【摘要】：目的:探討踝關節(jié)鏡微創(chuàng)技術結合解剖重建距腓前韌帶/跟腓韌帶(ATFL/CFL)治療慢性踝關節(jié)外側不穩(wěn)定的療效。方法:自2010年1月至2013年12月共計52例(52踝)保守治療無效的慢性踝關節(jié)外側不穩(wěn)定(ATFL/CFL損傷)患者納入研究,隨機分為A、B兩組,A組采用改良brostrom法(錨釘-韌帶-骨膜雙重錨定法)縫合修復,B組取自體半腱肌腱行ATFL/CFL雙束解剖重建。對術前、術后2年AOFAS足踝評分、患者主觀感覺、VAS疼痛評分、距骨前移及傾斜、踝關節(jié)活動度進行評估,對比兩組的療效差異。結果:平均隨訪34.7月(2~5年),兩組患者均無感染、神經(jīng)損傷、皮緣壞死、后足僵硬等并發(fā)癥,半腱肌腱供區(qū)無不適,末次隨訪無不穩(wěn)定復發(fā)。術后2年A、B兩組在踝關節(jié)跖屈、背伸、外翻活動度上無差異,在踝關節(jié)內(nèi)翻(P=0.025)、距骨傾斜(P=0.025)與前移(P=0.020)改善方面B組優(yōu)于A組,重建相較于修復顯示出更佳的穩(wěn)定性。AOFAS評分A組由術前46.90±9.10改善至術后2年87.15±4.22(P=0.000),B組由術前46.50±9.95改善至術后2年93.70±5.00(P=0.000),術后2年組間比較存在差異(P=0.035)。兩組在疼痛、異常步態(tài)、自主活動及功能、前后屈伸活動、后足活動及對線評分項目上無明顯差異;在地面步行(P=0.045)、最大步行距離(P=0.042)、穩(wěn)定性評分(P=0.045)上組間有差異。VAS視覺疼痛評分A組由術前7.10±5.30改善至術后2年2.05±1.95(P=0.000),B組由術前6.95±4.40改善至術后2年2.12±1.88(P=0.000),術后2年組間比較無差異(P=0.450)。主觀評級術后2年A組優(yōu)良率87.5%,B組95.83%(P=0.001);兩組內(nèi)AOFAS客觀評分與主觀評級相當,主客觀評價統(tǒng)一度較好。結論:依托關節(jié)鏡技術,借鑒尸體解剖數(shù)據(jù),半腱肌腱雙束解剖重建ATFL/CFL在有效恢復踝關節(jié)外側穩(wěn)定性的同時避免了后足僵硬等常見并發(fā)癥,尤其適用于功能期望值較高的青壯年患者及韌帶殘端質(zhì)量較差的翻修手術。手術切口的改進及保殘技術有助于降低術區(qū)神經(jīng)損傷幾率,恢復本體感覺,符合快速康復的理念,長期隨訪有待于進一步觀察。
[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 鹵9.10 before operation to 87.15 鹵4.22 (P0. 000) in 2 years after operation. In group B, it was improved from 46.50 鹵9.95 before operation to 93.70 鹵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 鹵5.30 before operation to 2.05 鹵1.95 (P0. 000) in group B from 6.95 鹵4.40 before operation to 2.12 鹵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.
【作者單位】： 濰坊市人民醫(yī)院骨關節(jié)外科;
【基金】：山東省濰坊市科技局立項課題(編號201104103)
【分類號】：R687.3

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