踝关节三角韧带损伤的诊断和治疗
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摘要
背景:在踝关节内侧组织中踝关节三角韧带为最重要的力学结构,对维持踝关节的稳定性起重要作用。对于踝关节急、慢性三角韧带损伤的诊断和治疗方式仍然存在争议。目的:综述近年来踝关节三角韧带损伤的诊断和治疗进展。方法:第一作者应用计算机检索2000年1月至2018年12月PubMed数据库、中国知网、维普中国期刊网等收录的与踝关节三角韧带损伤诊断和治疗的文献,优先选择近期发表或发表在权威杂志上的文章。英文检索词为"ankle,deltoidligament,management",中文检索词为"踝关节、三角韧带、损伤、诊断、治疗",初级共检出文献310篇,46篇文献符合纳入标准。结果与结论:通过对踝关节三角韧带解剖及功能、损伤机制、诊断方法及急慢性损伤的治疗5个方面进行综述讨论,系统阐述了踝关节三角韧带损伤的最新诊疗进展。踝关节三角韧带发挥着维持踝关节内侧稳定性的重要作用。三角韧带损伤的漏诊或者误诊,会导致严重的足踝部畸形和踝关节骨性关节炎。综合应力位X射线、MRI及超声等影像学检查,以及踝关节镜下探查,可以确诊三角韧带损伤及踝关节内侧不稳定。三角韧带损伤的手术治疗仍然存在较大争论,麻醉下的应力试验为医生提供了判断的依据,尤其存在下胫腓联合时,三角韧带的修复是至关重要的。带线锚钉技术已经成为修复三角韧带应用最广泛的技术,而慢性三角韧带损伤通常需要应用同种自体肌腱或异体肌腱进行三角韧带的重建,最终恢复踝关节的稳定性。
BACKGROUND: In the medial tissue of ankle joint, the deltoid ligament of ankle joint is the most important mechanical structure, which plays an important role in maintaining the stability of ankle joint. The diagnosis and treatment of acute and chronic deltoid ligament injury of ankle remain controversial.OBJECTIVE: To review the advance in the diagnosis and treatment of deltoid ligament injury of ankle joint.METHODS: A computer-based retrieval of PubMed, CNKI, and VIP databases was conducted for the literature concerning the diagnosis and treatment of ankle triangular ligament injury published from January 2000 to December 2018, and articles published recently or published in authoritative journals were selected in priority. The keywords were "ankle, deltoid ligament, management" in English and Chinese,respectively. A total of 310 documents were searched, and 48 of them met the inclusion criteria.RESULTS AND CONCLUSION: The anatomy and function of the deltoid ligament of ankle joint, injury mechanism, diagnosis method and treatment of acute and chronic injury were summarized and discussed, and the latest progress in diagnosis and treatment of the deltoid ligament injury of ankle joint was systematically elaborated. The deltoid ligament of ankle plays an important role in maintaining the stability of medial ankle joint. Moreover, misdiagnosis or misdiagnosis of deltoid ligament injury may lead to severe ankle deformity and ankle osteoarthritis. The triangular ligament injury and instability of the medial ankle joint can be diagnosed by X-ray, MRI, ultrasound and arthroscopic exploration of the ankle.Surgical treatment of deltoid ligament injury is still controversial. Stress test under anesthesia provides us with a basis for judgment, especially, the repair of the deltoid ligament is crucial in the presence of the inferior tibiofibular syndesmosis. In addition, wire anchor technique has become the most widely used technique for repairing deltoid ligament. However, chronic deltoid ligament injury usually requires the reconstruction of deltoid ligament with autologous or allogenic tendons to restore the stability of ankle joint.
BACKGROUND: In the medial tissue of ankle joint, the deltoid ligament of ankle joint is the most important mechanical structure, which plays an important role in maintaining the stability of ankle joint. The diagnosis and treatment of acute and chronic deltoid ligament injury of ankle remain controversial.OBJECTIVE: To review the advance in the diagnosis and treatment of deltoid ligament injury of ankle joint.METHODS: A computer-based retrieval of PubMed, CNKI, and VIP databases was conducted for the literature concerning the diagnosis and treatment of ankle triangular ligament injury published from January 2000 to December 2018, and articles published recently or published in authoritative journals were selected in priority. The keywords were "ankle, deltoid ligament, management" in English and Chinese,respectively. A total of 310 documents were searched, and 48 of them met the inclusion criteria.RESULTS AND CONCLUSION: The anatomy and function of the deltoid ligament of ankle joint, injury mechanism, diagnosis method and treatment of acute and chronic injury were summarized and discussed, and the latest progress in diagnosis and treatment of the deltoid ligament injury of ankle joint was systematically elaborated. The deltoid ligament of ankle plays an important role in maintaining the stability of medial ankle joint. Moreover, misdiagnosis or misdiagnosis of deltoid ligament injury may lead to severe ankle deformity and ankle osteoarthritis. The triangular ligament injury and instability of the medial ankle joint can be diagnosed by X-ray, MRI, ultrasound and arthroscopic exploration of the ankle.Surgical treatment of deltoid ligament injury is still controversial. Stress test under anesthesia provides us with a basis for judgment, especially, the repair of the deltoid ligament is crucial in the presence of the inferior tibiofibular syndesmosis. In addition, wire anchor technique has become the most widely used technique for repairing deltoid ligament. However, chronic deltoid ligament injury usually requires the reconstruction of deltoid ligament with autologous or allogenic tendons to restore the stability of ankle joint.
引文
[1]Waterman BR,Belmont PJ Jr,Cameron KL,et al.Risk factors for syndesmotic and medial ankle sprain:role of sex,sport,and level of competition.Am J Sports Med.2011;39(5):992-998.
[2]Yammine K.The morphology and prevalence of the deltoid complex ligament of the Ankle.Foot Ankle Spec.2017;10(1):55-62.
[3]Cromeens BP,Kirchhoff CA,Patterson RM,et al.An attachment-based description of the medial collateral and spring ligament complexes.Foot Ankle Int.2015;36:710-721.
[4]Lee S,Lin J,Hamid KS,et al.Deltoid ligament rupture in ankle fracture:diagnosis and management.J Am Acad Orthop Surg.2018.doi:10.5435/JAAOS-D-18-00198.
[5]Boss AP,Hintermann B.Anatomical study of the medial ankle ligament complex.Foot Ankle Int.2002;23(6):547-553.
[6]Panchani P,Chappell T,Moore G,et al.Anatomic study of the deltoid ligament of the ankle.Foot Ankle Int.2014;35(9):916-921.
[7]Campbell K,Michalski M,Wilson K,et al.The ligament anatomy of the deltoid complex of the ankle:a qualitative and quantitative anatomical study.J Bone Joint Surg Am.2014;96(8):e62.
[8]Lee T,Jang K,Choi G,et al.The contribution of anterior deltoid ligament to ankle stability in isolated lateral malleolar fractures.Injury 2016;47(7):1581-1585.
[9]高武长,王英振.切开复位内固定踝关节骨折:联合带线锚钉修复三角韧带损伤的意义[J].中国组织工程研究,2016,20(9):1255-1260.
[10]张明珠,俞光荣,赵有光,等.踝关节骨折合并三角韧带完全断裂的手术治疗-1项多中心研究报告[J].足踝外科电子杂志,2014,1(1):26-29.
[11]Fernandez I,Gerzina C,Thabet AM,et al.Adding deltoid ligament repair in ankle fracture treatment:is it necessary?A systematic review.Foot Ankle Surg.2018.doi:10.1016/j.fas.2018.11.001.
[12]Alshalawi S,Galhoum AE,Alrashidi Y,et al.Medial ankle instability:the deltoid dilemma.Foot Ankle Clin.2018;23(4):639-657.
[13]俞光荣,杨云峰,张凯,等.距下关节、踝关节对后足运动影响的实验研究[J].中华骨科杂志,2005,25(4):236-239.
[14]Oburu E,Myerson MS.Deltoid ligament repair in flatfoot deformity.Foot Ankle Clin.2017;22(3):503-514.
[15]Lotscher P,Lang T,Zwicky L,et al.Osteoligamentous injuries of the medial ankle joint.Eur J Trauma Emerg Surg2015;41(6):615-621.
[16]Femino JE,Vaseenon T,Phisitkul P,et al.Varus external rotation stress test for radiographic detection of deep deltoid ligament disruption with and without syndesmotic disruption:a cadaveric study.Foot Ankle Int.2013;34(2):251-260.
[17]Hastie G,Akhtar S,Butt U,et al.Weightbearing radiograph facilitate functional treatment of ankle fractures of uncertain stability.J Foot Ankle Surg 2015;54(6):1042-1066.
[18]Knupp M,Lang TH,Zwicky L,et al.Chronic ankle instability(medial and lateral).Clin Sports Med.2015;34:679-688.
[19]Ashraf A,Murphree J,Wait E,et al.Gravity stress radiographs and the effect of ankle position on deltoid ligament integrity and medial clear space measurements.JOrthop Trauma.2017;31(5):270-274.
[20]LeBa T,Gugala Z,Morris R,et al.Gravity versus manual external rotation stress view in evaluating ankle stability:a prospective study.Foot Ankle Spec.2015;8(3):175-179.
[21]Schottel PC,Fabricant PD,Berkes MB,et al.Manual stress ankle radiography has poor ability to predict deep deltoid ligament integrity in a supination external rotation fracture cohort.J Foot Ankle Surg.2015;54:531-535.
[22]王旭,张超,尹建文,等.MRI与术中外旋应力试验在旋后-外旋踝关节骨折中的应用价值比较[J].中国骨与关节外科,2014,7(4):276-279.
[23]Salat P,Le V,Veljkovic A,et al.Imaging in foot and ankle instability.Foot Ankle Clin.2018;23(4):499-522.
[24]Yu GR,Zhang MZ,Aiyer A,et al.Repair of the acute deltoid ligament complex rupture associated with ankle fractures:a multicenter clinical study.J Foot Ankle Surg.2015;54(2):198-202.
[25]Park HJ,Cha SD,Kim S,et al.Accuracy of MRI findings in chronic lateral ankle ligament injury:comparison with surgical findings.Clin Radiol 2012;67(4):313-318.
[26]Morvan G,Busson J,Wybier M,et al.Ultrasound of the ankle.Eur J Ultrasound 2001;14(1):73-82.
[27]Henari S,Banks LN,Radovanovic I,et al.Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle.Orthopedics.2011;34(10):639-643.
[28]Hintermann B,Boss A,Shafer D.Arthroscopic findings in patients with chronic ankle instability.Am J Sports Med.2002;30(3):402-409.
[29]Schairer W,Nwachukwu B,Dare DM,et al.Arthroscopically assisted open reduction-internal fixation of ankle fractures:significance of the arthroscopic ankle drive-through sign.Arthrosc Tech 2016;5(2):e407-e412.
[30]Hintermann B,Scha fer D.Arthroscopic assessment of the chronic unstable ankle joint.Knee Surg Sports Traumatol Arthrosc 1996;4(1):48-52.
[31]Dabash S,Elabd A,Potter E,et al.Adding deltoid ligament repair in ankle fracture treatment:is it necessary?Asystematic review.Foot Ankle Surg.2018.doi:10.1016/j.fas.2018.11.001.
[32]Warner SJ,Garner MR,Hinds RM,et al.Correlation between the Lauge-Hansen classification and ligament injuries in ankle fractures.J Orthop Trauma.2015;29(12):547-548.
[33]Mak MF,Gartner L,Pearce CJ.Management of syndesmosis injuries in the elite athlete.Foot Ankle Clin.2013;18(2):195-214.
[34]Sun X,Li T,Sun Z,et al.Does routinely repairing deltoid ligament injuries in type B ankle joint fractures influence long term outcomes?Injury.2018;49(12):2312-2317.
[35]Jones CR,Nunley JN.Deltoid ligament repair versus syndesmotic fixation in bimalleolar equivalent ankle fractures.J Orthop Trauma 2015;29(5):245-249.
[36]Zhao HM,Lu J,Zhang F,et al.Surgical treatment of ankle fracture with or without deltoid ligament repair:a comparative study.BMC Musculoskelet Disord.2017;18(1):543.
[37]Woo SH,Bae SY,Chung HJ.Short-term results of a ruptured deltoid ligament repair during an acute ankle fracture fixation.Foot Ankle Int 2018;39:35-45.
[38]俞光荣,洪浩.踝关节损伤的治疗进展与思考[J].中国骨伤,2016,29(12):1071-1073.
[39]Wang X,Ma X,Zhang C,et al.Treatment of chronic deltoid ligament injury using suture anchors.Orthop Surg.2014;6:223-228.
[40]Hsu AR,Lareau CR,Anderson RB.Repair of acute superficial deltoid complex avulsion during ankle fracture fixation in national football league players.Foot Ankle Int.2015;36:1272-1278.
[41]高怡加,黄枫,劳永生,等.锚钉修复三角韧带后踝关节的稳定性[J].中国组织工程研究,2017,21(19):3011-3016.
[42]Wang X,Zhang C,Yin J,et al.Treatment of medial malleolus or pure deltoid lig-ament injury in patients with supination-external rotation type IV ankle fractures.Orthop Surg.2017;9(1):42-48.
[43]Kusnezov N,Eisenstein E,Diab N,et al.Medial malleolar fractures and associated deltoid ligament disruptions:current management controversies.Orthopedics.2017;40(2):e216-e222.
[44]Stufkens SA,van den Bekerom MP,Knupp M,et al.The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures:a review.Strategies Trauma Lim Reconstr.2012;7:73-85.
[45]Pellegrini MJ,Torres N,Cuchacovich NR,et al.Chronic deltoid ligament insufficiency repair with Internal Brace augmentation.Foot Ankle Surg.2018.doi:10.1016/j.fas.2018.10.004.
[46]Jung HG,Park JT,Eom JS,et al.Reconstruction of superficial deltoid ligaments with allograft tendons in medial ankle instability:a technical report.Injury.2016;47(3):780-783.
[2]Yammine K.The morphology and prevalence of the deltoid complex ligament of the Ankle.Foot Ankle Spec.2017;10(1):55-62.
[3]Cromeens BP,Kirchhoff CA,Patterson RM,et al.An attachment-based description of the medial collateral and spring ligament complexes.Foot Ankle Int.2015;36:710-721.
[4]Lee S,Lin J,Hamid KS,et al.Deltoid ligament rupture in ankle fracture:diagnosis and management.J Am Acad Orthop Surg.2018.doi:10.5435/JAAOS-D-18-00198.
[5]Boss AP,Hintermann B.Anatomical study of the medial ankle ligament complex.Foot Ankle Int.2002;23(6):547-553.
[6]Panchani P,Chappell T,Moore G,et al.Anatomic study of the deltoid ligament of the ankle.Foot Ankle Int.2014;35(9):916-921.
[7]Campbell K,Michalski M,Wilson K,et al.The ligament anatomy of the deltoid complex of the ankle:a qualitative and quantitative anatomical study.J Bone Joint Surg Am.2014;96(8):e62.
[8]Lee T,Jang K,Choi G,et al.The contribution of anterior deltoid ligament to ankle stability in isolated lateral malleolar fractures.Injury 2016;47(7):1581-1585.
[9]高武长,王英振.切开复位内固定踝关节骨折:联合带线锚钉修复三角韧带损伤的意义[J].中国组织工程研究,2016,20(9):1255-1260.
[10]张明珠,俞光荣,赵有光,等.踝关节骨折合并三角韧带完全断裂的手术治疗-1项多中心研究报告[J].足踝外科电子杂志,2014,1(1):26-29.
[11]Fernandez I,Gerzina C,Thabet AM,et al.Adding deltoid ligament repair in ankle fracture treatment:is it necessary?A systematic review.Foot Ankle Surg.2018.doi:10.1016/j.fas.2018.11.001.
[12]Alshalawi S,Galhoum AE,Alrashidi Y,et al.Medial ankle instability:the deltoid dilemma.Foot Ankle Clin.2018;23(4):639-657.
[13]俞光荣,杨云峰,张凯,等.距下关节、踝关节对后足运动影响的实验研究[J].中华骨科杂志,2005,25(4):236-239.
[14]Oburu E,Myerson MS.Deltoid ligament repair in flatfoot deformity.Foot Ankle Clin.2017;22(3):503-514.
[15]Lotscher P,Lang T,Zwicky L,et al.Osteoligamentous injuries of the medial ankle joint.Eur J Trauma Emerg Surg2015;41(6):615-621.
[16]Femino JE,Vaseenon T,Phisitkul P,et al.Varus external rotation stress test for radiographic detection of deep deltoid ligament disruption with and without syndesmotic disruption:a cadaveric study.Foot Ankle Int.2013;34(2):251-260.
[17]Hastie G,Akhtar S,Butt U,et al.Weightbearing radiograph facilitate functional treatment of ankle fractures of uncertain stability.J Foot Ankle Surg 2015;54(6):1042-1066.
[18]Knupp M,Lang TH,Zwicky L,et al.Chronic ankle instability(medial and lateral).Clin Sports Med.2015;34:679-688.
[19]Ashraf A,Murphree J,Wait E,et al.Gravity stress radiographs and the effect of ankle position on deltoid ligament integrity and medial clear space measurements.JOrthop Trauma.2017;31(5):270-274.
[20]LeBa T,Gugala Z,Morris R,et al.Gravity versus manual external rotation stress view in evaluating ankle stability:a prospective study.Foot Ankle Spec.2015;8(3):175-179.
[21]Schottel PC,Fabricant PD,Berkes MB,et al.Manual stress ankle radiography has poor ability to predict deep deltoid ligament integrity in a supination external rotation fracture cohort.J Foot Ankle Surg.2015;54:531-535.
[22]王旭,张超,尹建文,等.MRI与术中外旋应力试验在旋后-外旋踝关节骨折中的应用价值比较[J].中国骨与关节外科,2014,7(4):276-279.
[23]Salat P,Le V,Veljkovic A,et al.Imaging in foot and ankle instability.Foot Ankle Clin.2018;23(4):499-522.
[24]Yu GR,Zhang MZ,Aiyer A,et al.Repair of the acute deltoid ligament complex rupture associated with ankle fractures:a multicenter clinical study.J Foot Ankle Surg.2015;54(2):198-202.
[25]Park HJ,Cha SD,Kim S,et al.Accuracy of MRI findings in chronic lateral ankle ligament injury:comparison with surgical findings.Clin Radiol 2012;67(4):313-318.
[26]Morvan G,Busson J,Wybier M,et al.Ultrasound of the ankle.Eur J Ultrasound 2001;14(1):73-82.
[27]Henari S,Banks LN,Radovanovic I,et al.Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle.Orthopedics.2011;34(10):639-643.
[28]Hintermann B,Boss A,Shafer D.Arthroscopic findings in patients with chronic ankle instability.Am J Sports Med.2002;30(3):402-409.
[29]Schairer W,Nwachukwu B,Dare DM,et al.Arthroscopically assisted open reduction-internal fixation of ankle fractures:significance of the arthroscopic ankle drive-through sign.Arthrosc Tech 2016;5(2):e407-e412.
[30]Hintermann B,Scha fer D.Arthroscopic assessment of the chronic unstable ankle joint.Knee Surg Sports Traumatol Arthrosc 1996;4(1):48-52.
[31]Dabash S,Elabd A,Potter E,et al.Adding deltoid ligament repair in ankle fracture treatment:is it necessary?Asystematic review.Foot Ankle Surg.2018.doi:10.1016/j.fas.2018.11.001.
[32]Warner SJ,Garner MR,Hinds RM,et al.Correlation between the Lauge-Hansen classification and ligament injuries in ankle fractures.J Orthop Trauma.2015;29(12):547-548.
[33]Mak MF,Gartner L,Pearce CJ.Management of syndesmosis injuries in the elite athlete.Foot Ankle Clin.2013;18(2):195-214.
[34]Sun X,Li T,Sun Z,et al.Does routinely repairing deltoid ligament injuries in type B ankle joint fractures influence long term outcomes?Injury.2018;49(12):2312-2317.
[35]Jones CR,Nunley JN.Deltoid ligament repair versus syndesmotic fixation in bimalleolar equivalent ankle fractures.J Orthop Trauma 2015;29(5):245-249.
[36]Zhao HM,Lu J,Zhang F,et al.Surgical treatment of ankle fracture with or without deltoid ligament repair:a comparative study.BMC Musculoskelet Disord.2017;18(1):543.
[37]Woo SH,Bae SY,Chung HJ.Short-term results of a ruptured deltoid ligament repair during an acute ankle fracture fixation.Foot Ankle Int 2018;39:35-45.
[38]俞光荣,洪浩.踝关节损伤的治疗进展与思考[J].中国骨伤,2016,29(12):1071-1073.
[39]Wang X,Ma X,Zhang C,et al.Treatment of chronic deltoid ligament injury using suture anchors.Orthop Surg.2014;6:223-228.
[40]Hsu AR,Lareau CR,Anderson RB.Repair of acute superficial deltoid complex avulsion during ankle fracture fixation in national football league players.Foot Ankle Int.2015;36:1272-1278.
[41]高怡加,黄枫,劳永生,等.锚钉修复三角韧带后踝关节的稳定性[J].中国组织工程研究,2017,21(19):3011-3016.
[42]Wang X,Zhang C,Yin J,et al.Treatment of medial malleolus or pure deltoid lig-ament injury in patients with supination-external rotation type IV ankle fractures.Orthop Surg.2017;9(1):42-48.
[43]Kusnezov N,Eisenstein E,Diab N,et al.Medial malleolar fractures and associated deltoid ligament disruptions:current management controversies.Orthopedics.2017;40(2):e216-e222.
[44]Stufkens SA,van den Bekerom MP,Knupp M,et al.The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures:a review.Strategies Trauma Lim Reconstr.2012;7:73-85.
[45]Pellegrini MJ,Torres N,Cuchacovich NR,et al.Chronic deltoid ligament insufficiency repair with Internal Brace augmentation.Foot Ankle Surg.2018.doi:10.1016/j.fas.2018.10.004.
[46]Jung HG,Park JT,Eom JS,et al.Reconstruction of superficial deltoid ligaments with allograft tendons in medial ankle instability:a technical report.Injury.2016;47(3):780-783.