第三腓骨肌动力解剖重建外侧副韧带
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摘要
[目的]介绍第三腓骨肌腱解剖重建外侧副韧带治疗踝关节慢性外侧不稳定的技术与临床疗效。[方法]回顾分析2015年12月～2018年01月采用第三腓骨肌动力解剖重建外侧副韧带治疗慢性踝关节外侧不稳63例。在第三腓骨肌肌腱远端止点处切断,向近端游离至远侧伸肌支持带近端,向下牵拉肌腱,于距骨颈距腓前韧带附着点放置锚钉,缝合固定第三腓骨肌腱。于外踝距腓前韧带及跟腓韧带附着点分别建立骨道并相通,将移植腱游离端穿过骨隧道,拉紧肌腱,Swivelock锚钉固定肌腱,重建距腓前韧带,再在跟骨止点建立骨道,将移植腱游离端导入,Swivelock锚钉固定,重建跟腓前韧带。[结果]随访时间为8～28个月。术后6个月,患者的AOFAS评分,应力下影像距骨倾斜角、距骨前移距离均较术前显著改善,差异均具有统计学意义(P<0.05)。末次随访时,临床结果评定为优11例,良49例,可3例,优良率为95.24%。[结论]应用第三腓骨肌解剖重建外侧副韧带,创伤小,操作简单,临床疗效满意。
[Objective] To introduce the operative technique and primary clinical outcomes of dynamic anatomic reconstruction of lateral collateral ligament with peroneus tertius for chronic ankle lateral instability. [Methods] From December2015 to January 2018, 63 patients with chronic lateral ankle instability were surgically treated with dynamic anatomic reconstruction of lateral collateral ligament of ankle by peroneus tertius in our department. The peroneus tertius tendon was detached from its distal insertion, freed reversely to the distal edge of extensor retinaculum, and secured the tendon without disconnection on the talus insertion of anterior talofibular ligament(ATFL) with an anchor suture under proper tension. After that, a curved bone tunnel was created and communicated from insertion of ATFL and calcaneofibular ligament(CFL) on the lateral malleolus.The tendon graft was passed through the tunnel, tightened and secured with interference screw to reconstruct ATFL. Finally, the free end of the graft was fastened into the bone tunnel with a swivelock anchor on the calcaneus at anatomic insertion of CFL to reconstruct the CFL. [Results] The patients were followed up for 8～28 months. At 6 months after operation, the AOFAS score,talus tilt and the distance of talus anterior displacement under stress measured on images statistically significantly improved in all the patients compared with those before operation(P<0.05). At the latest follow up, the clinical outcomes were graded as excellent in 11 cases, good in 49 cases and fair in 3 cases, with the excellent and good rate of 95.2%. [Conclusion] This dynamic anatomical reconstruction of lateral collateral ligament with peroneus tertius for chronic ankle lateral instability does achieve satisfactory primary clinical outcomes with advantages of minimized trauma and simplified surgical operation.
[Objective] To introduce the operative technique and primary clinical outcomes of dynamic anatomic reconstruction of lateral collateral ligament with peroneus tertius for chronic ankle lateral instability. [Methods] From December2015 to January 2018, 63 patients with chronic lateral ankle instability were surgically treated with dynamic anatomic reconstruction of lateral collateral ligament of ankle by peroneus tertius in our department. The peroneus tertius tendon was detached from its distal insertion, freed reversely to the distal edge of extensor retinaculum, and secured the tendon without disconnection on the talus insertion of anterior talofibular ligament(ATFL) with an anchor suture under proper tension. After that, a curved bone tunnel was created and communicated from insertion of ATFL and calcaneofibular ligament(CFL) on the lateral malleolus.The tendon graft was passed through the tunnel, tightened and secured with interference screw to reconstruct ATFL. Finally, the free end of the graft was fastened into the bone tunnel with a swivelock anchor on the calcaneus at anatomic insertion of CFL to reconstruct the CFL. [Results] The patients were followed up for 8～28 months. At 6 months after operation, the AOFAS score,talus tilt and the distance of talus anterior displacement under stress measured on images statistically significantly improved in all the patients compared with those before operation(P<0.05). At the latest follow up, the clinical outcomes were graded as excellent in 11 cases, good in 49 cases and fair in 3 cases, with the excellent and good rate of 95.2%. [Conclusion] This dynamic anatomical reconstruction of lateral collateral ligament with peroneus tertius for chronic ankle lateral instability does achieve satisfactory primary clinical outcomes with advantages of minimized trauma and simplified surgical operation.
引文
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[4]Brendan J,McCriskin,Kenneth L,et al.Management and prevention of acute and chronic lateral ankle instability in athletic patient populations[J].World J Orthop,2015,6(2):161-171.
[5]刘建永,王英振,姜鑫.慢性踝关节外侧不稳定解剖重建与修复疗效的比较观察[J].中国矫形外科杂志,2015,23(18):1667-1672.
[6]刘建永.慢性踝关节外侧不稳定距腓前韧带和跟腓韧带解剖重建[J].中国运动医学杂志,2016,35(2):126-131.
[7]夏志勇,陈少鹏,高建国,等.同种异体肌腱解剖重建修复慢性踝关节外侧不稳[J].中华创伤骨科杂志,2016,18(12):1092-1095.
[8]胡牧,徐向阳,刘津浩,等.自体与异体肌腱微创重建踝关节外侧韧带的临床对比研究[J].中华骨科杂志,2014,34(4):448-453.
[9]曲文庆,王振海,王丹,等.改良腓骨短肌腱转位联合锚钉缝合治疗Ⅲ度陈旧性踝关节外侧副韧带损伤[J].中华创伤骨科杂志,2015,17(12):1018-1023.
[10]Rao S,Sirasanagnadla A,Kumar Mr,et al.A rare case of variant morphology of peroneus tertius muscle[J].J Clin Diagnostic Res,2014,8(10):AD01-02.
[11]Verma P,Seema.Analysis of fibularis tertius in terms offrequency morphologymorphometryand clinical significance in north indian cadavers[J].Int J Anat Res,2015,3(4):1646-1650.
[12]Gusm?o LCBD,Lima JSB,Duarte FHG,et al.Anatomical basis for the use of the fibularis tertius muscle in myocutaneous flaps[J].Rev Bras Cir Plást,2013,28(Issue):191-195.
[2]Kitaoka HB,Alexander IJ,Adelaar RS,et a1.Clinical rating systerns for the ankle,hindfoot,midfoot,hallux,and lesser toes[J].Foot Ankle Int,1994,15(7):349-353.
[3]Junge A,Engebretsen L,Margo L,et al.Sports injuries during the Summer OlympicGames 2008[J].Am J Sports Med,2009,37(11):2165-2172.
[4]Brendan J,McCriskin,Kenneth L,et al.Management and prevention of acute and chronic lateral ankle instability in athletic patient populations[J].World J Orthop,2015,6(2):161-171.
[5]刘建永,王英振,姜鑫.慢性踝关节外侧不稳定解剖重建与修复疗效的比较观察[J].中国矫形外科杂志,2015,23(18):1667-1672.
[6]刘建永.慢性踝关节外侧不稳定距腓前韧带和跟腓韧带解剖重建[J].中国运动医学杂志,2016,35(2):126-131.
[7]夏志勇,陈少鹏,高建国,等.同种异体肌腱解剖重建修复慢性踝关节外侧不稳[J].中华创伤骨科杂志,2016,18(12):1092-1095.
[8]胡牧,徐向阳,刘津浩,等.自体与异体肌腱微创重建踝关节外侧韧带的临床对比研究[J].中华骨科杂志,2014,34(4):448-453.
[9]曲文庆,王振海,王丹,等.改良腓骨短肌腱转位联合锚钉缝合治疗Ⅲ度陈旧性踝关节外侧副韧带损伤[J].中华创伤骨科杂志,2015,17(12):1018-1023.
[10]Rao S,Sirasanagnadla A,Kumar Mr,et al.A rare case of variant morphology of peroneus tertius muscle[J].J Clin Diagnostic Res,2014,8(10):AD01-02.
[11]Verma P,Seema.Analysis of fibularis tertius in terms offrequency morphologymorphometryand clinical significance in north indian cadavers[J].Int J Anat Res,2015,3(4):1646-1650.
[12]Gusm?o LCBD,Lima JSB,Duarte FHG,et al.Anatomical basis for the use of the fibularis tertius muscle in myocutaneous flaps[J].Rev Bras Cir Plást,2013,28(Issue):191-195.