發(fā)布時(shí)間：2018-07-02 13:07

  本文選題：踝關(guān)節(jié) + 撞擊綜合征��； 參考：《安徽醫(yī)科大學(xué)》2014年碩士論文

【摘要】：目的 探討踝關(guān)節(jié)撞擊征在關(guān)節(jié)鏡下的表現(xiàn)形式，明確術(shù)前診斷、評(píng)估疾病預(yù)后、指導(dǎo)臨床治療。并根據(jù)鏡下模擬踝關(guān)節(jié)撞擊，了解具體的撞擊部位、撞擊程度、撞擊范圍和撞擊組織等表現(xiàn)特點(diǎn)，給予針對(duì)性的處理，評(píng)估其術(shù)后療效。 方法 回顧分析2009年3月至2013年4月間30例踝關(guān)節(jié)撞擊征患者的臨床資料，男性22例，女性8例，年齡16～55歲，平均28.6±5.3歲，右踝21例，左踝9例，有明確踝關(guān)節(jié)扭傷史26例。排除踝關(guān)節(jié)病理性疾病，如類風(fēng)濕性關(guān)節(jié)炎、關(guān)節(jié)結(jié)核及腫瘤、痛風(fēng)性關(guān)節(jié)炎等；排除明顯踝關(guān)節(jié)不穩(wěn)，需韌帶修補(bǔ)或重建者；排除嚴(yán)重骨關(guān)節(jié)炎及急性踝關(guān)節(jié)骨折及韌帶扭傷者。病程6～62個(gè)月，平均21±4.3月。術(shù)前均拍攝踝關(guān)節(jié)正側(cè)位X線片，6例發(fā)現(xiàn)存在關(guān)節(jié)游離體和增生骨贅，4例外踝陳舊性撕脫骨折。MRI檢查，17例踝關(guān)節(jié)內(nèi)嵌夾有軟組織，7例脛距關(guān)節(jié)軟骨損傷及骨髓水腫。術(shù)前根據(jù)臨床癥狀、體征和影像表現(xiàn)診斷為踝關(guān)節(jié)撞擊征。手術(shù)采用腰硬聯(lián)合或全身麻醉，術(shù)前用記號(hào)筆標(biāo)出內(nèi)外踝、脛骨前肌腱、足背動(dòng)脈、第3腓骨肌腱、腓淺及深神經(jīng)的主要分支及前內(nèi)側(cè)、前外側(cè)入路的位置。手術(shù)中通過(guò)關(guān)節(jié)鏡下踝關(guān)節(jié)被動(dòng)的背伸、跖屈、內(nèi)翻及外翻、關(guān)節(jié)的旋轉(zhuǎn)活動(dòng)，人為模擬踝關(guān)節(jié)撞擊的表現(xiàn)，觀察撞擊的部位、程度、范圍及撞擊組織的性質(zhì)等。探查順序從內(nèi)向外：三角韌帶、內(nèi)側(cè)溝、脛距關(guān)節(jié)前部、距骨前部的距骨頂和頸、脛腓韌帶、距腓韌帶、外側(cè)溝。主要觀察三角韌帶深面、下脛腓聯(lián)合韌帶前下方及外側(cè)溝有無(wú)韌帶撕裂、增生肥厚、瘢痕化，滑膜增生，關(guān)節(jié)軟骨的損傷情況，關(guān)節(jié)間隙有無(wú)骨贅、游離體及陳舊骨折等。直觀了解撞擊的病情，進(jìn)一步明確術(shù)前診斷；同時(shí)通過(guò)鏡下關(guān)節(jié)清理、增生滑膜切除、游離體取出、骨贅去除、關(guān)節(jié)軟骨損傷給予軟骨成形及微骨折術(shù)、對(duì)踝關(guān)節(jié)內(nèi)或外側(cè)韌帶松弛行低溫等離子消融皺縮等處理治療踝關(guān)節(jié)撞擊征。手術(shù)前及術(shù)后隨訪采用Meislin療效評(píng)定標(biāo)準(zhǔn)：優(yōu):患者休息及活動(dòng)時(shí)均無(wú)疼痛，體檢及自我評(píng)估均正常；良：患者休息及活動(dòng)時(shí)均無(wú)疼痛，但伴輕度腫脹，自我評(píng)估較治療前顯著改善；可：患者活動(dòng)時(shí)有輕微疼痛，體檢中度腫脹，自我評(píng)估較治療前有所緩解；差：臨床癥狀及體征未見(jiàn)改善或加重；AOFAS(American Orthopaedic FootAnkle Society，美國(guó)足踝外科協(xié)會(huì))評(píng)分：踝與后足功能評(píng)分（Ankle-Hindfoot Scale），滿分100分，分為疼痛40分，功能50分，包括活動(dòng)受限，需要輔助支撐、最大步行距離、行走地面、步態(tài)異常、矢狀面運(yùn)動(dòng)（屈曲加背伸）、后足運(yùn)動(dòng)（內(nèi)翻加外翻）、踝及后足的穩(wěn)定性（前后及內(nèi)外翻），對(duì)線10分，評(píng)分標(biāo)準(zhǔn):優(yōu)（90-100分）、良（75-89分）、可（50-74分）、差（小于50分）；及疼痛評(píng)價(jià)VAS評(píng)分（Visual AnalogueScale，視覺(jué)模擬評(píng)分法）等對(duì)患足進(jìn)行分析評(píng)估。VAS評(píng)分是一線形圖，分為10個(gè)等級(jí)，數(shù)字越大，表示疼痛強(qiáng)度越大，方法：劃一平行直線長(zhǎng)10cm，一端為無(wú)痛，一端為劇痛�；颊吒鶕�(jù)自己所感受的疼痛程度在直線上選擇某一點(diǎn)代表當(dāng)時(shí)疼痛程度。所有數(shù)據(jù)分析采用SPSS13.0軟件，計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差標(biāo)示，組間比較采用配對(duì)t檢驗(yàn)；等級(jí)資料組間比較采用Wilcoxon秩和檢驗(yàn),檢驗(yàn)水準(zhǔn)α=0.05。比較術(shù)前和術(shù)后踝關(guān)節(jié)功能評(píng)分結(jié)果及疼痛評(píng)分，P0.05有統(tǒng)計(jì)學(xué)差異。 結(jié)果 本組30例患者術(shù)后均獲隨訪，隨訪時(shí)間6-32個(gè)月，平均隨訪19.5個(gè)月。關(guān)節(jié)鏡監(jiān)視下模擬踝關(guān)節(jié)撞擊試驗(yàn)，進(jìn)一步明確術(shù)前診斷。被動(dòng)活動(dòng)踝關(guān)節(jié)時(shí)觀察到增生的滑膜及瘢痕組織形成活瓣樣或束帶狀結(jié)構(gòu)嵌夾在踝穴內(nèi)，以及增生骨贅和游離體與關(guān)節(jié)發(fā)生撞擊。發(fā)現(xiàn)3例單純前內(nèi)撞擊，16例單純前外撞擊，前內(nèi)和前外撞擊均存在11例。撞擊組織可分為骨性組織和軟組織，本組26例主要為滑膜組織撞擊,占86.7%(26/30)，伴有距腓前韌帶撞擊4例，下脛腓前韌帶遠(yuǎn)側(cè)束撞擊2例，，其他致密結(jié)締組織撞擊2例，骨性撞擊6例，其中22例位于前外側(cè)，8例位于前側(cè)及前內(nèi)側(cè)。術(shù)前在MRI檢查僅發(fā)現(xiàn)7例有軟骨損傷，術(shù)中關(guān)節(jié)鏡下發(fā)現(xiàn)有23例有軟骨損傷，原有7例被證實(shí)為Ⅲ～Ⅳ軟骨損傷。軟骨損傷根據(jù)Guhl分度法分為：Ⅰ度3例、Ⅱ度5例、Ⅲ度7例、Ⅳ度8例。所有23例距脛關(guān)節(jié)存在的軟骨損傷，其中距骨軟骨損傷8例，脛骨軟骨損傷5例，距脛關(guān)節(jié)相對(duì)面均存在軟骨損傷10例。所有患者術(shù)后疼痛均緩解，22例關(guān)節(jié)疼痛完全緩解，2例活動(dòng)時(shí)疼痛，6例活動(dòng)后有輕度疼痛，關(guān)節(jié)腫脹均緩解，踝關(guān)節(jié)活動(dòng)功能明顯改善。Meislin療效評(píng)估：術(shù)前優(yōu)0例（0%），良5例（16.7%），可8例（26.7%），差17例（56.7%），優(yōu)良率16.7%（5/30），術(shù)后隨訪優(yōu)18例（60%），良9例（30%），可3例（10%），差0例（0%），優(yōu)良率90%（27/30），手術(shù)前后比較差異有統(tǒng)計(jì)學(xué)意義（Z=6.0445，P=0.000）。AOFAS評(píng)分：術(shù)前43.3±5.1分（33-51分），術(shù)后隨訪89.8±4.3分（76-95分），手術(shù)前后兩者比較差異有統(tǒng)計(jì)學(xué)意義（t=38.1798，P=0.000）。VAS疼痛評(píng)分術(shù)前6.7±2.3分，術(shù)后隨訪2.8±1.6分，手術(shù)前后比較差異有統(tǒng)計(jì)學(xué)意義（t=7.6241，P=0.000）。所有患者術(shù)后均未出現(xiàn)神經(jīng)和血管損傷，切口均Ⅰ期愈合，無(wú)手術(shù)切口及關(guān)節(jié)腔的感染。 結(jié)論 對(duì)踝關(guān)節(jié)撞擊癥患者進(jìn)行關(guān)節(jié)鏡下的撞擊復(fù)制，可全面了解撞擊特點(diǎn)，進(jìn)一步明確術(shù)前診斷。鏡下視野全面、清楚，根據(jù)撞擊的部位、程度及撞擊組織進(jìn)行處理，手術(shù)針對(duì)性強(qiáng)，處理結(jié)果滿意，不易遺漏未處理的病灶。手術(shù)創(chuàng)傷小、疼痛輕、恢復(fù)快、功能恢復(fù)滿意。關(guān)節(jié)鏡對(duì)踝關(guān)節(jié)撞擊癥的診斷及治療有重要的應(yīng)用價(jià)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.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R687.4

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