距跟骨间韧带的基础与临床相关研究
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摘要
距跟骨间韧带位于距下关节中部的跗骨管内、关节运动轴的下方,是维持距下关节稳定的强大结构之一,因此该韧带的损伤可导致严重的距下关节不稳定。既往缺乏对这一问题的重视,对该韧带前、后两束的详细解剖及韧带功能的认识不够深入,且各学者的观点存在分歧。常规检查方法难以对距跟骨间韧带损伤作出满意诊断。磁共振成像(Magnetic Resonance Imaging,MRI)能够提供直接显示距跟骨间韧带的影像资料。为了获得更加理想的图像,本研究采用多种3D-MR扫描序列及扫描方法对距跟骨间韧带进行检查,对比各种扫描图像,优化扫描序列;对距跟骨间韧带的走行进行分析测量,确定断层解剖研究中铣切标本的方向,以便获得的断面能够更好地显示距跟骨间韧带的全程及附着点。通过拍摄各解剖断层的数字图像,并与MRI断层图像进行对比,研究距跟骨间韧带形态与影像表现的对应关系,为距跟骨间韧带的影像识别及损伤诊断提供解剖学依据。
目前,距跟骨间韧带各径线的测量主要见于解剖学研究,然而,由于尸体标本与活体组织的不同以及个体化的差异,这些数据不易直接应用于临床。影像学检查是临床诊断各种损伤的重要手段。对于韧带损伤的观察, MRI检查是主要手段之一。在MRI各种重建图像上测量距跟骨间韧带的长度和宽度并与解剖学研究相比较,这类研究甚少。本研究通过对足踝部行MRI扫描,重建其矢状面和斜冠状面,观察并测量距跟骨间韧带的相关径线,提供定量影像学资料。在诊治足踝部外伤时,X线或者CT扫描是常用的快速检查手段,如果能够通过对骨性结构的观察和测量来反映距跟骨间韧带的走形、径线和损伤的严重程度,有助于决定进一步的检查和治疗手段。本研究对志愿者行CT扫描,观察其矢状面和斜冠状面上距跟骨间韧带的走行,测量其长度,并与MRI扫描图像上测量的数据对比。在此基础上,通过对后足行不同角度X线摄片,观察距跟骨间韧带间隙的显示情况,确定最佳的投照角度,测量其长度径线,并与CT扫描图像上测量的数据对比。探讨在X线片或CT图像上观察距跟骨间韧带走行并辅助判断该韧带损伤的可行性,以及其与MRI图像的可比性。
跟骨骨折约占全部骨折的2%,约占跗骨损伤患者的60%。目前跟骨骨折的诊断和治疗主要集中于骨折本身,对于伴发的韧带损伤,尤其是距跟骨间韧带损伤,相关研究较少。跟骨骨折患者保守治疗或者手术治疗后,部分患者发生距下关节炎、距下关节不稳等后遗症,症状严重时,需行距下关节融合术治疗,对足踝部的功能和生活工作造成不良影响。关于跟骨骨折患者是否伴有距跟骨间韧带损伤以及损伤的部位和形态,相关研究甚少。本研究通过对跟骨骨折患者行MRI扫描,了解距跟骨间韧带损伤的发病率和损伤特点。
第一部分距跟骨间韧带MR扫描序列的研究
目的:量化评价并比较各种3D MRI扫描序列重建图像对距跟骨间韧带的显示质量,实现距跟骨间韧带扫描序列的优化;观察并测量距跟骨间韧带的走行方向,探讨距跟骨间韧带与体表标志的关系,为断层解剖研究中断面方向的选取提供依据。
方法:研究对象为健康志愿者32人,男性17人,女性15人,年龄15～69岁,平均年龄35.6岁,经跟骨侧位、轴位X线检查均未发现骨性结构异常。MRI检查的体位为侧卧位、足先进,检查侧在上,足踝部处于自然体位并予以固定。采用Siemens公司Avanto 1.5-T超导型MR机及Coil elements KN,对32个距下关节均采用3D序列扫描。首先,对10个距下关节行T1-MPR、T1-VIBE、3D-VIBE+Fs、3D-SPACE、3D-Medic、3D-True FISP和3D-FLASH共7个序列扫描,并采用多层面重组技术进行矢状面、斜冠状面和斜横断面图像重建。经盲法筛选出优质图像,按扫描序列分为T1和T2两组,各包含2个和5个亚组。由3位影像科医师在盲法下对图像进行综合评价,采用5分制法将其显示距跟骨间韧带的质量量化,对每幅图像取3人评分的均数作为其评分。采用单因素方差分析法对T1组和T2组分别进行统计学处理,并采用SNK法对T2组5个亚组进行两两比较,得出最佳扫描序列。同时,对图像中骨质、关节面、关节间隙、韧带、肌肉软组织及关节液的显示情况进行评价。然后,采用最佳序列完成对其余22个距下关节的扫描并进行矢状面、斜冠状面及斜横断面重建。对所有研究对象,在矢状面上测量距跟骨间韧带长轴与后足足底之间的夹角。在斜冠状面上,测量距跟骨间韧带长轴与踝关节面之间的夹角。
结果:3位医师对MR图像中距下关节显示质量的评分具有一致性(Kappa=0.85)。对每幅图像取3位医师评分的均数作为该图像的评分进行分析。T1组经方差齐性检验接受2亚组评分总体方差相等,进行单因素方差分析,F=113.01,P<0.001,2组之间具有统计学差异,T1-VIBE序列优于T1-MPR序列。T2组经方差齐性检验接受5亚组评分总体方差相等,进行单因素方差分析,F=119.64,P<0.001,5组之间具有统计学差异,采用SNK法进行5组间的两两比较,3D-VIBE+Fs序列与3D-FLASH序列较优,2组间无显著差异;3D-SPACE序列、3D-MEDIC序列、3D-True FISP序列其次,3组间不具有显著差异性。在矢状面上,距跟骨间韧带长轴与后足足底平面之间的夹角为(61.19±4.65)°。在斜冠状面上,距跟骨间韧带长轴与踝关节面之间的夹角为(46.59±4.37)°。
结论:1.T1加权T1-VIBE序列对距跟骨间韧带及距下关节骨质的显示明显优于T1-MPR序列。2.T2加权3D-VIBE+Fs和3D-FLASH序列对骨质、关节软骨以及关节液的显示明显优于3D-SPACE、3D-MEDIC及3D-True FISP序列。3D-VIBE+Fs序列和3D-FLASH序列之间无明显差异。3.距跟骨间韧带在矢状面上斜向前上方走行,其长轴与后足足底之间的夹角为(61.19±4.65)°。4.距跟骨间韧带在冠状面上向斜内上方走行,其长轴与踝关节面之间为的夹角(46.59±4.37)°。
第二部分距跟骨间韧带断层图像与MRI图像的对照研究
目的:获取国人足部薄层断层数字图像和MRI图像,对距跟骨间韧带及周围相关结构进行观察,并将两种图像进行对比,为距跟骨间韧带损伤的诊治提供解剖学依据。
方法:选用6具正常的新鲜足标本并分为A、B、C三组。对各组标本按不同位置进行包埋、固定和冰冻,然后进行铣削(层厚0.2mm,精确度0.00lmm),分别获得足矢状面、斜冠状面和斜横断面断层,使用数码相机(820万象素)拍摄各断层的数字图像。
选择无足踝部外伤、手术史及任何不适的成年志愿者32位,男性17位,女性15位,年龄15岁至69岁(平均35.6岁),共32个距下关节,行跟骨侧位、轴位X线检查均未见骨质异常。研究对象取侧卧位,应用高分辨率膝关节线圈,采用T1-VIBE、3D-VIBE +Fs和3D-FLASH 3个序列进行足踝部MRI扫描。图像采用多层面重组技术进行矢状面、斜冠状面和斜横断面重建。由3名高年资医师对相应的断层图像和MRI图像进行观察和对照,分析距跟骨间韧带的解剖学和影像学特征。
结果:新鲜冰冻足标本薄层断层数字图像与正常成人活体足部MRI图像均可清晰显示韧带、脂肪、关节软骨、骨及肌肉等组织结构。断层图像的组织分辨率高于MRI图像,但其断面方向不够精确,因此有些结构在两种图像上不能完全对应。在过距骨颈中部和外侧的矢状面可见距跟骨间韧带,位于颈韧带后方,分为前、后两束,后束位于跗骨管后外侧部、后距下关节前方,呈条状或梯形,向内前上方斜行;前束位于后束前内侧,呈梭形或条索状,两束之间有脂肪相隔;在MRI图像上距跟骨间韧带两束均呈低信号强度,前、后束区分不如斜冠状面理想。在过距骨颈中后部的斜冠状面可见纵行的距跟骨间韧带前束,在过距骨后跟关节面前方的斜冠状面可见距跟骨间韧带前、后束,均呈斜行的条带状,上端稍细,后束纤维较粗大;在相应MRI图像上距跟骨间韧带位于跗骨窦最内侧,呈低信号强度,由外下斜向内上走行。在斜冠状面图像上能够很好地区分距跟骨间韧带前、后束,两束间以伸肌下支持带中间根相隔,后束与伸肌下支持带内侧根相邻。在过骨间沟的斜横断面可见距跟骨间韧带,呈均匀的条带状,下端附着于跟骨沟,向前上方斜行,抵达距骨沟。斜横断面图像能够很好的区分距跟骨间韧带前、后束。
结论:1.距跟骨间韧带纤维向上前内方斜行,分为前、后两束,后束位于跗骨管后外侧部、后距下关节前方起自跟骨沟后部、跟骨后距关节面前缘,止于距骨沟底部;前束位于后束的前内侧及前中距下关节后方,起自后束起点的前内侧、跗骨管底壁前缘,止于跗骨管顶壁。2.新鲜冰冻足标本薄层断层图像与正常成人活体足部MRI图像在显示距跟骨间韧带及其周围组织方面具很强的可比性,因此MRI检查可用于距跟骨间韧带损伤的诊断,其矢状面图像的重点观察区域为距骨外侧缘至跟骨载距突内侧缘之间,斜冠状面为前距下关节前端至跗骨管后缘之间,斜横断面为跗骨管下缘至距骨颈平面之间。
第三部分距跟骨间韧带影像学测量和损伤特征
目的:探讨应用MRI,CT和X线图像显示距跟骨间韧带及其所在间隙?的可行性及可比性;探讨跟骨骨折患者中距跟骨间韧带损伤的特征。
方法:1.选择于2008年2月至2010年3月间因非创伤原因在我院行足部MRI检查的患者作为研究对象,采用T1-VIBE序列,T2-3D-VIBE+Fs和3D-FLASH序列扫描,行矢状面和斜冠状面重建,在重建图像上测量距跟骨间韧带的长度和宽度。2.选择30名健康成人60侧足作为研究对象,行足踝部CT扫描,并进行矢状位和斜冠状位重建,在重建图像上测量距跟骨间韧带所在间隙的长度。3.对上述60侧足进行侧位X线摄像,被检者侧卧,检查侧在下,定位线通过距下关节间隙。设定球管与床面垂直为中立位(0°),向肢体近端偏转为尾侧投照,向肢体远端偏转为头侧投照,依次自尾侧15°、10°、5°、0°、头侧5°、10°、15°进行投照,选出能够清晰显示距跟骨间韧带间隙及其跟骨侧和距骨侧界线的最佳投照角度,在其所得图像上测量距跟骨间韧带间隙的长度,并与MRI和CT图像上距跟骨间韧带或其所在间隙的长度进行比较。4.收集2008年2月至2010年3月间在我院行足踝部MRI检查的跟骨骨折患者的资料,观察MRI图像上距跟骨间韧带损伤的类型和部位及是否伴发其它损伤,并进行统计。
结果:1. MRI图像上距跟骨间韧带的长度:矢状面,男性为(13.2±3.0)mm,女性为(12.1±2.7)mm;斜冠状面,男性为(14.7±3.5)mm,女性为(13.8)±3.2mm;在矢状面和斜冠状面,同性别左、右侧间无明显差异(P>0.05),同侧别男性大于女性(P<0.05);同性别,矢状面上的长度小于斜冠状面上的长度(P<0.05)。2. CT图像上距跟骨间韧带所在间隙的长度:矢状面,男性为(13.1±2.9)mm,女性为(12.2±2.5)mm;斜冠状面,男性为(14.7±3.3)mm,女性为(13.7±2.9)mm;在矢状面和斜冠状面上,同性别左、右侧间无明显差异(P>0.05),同侧别男性大于女性(P<0.05);同性别矢状面上的长度明显小于斜冠状面上的长度(P<0.05)。3.同一投照角度X线片上距跟骨间韧带间隙的长度:同性别左、右侧间无明显差异(P>0.05),同侧别男性明显大于女性(P<0.05)。侧位X线片上距跟骨间韧带间隙的长度与相应矢状面CT图像上的长度相比较:尾侧3个角度及中立位片上的长度均大于CT图像上的长度(P<0.05);头侧5°和10°片上的长度与相应CT图像上的长度无明显差异(P>0.05)。头侧10°片显示距跟骨间韧带间隙清晰,呈长方形,自后下斜向前上,距骨侧和跟骨侧界线明确,故认为该角度为显示距跟骨间韧带?间隙的最佳投照角度,在该片上测量距跟骨间韧带间隙的长度,在男性为(14.2±3.1)mm,女性为(12.3±2.3)mm。4.按照跟骨骨折Sanders分型,本组包括Ⅱ型骨折11侧,Ⅲ型骨折37侧,Ⅳ型骨折30侧。44侧(56.4%)跟骨骨折伴距跟骨间韧带损伤,其中36侧(81.8%)为距跟骨间韧带断裂,8侧(19.2%)为部分断裂,42侧(95.5%)损伤位于跟骨侧1/3,2侧(4.5%)位于中间1/3。34侧跟骨骨折伴有颈韧带损伤者均有距跟骨间韧带损伤,其中29侧(85.3%)颈韧带断裂,5侧(14.7%)颈韧带牵拉损伤。
结论:足部MRI图像和CT图像上距跟骨间韧带或其所在间隙的长度无侧别差异,男性明显大于女性;矢状面和斜冠状面MRI图像上的距跟骨间韧带长度和相应CT图像上距跟骨间韧带所在间隙的长度均具有可比性。头侧10°为显示距跟骨间韧带间隙的最佳投照角度,自该角度拍摄的侧位片上的距跟骨间韧带间隙长度与CT和MRI矢状面图像上韧带或间隙的长度无明显差异。
The interosseous talocalcaneal ligament(ITCL) lies in the tarsal canal in the midle of the subtalar joint. The ITCL is just under the axis of the subtalar joint which is one of the main ligaments maintainning the subtalar joint stability. Therefore, injeries of the ITCL ligaments can lead to serious subtalar joint instability. In the past, few attentions were paid to this issue. The detailed anatomy of the anterior and posterior bundles of the ITCL and their funcitons are not understood totally and thoroughly. There are various views about the ITCL among different scholars. Routine examinations cannot guarantee satisfactory diagnosis of the injured ITCL. Magnetic Resonance Imaging(MRI) can demonstrates directly the ITCL. In order to obtain a more desirable image, this study selected a variety of 3D-MR sequences and scanning technique to test the ITCL. The images obtained with various MR sequences were compared and teh optimal MR sequence was identified. The course of the ITCL was observed and the widths and lengths of the ITCL on varous MR images were measured and analyzed. Based upon the MRI images of the ITCL, the position of the ITCL was determined to milling the specimens in the sectional anatomical study, aiming to obtain better cross-sections to demonstrate the intact course and the attachments of the ITCL. Digital photographs of the sectional images were taken and compared with the MRI images to study the ralationship between the MRI images and the sectional images of the ITCL. This can provide anatomical basis for the imageological identification and the diagnosis of the ITCL.
At present, the measurements of the ITCL are included mainly in the anatomical study. However, these data cannot be applied into the clinics directly due to the individual discrepency and the difference between the specimens and the living body. Imageological examinations are the important resorts to diagnose the various injuries. MRI scan is one of the principal means to oberve the ligament injury.
Few research exists regarding the comparision of the ITCL lengths and widths between the reconstructed MRI images and the anatomical studies. This study is to provide quantitative image data by observing and measuring the width and length of the ITCL on reconstructed saggital and oblique coronal MR images of the foot and ankle. X ray or CT scan is the commonly used means for quick examinations of the injuries of the foot and ankle. If the observations and measurements of the bone structure can reflect indirectly the course, dimensions and the injury severity, it will help to determine further examination and treatment. In this study, the length and width of the ITCL were measured on the sagittal and oblique coronal CT images of the volunteers and the data was compared with that obtained on MR images. On the basis of the above-mentioned study, various radiographs of the foot were taken following the X-ray beams in different directions. The gap where the ITCL lies was observed. The optimal radiograph was determined to show the intact ITCL gap on which the length of gap was measured. The gap length was compared with that measured on the corresponding saggital CT images. In short, we aim to explore the feasibility of oberving the course and the injury of the ITCL using X-ray films or CT images, and test their comparability regarding ITCL with the MRI images.
Calcaneal fracture accounts for about 2% of all fractures and about 60% of tarsal bone fractures. Currently, the diagnosis and treatment of calcaneal fractures mainly focus on the fracture itself. The associated ligament injuries, especially the ITCL injuries, were involved in few study. Some patients with calcaneal fractures may sustain subtalar arthritis and other complications with regard to subtalar joint instability after either conservative treatment or surgical management. If severe symptoms occurred in these patients, subtalar arthrodesis is required to relieves the symptom. However, this procedure will cause the impairment of the function of the ankle joint and affects inevitably work or even daily life. There is little study with regard to whether the patients with calcaneal fractures are with associated ITCL injuries and the injured sites and morphous of the ITCL. The current study aims to investigate the incidence and the injured features of the ITCL in patients with calcaneal fracturs with the use of MRI.
Part 1 The study of the MRI sequences on scanning the interosseous talocalcaneal ligament
Objective: To optimize the MRI sequences for interosseous talocalcaneal ligaments by evaluating and comparing quantitatively the quality of the reconstructed images of interosseous talocalcaneal ligaments scanned using a variety of 3D MRI sequences. By observing and measuring the course of the interosseous talocalcaneal ligaments, the relationship between the interosseous talocalcaneal ligament and the body surface symbol was invesgated, which can help guiding the selection of the sectional direction in the sectional anatomical study.
Methods: There were 32 healthy volunteers in the study, including 17 men and 15 women with an average age of 35.6 years(ranged, from 15 to 69 years). No bone abnormality was detected on the the lateral calcaneal and axial radiographies. When taking MRI scans, the volunteers lay supine with foot advancing and the foot and ankle fixed at a natural state. The Siemens Avanto 1.5-T superconducting MR machine and Coil elements KN were used and 32 subtalar joints were scaned using 3D MRI sequences. Firstly, 10 subtalar joints were scanned by T1-MPR, T1-VIBE, 3D-VIBE+Fs, 3D-SPACE, 3D-Medic, 3D-True FISP, and 3D-FLASH sequences, and the saggital images, oblique coronal images and oblique horizontal images were reconstructed using the multi-plannar reconstruction technology. The optimal images were selected blindly and the sequences were divided into two groups, T1 group with 2 subgroups and T2 group with 5 subgroups. Three radiological physicians eveluated the images and assess quantitatively the interosseous talocalcaneal ligaments with 5.0 basis. The mean score of the three physicians on each image is defined as its score. The T1 and T2 groups were assessed with statistical analysis using the single factor analysis of variance, respectively. The subgroups of T2 group 5 subgroups were analyzed with the use of SNK method to identify the optimal scanning sequence. Meanwhile, the demonstration of the bone, joint, joint space, ligament, muscle and soft tissue and joint fluid on the images were assessed. Subsequently, the other 22 subtalar joints were scanned using the optimal MRI sequences and the sagittal, oblique coronal and oblique horizontal images were reconstructed. The angle between tha planta pedis of the hindfoot and the long axis of the interosseous talocalcaneal ligament was measured on each saggital image. The angle between tha articular surface of the ankle joint and the long axis of the interosseous talocalcaneal ligament was measured on each oblique coronal image.
Results: The three physicians shared consistency on the eveluation of the quality of MR images demonstrating the subtalar joint(Kappa = 0.85). The mean score of each image was selected for analysis. In T1 group, the overall variance of the two subgroups was equal to each other after homogeneity test of variance. While, univariate analysis of variance revealed that T1-VIBE sequence was superior to T1-MPR sequences wiht F=113.01 and P<0.001. In T2 group, the overall variance of the five subgroups was equal to each other after homogeneity test of variance. While, univariate analysis of variance revealed that there was significant difference among the five subgroups with F=119.64 and P<0.001. SNK tests showed that the 3D-VIBE+Fs and 3D-FLASH sequences were better than 3D-SPACE, 3D-MEDIC and 3D-True FISP sequences, although no significant difference was found either between the 3D-VIBE+Fs and 3D-FLASH sequences or among 3D-SPACE, 3D-MEDIC and 3D-True FISP sequences. The angle between tha planta pedis of the hindfoot and the long axis of the interosseous talocalcaneal ligament was (61.19±4.65)°on each saggital image. The angle between tha articular surface of the ankle joint and the long axis of the interosseous talocalcaneal ligament was (46.59±4.37)°on each oblique coronal image.
Conclusion: 1. T1 weighted T1-VIBE sequence is better than T1-MPR sequences in demonstrating the interosseous talocalcaneal ligament and the bone of the subtalar joint. 2. T2 weighted 3D-VIBE + Fs and 3D-FLASH sequences are much better than 3D-SPACE, 3D-MEDIC and 3D-True FISP sequences in demonstrating the bone, cartilage and synovial fluid. There is no significant difference between 3D-VIBE + Fs sequence and 3D-FLASH sequence. 3. On the saggital images, the course of the interosseous talocalcaneal ligament runs anterosuperiorly, and the angle between tha planta pedis of the hindfoot and the long axis of the ligament was (61.19±4.65)°. 4. On the oblique coronal images, the course of the interosseous talocalcaneal ligament runs medial-superiorly, and the angle tha articular surface of the ankle joint and the long axis of ligament the was (46.59±4.37)°.
Part 2 The comparative study between digital sectional images and MRI images of the interosseous talocalcaneal ligament
Objective: To obtain digital images of thin sections and 3D reconstructed MR images of normal chinese adult feet, to observe the interosseous talocalcaneal ligament and its surrounding structures, and to compare MR images to their corresponding sectional digital images, providing anatomical basis for diagnosing and treating lesions of the interosseous talocalcaneal ligament.
Methods: Six normal fresh feet specimens were selected and divided into three groups named A, B, and C. Specimens in three different groups which were embedded, fixed and frozen in different positions, were milled(thickness = 0.2mm, accuracy = 0.00lmm) to obtain sagittal, coronal oblique, and transverse oblique sections respectively. Digital images of all sections were taken by a digital camera (8.2 megapixel). Thirty-two adult volunteers with no trauma and surgery history and no complaints of foot/ankle were recruited, including 17 males and 15 females, aged from 15 to 69 years old(average 35.6), providing 32 ankle-subtalar joints. Bony abnormity were excluded in all volunteers using radiography before the MR examination. The subjects were placed in lateral position. T1-VIBE, 3D-VIBE+Fs and 3D-FLASH MR sequences were scanned using Coil element KN for All ankle-subtalar joints. Then multi-planar reconstruction images were created in sagittal, oblique coronal, oblique horizontal orientations. Sectional images and their corresponding MR images in three different planes were visualized and compared by 3 experienced radiologists, to explore anatomical and iconographic characteristics of the intersseous talocalcaneal ligament.
Results: Both digital images of thin sections of fresh frozen cadaver feet and in vivo MRI images of healthy adult feet could distinctly displayed different tissues and structures such as ligament, fat, cartilage, bone, and tendon, while the former had higher resolution than the later did. However, orientations of thin sections were not accurate enough to achieve complete correspondence of certain structures between the two types of images. In sagittal planes which cut through central and lateral part of the neck of talus, the interosseous talocalcaneal ligament(ITCL) is located posterior to the cervical ligament, consisted of two bundles, anterior and posterior. The posterior bundle, whose shape is column or trapezoid, stands just anterior to the posterior subtalar joint in the posterolateral part of the tarsal tunnel. Its fibers are orientated anterosuperomedially. The anterior bundle, which is fusiform or cordlike, is found anteromedial to the posterior bundle. There necessarily are some fatty tissue in between the two bundles. Bundles of the ITCL both appear hypointense on the MRI image, and It is more difficult to distinguish them on these images than on images in coronal oblique plane. In coronal oblique planes which cut through the postmedian part of the neck of talus, the anterior bundle of the ITCL is seen running longitudinally. In coronal oblique planes just anterior to the posterior facet of the talus, the anterior bundle and the posterior bundle which is thicker, are both oblique bands with broader lower end. On their corresponding MRI images, the hypointense ITCL in the innermost of the tarsal canal runs from lateroinferior to mediosuperior. Its two bundles can be distinguished clearly from each other on these planes, between which the intermediate root of the inferior extensor retinaculum is located. In transverse oblique planes, the rhombic ITCL attaches to the sulcus calcanei and runs anterosuperiorly toward the sulcus tarsi. Its two bundles can also be distinguished clearly from each other on these planes.
Conclusions: 1. Fibers of the ITCL are orientated obliquely anterosuperomedially and divided into two bundles. The posterior bundle is located anterior to the posterior subtalar joint in the posterolateral part of the tarsal tunnel, arising from the sulcus calcanei anterior to the posterior facet of the talus, inserting into the sulcus tarsi. The anterior bundle is located anteromedial to the posterior bundle and posterior to the anterior and middle subtalar joints, originating from the anterior floor of the tarsal tunnel, anterior and medial to the origin of the posterior bundle, and inserting into the roof of the tarsal tunnel. 2. In this study, excellent comparability is found between digital images of thin sections of fresh frozen cadaver feet and in vivo MRI images of healthy adult feet. Therefore, MRI examination is considered to be qualified for diagnosing ITCL injuries. The focused observation area, is between the lateral margin of talus and medial margin of the sustentaculum tali of calcaneus on sagittal images, between the fore-end of the anterior subtalar joint and the posterior border of the tarsal tunnel on coronal oblique images, and between the floor of the tarsal tunnel and the neck of talus on transverse oblique images.
Part 3 The imageological measurement and the injured characterics of the interosseous talocalcaneal ligament
Objective: To investigate the characteristics of the injuries of interosseous talocalcaneal ligament in patients with calcaneal fractures and to explore the feasibility and comparability of magnetic resonance imaging(MRI), computed tomography(CT) scan and radiograph in demonstrating the interosseous talocalcaneal ligament and the gap where the ligament lies. Methods: 1. From February 2008 to march 2010, patients with calcaneal fractures who had undergone magnetic resonance imaging (MRI) were included in the study. The MRI images were studied to observe whether interosseous talocalcaneal ligament was disrupted. If injured, the site and injury pattern of disrupted ligametns were identified. Its incident rate was analysed. Concomitant injure were also identified on the images. 2. From February 2008 to March 2010 patients who had undergone MRI while without ?fractures and ligaments’injury were enrolled in the study. MRI scan of the ankle and foot following T1-vibe sequence, T2 3D VIBE sequence and 3D FLASH sequence were taken and the sagittal, oblique coronal planes were rebuilted. The length and width of interosseous talocalcaneal ligament were measured in the reconstructed imageds with the use of the measurement software on the workstation. The largest length was defined as the length of the interosseous talocalcaneal ligament. 3. Thirty healthy adults were selected in the group. The lengthes of the gap where the ITCL lies were measured on the consecutive reconstructed saggital and oblique coronal planes obtained from CT scans. The maximal length was defined as the length of the gap of interosseous talocalcaneal ligament. 4. The radiographs of the foot and ankle of 30 volunteers were taken with X-ray beam in various rotations. When taking radiographes, the volunteers lie on side and the line of position(LOP) runs through the gap between the talus and the calcaneus. adjust the rotation angle, set the tube vertical. The neutrol position was defined as the tube of the radiographic system being vertical to the radiographic table. The tube tilited distally is taken as cephalic rotation and the tube tilted proximally is considered as caudal rotation. Seven radiographes were taken on each foot at 15, 10, 5 degrees cephalic rotation, neutral position, 5, 10, and 15 degrees caudal rotation. The gap where the ITCL lies was observed and measured on each radiograph. The data was compared with thosed obtained from CT or MRI images.
Results: 1. According to Sanders classification of calcaneal fractures,Ⅱfracture 11 sides,Ⅲfracture 37 side,Ⅳfracture 30 side were included in this group. 44 lateral calcaneal fracture (56.4%) with interosseous talocalcaneal ligament injured, the injury near the heel side, 36 sides (81.8%) with interosseous talocalcaneal ligament disrupted, , 8 sides (19.2%) with partly disrupted, 42 sides (95.5%)were in the calcaneal side of the 1/3, 2 sides (4.5%) were in the ligament of middle 1/3. thirty-four lateral in the group with cervical ligament injury, of which 29 sides (85.3%) cervical ligament disrupted, 5 sides (14.7%) cervical ligament stretch injury. 2. The length of interosseous talocalcaneal ligament was 13.2mm±3.0mm for male and 12.1mm±2.7mm for female on MRI saggital images, and 14.7mm±3.5mm for male and 13.8mm±3.2mm for female on MRI oblique coronal images. There is no significant difference between the lengths of the right and left interosseous talocalcaneal ligaments either on saggital or oblique coronal MRI images in the same gender(P>0.05). The length of interosseous talocalcaneal ligaments for male is longer than that for female on both saggital and oblique coronal MRI images(P>0.05). 3. The gap length of the interosseous talocalcaneal ligament was 13.1mm±2.9mm for male and 12.2mm±2.5mm for female on saggital CT images, and the gap length was 14.7mm±3.3mm for male and 13.7mm±2.9mm for female on the oblique coronal images. There is no significant difference between the lengths of the right and left interosseous talocalcaneal ligaments either on saggital or oblique coronal CT images in the same gender(P>0.05). The length of interosseous talocalcaneal ligaments for male is longer than that for female on both saggital and oblique coronal CT images(P>0.05). The length of interosseous talocalcaneal ligaments on saggital CT images is shorter than that on oblique coronal CT images(P<0.05). 4. The gap lengths of the interosseous talocalcaneal ligament on radiographs obtained from X-ray beam in different rotation angle are various. The gap length of the interosseous talocalcaneal ligament of the left side is similar with that of right side obtained from the same angle of X-ray beam rotation(P>0.05). The gap length of the interosseous talocalcaneal ligament for male is longer than that for female in the same side obtained from the same angle of X-ray beam rotation(P<0.05). The gap lengths on the lateral radiographs obtained from three caudal rotations and the neutral position is longer than that obtained from the saggital CT images(P<0.05). The gap lengths on the lateral radiographs obtained from 5 and 10 degrees cephalic rotation is similar with that obtained from the saggital CT images(P>0.05). The gap of the interosseous talocalcaneal ligament is demonstrated clearly on the 10 degrees cephalic rotation, which is rectangle and runs from posteroinferior to anteosuperior. The calcaneal and talar side of the gap is easily identified. Therefore the gap length measured on the radiographs obtained from 10 degrees cephalic rotation is defined as the length of the ligament measured on the lateral radiographs and the length is (14.2±3.1)mm for male and (12.3±2.3)mm female.
Conclusion: The study reveals that the length of interosseous talocalcaneal ligament obtained from MRI and CT has no significant difference between the right side and the left side, while the length of interosseous talocalcaneal ligament of the male is larger than that of female. The length of the ligament measured on the both CT and MRI sagittal and coronal images are comparable, respectively. The 10 degrees cephalic rotation lateral radiographs of the foot can demonstrate clearly the gap where interosseous talocalcaneal ligament lies, on which the gap length measured has no significant difference when comparing with the length measured on the the CT and MRI sagittal images.
目前,距跟骨间韧带各径线的测量主要见于解剖学研究,然而,由于尸体标本与活体组织的不同以及个体化的差异,这些数据不易直接应用于临床。影像学检查是临床诊断各种损伤的重要手段。对于韧带损伤的观察, MRI检查是主要手段之一。在MRI各种重建图像上测量距跟骨间韧带的长度和宽度并与解剖学研究相比较,这类研究甚少。本研究通过对足踝部行MRI扫描,重建其矢状面和斜冠状面,观察并测量距跟骨间韧带的相关径线,提供定量影像学资料。在诊治足踝部外伤时,X线或者CT扫描是常用的快速检查手段,如果能够通过对骨性结构的观察和测量来反映距跟骨间韧带的走形、径线和损伤的严重程度,有助于决定进一步的检查和治疗手段。本研究对志愿者行CT扫描,观察其矢状面和斜冠状面上距跟骨间韧带的走行,测量其长度,并与MRI扫描图像上测量的数据对比。在此基础上,通过对后足行不同角度X线摄片,观察距跟骨间韧带间隙的显示情况,确定最佳的投照角度,测量其长度径线,并与CT扫描图像上测量的数据对比。探讨在X线片或CT图像上观察距跟骨间韧带走行并辅助判断该韧带损伤的可行性,以及其与MRI图像的可比性。
跟骨骨折约占全部骨折的2%,约占跗骨损伤患者的60%。目前跟骨骨折的诊断和治疗主要集中于骨折本身,对于伴发的韧带损伤,尤其是距跟骨间韧带损伤,相关研究较少。跟骨骨折患者保守治疗或者手术治疗后,部分患者发生距下关节炎、距下关节不稳等后遗症,症状严重时,需行距下关节融合术治疗,对足踝部的功能和生活工作造成不良影响。关于跟骨骨折患者是否伴有距跟骨间韧带损伤以及损伤的部位和形态,相关研究甚少。本研究通过对跟骨骨折患者行MRI扫描,了解距跟骨间韧带损伤的发病率和损伤特点。
第一部分距跟骨间韧带MR扫描序列的研究
目的:量化评价并比较各种3D MRI扫描序列重建图像对距跟骨间韧带的显示质量,实现距跟骨间韧带扫描序列的优化;观察并测量距跟骨间韧带的走行方向,探讨距跟骨间韧带与体表标志的关系,为断层解剖研究中断面方向的选取提供依据。
方法:研究对象为健康志愿者32人,男性17人,女性15人,年龄15～69岁,平均年龄35.6岁,经跟骨侧位、轴位X线检查均未发现骨性结构异常。MRI检查的体位为侧卧位、足先进,检查侧在上,足踝部处于自然体位并予以固定。采用Siemens公司Avanto 1.5-T超导型MR机及Coil elements KN,对32个距下关节均采用3D序列扫描。首先,对10个距下关节行T1-MPR、T1-VIBE、3D-VIBE+Fs、3D-SPACE、3D-Medic、3D-True FISP和3D-FLASH共7个序列扫描,并采用多层面重组技术进行矢状面、斜冠状面和斜横断面图像重建。经盲法筛选出优质图像,按扫描序列分为T1和T2两组,各包含2个和5个亚组。由3位影像科医师在盲法下对图像进行综合评价,采用5分制法将其显示距跟骨间韧带的质量量化,对每幅图像取3人评分的均数作为其评分。采用单因素方差分析法对T1组和T2组分别进行统计学处理,并采用SNK法对T2组5个亚组进行两两比较,得出最佳扫描序列。同时,对图像中骨质、关节面、关节间隙、韧带、肌肉软组织及关节液的显示情况进行评价。然后,采用最佳序列完成对其余22个距下关节的扫描并进行矢状面、斜冠状面及斜横断面重建。对所有研究对象,在矢状面上测量距跟骨间韧带长轴与后足足底之间的夹角。在斜冠状面上,测量距跟骨间韧带长轴与踝关节面之间的夹角。
结果:3位医师对MR图像中距下关节显示质量的评分具有一致性(Kappa=0.85)。对每幅图像取3位医师评分的均数作为该图像的评分进行分析。T1组经方差齐性检验接受2亚组评分总体方差相等,进行单因素方差分析,F=113.01,P<0.001,2组之间具有统计学差异,T1-VIBE序列优于T1-MPR序列。T2组经方差齐性检验接受5亚组评分总体方差相等,进行单因素方差分析,F=119.64,P<0.001,5组之间具有统计学差异,采用SNK法进行5组间的两两比较,3D-VIBE+Fs序列与3D-FLASH序列较优,2组间无显著差异;3D-SPACE序列、3D-MEDIC序列、3D-True FISP序列其次,3组间不具有显著差异性。在矢状面上,距跟骨间韧带长轴与后足足底平面之间的夹角为(61.19±4.65)°。在斜冠状面上,距跟骨间韧带长轴与踝关节面之间的夹角为(46.59±4.37)°。
结论:1.T1加权T1-VIBE序列对距跟骨间韧带及距下关节骨质的显示明显优于T1-MPR序列。2.T2加权3D-VIBE+Fs和3D-FLASH序列对骨质、关节软骨以及关节液的显示明显优于3D-SPACE、3D-MEDIC及3D-True FISP序列。3D-VIBE+Fs序列和3D-FLASH序列之间无明显差异。3.距跟骨间韧带在矢状面上斜向前上方走行,其长轴与后足足底之间的夹角为(61.19±4.65)°。4.距跟骨间韧带在冠状面上向斜内上方走行,其长轴与踝关节面之间为的夹角(46.59±4.37)°。
第二部分距跟骨间韧带断层图像与MRI图像的对照研究
目的:获取国人足部薄层断层数字图像和MRI图像,对距跟骨间韧带及周围相关结构进行观察,并将两种图像进行对比,为距跟骨间韧带损伤的诊治提供解剖学依据。
方法:选用6具正常的新鲜足标本并分为A、B、C三组。对各组标本按不同位置进行包埋、固定和冰冻,然后进行铣削(层厚0.2mm,精确度0.00lmm),分别获得足矢状面、斜冠状面和斜横断面断层,使用数码相机(820万象素)拍摄各断层的数字图像。
选择无足踝部外伤、手术史及任何不适的成年志愿者32位,男性17位,女性15位,年龄15岁至69岁(平均35.6岁),共32个距下关节,行跟骨侧位、轴位X线检查均未见骨质异常。研究对象取侧卧位,应用高分辨率膝关节线圈,采用T1-VIBE、3D-VIBE +Fs和3D-FLASH 3个序列进行足踝部MRI扫描。图像采用多层面重组技术进行矢状面、斜冠状面和斜横断面重建。由3名高年资医师对相应的断层图像和MRI图像进行观察和对照,分析距跟骨间韧带的解剖学和影像学特征。
结果:新鲜冰冻足标本薄层断层数字图像与正常成人活体足部MRI图像均可清晰显示韧带、脂肪、关节软骨、骨及肌肉等组织结构。断层图像的组织分辨率高于MRI图像,但其断面方向不够精确,因此有些结构在两种图像上不能完全对应。在过距骨颈中部和外侧的矢状面可见距跟骨间韧带,位于颈韧带后方,分为前、后两束,后束位于跗骨管后外侧部、后距下关节前方,呈条状或梯形,向内前上方斜行;前束位于后束前内侧,呈梭形或条索状,两束之间有脂肪相隔;在MRI图像上距跟骨间韧带两束均呈低信号强度,前、后束区分不如斜冠状面理想。在过距骨颈中后部的斜冠状面可见纵行的距跟骨间韧带前束,在过距骨后跟关节面前方的斜冠状面可见距跟骨间韧带前、后束,均呈斜行的条带状,上端稍细,后束纤维较粗大;在相应MRI图像上距跟骨间韧带位于跗骨窦最内侧,呈低信号强度,由外下斜向内上走行。在斜冠状面图像上能够很好地区分距跟骨间韧带前、后束,两束间以伸肌下支持带中间根相隔,后束与伸肌下支持带内侧根相邻。在过骨间沟的斜横断面可见距跟骨间韧带,呈均匀的条带状,下端附着于跟骨沟,向前上方斜行,抵达距骨沟。斜横断面图像能够很好的区分距跟骨间韧带前、后束。
结论:1.距跟骨间韧带纤维向上前内方斜行,分为前、后两束,后束位于跗骨管后外侧部、后距下关节前方起自跟骨沟后部、跟骨后距关节面前缘,止于距骨沟底部;前束位于后束的前内侧及前中距下关节后方,起自后束起点的前内侧、跗骨管底壁前缘,止于跗骨管顶壁。2.新鲜冰冻足标本薄层断层图像与正常成人活体足部MRI图像在显示距跟骨间韧带及其周围组织方面具很强的可比性,因此MRI检查可用于距跟骨间韧带损伤的诊断,其矢状面图像的重点观察区域为距骨外侧缘至跟骨载距突内侧缘之间,斜冠状面为前距下关节前端至跗骨管后缘之间,斜横断面为跗骨管下缘至距骨颈平面之间。
第三部分距跟骨间韧带影像学测量和损伤特征
目的:探讨应用MRI,CT和X线图像显示距跟骨间韧带及其所在间隙?的可行性及可比性;探讨跟骨骨折患者中距跟骨间韧带损伤的特征。
方法:1.选择于2008年2月至2010年3月间因非创伤原因在我院行足部MRI检查的患者作为研究对象,采用T1-VIBE序列,T2-3D-VIBE+Fs和3D-FLASH序列扫描,行矢状面和斜冠状面重建,在重建图像上测量距跟骨间韧带的长度和宽度。2.选择30名健康成人60侧足作为研究对象,行足踝部CT扫描,并进行矢状位和斜冠状位重建,在重建图像上测量距跟骨间韧带所在间隙的长度。3.对上述60侧足进行侧位X线摄像,被检者侧卧,检查侧在下,定位线通过距下关节间隙。设定球管与床面垂直为中立位(0°),向肢体近端偏转为尾侧投照,向肢体远端偏转为头侧投照,依次自尾侧15°、10°、5°、0°、头侧5°、10°、15°进行投照,选出能够清晰显示距跟骨间韧带间隙及其跟骨侧和距骨侧界线的最佳投照角度,在其所得图像上测量距跟骨间韧带间隙的长度,并与MRI和CT图像上距跟骨间韧带或其所在间隙的长度进行比较。4.收集2008年2月至2010年3月间在我院行足踝部MRI检查的跟骨骨折患者的资料,观察MRI图像上距跟骨间韧带损伤的类型和部位及是否伴发其它损伤,并进行统计。
结果:1. MRI图像上距跟骨间韧带的长度:矢状面,男性为(13.2±3.0)mm,女性为(12.1±2.7)mm;斜冠状面,男性为(14.7±3.5)mm,女性为(13.8)±3.2mm;在矢状面和斜冠状面,同性别左、右侧间无明显差异(P>0.05),同侧别男性大于女性(P<0.05);同性别,矢状面上的长度小于斜冠状面上的长度(P<0.05)。2. CT图像上距跟骨间韧带所在间隙的长度:矢状面,男性为(13.1±2.9)mm,女性为(12.2±2.5)mm;斜冠状面,男性为(14.7±3.3)mm,女性为(13.7±2.9)mm;在矢状面和斜冠状面上,同性别左、右侧间无明显差异(P>0.05),同侧别男性大于女性(P<0.05);同性别矢状面上的长度明显小于斜冠状面上的长度(P<0.05)。3.同一投照角度X线片上距跟骨间韧带间隙的长度:同性别左、右侧间无明显差异(P>0.05),同侧别男性明显大于女性(P<0.05)。侧位X线片上距跟骨间韧带间隙的长度与相应矢状面CT图像上的长度相比较:尾侧3个角度及中立位片上的长度均大于CT图像上的长度(P<0.05);头侧5°和10°片上的长度与相应CT图像上的长度无明显差异(P>0.05)。头侧10°片显示距跟骨间韧带间隙清晰,呈长方形,自后下斜向前上,距骨侧和跟骨侧界线明确,故认为该角度为显示距跟骨间韧带?间隙的最佳投照角度,在该片上测量距跟骨间韧带间隙的长度,在男性为(14.2±3.1)mm,女性为(12.3±2.3)mm。4.按照跟骨骨折Sanders分型,本组包括Ⅱ型骨折11侧,Ⅲ型骨折37侧,Ⅳ型骨折30侧。44侧(56.4%)跟骨骨折伴距跟骨间韧带损伤,其中36侧(81.8%)为距跟骨间韧带断裂,8侧(19.2%)为部分断裂,42侧(95.5%)损伤位于跟骨侧1/3,2侧(4.5%)位于中间1/3。34侧跟骨骨折伴有颈韧带损伤者均有距跟骨间韧带损伤,其中29侧(85.3%)颈韧带断裂,5侧(14.7%)颈韧带牵拉损伤。
结论:足部MRI图像和CT图像上距跟骨间韧带或其所在间隙的长度无侧别差异,男性明显大于女性;矢状面和斜冠状面MRI图像上的距跟骨间韧带长度和相应CT图像上距跟骨间韧带所在间隙的长度均具有可比性。头侧10°为显示距跟骨间韧带间隙的最佳投照角度,自该角度拍摄的侧位片上的距跟骨间韧带间隙长度与CT和MRI矢状面图像上韧带或间隙的长度无明显差异。
The interosseous talocalcaneal ligament(ITCL) lies in the tarsal canal in the midle of the subtalar joint. The ITCL is just under the axis of the subtalar joint which is one of the main ligaments maintainning the subtalar joint stability. Therefore, injeries of the ITCL ligaments can lead to serious subtalar joint instability. In the past, few attentions were paid to this issue. The detailed anatomy of the anterior and posterior bundles of the ITCL and their funcitons are not understood totally and thoroughly. There are various views about the ITCL among different scholars. Routine examinations cannot guarantee satisfactory diagnosis of the injured ITCL. Magnetic Resonance Imaging(MRI) can demonstrates directly the ITCL. In order to obtain a more desirable image, this study selected a variety of 3D-MR sequences and scanning technique to test the ITCL. The images obtained with various MR sequences were compared and teh optimal MR sequence was identified. The course of the ITCL was observed and the widths and lengths of the ITCL on varous MR images were measured and analyzed. Based upon the MRI images of the ITCL, the position of the ITCL was determined to milling the specimens in the sectional anatomical study, aiming to obtain better cross-sections to demonstrate the intact course and the attachments of the ITCL. Digital photographs of the sectional images were taken and compared with the MRI images to study the ralationship between the MRI images and the sectional images of the ITCL. This can provide anatomical basis for the imageological identification and the diagnosis of the ITCL.
At present, the measurements of the ITCL are included mainly in the anatomical study. However, these data cannot be applied into the clinics directly due to the individual discrepency and the difference between the specimens and the living body. Imageological examinations are the important resorts to diagnose the various injuries. MRI scan is one of the principal means to oberve the ligament injury.
Few research exists regarding the comparision of the ITCL lengths and widths between the reconstructed MRI images and the anatomical studies. This study is to provide quantitative image data by observing and measuring the width and length of the ITCL on reconstructed saggital and oblique coronal MR images of the foot and ankle. X ray or CT scan is the commonly used means for quick examinations of the injuries of the foot and ankle. If the observations and measurements of the bone structure can reflect indirectly the course, dimensions and the injury severity, it will help to determine further examination and treatment. In this study, the length and width of the ITCL were measured on the sagittal and oblique coronal CT images of the volunteers and the data was compared with that obtained on MR images. On the basis of the above-mentioned study, various radiographs of the foot were taken following the X-ray beams in different directions. The gap where the ITCL lies was observed. The optimal radiograph was determined to show the intact ITCL gap on which the length of gap was measured. The gap length was compared with that measured on the corresponding saggital CT images. In short, we aim to explore the feasibility of oberving the course and the injury of the ITCL using X-ray films or CT images, and test their comparability regarding ITCL with the MRI images.
Calcaneal fracture accounts for about 2% of all fractures and about 60% of tarsal bone fractures. Currently, the diagnosis and treatment of calcaneal fractures mainly focus on the fracture itself. The associated ligament injuries, especially the ITCL injuries, were involved in few study. Some patients with calcaneal fractures may sustain subtalar arthritis and other complications with regard to subtalar joint instability after either conservative treatment or surgical management. If severe symptoms occurred in these patients, subtalar arthrodesis is required to relieves the symptom. However, this procedure will cause the impairment of the function of the ankle joint and affects inevitably work or even daily life. There is little study with regard to whether the patients with calcaneal fractures are with associated ITCL injuries and the injured sites and morphous of the ITCL. The current study aims to investigate the incidence and the injured features of the ITCL in patients with calcaneal fracturs with the use of MRI.
Part 1 The study of the MRI sequences on scanning the interosseous talocalcaneal ligament
Objective: To optimize the MRI sequences for interosseous talocalcaneal ligaments by evaluating and comparing quantitatively the quality of the reconstructed images of interosseous talocalcaneal ligaments scanned using a variety of 3D MRI sequences. By observing and measuring the course of the interosseous talocalcaneal ligaments, the relationship between the interosseous talocalcaneal ligament and the body surface symbol was invesgated, which can help guiding the selection of the sectional direction in the sectional anatomical study.
Methods: There were 32 healthy volunteers in the study, including 17 men and 15 women with an average age of 35.6 years(ranged, from 15 to 69 years). No bone abnormality was detected on the the lateral calcaneal and axial radiographies. When taking MRI scans, the volunteers lay supine with foot advancing and the foot and ankle fixed at a natural state. The Siemens Avanto 1.5-T superconducting MR machine and Coil elements KN were used and 32 subtalar joints were scaned using 3D MRI sequences. Firstly, 10 subtalar joints were scanned by T1-MPR, T1-VIBE, 3D-VIBE+Fs, 3D-SPACE, 3D-Medic, 3D-True FISP, and 3D-FLASH sequences, and the saggital images, oblique coronal images and oblique horizontal images were reconstructed using the multi-plannar reconstruction technology. The optimal images were selected blindly and the sequences were divided into two groups, T1 group with 2 subgroups and T2 group with 5 subgroups. Three radiological physicians eveluated the images and assess quantitatively the interosseous talocalcaneal ligaments with 5.0 basis. The mean score of the three physicians on each image is defined as its score. The T1 and T2 groups were assessed with statistical analysis using the single factor analysis of variance, respectively. The subgroups of T2 group 5 subgroups were analyzed with the use of SNK method to identify the optimal scanning sequence. Meanwhile, the demonstration of the bone, joint, joint space, ligament, muscle and soft tissue and joint fluid on the images were assessed. Subsequently, the other 22 subtalar joints were scanned using the optimal MRI sequences and the sagittal, oblique coronal and oblique horizontal images were reconstructed. The angle between tha planta pedis of the hindfoot and the long axis of the interosseous talocalcaneal ligament was measured on each saggital image. The angle between tha articular surface of the ankle joint and the long axis of the interosseous talocalcaneal ligament was measured on each oblique coronal image.
Results: The three physicians shared consistency on the eveluation of the quality of MR images demonstrating the subtalar joint(Kappa = 0.85). The mean score of each image was selected for analysis. In T1 group, the overall variance of the two subgroups was equal to each other after homogeneity test of variance. While, univariate analysis of variance revealed that T1-VIBE sequence was superior to T1-MPR sequences wiht F=113.01 and P<0.001. In T2 group, the overall variance of the five subgroups was equal to each other after homogeneity test of variance. While, univariate analysis of variance revealed that there was significant difference among the five subgroups with F=119.64 and P<0.001. SNK tests showed that the 3D-VIBE+Fs and 3D-FLASH sequences were better than 3D-SPACE, 3D-MEDIC and 3D-True FISP sequences, although no significant difference was found either between the 3D-VIBE+Fs and 3D-FLASH sequences or among 3D-SPACE, 3D-MEDIC and 3D-True FISP sequences. The angle between tha planta pedis of the hindfoot and the long axis of the interosseous talocalcaneal ligament was (61.19±4.65)°on each saggital image. The angle between tha articular surface of the ankle joint and the long axis of the interosseous talocalcaneal ligament was (46.59±4.37)°on each oblique coronal image.
Conclusion: 1. T1 weighted T1-VIBE sequence is better than T1-MPR sequences in demonstrating the interosseous talocalcaneal ligament and the bone of the subtalar joint. 2. T2 weighted 3D-VIBE + Fs and 3D-FLASH sequences are much better than 3D-SPACE, 3D-MEDIC and 3D-True FISP sequences in demonstrating the bone, cartilage and synovial fluid. There is no significant difference between 3D-VIBE + Fs sequence and 3D-FLASH sequence. 3. On the saggital images, the course of the interosseous talocalcaneal ligament runs anterosuperiorly, and the angle between tha planta pedis of the hindfoot and the long axis of the ligament was (61.19±4.65)°. 4. On the oblique coronal images, the course of the interosseous talocalcaneal ligament runs medial-superiorly, and the angle tha articular surface of the ankle joint and the long axis of ligament the was (46.59±4.37)°.
Part 2 The comparative study between digital sectional images and MRI images of the interosseous talocalcaneal ligament
Objective: To obtain digital images of thin sections and 3D reconstructed MR images of normal chinese adult feet, to observe the interosseous talocalcaneal ligament and its surrounding structures, and to compare MR images to their corresponding sectional digital images, providing anatomical basis for diagnosing and treating lesions of the interosseous talocalcaneal ligament.
Methods: Six normal fresh feet specimens were selected and divided into three groups named A, B, and C. Specimens in three different groups which were embedded, fixed and frozen in different positions, were milled(thickness = 0.2mm, accuracy = 0.00lmm) to obtain sagittal, coronal oblique, and transverse oblique sections respectively. Digital images of all sections were taken by a digital camera (8.2 megapixel). Thirty-two adult volunteers with no trauma and surgery history and no complaints of foot/ankle were recruited, including 17 males and 15 females, aged from 15 to 69 years old(average 35.6), providing 32 ankle-subtalar joints. Bony abnormity were excluded in all volunteers using radiography before the MR examination. The subjects were placed in lateral position. T1-VIBE, 3D-VIBE+Fs and 3D-FLASH MR sequences were scanned using Coil element KN for All ankle-subtalar joints. Then multi-planar reconstruction images were created in sagittal, oblique coronal, oblique horizontal orientations. Sectional images and their corresponding MR images in three different planes were visualized and compared by 3 experienced radiologists, to explore anatomical and iconographic characteristics of the intersseous talocalcaneal ligament.
Results: Both digital images of thin sections of fresh frozen cadaver feet and in vivo MRI images of healthy adult feet could distinctly displayed different tissues and structures such as ligament, fat, cartilage, bone, and tendon, while the former had higher resolution than the later did. However, orientations of thin sections were not accurate enough to achieve complete correspondence of certain structures between the two types of images. In sagittal planes which cut through central and lateral part of the neck of talus, the interosseous talocalcaneal ligament(ITCL) is located posterior to the cervical ligament, consisted of two bundles, anterior and posterior. The posterior bundle, whose shape is column or trapezoid, stands just anterior to the posterior subtalar joint in the posterolateral part of the tarsal tunnel. Its fibers are orientated anterosuperomedially. The anterior bundle, which is fusiform or cordlike, is found anteromedial to the posterior bundle. There necessarily are some fatty tissue in between the two bundles. Bundles of the ITCL both appear hypointense on the MRI image, and It is more difficult to distinguish them on these images than on images in coronal oblique plane. In coronal oblique planes which cut through the postmedian part of the neck of talus, the anterior bundle of the ITCL is seen running longitudinally. In coronal oblique planes just anterior to the posterior facet of the talus, the anterior bundle and the posterior bundle which is thicker, are both oblique bands with broader lower end. On their corresponding MRI images, the hypointense ITCL in the innermost of the tarsal canal runs from lateroinferior to mediosuperior. Its two bundles can be distinguished clearly from each other on these planes, between which the intermediate root of the inferior extensor retinaculum is located. In transverse oblique planes, the rhombic ITCL attaches to the sulcus calcanei and runs anterosuperiorly toward the sulcus tarsi. Its two bundles can also be distinguished clearly from each other on these planes.
Conclusions: 1. Fibers of the ITCL are orientated obliquely anterosuperomedially and divided into two bundles. The posterior bundle is located anterior to the posterior subtalar joint in the posterolateral part of the tarsal tunnel, arising from the sulcus calcanei anterior to the posterior facet of the talus, inserting into the sulcus tarsi. The anterior bundle is located anteromedial to the posterior bundle and posterior to the anterior and middle subtalar joints, originating from the anterior floor of the tarsal tunnel, anterior and medial to the origin of the posterior bundle, and inserting into the roof of the tarsal tunnel. 2. In this study, excellent comparability is found between digital images of thin sections of fresh frozen cadaver feet and in vivo MRI images of healthy adult feet. Therefore, MRI examination is considered to be qualified for diagnosing ITCL injuries. The focused observation area, is between the lateral margin of talus and medial margin of the sustentaculum tali of calcaneus on sagittal images, between the fore-end of the anterior subtalar joint and the posterior border of the tarsal tunnel on coronal oblique images, and between the floor of the tarsal tunnel and the neck of talus on transverse oblique images.
Part 3 The imageological measurement and the injured characterics of the interosseous talocalcaneal ligament
Objective: To investigate the characteristics of the injuries of interosseous talocalcaneal ligament in patients with calcaneal fractures and to explore the feasibility and comparability of magnetic resonance imaging(MRI), computed tomography(CT) scan and radiograph in demonstrating the interosseous talocalcaneal ligament and the gap where the ligament lies. Methods: 1. From February 2008 to march 2010, patients with calcaneal fractures who had undergone magnetic resonance imaging (MRI) were included in the study. The MRI images were studied to observe whether interosseous talocalcaneal ligament was disrupted. If injured, the site and injury pattern of disrupted ligametns were identified. Its incident rate was analysed. Concomitant injure were also identified on the images. 2. From February 2008 to March 2010 patients who had undergone MRI while without ?fractures and ligaments’injury were enrolled in the study. MRI scan of the ankle and foot following T1-vibe sequence, T2 3D VIBE sequence and 3D FLASH sequence were taken and the sagittal, oblique coronal planes were rebuilted. The length and width of interosseous talocalcaneal ligament were measured in the reconstructed imageds with the use of the measurement software on the workstation. The largest length was defined as the length of the interosseous talocalcaneal ligament. 3. Thirty healthy adults were selected in the group. The lengthes of the gap where the ITCL lies were measured on the consecutive reconstructed saggital and oblique coronal planes obtained from CT scans. The maximal length was defined as the length of the gap of interosseous talocalcaneal ligament. 4. The radiographs of the foot and ankle of 30 volunteers were taken with X-ray beam in various rotations. When taking radiographes, the volunteers lie on side and the line of position(LOP) runs through the gap between the talus and the calcaneus. adjust the rotation angle, set the tube vertical. The neutrol position was defined as the tube of the radiographic system being vertical to the radiographic table. The tube tilited distally is taken as cephalic rotation and the tube tilted proximally is considered as caudal rotation. Seven radiographes were taken on each foot at 15, 10, 5 degrees cephalic rotation, neutral position, 5, 10, and 15 degrees caudal rotation. The gap where the ITCL lies was observed and measured on each radiograph. The data was compared with thosed obtained from CT or MRI images.
Results: 1. According to Sanders classification of calcaneal fractures,Ⅱfracture 11 sides,Ⅲfracture 37 side,Ⅳfracture 30 side were included in this group. 44 lateral calcaneal fracture (56.4%) with interosseous talocalcaneal ligament injured, the injury near the heel side, 36 sides (81.8%) with interosseous talocalcaneal ligament disrupted, , 8 sides (19.2%) with partly disrupted, 42 sides (95.5%)were in the calcaneal side of the 1/3, 2 sides (4.5%) were in the ligament of middle 1/3. thirty-four lateral in the group with cervical ligament injury, of which 29 sides (85.3%) cervical ligament disrupted, 5 sides (14.7%) cervical ligament stretch injury. 2. The length of interosseous talocalcaneal ligament was 13.2mm±3.0mm for male and 12.1mm±2.7mm for female on MRI saggital images, and 14.7mm±3.5mm for male and 13.8mm±3.2mm for female on MRI oblique coronal images. There is no significant difference between the lengths of the right and left interosseous talocalcaneal ligaments either on saggital or oblique coronal MRI images in the same gender(P>0.05). The length of interosseous talocalcaneal ligaments for male is longer than that for female on both saggital and oblique coronal MRI images(P>0.05). 3. The gap length of the interosseous talocalcaneal ligament was 13.1mm±2.9mm for male and 12.2mm±2.5mm for female on saggital CT images, and the gap length was 14.7mm±3.3mm for male and 13.7mm±2.9mm for female on the oblique coronal images. There is no significant difference between the lengths of the right and left interosseous talocalcaneal ligaments either on saggital or oblique coronal CT images in the same gender(P>0.05). The length of interosseous talocalcaneal ligaments for male is longer than that for female on both saggital and oblique coronal CT images(P>0.05). The length of interosseous talocalcaneal ligaments on saggital CT images is shorter than that on oblique coronal CT images(P<0.05). 4. The gap lengths of the interosseous talocalcaneal ligament on radiographs obtained from X-ray beam in different rotation angle are various. The gap length of the interosseous talocalcaneal ligament of the left side is similar with that of right side obtained from the same angle of X-ray beam rotation(P>0.05). The gap length of the interosseous talocalcaneal ligament for male is longer than that for female in the same side obtained from the same angle of X-ray beam rotation(P<0.05). The gap lengths on the lateral radiographs obtained from three caudal rotations and the neutral position is longer than that obtained from the saggital CT images(P<0.05). The gap lengths on the lateral radiographs obtained from 5 and 10 degrees cephalic rotation is similar with that obtained from the saggital CT images(P>0.05). The gap of the interosseous talocalcaneal ligament is demonstrated clearly on the 10 degrees cephalic rotation, which is rectangle and runs from posteroinferior to anteosuperior. The calcaneal and talar side of the gap is easily identified. Therefore the gap length measured on the radiographs obtained from 10 degrees cephalic rotation is defined as the length of the ligament measured on the lateral radiographs and the length is (14.2±3.1)mm for male and (12.3±2.3)mm female.
Conclusion: The study reveals that the length of interosseous talocalcaneal ligament obtained from MRI and CT has no significant difference between the right side and the left side, while the length of interosseous talocalcaneal ligament of the male is larger than that of female. The length of the ligament measured on the both CT and MRI sagittal and coronal images are comparable, respectively. The 10 degrees cephalic rotation lateral radiographs of the foot can demonstrate clearly the gap where interosseous talocalcaneal ligament lies, on which the gap length measured has no significant difference when comparing with the length measured on the the CT and MRI sagittal images.
引文
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13沙勇,张绍祥,刘正津,等.踝、距下关节外侧韧带断层与MRI图像的对照研究及临床意义.中国临床解剖学杂志,2000,18(4):289-293
14张凯,俞光荣,施向挺,等.距跟骨间韧带的应用解剖学.同济大学学报(医学版),2005,26:80-82
15 Kapardji A, Honore LH. The Physiology of the Joints. New York: Churchill-Livingstone, 1974. 92
16 Tochigi Y,Takabashi K,Yamagata M,et a1.Influence ofthe in·terosseous talocalcaneal ligament injury on stability of the an- kle·subtalar joint complex:a cadavefic experimental study.Foot Ankle Int,2oo2,23:486-491
17 Erickson SJ, Smith JW, Ruiz ME, et al. MR imaging of the lateral collateral ligament of the ankle. AJR Am J Roentgenol 1991;156:131-136
18 Schneck CD, Mesgarzadeh M, Bonakdarpour A, et al. MR imaging of the most commonly injured ankle ligaments. Part I. Normal anatomy. Radiology 1992;184:499-506
19 Haygood TM. Magnetic resonance imaging of the musculoskeletal system: part 7. The ankle. Clin Orthop Relat Res 1997:318-336
20 Muhle C, Frank LR, Rand T, et al. Collateral ligaments of the ankle: high-resolution MR imaging with a local gradient coil and anatomic correlation in cadavers. Radiographics 1999;19:673-683
21 Smith JW. The ligamentous structures in the canalis and sinus tarsi. J nat 1958; 92:616-621
22 Cahill DR. The anatomy and function of the contents of the human tarsal sinus and canal. Anat Rec 1965; 158:1-18
23 Klein MA, Spreitzer AM. MR imaging of the tarsal sinus and canal: normal anatomy, pathologic findings, and features of the sinus tarsi syndrome. Radiology 1993; 186:233-240
24王正义,编著.足踝外科学.北京:人民卫生出版社,2006. 160
25 Beltran J,Munchow AM,Khabiri H,et al. Ligaments of the lateral aspect of the ankle and sinus tarsi: an MR imaging study. Radiology,1990,177(2):455-458
26 Mabit C, Boncoeur-Martel MP, Chaudruc JM, et al. Anatomic and MRI study of the subtalar ligamentous support. Surg Radiol Anat 1997;19:111-117
1 Tham SC, Tsou IY, Chee TS. Knee and ankle ligaments: magnetic resonance imaging findings of normal anatomy and at injury. Ann Acad Med Singapore 2008;37:324-329
2 Balduini FC, Vegso JJ, Torg JS, et al. Management and rehabilitation of ligamentous injuries to the ankle. Sports Med 1987;4:364-380
3 Larsen E, Jensen PK, Jensen PR. Long～term outcome of knee and ankle injuries in elite football. Scand J Med Sci Sports 1999;9:285-289
4 Kato T. The diagnosis and treatment of instability of the subtalar joint. J Bone Joint Surg Br 1995;77:400-406
5 Meyer JM, Garcia J, Hoffmeyer P, et al. The subtalar sprain. A roentgenographic study. Clin Orthop Relat Res 1988:169-173
6 Tochigi Y, Yoshinaga K, Wada Y, et al. Acute inversion injury of the ankle: magnetic resonance imaging and clinical outcomes. Foot Ankle Int 1998;19:730-734
7 Cahill DR. The anatomy and function of the contents of the human tarsal sinus and canal. Anat Rec 1965;153:1-17
8 Kjaersgaard～Andersen P, Wethelund JO, Helmig P, et al. The stabilizing effect of the ligamentous structures in the sinus and canalis tarsi on movements in the hindfoot. An experimental study. Am J Sports Med 1988;16:512-516
9 Knudson GA, Kitaoka HB, Lu CL, et al. Subtalar joint stability. Talocalcaneal interosseous ligament function studied in cadaver specimens. Acta Orthop Scand 1997;68:442-446
10 Sarrafian SK. Biomechanics of the subtalar joint complex. Clin Orthop Relat Res 1993:17-26
11 Smith JW. The ligamentous structures in the canalis and sinus tarsi. J Anat 1958;92:616-620
12 Oae K, Takao M, Naito K, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology 2003;227:155-161
13 Brown KW, Morrison WB, Schweitzer ME, et al. MRI findings associated with distal tibiofibular syndesmosis injury. AJR Am J Roentgenol 2004;182:131-136
14沙勇,张绍祥,刘正津,等.踝、距下关节外侧韧带断层与MRI图像的对照研究及临床意义.中国临床解剖学杂志2000;18:289-293
15毛宾尧,刘明廷,杨星光,等.距跟关节的内稳定结构和不稳矫正.临床骨科杂志1999;2:4-6
16 Karlsson J, Eriksson BI, Renstrom P. Subtalar instability of the foot. A review and results after surgical treatment. Scand J Med Sci Sports 1998;8:191-197
17张凯,俞光荣,施向挺,等.距跟骨间韧带的应用解剖.同济大学学报(医学版) 2005;26:80-82
18 Mabit C, Boncoeur-Martel MP, Chaudruc JM, et al. Anatomic and MRI study of the subtalar ligamentous support. Surg Radiol Anat 1997;19:111-117
19 Beltran J, Munchow AM, Khabiri H, et al. Ligaments of the lateral aspect of the ankle and sinus tarsi: an MR imaging study. Radiology 1990;177:455-458
20沙勇,张绍祥,刘正津,等.踝关节外侧副韧带和距下关节韧带的断层解剖学研究.第三军医大学学报2001;23:36-38
21毛宾尧,刘明廷,李保文,等.距下关节的解剖学测量和运动学分析.中华骨科杂志1996;16:50-62
22 Tochigi Y, Takahashi K, Yamagata M, et al. Influence of the interosseous talocalcaneal ligament injury on stability of the ankle-subtalar joint complex-a cadaveric experimental study. Foot Ankle Int 2000;21:486-491
23 Keefe DT, Haddad SL. Subtalar instability. Etiology, diagnosis, and management. Foot Ankle Clin 2002;7:577-609
24张凯,俞光荣.距下关节韧带的解剖学和生物力学特性研究进展.中国临床解剖学杂志2004;22:106-108
25 Budny A. Subtalar joint instability: current clinical concepts. ClinPodiatr Med Surg 2004;21:449-460, viii
26 Sijbrandij ES, van Gils AP, van Hellemondt FJ, et al. Assessing the subtalar joint: the Broden view revisited. Foot Ankle Int 2001;22:329-334
27 Hockenbury RT, Sammarco GJ. Evaluation and treatment of ankle sprains: clinical recommendations for a positive outcome. Phys Sportsmed 2001;29:57-64
28曹鹏,陆哀照,刘志宏.距下关节损伤的实验研究及临床意义.中华骨科杂志1994;14:739-741
29 Wirth CJ, Artmann M. Chronic fibular instability of the ankle joint- x-ray diagnostic and ligamentous graft (author's transl). Arch Orthop Unfallchir 1977;88:313-320
30 Hertel J, Denegar CR, Monroe MM, et al. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc 1999;31:1501-1508
31 Zwipp H, Rammelt S, Grass R. Ligamentous injuries about the ankle and subtalar joints. Clin Podiatr Med Surg 2002;19:195-229, v
32 Kirby KA. Subtalar joint axis location and rotational equilibrium theory of foot function. J Am Podiatr Med Assoc 2001;91:465-487
33 Aerts P, Disler DG. Abnormalities of the foot and ankle: MR imaging findings. AJR Am J Roentgenol 1995;165:119-124
34 Marder RA, Swanson TV, Sharkey NA, et al. Effects of partial patellectomy and reattachment of the patellar tendon on patellofemoral contact areas and pressures. J Bone Joint Surg Am 1993;75:35-45
35 Jarde O, Havet E, Gabrion A, et al. [Long～term outcome following surgical repair of ruptures of the fibular collateral ligament of the ankle. A report of 50 cases]. Acta Orthop Belg 1999;65:340-345
36 Jarde O, Duboille G, Abi～Raad G, et al. [Ankle instability with involvement of the subtalar joint demonstrated by MRI. Results with the Castaing procedure in 45 cases]. Acta Orthop Belg 2002;68:515-528
1 Jotoku T, Kinoshita M, Okuda R, et al. Anatomy of ligamentous structures in the tarsal sinus and canal. Foot Ankle Int, 2006, 27: 533-538
2毛宾尧,刘明廷,杨星光,等.距跟关节的内稳定结构和不稳矫正.临床骨科杂志, 1999, 2(1): 4-6
3 Stagni R, Leardini A, O′Connor JJ, et al. Role of passive structures in the mobility and stability of the human subtalar joint: a literature review. Foot Ankle Int, 2003, 24(5): 402-409
4 Keefe DT, Haddad SL. Subtalar instability: etiology, diagnosis, and management. Foot Ankle Clin N Am, 2002, 7: 577-609
5 Budny A. Subtalar joint instability: current clinical concepts. Clin Podiatr Med Surg, 2004, 21: 449-460
6 Mabit C, Boncoeur～Martel MP, Chaudruc JM, et al. Anatomic and MRI study of the subtalar ligamentous support. Surg Radiol Anat, 1997, 19: 111-117
7沙勇,张绍祥,刘正津,等.踝、距下关节外侧韧带断层与MRI图像的对照研究及临床意义.中国临床解剖学杂志, 2000, 18(4): 289-293
8沙勇,张绍祥,刘正津,等.踝关节外侧副韧带和距下关节韧带的断层解剖学研究.第三军医大学学报, 2001, 23(1): 36-38
9王义龙,马兆龙,王民,等.踝关节与距下关节矢状断层解剖学.解剖学杂志, 2005, 28(1): 71-73
10 Tochigi Y, Amendola A, Rudert MJ, et al. The role of the interosseous talocalcaneal ligament in subtalar joint stability. Foot Ankle Int, 2004, 25(8): 588-596
11丁晶,徐达传.踝关节外侧韧带和距下关节韧带修复重建的应用解剖.中国临床解剖学杂志, 2002, 20(5): 366-368
12张凯,俞光荣,施向挺,等.距跟骨间韧带的应用解剖.同济大学学报(医学版), 2005, 26(2): 80-82
13 Linklater J, Hayter CL, Vu D, et al. Anatomy of the subtalar joint and imaging of talo～calcaneal coalition. Skeletal Radiol, 2009, 38: 437-449
14 Kjaersgaard～Andersen P, Wethelund JO, Helmig P, et al. The stabilizing effect of the ligamentous structures in the sinus and canalis tarsi on movements in the hindfoot. An experimental study. Am J Sports Med, 1988, 16: 512-516
15 Hintermann B, Sommer C, Nigg BM. Influence of ligament transaction on tibial and calcaneal rotation with loading and dorsi～plantarflexion. Foot Ankle Int, 1995, 16(9): 567-571
16 Knudson GA, Kitaoka HB, Lu CL, et al. Subtalar joint stability. Talocalcaneal interosseous ligament function s tudied in cadaver specimens. Acta Orthop Scand, 1997, 68(5): 442-446
17 Tochigi Y, Takahashi K, Yamagata M, et al. Influence of the interosseous talocalcaneal ligament injury on stability of the ankle～subtalar joint complex～a cadaveric experimental study. Foot Ankle Int, 2000, 21(6): 486-491
18王鹏程,李昭.距跟骨间韧带的生物力学研究.中华创伤骨科杂志, 2008, 10(4):367-369
19 Tochigi Y, Yoshinaga K, Wada Y, et al. Acute inversion injury of the ankle: magnetic resonance imaging and clinical outcomes. Foot Ankle Int, 1998, 19(11): 730-734
20 Meyer JM, Garcia J, Hoffmeyer P, et al. The subtalar sprain: a roentgenographic study. Clin Orthop Relat Res, 1988, 226: 169-173
21 Sugimoto K, Samoto N, Shimaoka H, et al. Subtalar arthrography of sprained ankle. Bessatsu Seikeigeka, 1994, 25: 231-234
22 Heilman AE, Braly G, Bishop JO, et al. An anatomic study of subtalar instability. Foot Ankle, 1990, 10: 224-228
23 Wright IC, Neptune RR, van den Bogert AJ, et al. The influence of foot positioning on ankle sprains. Journal of Biomechanics, 2000, 33: 513-519
24 Pisani G. Chronic laxity of the subtalar joint. Orthop, 1996, 19: 431-437
25 Biga N. Clinical examination of the foot and the ankle. Data collection and interpretation of the pathogenic causal sequence of disorders. Orthop Trauma Surg Res, 2009, 95S: S41-S48
26 Frey C, Feder KS, DiGiovanni C. Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist? Foot Ankle Int, 1999, 20(3): 185-191
27 Breitenseher MJ, Haller J, Kukla C, et al. MRI of the sinus tarsi in acute ankle sprain injuries. J Comput Assist Tomogr, 1997, 21(2): 274-279
28 Kato T. The diagnosis and treatment of instability of the subtalar joint. J Bone Joint Surg Br, 1995, 77(3): 400-406
29 Thermann H, Zwipp H, Tscheme H. Treatment algorithm of chronic ankle and subtalar instability. Foot Ankle Int, 1997, 18(3): 163-169
30 Sijbrandij ES, van Gils AP, van Hellemondt FJ, et al. Assessing the subtalar joint: the Brodén view revisited. Foot Ankle Int, 2001, 22(4): 329-334
31 Ishii T, Miyagawa S, Fukubayashi T, et al. Subtalar stress radiography using forced dorsiflexion and supination. J Bone Joint Surg, 1996, 78～B: 56-60
32曹鹏,陆宸照,刘志宏.距下关节损伤的实验研究及临床意义.中华骨科杂志, 1994, 14(12): 739-741
33 Yamamoto H, Yagishita K, Ogiuchi T, et al. Subtalar instability following lateral ligament injuries of the ankle. Injury, 1998, 29(4): 265-268
34 Louwerens JWK, Ginai AZ, van Linge B, et al. Stress radiography of the talocrural and subtalar joints. Foot Ankle Int, 1995, 16(3): 148-155
35 van Hellemondt FJ, Louwerens JWK, Sijbrandij ES, et al. Stress radiography and stress examination of the talocrural and subtalar joint on helical computed tomography. Foot Ankle Int, 1997, 18(8): 482-488
36 Beimers L, Tuijthof GJM, Blankevoort L, et al. In～vivo range of motion of the subtalar joint using computed tomography. J Biomech, 2008, 41: 1390-1397
37 Sugimoto K, Takakura Y, Samoto N, et al. Subtalar arthrography in recurrent instability of the ankle. Clin Orthop Relat Res, 2002, 394: 169-176
38 Lee KB, Bai LB, Park JG, et al. Efficacy of MRI versus arthroscopy forevaluation of sinus tarsi syndrome. Foot Ankle Int, 2008, 29(11): 1111-1116
39 Siegler S, Udupa JK, Ringleb SI, et al. Mechanics of the ankle and subtalar joints revealed through a 3D quasi～static stress MRI technique. J Biomech, 2005, 38: 567-578
40 Beltran J .Ligament of the lateral aspect of the ankle and sinus tarsi : An MR imaging study. Radiology, 1990, 177: 455
41 Rand T,Frank L, Pretterklieber M, et al. Intertarsal ligaments: high resolution MRI and anatomic correlation. J Comput Assist Tomogr, 2000, 24(4): 584-593
42王旭东,杨茂伟,李中华,等.距跟骨间韧带断层解剖及磁共振n成像的对照研究及临床意义.解剖学报, 2009, 40(5): 834-836
43 Lektrakul N, Chung CB, Lai YM, et al. Tarsal sinus: arthrographic, MR imaging, MR arthrographic, and pathologic findings in cadavers and retrospective study data in patients with sinus tarsi syndrome. Radiology, 2001, 219: 802-810
44 Parisien JS, Vangsness T. Arthroscopy of the subtalar joint: an experimental approach. Arthroscopy, 1985, 1(1): 53-57
45 Pisani G, Pisani PC, Parino E. Sinus tarsi syndrome and subtalar joint instability. Clin Pediatr Med Surg, 2005, 22: 63-77
2张凯,俞光荣,施向挺,等.距跟骨间韧带的应用解剖学.同济大学学报(医学版),2005,26:80-82
3 Aerts P, Disler DG. Abnormalities of the foot and ankle: MR imaging findings. AJR Am J Roentgenol 1995;165:119-124
4 Kapardji A, Honore LH. The Physiology of the Joints. New York: Churchill-Livingstone, 1974. 92
5 Wirth CJ, Artmann M. Chronic fibular in stability of the ankle-joint-x-ray diagnostic and ligamentous graft Arch Orthop UnfallChir, 1977, 88(3):313-320
6 Hertel J, Denegar CR,Monroe MM,et al. Talocrural and subtalar joint in stability after lateral ankle sprain. Med Sci Sports Exerc,1999,31(11):1501-1508
7 Sijbrandij ES,van Gils AP,van Hellemondt FJ,et al. Assessing the subtalar joint: the Broden view revisited. Foot Ankle Int,2001,22(4): 329-334
8 Fleiss DJ. Arthroscopically assisted arthrodesis for osteoarthrotic ankles. J Bone Joint Surg Am 1994;76:1112
9 Jarde O, Havet E, Gabrion A, et al. [Long-term outcome following surgical repair of ruptures of the fibular collateral ligament of the ankle.A report of 50 cases]. Acta Orthop Belg 1999;65:340-345
10 Akseki D, Pinar H, Bozkurt M, et al. The distal fascicle of the anterior inferior tibio-fibular ligament as a cause of anterolateral ankle impingement: results of arthroscopic resection. Acta Orthop Scand 1999;70:478-482
11 Chandnani VP,Harper MT,Ficke JR,et al. Chronic ankle instability: evaluation with MR arthrography,MR imaging,and stress radiography. Radiology,1994,192(1):189-194
12 Helgason JW, Chandnani VP. MR arthrography of the ankle. Radiol Clin North Am 1998;36:729-738
13 Erickson SJ, Smith JW, Ruiz ME, et al. MR imaging of the lateral collateral ligament of the ankle. AJR Am J Roentgenol 1991;156:131-136
14 Schneck CD, Mesgarzadeh M, Bonakdarpour A, et al. MR imaging of the most commonly injured ankle ligaments. Part I. Normal anatomy. Radiology 1992;184:499-506
15 Haygood TM. Magnetic resonance imaging of the musculoskeletal system: part 7. The ankle. Clin Orthop Relat Res 1997:318-336
16 Muhle C, Frank LR, Rand T, et al. Collateral ligaments of the ankle: high-resolution MR imaging with a local gradient coil and anatomic correlation in cadavers. Radiographics 1999;19:673-683
17 Smith JW. The ligamentous structures in the canalis and sinus tarsi. J nat 1958; 92:616-621
18 Cahill DR. The anatomy and function of the contents of the human tarsal sinus and canal. Anat Rec 1965; 158:1-18
19 Klein MA, Spreitzer AM. MR imaging of the tarsal sinus and canal: normal anatomy, pathologic findings, and features of the sinus tarsi syndrome. Radiology 1993; 186:233-240
20王正义,编著.足踝外科学.北京:人民卫生出版社,2006. 160
21 Beltran J,Munchow AM,Khabiri H,et al. Ligaments of the lateral aspect of the ankle and sinus tarsi: an MR imaging study. Radiology,1990,177(2):455-458
22 Mabit C, Boncoeur-Martel MP, Chaudruc JM, et al. Anatomic and MRI study of the subtalar ligamentous support. Surg Radiol Anat 1997;19:111-117
1 Karlsson J, Lansinger O. Lateral instability of the ankle joint. Clin Orthop, 1992, 276: 253
2 Clanton Thomas O. Instability of the subtalar joint. Orthop Clin North Am, 1989, 20(4): 583
3 Meyer JM, Gareia J, Hoffmeyer P. The subtalar sprain. Clin Orthop, 1988, 226: 169
4 Tetsuya Kato. The diagnosis and treatment of instability of the subtalar joint. J Bone Joint Surg Br, 1995, 77B: 400
5 Luttke G, Lehner K, Heuck A, et al.陈易人译.关节疾病的磁共振诊断.放射学实践, 1991, 6(4): 173
6 Aerts P, Disler DG. Abnormalities of the foot and ankle: MR imaging findings. AJR, 1995, 165(1):119
7 Beltran J. Ligament of the lateral aspect of the ankle and sinus tarsi: An MR imaging study. Radiology, 1990, 177: 455
8 Erickson SJ, Smith JW, Ruiz ME. et al. MR imaging of the lateral collateral ligament of the ankle. Am J Roentgenol, 1991,156:131
9 Mabit C, Bonconeur-Martel JM, Chaudruc D, et al. Anatomic and MRI study of the subtalar ligamentous support. Surg Radiol Anat, 1997, 19:
10 Hochman MG, Min KK, Zilberfarb J. MR Imaging of the symptomatic ankle and foot. Orth Clin North Am, 1997,28(4):659
11 Javior Beltran MD. Ligament of the lateral aspect of the ankle and sinus tarsi: An MR imaging study. Radiology, 1990, 177:455
12 Lucas P, Kaplan P, Dussault R, et al. MRI of the foot and ankle. Curr Probl Diagn Radiol, 1997, 26(5):209
13沙勇,张绍祥,刘正津,等.踝、距下关节外侧韧带断层与MRI图像的对照研究及临床意义.中国临床解剖学杂志,2000,18(4):289-293
14张凯,俞光荣,施向挺,等.距跟骨间韧带的应用解剖学.同济大学学报(医学版),2005,26:80-82
15 Kapardji A, Honore LH. The Physiology of the Joints. New York: Churchill-Livingstone, 1974. 92
16 Tochigi Y,Takabashi K,Yamagata M,et a1.Influence ofthe in·terosseous talocalcaneal ligament injury on stability of the an- kle·subtalar joint complex:a cadavefic experimental study.Foot Ankle Int,2oo2,23:486-491
17 Erickson SJ, Smith JW, Ruiz ME, et al. MR imaging of the lateral collateral ligament of the ankle. AJR Am J Roentgenol 1991;156:131-136
18 Schneck CD, Mesgarzadeh M, Bonakdarpour A, et al. MR imaging of the most commonly injured ankle ligaments. Part I. Normal anatomy. Radiology 1992;184:499-506
19 Haygood TM. Magnetic resonance imaging of the musculoskeletal system: part 7. The ankle. Clin Orthop Relat Res 1997:318-336
20 Muhle C, Frank LR, Rand T, et al. Collateral ligaments of the ankle: high-resolution MR imaging with a local gradient coil and anatomic correlation in cadavers. Radiographics 1999;19:673-683
21 Smith JW. The ligamentous structures in the canalis and sinus tarsi. J nat 1958; 92:616-621
22 Cahill DR. The anatomy and function of the contents of the human tarsal sinus and canal. Anat Rec 1965; 158:1-18
23 Klein MA, Spreitzer AM. MR imaging of the tarsal sinus and canal: normal anatomy, pathologic findings, and features of the sinus tarsi syndrome. Radiology 1993; 186:233-240
24王正义,编著.足踝外科学.北京:人民卫生出版社,2006. 160
25 Beltran J,Munchow AM,Khabiri H,et al. Ligaments of the lateral aspect of the ankle and sinus tarsi: an MR imaging study. Radiology,1990,177(2):455-458
26 Mabit C, Boncoeur-Martel MP, Chaudruc JM, et al. Anatomic and MRI study of the subtalar ligamentous support. Surg Radiol Anat 1997;19:111-117
1 Tham SC, Tsou IY, Chee TS. Knee and ankle ligaments: magnetic resonance imaging findings of normal anatomy and at injury. Ann Acad Med Singapore 2008;37:324-329
2 Balduini FC, Vegso JJ, Torg JS, et al. Management and rehabilitation of ligamentous injuries to the ankle. Sports Med 1987;4:364-380
3 Larsen E, Jensen PK, Jensen PR. Long～term outcome of knee and ankle injuries in elite football. Scand J Med Sci Sports 1999;9:285-289
4 Kato T. The diagnosis and treatment of instability of the subtalar joint. J Bone Joint Surg Br 1995;77:400-406
5 Meyer JM, Garcia J, Hoffmeyer P, et al. The subtalar sprain. A roentgenographic study. Clin Orthop Relat Res 1988:169-173
6 Tochigi Y, Yoshinaga K, Wada Y, et al. Acute inversion injury of the ankle: magnetic resonance imaging and clinical outcomes. Foot Ankle Int 1998;19:730-734
7 Cahill DR. The anatomy and function of the contents of the human tarsal sinus and canal. Anat Rec 1965;153:1-17
8 Kjaersgaard～Andersen P, Wethelund JO, Helmig P, et al. The stabilizing effect of the ligamentous structures in the sinus and canalis tarsi on movements in the hindfoot. An experimental study. Am J Sports Med 1988;16:512-516
9 Knudson GA, Kitaoka HB, Lu CL, et al. Subtalar joint stability. Talocalcaneal interosseous ligament function studied in cadaver specimens. Acta Orthop Scand 1997;68:442-446
10 Sarrafian SK. Biomechanics of the subtalar joint complex. Clin Orthop Relat Res 1993:17-26
11 Smith JW. The ligamentous structures in the canalis and sinus tarsi. J Anat 1958;92:616-620
12 Oae K, Takao M, Naito K, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology 2003;227:155-161
13 Brown KW, Morrison WB, Schweitzer ME, et al. MRI findings associated with distal tibiofibular syndesmosis injury. AJR Am J Roentgenol 2004;182:131-136
14沙勇,张绍祥,刘正津,等.踝、距下关节外侧韧带断层与MRI图像的对照研究及临床意义.中国临床解剖学杂志2000;18:289-293
15毛宾尧,刘明廷,杨星光,等.距跟关节的内稳定结构和不稳矫正.临床骨科杂志1999;2:4-6
16 Karlsson J, Eriksson BI, Renstrom P. Subtalar instability of the foot. A review and results after surgical treatment. Scand J Med Sci Sports 1998;8:191-197
17张凯,俞光荣,施向挺,等.距跟骨间韧带的应用解剖.同济大学学报(医学版) 2005;26:80-82
18 Mabit C, Boncoeur-Martel MP, Chaudruc JM, et al. Anatomic and MRI study of the subtalar ligamentous support. Surg Radiol Anat 1997;19:111-117
19 Beltran J, Munchow AM, Khabiri H, et al. Ligaments of the lateral aspect of the ankle and sinus tarsi: an MR imaging study. Radiology 1990;177:455-458
20沙勇,张绍祥,刘正津,等.踝关节外侧副韧带和距下关节韧带的断层解剖学研究.第三军医大学学报2001;23:36-38
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