2 下胫腓联合损伤

在急性踝关节外侧损伤中,有超过20 %的患者为单纯的胫腓联合损伤,并成为长期功能受限的原因[5 ,7 ] 。一般情况下并不会发生全部联合韧带的断裂,因此在诊断和治疗中有一定困难;而由于误诊或延误诊断而导致慢性功能受限和不稳定并不少见。对这一问题认识不足导致长期以来的治疗延误。这方面的文献报道也不多。已经普遍认同的手术方法为下胫腓螺钉的固定,对韧带本身很少做直接修复。下胫腓固定时如何选择合适的内固定物、适当的取出时间,内固定物的折断等可能的并发症,也影响踝关节运动功能的恢复[29 ] 。生物可吸收螺钉、下胫腓融合、晚期韧带修补等方法都有良好效果的报道[5 ,7 ] 。Marqueen 进行生物力学研究,分别比较下胫腓固定时使用门形钉及经胫腓联合的415 mm 螺钉固定效果:在失效载荷测试中无显著性差异;但是作者认为,螺钉固定时容易把腓骨固定在前内侧,处于相对旋转位置,因此作者认为门形钉能提供更好的固定方式,在腓骨受到扭转负荷下能将腓骨稳定在更加理想的位置[30 ] 。目前还有报道用钮扣缝合固定来修复胫腓联合的损伤[30 ] 。此种固定为柔性固定,通过经下胫腓联合做隧道,引入弹性固定材料,两端分别在胫骨、腓骨表面用钮扣挂在隧道口,理论上可以早期负重,不用取出,复位效果不会丢失,无折断等优点,但还需进一步的临床评价。Thornes 已有在尸骨上的生物力学测试及短期临床应用的报道[31 ] 。

3 结论

踝关节慢性外侧不稳定是严重扭伤后的常见后果,胫腓联合的损伤处理不当也可转为慢性,影响功能恢复,而且处理困难。因此提高对急性踝关节扭伤的诊断和早期专业治疗水平是预防CAI 的关键因素。功能锻炼仍然是处理外侧不稳定的首选,但是保守治疗无效时也需考虑手术,可供选择的术式很多。随着界面螺钉技术及各种同种异体或生物移植材料的面世,更接近于生理状态的原位解剖重建相对将更能满足重建后生物力学机制的需要,减少非解剖重建术式可能带来的关节活动受限、正常肌腱替代后的并发症等不足。术前仍需仔细评价有无软骨损伤、内侧不稳定等。关节镜技术在诊断及治疗中都有极大作用。

[参考文献]

[ 1 ]Sammarco VJ . Complications of lateral ankle ligament reconst ruction[J ] . Clin Ort hop Relat Res , 2001 , 397 :123 - 132.

[ 2 ] Hinterman B , Boss A , Schafer D. Art hroscopic findings in patient swit h chronic ankle instability[J ] . Am J Sport s Med , 2002 , 30 :402- 409.

[ 3 ]Coughlin MJ , Schenck RC , Grebing BR , et al . Comprehensive re2const ruction of t he lateral ankle for chronic instability using a f reegracilis graft [J ] . Foot Ankle Int , 2004 , 25 :231 - 241.

[ 4 ]王正义. 足踝外科学[M] . 北京:人民卫生出版社,2006 :201 - 203.

[ 5 ]Clanton TO , Paul P. Syndesmosis injuries in at hletes[J ] . Foot An2kle Clin Nort h Am , 2002 , 7 :529 - 549.

[ 6 ] Mosier2LaClair S , Pike H , Pomeroy G. Syndesmosis injuries : a2cute , chronic , new techniques for failed management [J ] . Foot An2kle Clin Nort h Am , 2002 , 7 : 551 - 556.

[ 7 ]Baltopoulos P , Tzagarakis GP , Kaseta MA. Midterm result s of amodified Evans repair for chronic lateral ankle instability [ J ] . ClinOrt hop Relat Res , 2004 , 422 :180 - 185.

[ 8 ]Mizel MS , Hecht PS , Marymont JV , et al . Evaluation and t reat2ment of chronic ankle pain[J ] . J Bone Joint Surg Am , 2004 , 86 :622- 632.

[9 ] Tropp H , Odenrick P , Gillquist J . Stabilomet ry recordings in func2tional and mechanical instability of t he ankle joint [ J ] . Int J Sport sMed , 1985 , 6 :180 - 182.

[ 10 ] Santilli V , Frascarelli MA , Paoloni M , et al . Peroneus longusmuscle activation pattern during gait cycle in at hletes affected byfunctional ankle instability. A surface elect romyographic study [J ] .Am J Sport s Med , 2005 , 33 :1183 - 1187.

[ 11 ] Pijnenburg ACM , Bogaard K, Krips R , et al . Operative and func2tional t reatment of rupture of t he lateral ligament of t he ankle[J ] . JBone Joint Surg Br , 2002 , 85 :525 - 530.

[ 12 ] Hinterman B , Valderrabano V , Boss A , et al . Medial ankle insta2bility. An exploratory , prospective study of fifty2two cases[J ] . AmJ Sport s Med , 2004 , 32 :183 - 190.

[ 13 ]DiGiovanni BF , Partal G, Baumhauer J F. Acute ankle injury andchronic lateral instability in t he at hlete[J ] . Clin Sport s Med , 2004 ,23 :1 - 19.

[ 14 ]Schmidt R , GergroüH , Friemert B , et al . The peroneal reactiontime. Reference data in a healt hy sample population[J ] . Foot AnkleInt , 2005 , 26 :382 - 386.

[ 15 ] Konradsen L , Ravn JB. Prolonged peroneal reaction time in ankleinstability[J ] . Int J Sport s Med , 1991 , 12 :290 - 292.

[ 16 ]Schmidt R , Benesch S , Friemert B , et al . Anatomical repair of lat2eral ligament s in patient s wit h chronic ankle instability [ J ] . KneeSurg Sport s Traumatol Art hrosc , 2005 , 13 :231 - 237.

[ 17 ] Trepman E , Lutter LD , Richardson EG, et al . Special Report .Highlight s of t he Twentiet h Annual Summer Meeting of t he Ameri2can Ort hopaedic Foot And Ankle Society , Seattle , Washington , J uly29 - 31 , 2004[J ] . Foot Ankle Int , 2005 , 26 :416 - 425.

[ 18 ]Brodsky AR , O’Malley MJ , Bohne WH , et al . An analysis of out2come measures following t he Brost rêm2Gould procedure for chroniclateral ankle instability[J ] . Foot Ankle Int , 2005 , 26 :816 - 819.

[ 19 ] Takao M , Oae K, Uchio Y, et al . Anatomical reconst ruction of t helateral ligament s of t he ankle wit h a gracilis autograft [ J ] . Am JSport s Med , 2005 , 33 :814 - 823.

[ 20 ] Krips R , van Dijk CN , Halasi PT , et al . Long2term outcome of an2atomical reconst ruction versus tenodesis for t he t reatment of chronicanterolateral instability of t he ankle joint . A multicenter study[J ] .Foot Ankle Int , 2001 , 22 :415 - 421.

[ 21 ]Okazaki K, Miyagi S , Tokunaga J . Anatomic reconst ruction of t helateral ligament of t he ankle using a Periosteal Flap f rom t he fibula[J ] . Techni Foot Ankle Surg , 2005 , 4 (2) :98 - 103.

[ 22 ]Schmidt R , Cordier E , Bert sch C , et al . Reconst ruction of t he lat2eral ligament s. Do t he anatomical procedures restore physiologic an2kle kinematics ? [J ] . Foot Ankle Int , 2004 , 25 :31 - 36.

[ 23 ] Paterson R , Cohen B , Taylor D , et al . Reconst ruction of t he later2al ligament s of t he ankle using semitendinosis graft [J ] . Foot AnkleInt , 2000 , 21 :413 - 419.

[ 24 ]Okuda R , Kinoshita M , Morikawa J , et al . Art hroscopic findingsin chronic lateral ankle instability. Do focal chondral lesions influ2ence t he result s of ligament reconst ruction ? [J ] . Am J Sport s Med ,2005 , 33 :35 - 42.

[ 25 ] Takahashi T , Nakahira M , Kaho K, et al . Anatomical reconst ruc2tion of chronic lateral ligament injury of t he ankle using pedicle ten2don of t he extensor digitorum longus [ J ] . Arch Ort hop TraumaSurg , 2003 , 123 :175 - 179.

[ 26 ] Takao M , Uchio Y, Naito K, et al . Art hroscopic assessment forint ra2articular disorders in residual ankle disability after sprain [ J ] .Am J Sport s Med , 2005 , 33 :686 - 692.

[ 27 ]Berlet GC , Saar WE , Ryan A , et al . Thermal2assisted capsularmodification for functional ankle instability [ J ] . Foot Ankle ClinNort h Am , 2002 , 7 :567 - 576.

[ 28 ]Maiotti M , Massoni C , Tarantino U. The use of art hroscopic t her2mal shrinkage to t reat chronic lateral ankle instability in young at h2letes[J ] . Art hroscopy , 2005 , 21 :751 - 757.

[ 29 ] Thornes B , Wal sh A , Hislop M , et al . Suture2endobutton fixationof ankle tibio2fibular diastasis : a cadaver study[J ] . Foot Ankle Int ,2003 , 24 :142 - 146.

[ 30 ]Marqueen T , Owen J , Nicandri G, et al . Comparison of t he syn2desmotic staple to t he t ranssyndesmotic screw. A biomechanicalstudy[J ] . Foot Ankle Int , 2005 , 26 :224 - 230.

[31 ] Thornes B , Shannon F , Guiney AM , et al . Sut ure2button syndes2mosis fixation. Accelerated rehabilitation and improved outcomes[J ] . Clin Ort hop Relat Res , 2005 , 431 :207 - 212.