic tibiocalcaneal arthrodesis is presented.     

Anterolateral ankle impingement: mr arthrographic assessment of the anterolateral recess

PURPOSE: To determine the accuracy of magnetic resonance (MR) arthrography in assessing the anterolateral recess of the ankle. MATERIALS AND METHODS: Thirty-two patients with chronic ankle pain prospectively underwent gadolinium-enhanced MR arthrography of the tibiotalar joint. All underwent clinical examination and were included if anterolateral impingement (n = 13) or a control condition (n = 19; suspected osteochondral defect, intraarticular bodies, instability, osteoarthritis) was diagnosed. MR imaging included transverse and coronal T1-weighted and sagittal T2-weighted imaging sequences. Images were prospectively analyzed by two readers blinded to the clinical diagnosis. The anterolateral gutter contour was assessed. MR arthrographic findings were correlated with subsequent arthroscopic appearances. RESULTS: MR arthrographic assessment of the anterolateral soft tissues had an accuracy of 97%, sensitivity of 96%, specificity of 100%, negative predictive value of 89%, and positive predictive value of 100%. Accuracy was 100% with clinical anterolateral impingement, with an arthroscopically confirmed abnormality in 12 cases and a normal appearance in one. Anterolateral soft-tissue thickening was identified at MR arthrography in 11 control cases, with arthroscopic confirmation in all. The remaining cases had normal appearances, with an arthroscopic soft-tissue abnormality in one case and a normal appearance in seven. CONCLUSION: MR arthrography of the tibiotalar joint is accurate in assessing the anterolateral recess of the ankle.     

运动员踝关节骨折脱位及下胫腓分离的治疗

本文报告了运动损伤所致踝关节骨折,脱位及合并下胫腓分离48例的治疗结果,重点对运动员下胫腓关节分离的处理原则,治疗方法及创伤性骨关节炎的防治进行了分析探讨,同时阐述了踝关节骨折、脱位的治疗原则。针对运动员对踝关节稳定性要求较高的特点,建议运动员不稳定踝关节骨折,合并严重的韧带断裂及下胫腓分离应尽早手术,切开复位内固定治疗。     

33例全关节结核的关节镜治疗经验总结

目的:探讨应用关节镜治疗全关节结核的方法和疗效. 方法:收集1995年2月至2006年5月经关节镜治疗的33例全关节结核病例,其中肩关节结核4例,肘关节结核3例,髋关节结核5例,膝关节结核18例,踝关节结核3例.镜下对关节彻底清理,对干酪样坏死组织或脓液进行结核杆菌培养和药物敏感性试验,术毕置管冲洗.术后关节腔用抗结核药物冲洗1～2周,肩、肘关节绷带固定3周后活动,髋、膝、踝关节石膏固定12周(22例)或外固定架固定3～6个月(2例).根据药敏试验结果进行抗结核治疗,持续1年.结果:本组33例均获3个月以上随访,根据Ikeuchi膝关节评分标准,疗效优25例,良8例.髋、膝、踝关节全部融合,所有关节伤口均一期愈合.结论:对于早、中、晚期,甚至合并窦道形成的全关节结核,均可考虑行关节镜下关节清理术.对全关节结核的镜下清理可以彻底清创,减轻创伤,降低伤口不愈合率,保持非负重关节的功能,提高负重关节的融合率.在药敏试验指导下的有针对性的抗结核治疗非常重要.