慢性踝关节外侧不稳定距腓前韧带和跟腓韧带解剖重建
发布时间：2018-08-03 08:35
【摘要】：目的:探讨踝关节镜微创技术结合解剖重建距腓前韧带/跟腓韧带(ATFL/CFL)治疗慢性踝关节外侧不稳定的疗效。方法:自2010年1月至2013年12月共计52例(52踝)保守治疗无效的慢性踝关节外侧不稳定(ATFL/CFL损伤)患者纳入研究,随机分为A、B两组,A组采用改良brostrom法(锚钉-韧带-骨膜双重锚定法)缝合修复,B组取自体半腱肌腱行ATFL/CFL双束解剖重建。对术前、术后2年AOFAS足踝评分、患者主观感觉、VAS疼痛评分、距骨前移及倾斜、踝关节活动度进行评估,对比两组的疗效差异。结果:平均随访34.7月(2~5年),两组患者均无感染、神经损伤、皮缘坏死、后足僵硬等并发症,半腱肌腱供区无不适,末次随访无不稳定复发。术后2年A、B两组在踝关节跖屈、背伸、外翻活动度上无差异,在踝关节内翻(P=0.025)、距骨倾斜(P=0.025)与前移(P=0.020)改善方面B组优于A组,重建相较于修复显示出更佳的稳定性。AOFAS评分A组由术前46.90±9.10改善至术后2年87.15±4.22(P=0.000),B组由术前46.50±9.95改善至术后2年93.70±5.00(P=0.000),术后2年组间比较存在差异(P=0.035)。两组在疼痛、异常步态、自主活动及功能、前后屈伸活动、后足活动及对线评分项目上无明显差异;在地面步行(P=0.045)、最大步行距离(P=0.042)、稳定性评分(P=0.045)上组间有差异。VAS视觉疼痛评分A组由术前7.10±5.30改善至术后2年2.05±1.95(P=0.000),B组由术前6.95±4.40改善至术后2年2.12±1.88(P=0.000),术后2年组间比较无差异(P=0.450)。主观评级术后2年A组优良率87.5%,B组95.83%(P=0.001);两组内AOFAS客观评分与主观评级相当,主客观评价统一度较好。结论:依托关节镜技术,借鉴尸体解剖数据,半腱肌腱双束解剖重建ATFL/CFL在有效恢复踝关节外侧稳定性的同时避免了后足僵硬等常见并发症,尤其适用于功能期望值较高的青壮年患者及韧带残端质量较差的翻修手术。手术切口的改进及保残技术有助于降低术区神经损伤几率,恢复本体感觉,符合快速康复的理念,长期随访有待于进一步观察。
[Abstract]:Objective: to evaluate the effect of ankle arthroscopy combined with anatomical reconstruction of anterior talofibular ligament / calcaneus fibular ligament (ATFL/CFL) in the treatment of chronic lateral ankle instability. Methods: from January 2010 to December 2013, 52 patients (52 malleolus) with chronic lateral ankle instability (ATFL/CFL) were enrolled in the study. Group A was randomly divided into two groups: group A was treated with modified brostrom method (Anchor ligaments-periosteum double Anchorage) suture repair group B was taken from the semitendinosus tendon to perform ATFL/CFL double bundle anatomical reconstruction. The preoperative and postoperative AOFAS foot and ankle score, subjective sensation and pain score, anterior and oblique talus, ankle motion were evaluated, and the curative effects of the two groups were compared. Results: the average follow-up was 34.7 months (2 ~ 5 years). There was no infection, nerve injury, necrosis of the skin margin, stiffness of the hind foot, no discomfort in the semitendinosus donor area, and no unstable recurrence in the last follow-up. 2 years after operation, there was no difference in flexion, extension and valgus of ankle joint between group A and B, and group B was better than group A in the improvement of ankle joint varus (Pn0. 025), talus tilt (Pn0. 025) and anterior displacement (P0. 020). The stability of reconstruction was better than that of repair. AOFAS score in group A was improved from 46.90 卤9.10 before operation to 87.15 卤4.22 (P0. 000) in 2 years after operation. In group B, it was improved from 46.50 卤9.95 before operation to 93.70 卤5.00 (P0. 000) in 2 years after operation, and there was a difference between two groups (P0.035). There was no significant difference in pain, abnormal gait, autonomic activity and function, flexion and extension activity, hind foot activity and line score between the two groups. The visual pain score of group A was improved from 7.10 卤5.30 before operation to 2.05 卤1.95 (P0. 000) in group B from 6.95 卤4.40 before operation to 2.12 卤1.88 (P0. 000) at 2 years after operation, but there was no difference between two groups (P0. 450). The excellent and good rate of group A was 87.5% and that of group B was 95.83% (P0. 001) 2 years after subjective rating, the objective score of AOFAS in both groups was equal to that of subjective rating, and the unity of subjective and objective evaluation was better. Conclusion: based on arthroscopic technique and cadaveric data, hemitendinosus double bundle anatomical reconstruction can effectively restore the lateral stability of ankle and avoid common complications such as posterior foot stiffness. It is especially suitable for young patients with high functional expectation and revision surgery with poor quality of ligament stump. The improvement of surgical incision and the technique of disability preservation are helpful to reduce the probability of nerve injury, restore the proprioceptive sensation, and accord with the idea of rapid recovery. The long-term follow-up needs further observation.
【作者单位】： 潍坊市人民医院骨关节外科;
【基金】：山东省潍坊市科技局立项课题(编号201104103)
【分类号】：R687.3
本文编号：2161192
[Abstract]:Objective: to evaluate the effect of ankle arthroscopy combined with anatomical reconstruction of anterior talofibular ligament / calcaneus fibular ligament (ATFL/CFL) in the treatment of chronic lateral ankle instability. Methods: from January 2010 to December 2013, 52 patients (52 malleolus) with chronic lateral ankle instability (ATFL/CFL) were enrolled in the study. Group A was randomly divided into two groups: group A was treated with modified brostrom method (Anchor ligaments-periosteum double Anchorage) suture repair group B was taken from the semitendinosus tendon to perform ATFL/CFL double bundle anatomical reconstruction. The preoperative and postoperative AOFAS foot and ankle score, subjective sensation and pain score, anterior and oblique talus, ankle motion were evaluated, and the curative effects of the two groups were compared. Results: the average follow-up was 34.7 months (2 ~ 5 years). There was no infection, nerve injury, necrosis of the skin margin, stiffness of the hind foot, no discomfort in the semitendinosus donor area, and no unstable recurrence in the last follow-up. 2 years after operation, there was no difference in flexion, extension and valgus of ankle joint between group A and B, and group B was better than group A in the improvement of ankle joint varus (Pn0. 025), talus tilt (Pn0. 025) and anterior displacement (P0. 020). The stability of reconstruction was better than that of repair. AOFAS score in group A was improved from 46.90 卤9.10 before operation to 87.15 卤4.22 (P0. 000) in 2 years after operation. In group B, it was improved from 46.50 卤9.95 before operation to 93.70 卤5.00 (P0. 000) in 2 years after operation, and there was a difference between two groups (P0.035). There was no significant difference in pain, abnormal gait, autonomic activity and function, flexion and extension activity, hind foot activity and line score between the two groups. The visual pain score of group A was improved from 7.10 卤5.30 before operation to 2.05 卤1.95 (P0. 000) in group B from 6.95 卤4.40 before operation to 2.12 卤1.88 (P0. 000) at 2 years after operation, but there was no difference between two groups (P0. 450). The excellent and good rate of group A was 87.5% and that of group B was 95.83% (P0. 001) 2 years after subjective rating, the objective score of AOFAS in both groups was equal to that of subjective rating, and the unity of subjective and objective evaluation was better. Conclusion: based on arthroscopic technique and cadaveric data, hemitendinosus double bundle anatomical reconstruction can effectively restore the lateral stability of ankle and avoid common complications such as posterior foot stiffness. It is especially suitable for young patients with high functional expectation and revision surgery with poor quality of ligament stump. The improvement of surgical incision and the technique of disability preservation are helpful to reduce the probability of nerve injury, restore the proprioceptive sensation, and accord with the idea of rapid recovery. The long-term follow-up needs further observation.
【作者单位】： 潍坊市人民医院骨关节外科;
【基金】：山东省潍坊市科技局立项课题(编号201104103)
【分类号】：R687.3
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