踝关节外侧韧带和距下关节韧带修复重建的解剖、生物力学及影像学研究
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摘要
研究目的
研究踝关节外侧韧带和距下关节韧带的形态特点及其临床意义，踝
关节外侧韧带和距下关节韧带损伤的生物力学机理，评价应力试验X光
片、CT、MRI和关节镜对踝关节外侧韧带和距下关节韧带损伤的诊断价
值。
材料与方法
1．经防腐处理、灌注乳胶的成人小腿足标本32侧，观测踝关节外
侧韧带、距下关节韧带和用作移植的肌腱和韧带的起、止、走行和长、
宽、厚。小腿动脉铸型标本4侧，墨汁灌注小腿标本1侧，动脉造影1
例观测踝部血管网。干骨标本25侧，观测跗骨窦形态特点。
2．新鲜小腿足标本8侧，3侧选取足体表标志和标志点间连线为
标志线，解剖定位韧带。5侧用于研究后足的手术入路和模拟韧带损伤
修复重建术。
3．新鲜小腿足标本7侧置于MTS实验机上，4侧踝跖屈15°，3
侧踝背屈10°，在5秒内压力逐渐增加到1000N，使踝、距下关节内翻，
观察韧带内翻损伤的过程。新鲜踝关节标本6侧，踝关节固定在中立位，
置于三维运动试验机上，测量距下关节韧带切断前后的活动度。
4．新鲜小腿标本8侧，保留胫腓连结和骨间膜的完整，置于SWD10
实验机上，以1mm/min的速度施加载荷，记录胫腓连结切断前和切断后
用普通螺丝钉、拉力螺丝钉和“U”形钉固定的活动度。
5．在MTS上以内翻暴力造成踝关节外侧韧带、距下关节韧带损伤
的小腿足标本6侧，行前抽屉试验、内翻应力踝穴位、Merrill位拍摄
X光片和关节镜检查，2侧标本行踝、距下关节CT、MRI扫描。标本解
剖检查作为金标准对照影像检查结果。踝关节外侧韧带损伤患者4例，
拍摄前抽屉试验、内翻应力试验踝穴位、Merrill位X光片和CT检查，
与手术探查对照。
结 果
①距胖前韧带起自外踝尖前上 Icm的范困内，韧带向远内侧行，与
内、外踝连线成26”～30”角，与外踝尖至第5 M骨基底的连线成50
”角，止于距骨颈外上颈韧带止点上4mm处：跟胖韧带起自外踝尖端，
与用滑纵线成 130“～145“角，与外踝至跟鲢止点连线成 20”角，向
内、后、远侧走行，止于跟骨外侧面中部，止点离距下关节面 12～15nun，
韧带向前上的延长线通过外踝前距胖前韧带的起点；颈韧带居附骨窦
内，起于跟骨上面的颈峪，呈45”角向上、内行，止于距骨颈下外的
结节，距胖前韧带止点下前4nun，韧带延长线外侧通过外踝尖至第5肠
骨基底的连线的中点；距跟骨间韧带位于附骨管内，由前、后两束交叉
组成，前束附于跟骨前和距骨关节面后方，行向前外，止于距骨颈下面，
后束起于跟骨后、距骨关节面前，行向上后外，止于距骨后、跟关节面
前，韧带延长线向足背经过内、外踝连线与足纵线的交点，向足底经跷
健膜的止点与足纵线在足背的投影线成90”角。小趾趾长伸肌健、第
三跳骨肌健、胖骨短肌腾、伸肌下支持带解剖位置恒定，与踝关节外侧
韧带和距下关节韧带相毗邻，具有一定的长、宽、厚度，便于移位移植。
②跑骨窦位于足背外侧，距下关节前后关节面之间，内有伸肌下支
持带、颈韧带、距跟骨间韧带和附骨窦动、静脉等，各结构间由脂肪组
织填充。
③踝部血供总体上可以胖骨外侧缘中线、胚骨内侧中线和腿健后面
中线分为前区、后外侧区、后内侧区3个区。前区以腔前动脉为主，后
外侧区以脓动脉为主，后内侧区以胚后动脉后主，各区之间有丰富的吻
合。临床应用17例，创面愈合满意。
④踝、距下关节在厢屈位内翻时，韧带断裂的顺序是：前距胖韧带
一跟脓韧带一颈韧带；背屈位内翻时韧带断裂顺序是：跟胖韧带一距脓
前韧带一颈韧带。距下关节在韧带切断后活动度明显加大，与切断前比
相差非常显著（P＜0刀1人
2
⑤腔胖连结正常的生理活动度为：前一后 1．83 i 0．83nun、后一前
L89土0．d0M、外一内1．42士0．34一 内一外1．36士0．65M。用普通
螺丝钉和拉力螺钉固定胜胖连结，外踝的活动明显受限，与正常比较相
差非常显著（p＜0刀1人 用‘儿”形钉固定后，活动度与正常比较相差不
：显著（p＞0．05）
③影像检查中前抽屉试验6侧标本5侧阳性，阳性率为83．3％，4
例患者2例阳性，阳性率50％；内翻应力踝穴位片5侧阳性，阳性率为
83．3％，l例患者为假阴性；距下关节韧带损伤，Merr ifl位片阳性率 50％；
经关节镜可检查到距胖前韧带和距跟骨k椰带后束，在新鲜损伤，或关
节囊有撕裂时跟脓韧带可检查到，颈韧带经关节镜难以探查到：2侧标
本、4例患者行 CT检查均无阳性结果；2侧标本 MR检查除 1侧颈韧带
损伤未查到外，其余均为阳性。
结 论
①踝关节外侧韧带和距下关节韧带结合足体表标志均能精确地解剖
定位?
Objective
The purpose of this thesis is to acquire better knowledge of ankle-subtalar ligaments injuries, discuss the anatomy and the clinical significance of ankle-subtalar ligaments, study the mechanism of ankle-subtalar ligaments inversion injuries evaluate the value of stress test plain X-ray film, CT, MRI and arthroscopy in the diagnosis of ankle-subtalar ligaments injuries. Three approaches were used: anatomy, biomechanics and imagine. The knowledge is intended to serve as a basis development of diagnosis and reconstruction of ankle-subtalar ligaments injuries.
Materials and Methods
In the anatomic approach, the ankle lateral ligaments, subtalar ligaments and related reconstructive tendons and ligaments that could be transferred were studied on 32 leg-foot specimens. 25 dry foot bone specimens were used. The artery supply around ankle joint and sinus tarsi were studied in the same time. Several reconstuctive operations were imitated in the cadaver. In the biomechanical approach, 7 cases of fresh-frozen ankle- foot specimens were injured imitated the clinical injury of ankle-subtalar joint inversion in the MTS, the 3-D dimension motion of the subtalar joint of 6 cases of fresh injured specimens in the 3-D motion apparatus, the inferior tibia-fibular syndesmosis injury were studied on 8 cases fresh leg specimens in SWD10 material test apparatus. In the imaging approach, the 6 cases injured ankle-subtalar complexes specimens were examined with X-ray, CT, MRI and arthroscrpy, The results were compared with anatomy of the injured specimens, and 4 cases patients of ankle inversion injured were examined with X-ray, CT compared with found during operation.
Result
Anterior talofibular ligament areas of attachments is located in the range 1 cm of superior-anterior lateral malleolus, forward and medially, to the superior-lateral neck of talus, in front of its lateral articular facet. The calcaneofibular ligament, the longest of the three, is a narrow, rounded cord,
running from the apex of the fibular malleolus downward and slightly backward to a tubercle on the lateral surface of the calcaneus. It is covered by the tendons of the Peronasi longus and birevis. Cervical ligament extends from the front and lateral surface of the neck of the talus to the superior surface of the calcaneus. It forms the posterior boundary of the talocalcaneonavicular joint, and is sometimes described as the anterior interosseous ligament. The posterior talocalcaneal ligament connects the lateral tubercle of the talus with the upper and medial part of the calcaneus; it include two crass short band, and its fibers radiate from their narrow attachment to the talus.
The locations of the extensor longus tendon of little toe, the peroneus brevis tendon, the peroneus tertius tendon and the inferior extensor retinaculum were near the lateral ankle and subtalar ligaments; There were enough of length, width and thickness to reconstruct the lateral ankle and subtalar ligaments.
The sinus tarsi is a conical shaped cavity located between the anterosuperior surface of the calcaneus and the inferior aspect of the neck of the talus. It opens laterally, anterior to the fibular malleolus and terminates posteromedially directly behind the sustentaculum tali. The contents of the sinus tarsi include interosseous talocalcaneal ligament and cervical ligament, medial, inferior and lateral roots of the inferior extensor retinaculum,artery and venous of the tarsal canal, filled with fat tissue.
The ankle artery supply could be divided into the anterior, lateral- posterior and medial-posterior three areas, there are sufficient communicating branches among three areas.
In the ankle-subtalar joint inversion injuries, the Anterior talofibular ligament was injured firstly when ankle was plantarflexion, second was calcaneofibular ligament, when ankle joint was dorsiflexion, calcaneofibular ligament was injured firstly, secondly was talofibular ligament, the last injured in both situation were subtalar ligaments. The 3-D motion of subtalar joint
研究踝关节外侧韧带和距下关节韧带的形态特点及其临床意义，踝
关节外侧韧带和距下关节韧带损伤的生物力学机理，评价应力试验X光
片、CT、MRI和关节镜对踝关节外侧韧带和距下关节韧带损伤的诊断价
值。
材料与方法
1．经防腐处理、灌注乳胶的成人小腿足标本32侧，观测踝关节外
侧韧带、距下关节韧带和用作移植的肌腱和韧带的起、止、走行和长、
宽、厚。小腿动脉铸型标本4侧，墨汁灌注小腿标本1侧，动脉造影1
例观测踝部血管网。干骨标本25侧，观测跗骨窦形态特点。
2．新鲜小腿足标本8侧，3侧选取足体表标志和标志点间连线为
标志线，解剖定位韧带。5侧用于研究后足的手术入路和模拟韧带损伤
修复重建术。
3．新鲜小腿足标本7侧置于MTS实验机上，4侧踝跖屈15°，3
侧踝背屈10°，在5秒内压力逐渐增加到1000N，使踝、距下关节内翻，
观察韧带内翻损伤的过程。新鲜踝关节标本6侧，踝关节固定在中立位，
置于三维运动试验机上，测量距下关节韧带切断前后的活动度。
4．新鲜小腿标本8侧，保留胫腓连结和骨间膜的完整，置于SWD10
实验机上，以1mm/min的速度施加载荷，记录胫腓连结切断前和切断后
用普通螺丝钉、拉力螺丝钉和“U”形钉固定的活动度。
5．在MTS上以内翻暴力造成踝关节外侧韧带、距下关节韧带损伤
的小腿足标本6侧，行前抽屉试验、内翻应力踝穴位、Merrill位拍摄
X光片和关节镜检查，2侧标本行踝、距下关节CT、MRI扫描。标本解
剖检查作为金标准对照影像检查结果。踝关节外侧韧带损伤患者4例，
拍摄前抽屉试验、内翻应力试验踝穴位、Merrill位X光片和CT检查，
与手术探查对照。
结 果
①距胖前韧带起自外踝尖前上 Icm的范困内，韧带向远内侧行，与
内、外踝连线成26”～30”角，与外踝尖至第5 M骨基底的连线成50
”角，止于距骨颈外上颈韧带止点上4mm处：跟胖韧带起自外踝尖端，
与用滑纵线成 130“～145“角，与外踝至跟鲢止点连线成 20”角，向
内、后、远侧走行，止于跟骨外侧面中部，止点离距下关节面 12～15nun，
韧带向前上的延长线通过外踝前距胖前韧带的起点；颈韧带居附骨窦
内，起于跟骨上面的颈峪，呈45”角向上、内行，止于距骨颈下外的
结节，距胖前韧带止点下前4nun，韧带延长线外侧通过外踝尖至第5肠
骨基底的连线的中点；距跟骨间韧带位于附骨管内，由前、后两束交叉
组成，前束附于跟骨前和距骨关节面后方，行向前外，止于距骨颈下面，
后束起于跟骨后、距骨关节面前，行向上后外，止于距骨后、跟关节面
前，韧带延长线向足背经过内、外踝连线与足纵线的交点，向足底经跷
健膜的止点与足纵线在足背的投影线成90”角。小趾趾长伸肌健、第
三跳骨肌健、胖骨短肌腾、伸肌下支持带解剖位置恒定，与踝关节外侧
韧带和距下关节韧带相毗邻，具有一定的长、宽、厚度，便于移位移植。
②跑骨窦位于足背外侧，距下关节前后关节面之间，内有伸肌下支
持带、颈韧带、距跟骨间韧带和附骨窦动、静脉等，各结构间由脂肪组
织填充。
③踝部血供总体上可以胖骨外侧缘中线、胚骨内侧中线和腿健后面
中线分为前区、后外侧区、后内侧区3个区。前区以腔前动脉为主，后
外侧区以脓动脉为主，后内侧区以胚后动脉后主，各区之间有丰富的吻
合。临床应用17例，创面愈合满意。
④踝、距下关节在厢屈位内翻时，韧带断裂的顺序是：前距胖韧带
一跟脓韧带一颈韧带；背屈位内翻时韧带断裂顺序是：跟胖韧带一距脓
前韧带一颈韧带。距下关节在韧带切断后活动度明显加大，与切断前比
相差非常显著（P＜0刀1人
2
⑤腔胖连结正常的生理活动度为：前一后 1．83 i 0．83nun、后一前
L89土0．d0M、外一内1．42士0．34一 内一外1．36士0．65M。用普通
螺丝钉和拉力螺钉固定胜胖连结，外踝的活动明显受限，与正常比较相
差非常显著（p＜0刀1人 用‘儿”形钉固定后，活动度与正常比较相差不
：显著（p＞0．05）
③影像检查中前抽屉试验6侧标本5侧阳性，阳性率为83．3％，4
例患者2例阳性，阳性率50％；内翻应力踝穴位片5侧阳性，阳性率为
83．3％，l例患者为假阴性；距下关节韧带损伤，Merr ifl位片阳性率 50％；
经关节镜可检查到距胖前韧带和距跟骨k椰带后束，在新鲜损伤，或关
节囊有撕裂时跟脓韧带可检查到，颈韧带经关节镜难以探查到：2侧标
本、4例患者行 CT检查均无阳性结果；2侧标本 MR检查除 1侧颈韧带
损伤未查到外，其余均为阳性。
结 论
①踝关节外侧韧带和距下关节韧带结合足体表标志均能精确地解剖
定位?
Objective
The purpose of this thesis is to acquire better knowledge of ankle-subtalar ligaments injuries, discuss the anatomy and the clinical significance of ankle-subtalar ligaments, study the mechanism of ankle-subtalar ligaments inversion injuries evaluate the value of stress test plain X-ray film, CT, MRI and arthroscopy in the diagnosis of ankle-subtalar ligaments injuries. Three approaches were used: anatomy, biomechanics and imagine. The knowledge is intended to serve as a basis development of diagnosis and reconstruction of ankle-subtalar ligaments injuries.
Materials and Methods
In the anatomic approach, the ankle lateral ligaments, subtalar ligaments and related reconstructive tendons and ligaments that could be transferred were studied on 32 leg-foot specimens. 25 dry foot bone specimens were used. The artery supply around ankle joint and sinus tarsi were studied in the same time. Several reconstuctive operations were imitated in the cadaver. In the biomechanical approach, 7 cases of fresh-frozen ankle- foot specimens were injured imitated the clinical injury of ankle-subtalar joint inversion in the MTS, the 3-D dimension motion of the subtalar joint of 6 cases of fresh injured specimens in the 3-D motion apparatus, the inferior tibia-fibular syndesmosis injury were studied on 8 cases fresh leg specimens in SWD10 material test apparatus. In the imaging approach, the 6 cases injured ankle-subtalar complexes specimens were examined with X-ray, CT, MRI and arthroscrpy, The results were compared with anatomy of the injured specimens, and 4 cases patients of ankle inversion injured were examined with X-ray, CT compared with found during operation.
Result
Anterior talofibular ligament areas of attachments is located in the range 1 cm of superior-anterior lateral malleolus, forward and medially, to the superior-lateral neck of talus, in front of its lateral articular facet. The calcaneofibular ligament, the longest of the three, is a narrow, rounded cord,
running from the apex of the fibular malleolus downward and slightly backward to a tubercle on the lateral surface of the calcaneus. It is covered by the tendons of the Peronasi longus and birevis. Cervical ligament extends from the front and lateral surface of the neck of the talus to the superior surface of the calcaneus. It forms the posterior boundary of the talocalcaneonavicular joint, and is sometimes described as the anterior interosseous ligament. The posterior talocalcaneal ligament connects the lateral tubercle of the talus with the upper and medial part of the calcaneus; it include two crass short band, and its fibers radiate from their narrow attachment to the talus.
The locations of the extensor longus tendon of little toe, the peroneus brevis tendon, the peroneus tertius tendon and the inferior extensor retinaculum were near the lateral ankle and subtalar ligaments; There were enough of length, width and thickness to reconstruct the lateral ankle and subtalar ligaments.
The sinus tarsi is a conical shaped cavity located between the anterosuperior surface of the calcaneus and the inferior aspect of the neck of the talus. It opens laterally, anterior to the fibular malleolus and terminates posteromedially directly behind the sustentaculum tali. The contents of the sinus tarsi include interosseous talocalcaneal ligament and cervical ligament, medial, inferior and lateral roots of the inferior extensor retinaculum,artery and venous of the tarsal canal, filled with fat tissue.
The ankle artery supply could be divided into the anterior, lateral- posterior and medial-posterior three areas, there are sufficient communicating branches among three areas.
In the ankle-subtalar joint inversion injuries, the Anterior talofibular ligament was injured firstly when ankle was plantarflexion, second was calcaneofibular ligament, when ankle joint was dorsiflexion, calcaneofibular ligament was injured firstly, secondly was talofibular ligament, the last injured in both situation were subtalar ligaments. The 3-D motion of subtalar joint
引文
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13. Becker HP, Rosenbaum D. Chronic recurrent ligament instability on the lateral ankle. Orthopade, 1999, 28(6): 483-492.
14. Michelson JD, Hutchins C. Mechanoreceptors in human ankle ligaments. J Bone Joint Surg. 1995,77B(2):219～224.
15. Tohyama H, Beynnon BD, Pope MH, et al. Laxity and flexibility of the ankle following reconstruction with the Chrisman-Snook procedure. J Orthop Res, 1997, 15(5): 707-711.
16. Frank CB, Amiel D, Woo SYL, el al. Normal ligament properties and ligament healing. Clin Orthop, 1985,196:15～23.
17. O · Conner D. Sinus tarsi syndrome. A clinical entity. J Bone Joint Surg (Am), 1958, 40:720.
18. 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.
19. Hertel J, Denegar CR, Monroe MM, Stokes WL. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc, 1999, 31(11): 1501-1508.
20．吴晋宝，程心恒，秦月琴，等．足背和足底的动脉分布．解剖学报，1980，11(1)：13-22．
21. Schwarzenbach B, Dora C, Lang A. Blood vessels of the sinus tarsi and the sinus tarsi syndrome. Clin Anat, 1997,10(3): 173-182.
22. Andermahr J, Helling HJ, Rehm KE. The vascularization of the os calcaneum and the clinical consequences. Clin Orthop, 1999 363(7): 212-218
23．张发惠，陈振光，郑和平，等．带血管蒂跗骨瓣转位术的应用解剖学．中华显微外科杂志，1993，16(4)：288-289
24. Canale ST Campbell′s Operativ Orthopaedic. Ninth Edition. 北京：科学出版社, Harcourt Asia Mosby. 2001, volume one: 51-55
25．孙材江，滕学仁．关节镜学．长沙：湖南科学技术出社，1997．219-221
26. Takao M, Uchio Y, Shu N, et aL Anatomic bases of ankle arthroscopy: study of superficial and deep peroneal nerves around anterolateral and anterocentral approach. Surg Radiol Anat, 1998, 20(5): 317-320.
27. Saito A, Kikuchi S. Anatomic relations between ankle arthroscopic portal sites and the superficial peroneal and saphenous nerves. Foot Ankle Int, 1998, 19(11): 748-752.
28. Feiwell LA, Frey C. Anatomic study of arthroscopic portal sites of the ankle. Foot Ankle. 1993, 14(3): 142-147.
29. Frey C, Gasser S, Feder K. Arthroscopy of the subtalar joint. Foot Ankle Int, 1994 15(8): 424-428.
30．钟世镇．临床应用解剖学．北京：人民军医出版社，1998．463-528．
31．钟世镇，徐达传，丁自海．显微外科临床解剖学．济南：山东科学技术出版社．2000．92-105．
32．徐达传．实用临床骨缺损修复应用解剖学．北京：中国医药科技出版社，2000．372-408
33．张发惠，陈振光，郑和平，等．带血管蒂跗骨瓣转移的应用解剖．中国临床解剖学杂志，1991，9：193-194．
34．张玉柱，刘元侠，姜永涛．带蒂骨瓣移位术治疗距骨缺血性坏死．中国修复重建外科杂志，1998，12：285-287．
35. Giebel GD, Meyer C, Koebke J,et al. The arterial supply of the ankle joint and its importance for the operative fracture treatment. Surg Radiol Anat. 1997, 19(4): 231-235.
36．黄文华，朱青安，钟世镇，等．脊柱三维运动定位的计算机视觉方法．计算机应用，2000，20(增刊)：215-217．
37. Clanton TO. Instability of the subtalar joint. Orthop Clinic North Am, 1989,20(4): 583-592.
38. DeMaio M, Paine R, Drez D Jr. Chronic lateral ankle instability—inversion sprains: Part Ⅰ. Orthopedics, 1992,15(1): 87-96.
39. Perlman M, Leveille D, DeLeonibus J, et al. Inversion lateral ankle trauma: differential diagnosis, review of the literature, and prospective study, J Foot Surg 1987;26(2):95-135.
40. Hertel J, DenegarCR, Monroe MM,et al. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc, 1999, 31(11): 1501-1508.
41. Meyer JM; Hoffmeyer P; Savoy X. High resolution computed tomography in the chronically painful ankle sprain. Foot - Ankle, 1988,8(6): 291-296.
42. Meyer JM, Garcia J, Hoffmeyer P. The subtalar sprain. A roentgenographic study. Clin Orthop, 1988, 226(1): 169-173.
43. Cedell C. Ankle lesions. Acta Orthop Scand., 1975, 46(7): 425-445.
44. Hopkinson WJ, St. Pierre P, Ryan JB. et al. Syndesmosis sprains of the ankle. Foot Ankle, 1990, 10(6): 325-330.
45．荣国威．下胫腓分离的实验研究．中华外科杂志，1983，21(1)：5-6．
46．钟世镇．临床应用解剖学．北京：人民军医出版社，1998，622．
47．姚太顺．手法整复经皮钳夹固定下胫腓分离．中国中医骨伤科杂志，1995，3(1)：41．
48. Farhan M J, Smith TW. Fixation of diastasis of the inferior tibiofibular joint using the syndesmosis hook. Injury, 1985.16(5): 309-311.
49．辛景义，张铁良，韩慧，等．弹性外固定器治疗合并下胫腓损伤的踝关节骨折．中华骨科杂志，1998，18(9)：525-527．
50．罗振东，王日光，孙凌宇．下胫腓关节分离的诊断及手术治疗．中国局解手术学杂志，1998，7(4)：223-224．
51．关夷，谢汉国，张宗平．趾长伸肌腱内侧束转位修复下胫腓联合分离的解剖学基础．临床军医杂志，2000，28(1)：1-2．
52. Rand T, Ahn JM, Muhle C, et al. Ligaments and tendons of the ankle. Evaluation with low-field (0.2 T) MR imaging. Acta Radiol, 1999, 40(3): 303-308.
53. Ahmad MA, Pandey UC, Crerand JJ, et al. Magnetic resonance imaging of the normal and injured lateral collateral ligaments of the ankle. Ann Chir Gynaecol, 1998, 87(4): 311-316.
54. Baker CL, Graham(jnr) JM. Current concepts in ankle arthroscopy. Orthopaedics, 1993, 16 (9): 1027-1035.
55. Ogilvie Harris DJ, Gilbart MK, Chorney K. Chronic pain following ankle sprains in athletes: The role of arthroscopic surgery. Arthroscopy, 1997, 13 (5):564-574.
56. Lee SH, Jacobson J, Trudell D, et al. Ligaments of the ankle: normal anatomy with MR arthrography. J Comput Assist Tomogr, 1998, 22(5): 807-813.
57. KarlssonJ. Chronic lateral instability of the ankle joint: A clinical, radiological and experiment study. Diss. University of G(?)teborg, 1989,25-34
58．张如明．踝关节外侧韧带断裂的早期诊断和治疗．中华外科杂志，1981，18(4)：339．
59. David L. Lateral ankle ligament injuries. Clin Orthop, 1984,183 (7) :153-156.
60. Larsen E. Experimental instability of the ankle. A radiographic investigation. Clin Orthop, 1986, 204(3):193-200.
61. Fujii T, Luo ZP, Kitaoka HB, et al. The manual stress test may not be sufficient to differentiate ankle ligament injuries. Clin Biomech, 2000,15(8):619-623.
62. Hauger O, Moinard M, Lasalarie JC, et al. Anterolateral compartment of the ankle in the lateral impingement syndrome: appearance on CT arthrography. AJR Am J Roentgenol, 1999, 173(3):685-690.
63. Clark TW, Janzen DL, Logan PM, et al. Improving the detection of radiographically occult ankle fractures: positive predictive value of an ankle joint effusion. Clin Radiol, 1996, 51 (9):632-636.
64. Kashuk KB, Carbonell JA, Blum JA. Arthroscopic stabilization of the ankle. Clin Podiatr Med Surg, 1997, 14(3):459-478.
65. Komenda GA, Ferkel RD. Arthroscopic findings associated with the unstable ankle. Foot Ankle Int, 1999, 20(11):708-713.
66. Taga I, Shino K, Inoue M, Nakata K, et al. Articular cartilage lesions in ankles with lateral ligament injury. An arthroscopic study. Am J Sports Med, 1993, 21(1):120-126.
67. Jordan LK 3rd, Helms CA, Cooperman AE, et al. Magnetic resonance imaging findings in anterolateral impingement of the ankle. Skeletal Radiol, 2000, 29(1):34-39.
68. 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.
69．刘明廷，毛宾尧，杨星光，等．距下关节内在稳定机制的探讨．中国矫形外科杂志，1995，(2)1：31．
70. 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
71. Colville MR, Marder RA, Zarins B. Reconstruction of the lateral ankle ligaments: a biomechanical analysis. The American Journal of Sports Medicine, 1992, 20(5): 594-600.
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. Burks RT, Morgan J. Anatomy of the lateral ankle ligaments. Am J Sports Med, 1994, 22(1):72-77.
4. Inman VT, Ralston HJ, Todd F. Human Walking. Willams & Wilkins, baltimore, 1984.
5. Wright DG, Desai SM, Henderson WH. Action of the subtalar and ankle-joint complex during the stanse phase of walking. J Bone joint surg, 1964, 46A: 361-364.
6. Peters JW, Trevine SG, Renstrom PA. Chronic lateral ankle instability. Foot and Ankle, 1991, 12 (3):182-191.
7. Karlsson J, Eriksson BI, Renstrom PA. Subtalar ankle instability, A review. Sports Med, 1997, 24(5): 337-346.
8. Kashuk KB, Carbonell JA, Blum JA. Arthroscopic stabilisation of the ankle. Clinics in Podiatric Medicine and Surgery, 1997, 14 (3):459-478.
9. Lee SH, Jacobson J, Trudell D, et al. Ligaments of the ankle: normal anatomy with MR arthrography. J Comput Assist Tomogr, 1998, 22(5): 807-813.
10．曹鹏，唐梅英．距下关节不稳定．国外医学·创伤与外科基本问题分册，1995，16(2)：93-95．
11. Amiel D, Frank C, Harwood FL, et al. Tendons and ligaments: A morphological and biochemical comparison. J Orthop Res, 1984, 1:257.
12．陈宝兴．用小切口治疗足病．中国足外科荟萃—全国第二届足外科学术会议资料汇编，黄山：1994，46-50．
13. Becker HP, Rosenbaum D. Chronic recurrent ligament instability on the lateral ankle. Orthopade, 1999, 28(6): 483-492.
14. Michelson JD, Hutchins C. Mechanoreceptors in human ankle ligaments. J Bone Joint Surg. 1995,77B(2):219～224.
15. Tohyama H, Beynnon BD, Pope MH, et al. Laxity and flexibility of the ankle following reconstruction with the Chrisman-Snook procedure. J Orthop Res, 1997, 15(5): 707-711.
16. Frank CB, Amiel D, Woo SYL, el al. Normal ligament properties and ligament healing. Clin Orthop, 1985,196:15～23.
17. O · Conner D. Sinus tarsi syndrome. A clinical entity. J Bone Joint Surg (Am), 1958, 40:720.
18. 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.
19. Hertel J, Denegar CR, Monroe MM, Stokes WL. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc, 1999, 31(11): 1501-1508.
20．吴晋宝，程心恒，秦月琴，等．足背和足底的动脉分布．解剖学报，1980，11(1)：13-22．
21. Schwarzenbach B, Dora C, Lang A. Blood vessels of the sinus tarsi and the sinus tarsi syndrome. Clin Anat, 1997,10(3): 173-182.
22. Andermahr J, Helling HJ, Rehm KE. The vascularization of the os calcaneum and the clinical consequences. Clin Orthop, 1999 363(7): 212-218
23．张发惠，陈振光，郑和平，等．带血管蒂跗骨瓣转位术的应用解剖学．中华显微外科杂志，1993，16(4)：288-289
24. Canale ST Campbell′s Operativ Orthopaedic. Ninth Edition. 北京：科学出版社, Harcourt Asia Mosby. 2001, volume one: 51-55
25．孙材江，滕学仁．关节镜学．长沙：湖南科学技术出社，1997．219-221
26. Takao M, Uchio Y, Shu N, et aL Anatomic bases of ankle arthroscopy: study of superficial and deep peroneal nerves around anterolateral and anterocentral approach. Surg Radiol Anat, 1998, 20(5): 317-320.
27. Saito A, Kikuchi S. Anatomic relations between ankle arthroscopic portal sites and the superficial peroneal and saphenous nerves. Foot Ankle Int, 1998, 19(11): 748-752.
28. Feiwell LA, Frey C. Anatomic study of arthroscopic portal sites of the ankle. Foot Ankle. 1993, 14(3): 142-147.
29. Frey C, Gasser S, Feder K. Arthroscopy of the subtalar joint. Foot Ankle Int, 1994 15(8): 424-428.
30．钟世镇．临床应用解剖学．北京：人民军医出版社，1998．463-528．
31．钟世镇，徐达传，丁自海．显微外科临床解剖学．济南：山东科学技术出版社．2000．92-105．
32．徐达传．实用临床骨缺损修复应用解剖学．北京：中国医药科技出版社，2000．372-408
33．张发惠，陈振光，郑和平，等．带血管蒂跗骨瓣转移的应用解剖．中国临床解剖学杂志，1991，9：193-194．
34．张玉柱，刘元侠，姜永涛．带蒂骨瓣移位术治疗距骨缺血性坏死．中国修复重建外科杂志，1998，12：285-287．
35. Giebel GD, Meyer C, Koebke J,et al. The arterial supply of the ankle joint and its importance for the operative fracture treatment. Surg Radiol Anat. 1997, 19(4): 231-235.
36．黄文华，朱青安，钟世镇，等．脊柱三维运动定位的计算机视觉方法．计算机应用，2000，20(增刊)：215-217．
37. Clanton TO. Instability of the subtalar joint. Orthop Clinic North Am, 1989,20(4): 583-592.
38. DeMaio M, Paine R, Drez D Jr. Chronic lateral ankle instability—inversion sprains: Part Ⅰ. Orthopedics, 1992,15(1): 87-96.
39. Perlman M, Leveille D, DeLeonibus J, et al. Inversion lateral ankle trauma: differential diagnosis, review of the literature, and prospective study, J Foot Surg 1987;26(2):95-135.
40. Hertel J, DenegarCR, Monroe MM,et al. Talocrural and subtalar joint instability after lateral ankle sprain. Med Sci Sports Exerc, 1999, 31(11): 1501-1508.
41. Meyer JM; Hoffmeyer P; Savoy X. High resolution computed tomography in the chronically painful ankle sprain. Foot - Ankle, 1988,8(6): 291-296.
42. Meyer JM, Garcia J, Hoffmeyer P. The subtalar sprain. A roentgenographic study. Clin Orthop, 1988, 226(1): 169-173.
43. Cedell C. Ankle lesions. Acta Orthop Scand., 1975, 46(7): 425-445.
44. Hopkinson WJ, St. Pierre P, Ryan JB. et al. Syndesmosis sprains of the ankle. Foot Ankle, 1990, 10(6): 325-330.
45．荣国威．下胫腓分离的实验研究．中华外科杂志，1983，21(1)：5-6．
46．钟世镇．临床应用解剖学．北京：人民军医出版社，1998，622．
47．姚太顺．手法整复经皮钳夹固定下胫腓分离．中国中医骨伤科杂志，1995，3(1)：41．
48. Farhan M J, Smith TW. Fixation of diastasis of the inferior tibiofibular joint using the syndesmosis hook. Injury, 1985.16(5): 309-311.
49．辛景义，张铁良，韩慧，等．弹性外固定器治疗合并下胫腓损伤的踝关节骨折．中华骨科杂志，1998，18(9)：525-527．
50．罗振东，王日光，孙凌宇．下胫腓关节分离的诊断及手术治疗．中国局解手术学杂志，1998，7(4)：223-224．
51．关夷，谢汉国，张宗平．趾长伸肌腱内侧束转位修复下胫腓联合分离的解剖学基础．临床军医杂志，2000，28(1)：1-2．
52. Rand T, Ahn JM, Muhle C, et al. Ligaments and tendons of the ankle. Evaluation with low-field (0.2 T) MR imaging. Acta Radiol, 1999, 40(3): 303-308.
53. Ahmad MA, Pandey UC, Crerand JJ, et al. Magnetic resonance imaging of the normal and injured lateral collateral ligaments of the ankle. Ann Chir Gynaecol, 1998, 87(4): 311-316.
54. Baker CL, Graham(jnr) JM. Current concepts in ankle arthroscopy. Orthopaedics, 1993, 16 (9): 1027-1035.
55. Ogilvie Harris DJ, Gilbart MK, Chorney K. Chronic pain following ankle sprains in athletes: The role of arthroscopic surgery. Arthroscopy, 1997, 13 (5):564-574.
56. Lee SH, Jacobson J, Trudell D, et al. Ligaments of the ankle: normal anatomy with MR arthrography. J Comput Assist Tomogr, 1998, 22(5): 807-813.
57. KarlssonJ. Chronic lateral instability of the ankle joint: A clinical, radiological and experiment study. Diss. University of G(?)teborg, 1989,25-34
58．张如明．踝关节外侧韧带断裂的早期诊断和治疗．中华外科杂志，1981，18(4)：339．
59. David L. Lateral ankle ligament injuries. Clin Orthop, 1984,183 (7) :153-156.
60. Larsen E. Experimental instability of the ankle. A radiographic investigation. Clin Orthop, 1986, 204(3):193-200.
61. Fujii T, Luo ZP, Kitaoka HB, et al. The manual stress test may not be sufficient to differentiate ankle ligament injuries. Clin Biomech, 2000,15(8):619-623.
62. Hauger O, Moinard M, Lasalarie JC, et al. Anterolateral compartment of the ankle in the lateral impingement syndrome: appearance on CT arthrography. AJR Am J Roentgenol, 1999, 173(3):685-690.
63. Clark TW, Janzen DL, Logan PM, et al. Improving the detection of radiographically occult ankle fractures: positive predictive value of an ankle joint effusion. Clin Radiol, 1996, 51 (9):632-636.
64. Kashuk KB, Carbonell JA, Blum JA. Arthroscopic stabilization of the ankle. Clin Podiatr Med Surg, 1997, 14(3):459-478.
65. Komenda GA, Ferkel RD. Arthroscopic findings associated with the unstable ankle. Foot Ankle Int, 1999, 20(11):708-713.
66. Taga I, Shino K, Inoue M, Nakata K, et al. Articular cartilage lesions in ankles with lateral ligament injury. An arthroscopic study. Am J Sports Med, 1993, 21(1):120-126.
67. Jordan LK 3rd, Helms CA, Cooperman AE, et al. Magnetic resonance imaging findings in anterolateral impingement of the ankle. Skeletal Radiol, 2000, 29(1):34-39.
68. 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.
69．刘明廷，毛宾尧，杨星光，等．距下关节内在稳定机制的探讨．中国矫形外科杂志，1995，(2)1：31．
70. 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
71. Colville MR, Marder RA, Zarins B. Reconstruction of the lateral ankle ligaments: a biomechanical analysis. The American Journal of Sports Medicine, 1992, 20(5): 594-600.