本文選題：下脛腓聯(lián)合 + 下脛腓前韌帶　； 參考：《南京醫(yī)科大學(xué)》2017年博士論文

【摘要】：下脛腓聯(lián)合損傷在臨床上比較多見(jiàn),可以單獨(dú)存在,而更多的情況是與踝關(guān)節(jié)骨折同時(shí)并發(fā)1。下脛腓聯(lián)合不穩(wěn)定將產(chǎn)生踝關(guān)節(jié)疼痛、功能障礙、甚至最終發(fā)生創(chuàng)傷性骨關(guān)節(jié)炎2。下脛腓前韌帶是構(gòu)成下脛腓聯(lián)合的重要結(jié)構(gòu)之一,它呈多束復(fù)合結(jié)構(gòu),生物力學(xué)研究認(rèn)為該韌帶為下脛腓聯(lián)合提供約35%的穩(wěn)定性。然而長(zhǎng)期以來(lái),臨床上對(duì)下脛腓前韌帶損傷的處理卻是消極而冷淡的。事實(shí)上,許多基礎(chǔ)研究的證據(jù)表明3,下脛腓前韌帶非常重要,而且自我修復(fù)能力比較差。首先,下脛腓前韌帶由平行排列的致密膠原纖維構(gòu)成,這一組織學(xué)特性是與該韌帶需要承受較大應(yīng)力相適應(yīng)的。其次,運(yùn)動(dòng)學(xué)研究發(fā)現(xiàn),當(dāng)踝關(guān)節(jié)完成最大跖屈到最大背伸的運(yùn)動(dòng)時(shí),下脛腓聯(lián)合中腓骨的運(yùn)動(dòng)是輕微外移、后移和外旋,下脛腓前韌帶對(duì)于這三向運(yùn)動(dòng)都有非常直接的保護(hù)和限制作用。再次,血管造影研究發(fā)現(xiàn)4,大多數(shù)人(63%)下脛腓前韌帶的血供僅僅來(lái)源于腓動(dòng)脈的前支。腓動(dòng)脈的前支在踝關(guān)節(jié)面近端3cm處穿骨間膜到達(dá)前方,此血管在踝關(guān)節(jié)骨折的同時(shí)極有可能已經(jīng)斷裂,這注定下脛腓前韌帶的愈合非常困難。另一方面,目前下脛腓聯(lián)合損傷的最常用治療方法——下脛腓聯(lián)合螺釘受到了越來(lái)越深刻的反思5,6。人們?cè)絹?lái)越在意它過(guò)高的畸形復(fù)位率,越來(lái)越不希望犧牲可運(yùn)動(dòng)的下脛腓聯(lián)合關(guān)節(jié)的正常生理活動(dòng),越來(lái)越不愿承受二期需要取出該螺釘?shù)拇鷥r(jià)。踝關(guān)節(jié)的解剖性固定是既恢復(fù)下脛腓聯(lián)合穩(wěn)定而又避免使用下脛腓聯(lián)合螺釘?shù)南Ｍ�。舊理論認(rèn)為,當(dāng)一個(gè)穩(wěn)定環(huán)僅存在一處斷裂時(shí),該系統(tǒng)仍然是穩(wěn)定的。但該理論僅適用于剛性結(jié)構(gòu)的穩(wěn)定環(huán);而由多處韌帶連接的柔性穩(wěn)定環(huán),哪怕只殘留一處斷裂,依然可能造成整個(gè)系統(tǒng)的不穩(wěn)定。下脛腓聯(lián)合正是如此。因此,下脛腓前韌帶的損傷修復(fù)不應(yīng)繼續(xù)缺席,而應(yīng)作為一個(gè)重要的環(huán)節(jié)發(fā)揮作用。本研究詳細(xì)測(cè)量了國(guó)人下脛腓前韌帶的解剖學(xué)參數(shù);通過(guò)有限元分析闡明下脛腓前韌帶對(duì)于維持下脛腓聯(lián)合的穩(wěn)定,主要是外旋應(yīng)力下的穩(wěn)定性作用非常重要;對(duì)尸體標(biāo)本的動(dòng)作捕捉研究進(jìn)一步證實(shí)和強(qiáng)化了這一結(jié)論。本研究還證明,動(dòng)畫(huà)絲攻試驗(yàn)特異性?xún)?yōu)異的同時(shí)還大大提高了術(shù)中診斷下脛腓聯(lián)合不穩(wěn)的敏感性,從而找到了理想的術(shù)中診斷方法。我們?cè)O(shè)計(jì)了踝關(guān)節(jié)外側(cè)勺形切口,以保障處理后踝骨折的同時(shí)可以探查下脛腓前韌帶,并且切開(kāi)在直視下復(fù)位下脛腓聯(lián)合。在應(yīng)用該切口進(jìn)行臨床治療的過(guò)程中,我們對(duì)下脛腓前韌帶的損傷進(jìn)行了觀察和分類(lèi),將其分為3型。Ⅰ型為脛骨或腓骨側(cè)韌帶止點(diǎn)處較大塊的撕脫性骨折;Ⅱ型為韌帶從止點(diǎn)骨面處剝脫,可伴有極小塊的撕脫性骨折;Ⅲ型為韌帶體部的斷裂。我們制定了Ⅰ型以2.5mm空心雙頭加壓螺釘復(fù)位固定撕脫骨塊、Ⅱ型以錨釘或借助鋼板的縫合孔縫合修復(fù)、Ⅲ型予縫線(xiàn)端端吻合修復(fù)的治療策略,療效滿(mǎn)意。通過(guò)隨機(jī)對(duì)照研究,我們證實(shí)重建下脛腓前韌帶的穩(wěn)定性與使用下脛腓聯(lián)合螺釘相比,畸形復(fù)位率較低,無(wú)需二次手術(shù),并且療效相當(dāng),可以作為一項(xiàng)很有價(jià)值的治療選擇。
[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.
【學(xué)位授予單位】：南京醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R687.4

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