关节镜下治疗踝关节撞击征的疗效观察

发布时间：2018-07-02 13:07

本文选题：踝关节 + 撞击综合征　；参考：《安徽医科大学》2014年硕士论文

【摘要】：目的探讨踝关节撞击征在关节镜下的表现形式，明确术前诊断、评估疾病预后、指导临床治疗。并根据镜下模拟踝关节撞击，了解具体的撞击部位、撞击程度、撞击范围和撞击组织等表现特点，给予针对性的处理，评估其术后疗效。方法回顾分析2009年3月至2013年4月间30例踝关节撞击征患者的临床资料，男性22例，女性8例，年龄16～55岁，平均28.6±5.3岁，右踝21例，左踝9例，有明确踝关节扭伤史26例。排除踝关节病理性疾病，如类风湿性关节炎、关节结核及肿瘤、痛风性关节炎等；排除明显踝关节不稳，需韧带修补或重建者；排除严重骨关节炎及急性踝关节骨折及韧带扭伤者。病程6～62个月，平均21±4.3月。术前均拍摄踝关节正侧位X线片，6例发现存在关节游离体和增生骨赘，4例外踝陈旧性撕脱骨折。MRI检查，17例踝关节内嵌夹有软组织，7例胫距关节软骨损伤及骨髓水肿。术前根据临床症状、体征和影像表现诊断为踝关节撞击征。手术采用腰硬联合或全身麻醉，术前用记号笔标出内外踝、胫骨前肌腱、足背动脉、第3腓骨肌腱、腓浅及深神经的主要分支及前内侧、前外侧入路的位置。手术中通过关节镜下踝关节被动的背伸、跖屈、内翻及外翻、关节的旋转活动，人为模拟踝关节撞击的表现，观察撞击的部位、程度、范围及撞击组织的性质等。探查顺序从内向外：三角韧带、内侧沟、胫距关节前部、距骨前部的距骨顶和颈、胫腓韧带、距腓韧带、外侧沟。主要观察三角韧带深面、下胫腓联合韧带前下方及外侧沟有无韧带撕裂、增生肥厚、瘢痕化，滑膜增生，关节软骨的损伤情况，关节间隙有无骨赘、游离体及陈旧骨折等。直观了解撞击的病情，进一步明确术前诊断；同时通过镜下关节清理、增生滑膜切除、游离体取出、骨赘去除、关节软骨损伤给予软骨成形及微骨折术、对踝关节内或外侧韧带松弛行低温等离子消融皱缩等处理治疗踝关节撞击征。手术前及术后随访采用Meislin疗效评定标准：优:患者休息及活动时均无疼痛，体检及自我评估均正常；良：患者休息及活动时均无疼痛，但伴轻度肿胀，自我评估较治疗前显著改善；可：患者活动时有轻微疼痛，体检中度肿胀，自我评估较治疗前有所缓解；差：临床症状及体征未见改善或加重；AOFAS(American Orthopaedic FootAnkle Society，美国足踝外科协会)评分：踝与后足功能评分（Ankle-Hindfoot Scale），满分100分，分为疼痛40分，功能50分，包括活动受限，需要辅助支撑、最大步行距离、行走地面、步态异常、矢状面运动（屈曲加背伸）、后足运动（内翻加外翻）、踝及后足的稳定性（前后及内外翻），对线10分，评分标准:优（90-100分）、良（75-89分）、可（50-74分）、差（小于50分）；及疼痛评价VAS评分（Visual AnalogueScale，视觉模拟评分法）等对患足进行分析评估。VAS评分是一线形图，分为10个等级，数字越大，表示疼痛强度越大，方法：划一平行直线长10cm，一端为无痛，一端为剧痛。患者根据自己所感受的疼痛程度在直线上选择某一点代表当时疼痛程度。所有数据分析采用SPSS13.0软件，计量资料以均数±标准差标示，组间比较采用配对t检验；等级资料组间比较采用Wilcoxon秩和检验,检验水准α=0.05。比较术前和术后踝关节功能评分结果及疼痛评分，P0.05有统计学差异。结果本组30例患者术后均获随访，随访时间6-32个月，平均随访19.5个月。关节镜监视下模拟踝关节撞击试验，进一步明确术前诊断。被动活动踝关节时观察到增生的滑膜及瘢痕组织形成活瓣样或束带状结构嵌夹在踝穴内，以及增生骨赘和游离体与关节发生撞击。发现3例单纯前内撞击，16例单纯前外撞击，前内和前外撞击均存在11例。撞击组织可分为骨性组织和软组织，本组26例主要为滑膜组织撞击,占86.7%(26/30)，伴有距腓前韧带撞击4例，下胫腓前韧带远侧束撞击2例，，其他致密结缔组织撞击2例，骨性撞击6例，其中22例位于前外侧，8例位于前侧及前内侧。术前在MRI检查仅发现7例有软骨损伤，术中关节镜下发现有23例有软骨损伤，原有7例被证实为Ⅲ～Ⅳ软骨损伤。软骨损伤根据Guhl分度法分为：Ⅰ度3例、Ⅱ度5例、Ⅲ度7例、Ⅳ度8例。所有23例距胫关节存在的软骨损伤，其中距骨软骨损伤8例，胫骨软骨损伤5例，距胫关节相对面均存在软骨损伤10例。所有患者术后疼痛均缓解，22例关节疼痛完全缓解，2例活动时疼痛，6例活动后有轻度疼痛，关节肿胀均缓解，踝关节活动功能明显改善。Meislin疗效评估：术前优0例（0%），良5例（16.7%），可8例（26.7%），差17例（56.7%），优良率16.7%（5/30），术后随访优18例（60%），良9例（30%），可3例（10%），差0例（0%），优良率90%（27/30），手术前后比较差异有统计学意义（Z=6.0445，P=0.000）。AOFAS评分：术前43.3±5.1分（33-51分），术后随访89.8±4.3分（76-95分），手术前后两者比较差异有统计学意义（t=38.1798，P=0.000）。VAS疼痛评分术前6.7±2.3分，术后随访2.8±1.6分，手术前后比较差异有统计学意义（t=7.6241，P=0.000）。所有患者术后均未出现神经和血管损伤，切口均Ⅰ期愈合，无手术切口及关节腔的感染。结论对踝关节撞击症患者进行关节镜下的撞击复制，可全面了解撞击特点，进一步明确术前诊断。镜下视野全面、清楚，根据撞击的部位、程度及撞击组织进行处理，手术针对性强，处理结果满意，不易遗漏未处理的病灶。手术创伤小、疼痛轻、恢复快、功能恢复满意。关节镜对踝关节撞击症的诊断及治疗有重要的应用价值。
[Abstract]:objective
To investigate the manifestations of the ankle joint impact sign under arthroscopy, make clear the preoperative diagnosis, evaluate the prognosis of the disease, and guide the clinical treatment. According to the simulation of the ankle joint impact, the specific impact site, impact degree, impact range and impact tissue are understood, the specific treatment is given and the postoperative effect is evaluated.
Method
The clinical data of 30 patients with ankle impact syndrome from March 2009 to April 2013 were analyzed, including 22 males and 8 females, 16~55 years old, 28.6 + 5.3 years old, 21 cases of right ankle, 9 left malleolus, and 26 cases of ankle sprain, excluding the pathological malleolus, such as rheumatoid arthritis, joint tuberculosis and gouty arthritis, etc. The patients who were excluded from the apparent instability of the ankle, requiring ligament repair or reconstruction, excluded severe osteoarthritis and acute ankle fracture and ligament sprain. The course of the disease was 6~62 months, averaging 21 + 4.3 months. All the X-ray films of the ankle joint were taken before operation, 6 cases found the existence of joint free body and hyperplasia osteophyte, 4 cases of outmoded avulsion fracture of the outer malleolus, 17 cases of.MRI The ankle joint was embedded with soft tissue, 7 cases of cartilage injury of the tibia and bone marrow edema. Preoperative symptoms, signs and imaging findings were diagnosed as an ankle joint impact syndrome. The operation was performed with lumbar and hard combined or general anesthesia. The internal and external malleolus, the anterior tibial tendon, the dorsum pedis artery, the third fibula tendon, the superficial peroneal and deep nerve were marked before the operation. The position of the anterolateral approach to the anterolateral approach. During the operation, the ankle joint under arthroscopy passive back extension, metatarsal flexion, varus and valgus, the rotation of the joints, the performance of the ankle joint impact, the location of the impact, the degree, the scope and the nature of the impact tissue are observed. The sequence of exploration is from the inside to the outside: the trigonometric ligament, medial sulcus, tibial clearance. Anterior part of the talus, talus apex and neck, tibiofibular ligament, peroneal ligament, lateral sulcus. The main observation of the deep triangular ligament, the anterior inferior tibiofibular joint ligament, the anterior inferior and lateral sulcus without ligament tear, hypertrophic hypertrophy, scar, synovial hyperplasia, articular cartilage injury, joint space without osteophyte, free body and old fracture. The condition of the impact was further clear, and the preoperative diagnosis was further clarified; at the same time, arthroscopic joint cleaning, hyperplastic synovium removal, free body removal, osteophyte removal, articular cartilage injury were given to cartilage forming and microfracture, and the ankle joint or lateral ligaments were treated with low temperature plasma ablation. Meislin efficacy evaluation criteria: excellent: patients have no pain during rest and activity, physical examination and self-assessment are normal; good: patients have no pain during rest and activity, but with mild swelling, self-assessment is significantly better than before treatment; but patients have mild pain, moderate swelling in physical examination, and self evaluation before treatment. Remission; poor: no improvement or aggravation of clinical symptoms and signs; AOFAS (American Orthopaedic FootAnkle Society, American foot and ankle surgery association) score: ankle and foot function score (Ankle-Hindfoot Scale), full score of 100 points, divided into 40 points of pain, 50 points of function, including limited activity, supporting support, maximum walking distance, walking ground, Abnormality of gait, sagittal plane movement (flexion plus extension), posterior foot movement (varus plus valgus), stability of ankle and rear foot (back and forth and back and outside), line 10 points, scoring criteria: excellent (90-100 points), good (75-89), (50-74), poor (less than 50); and pain evaluation VAS score (Visual AnalogueScale, visual analogue scoring) and so on. The.VAS score is divided into 10 grades. The larger the number, the greater the pain intensity, the better the method: a parallel line length 10cm, one end for painless, and a severe pain at one end. The patient chooses a point on the line according to the pain degree of the patient to represent the pain and pain at that time. All data analysis uses SPSS13.0 software, measurement. The data were marked with mean standard deviation, and the paired t test was used in the group. Wilcoxon rank sum test was used among the class data groups. The test level of alpha =0.05. was compared with the results of ankle joint function score and pain score, and there was a statistical difference between P0.05 and =0.05..
Result
30 patients in this group were followed up after 6-32 months of follow-up, with an average follow-up of 19.5 months. Under the surveillance of ankle joint impact test under arthroscopy, the preoperative diagnosis was further clarified. When passive ankle joint was passive, the accretion of synovial and scar tissue was observed to form a valve like or band shaped knot in the ankle, and the proliferation of osteophyte and dissociation. There were 3 cases of simple anterior internal impact, 16 cases of anterior impingement and 11 cases of anterior and anterior impingement. The impingement tissue could be divided into bone tissue and soft tissue. The 26 cases of this group were mainly synovium, 86.7% (26/30), 4 cases with anterior peroneal ligaments, 2 cases of distal tibiofibular ligament and other compact. There were 2 cases of connective tissue impact and 6 cases of osseous impact, of which 22 cases were located in the anterolateral and 8 in the anterior and anterior medial. Before the operation, only 7 cases of cartilage injury were found in the MRI examination. 23 cases of cartilage injury were found under the arthroscopy, 7 cases were confirmed to be III to IV cartilage injury. The cartilage injury was divided into 3 cases, and 5 cases of grade II. There were 7 cases of degree III and 8 cases of IV degree. All 23 cases of cartilage injury in the tibial joint, including 8 cases of talar cartilage injury, 5 cases of tibial cartilage injury, 10 cases of cartilage injury in the relative surface of the tibia, all of the patients were relieved after operation, 22 cases of joint pain was completely relieved, 2 cases had pain, 6 cases had mild pain after activity and joint swelling both slowly The effect of ankle joint activity was obviously improved in.Meislin: 0 cases (0%) before operation, 5 cases (16.7%), 8 cases (26.7%), 17 cases (56.7%), 16.7% (5/30), 18 cases (60%) and good 9 cases (30%) after operation. The difference was statistically significant (Z=6.0445, P=0.000).AOFAS evaluation before and after operation. Points: 43.3 + 5.1 points (33-51 points) before operation and 89.8 + 4.3 points (76-95 points) after operation. The difference was statistically significant before and after operation (t=38.1798, P=0.000).VAS pain score before operation 6.7 + 2.3, postoperative follow-up was 2.8 + 1.6, and the difference was statistically significant (t=7.6241, P=0.000) before and after operation. All patients had no nerve and blood after operation. All wounds healed by first intention and no incision and joint cavity infection occurred.
conclusion
The impact replication under arthroscopy for patients with malleolus impingement can fully understand the characteristics of the impact and further clarify the preoperative diagnosis. The visual field under the microscope is comprehensive and clear, according to the location of the impact, the extent and the impact tissue, the operation is strong, the treatment results are satisfactory, and the untreated lesions are not easily missed. The operation is small, the pain is light and the restorer is restorable. Functional recovery is satisfactory. Arthroscopy has important application value in the diagnosis and treatment of ankle impingement.
【学位授予单位】：安徽医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.4

【参考文献】