下胫腓前韧带的功能与损伤修复

发布时间：2018-07-10 17:38

本文选题：下胫腓联合 + 下胫腓前韧带　；参考：《南京医科大学》2017年博士论文

【摘要】：下胫腓联合损伤在临床上比较多见,可以单独存在,而更多的情况是与踝关节骨折同时并发1。下胫腓联合不稳定将产生踝关节疼痛、功能障碍、甚至最终发生创伤性骨关节炎2。下胫腓前韧带是构成下胫腓联合的重要结构之一,它呈多束复合结构,生物力学研究认为该韧带为下胫腓联合提供约35%的稳定性。然而长期以来,临床上对下胫腓前韧带损伤的处理却是消极而冷淡的。事实上,许多基础研究的证据表明3,下胫腓前韧带非常重要,而且自我修复能力比较差。首先,下胫腓前韧带由平行排列的致密胶原纤维构成,这一组织学特性是与该韧带需要承受较大应力相适应的。其次,运动学研究发现,当踝关节完成最大跖屈到最大背伸的运动时,下胫腓联合中腓骨的运动是轻微外移、后移和外旋,下胫腓前韧带对于这三向运动都有非常直接的保护和限制作用。再次,血管造影研究发现4,大多数人(63%)下胫腓前韧带的血供仅仅来源于腓动脉的前支。腓动脉的前支在踝关节面近端3cm处穿骨间膜到达前方,此血管在踝关节骨折的同时极有可能已经断裂,这注定下胫腓前韧带的愈合非常困难。另一方面,目前下胫腓联合损伤的最常用治疗方法——下胫腓联合螺钉受到了越来越深刻的反思5,6。人们越来越在意它过高的畸形复位率,越来越不希望牺牲可运动的下胫腓联合关节的正常生理活动,越来越不愿承受二期需要取出该螺钉的代价。踝关节的解剖性固定是既恢复下胫腓联合稳定而又避免使用下胫腓联合螺钉的希望所在。旧理论认为,当一个稳定环仅存在一处断裂时,该系统仍然是稳定的。但该理论仅适用于刚性结构的稳定环;而由多处韧带连接的柔性稳定环,哪怕只残留一处断裂,依然可能造成整个系统的不稳定。下胫腓联合正是如此。因此,下胫腓前韧带的损伤修复不应继续缺席,而应作为一个重要的环节发挥作用。本研究详细测量了国人下胫腓前韧带的解剖学参数;通过有限元分析阐明下胫腓前韧带对于维持下胫腓联合的稳定,主要是外旋应力下的稳定性作用非常重要;对尸体标本的动作捕捉研究进一步证实和强化了这一结论。本研究还证明,动画丝攻试验特异性优异的同时还大大提高了术中诊断下胫腓联合不稳的敏感性,从而找到了理想的术中诊断方法。我们设计了踝关节外侧勺形切口,以保障处理后踝骨折的同时可以探查下胫腓前韧带,并且切开在直视下复位下胫腓联合。在应用该切口进行临床治疗的过程中,我们对下胫腓前韧带的损伤进行了观察和分类,将其分为3型。Ⅰ型为胫骨或腓骨侧韧带止点处较大块的撕脱性骨折;Ⅱ型为韧带从止点骨面处剥脱,可伴有极小块的撕脱性骨折;Ⅲ型为韧带体部的断裂。我们制定了Ⅰ型以2.5mm空心双头加压螺钉复位固定撕脱骨块、Ⅱ型以锚钉或借助钢板的缝合孔缝合修复、Ⅲ型予缝线端端吻合修复的治疗策略,疗效满意。通过随机对照研究,我们证实重建下胫腓前韧带的稳定性与使用下胫腓联合螺钉相比,畸形复位率较低,无需二次手术,并且疗效相当,可以作为一项很有价值的治疗选择。
[Abstract]:Lower tibiofibular joint injury is more common in clinic and can exist alone, and more cases are associated with ankle joint fracture with 1. lower tibiofibular joint instability which will produce ankle pain, dysfunction, and even final traumatic osteoarthritis of the 2. lower tibiofibular ligament is one of the most important structures of the lower tibiofibular joint. The composite structure, biomechanical study suggests that the ligament provides about 35% of the stability of the lower tibiofibular joint. However, for a long time, the treatment of the anterior tibiofibular ligament injury is negative and cold. In fact, many basic research evidence suggests that 3, the anterior tibiofibular ligament is very important, and the ability of self repair is poor. First, lower. The anterior tibiofibular ligament is composed of a compact collagenous fiber arranged in parallel, which is adapted to the need for greater stress in the ligament. Secondly, the kinematic study found that when the ankle joint completes the maximum flexion to the maximum extension movement, the movement of the lower tibiofibular joint fibula is slightly outward, backward and external, and the anterior tibia and fibula are toughened. The band has a very direct protective and restrictive effect on these three movements. Again, the angiography study found that 4, most people (63%) the blood supply of the anterior tibiofibular ligament is only from the anterior branch of the peroneal artery. The anterior branch of the peroneal artery passes the interosseous membrane at the proximal 3cm of the ankle joint to the front, and this vessel is extremely likely to have been fractured at the ankle joint. The healing of the anterior tibiofibular ligament is very difficult by fracture. On the other hand, the most commonly used treatment of the joint tibiofibular joint injury, the lower tibiofibular joint screw, is becoming more and more deeply introspection 5,6. people are more and more concerned about its high deformity reduction rate, and more and more do not want to sacrifice the movement of the joint joint of the lower tibia and fibula. There is a growing reluctance to withstand the cost of the two phase of the screw. The anatomical fixation of the ankle is the hope of restoring the joint stability of the lower tibiofibula and avoiding the use of the lower tibiofibular joint screws. The old theory holds that the system is still stable when a stable ring only exists in one fracture. The stable ring of the rigid structure, and the flexible stable ring connected by the multiple ligaments, even a single residual fracture, may still cause the whole system instability. The lower tibiofibular joint is the same. Therefore, the repair of the anterior tibiofibular ligament should not continue to be absent, and should be used as an important link. This study has measured in detail. The anatomical parameters of the anterior tibiofibular ligament of the tibia and the anterior tibiofibular ligament were analyzed by the finite element analysis. The stability of the anterior tibiofibular ligament for maintaining the stability of the lower tibiofibular joint was important. The action capture study of the cadaver specimens further confirmed and strengthened this conclusion. This study also proved that the animated tapping test was specific. The sensitivity of intraoperative diagnosis of tibiofibular instability was greatly enhanced and an ideal diagnostic method was found. We designed a spoon - shaped incision in the lateral ankle to ensure the treatment of the posterior fracture of the ankle and the anterior tibiofibular ligament, and the incision was made under direct reduction for the lower tibiofibular joint. The incision was applied to the incision. In the course of clinical treatment, we observe and classify the injury of the anterior tibia and peroneal ligament, and divide it into 3 types. Type I is the avulsion fracture at the end of the tibial or the fibula side ligament; type II is ligaments exfoliate from the point of the point of the bone and can be accompanied by a very small avulsion fracture; type III is a fracture of the ligamentous body. Type I was repositioned with 2.5mm hollow double head compression screw and fixed avulsion block. Type II was repaired with anchors or suture with steel plate suture. The treatment strategy of type III end-to-end anastomosis repair was satisfactory. Through a randomized controlled study, we confirmed that the stability of the anterior tibiofibular ligament reconstruction was compared with the use of the lower tibiofibular screw. The reduction rate is low, no two operations are needed, and the curative effect is comparable. It can be regarded as a valuable therapeutic option.
【学位授予单位】：南京医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R687.4

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