本文選題：下脛腓聯(lián)合 + 下脛腓前韌帶�。� 參考：《南京醫(yī)科大學》2017年博士論文

【摘要】：下脛腓聯(lián)合損傷在臨床上比較多見,可以單獨存在,而更多的情況是與踝關節(jié)骨折同時并發(fā)1。下脛腓聯(lián)合不穩(wěn)定將產(chǎn)生踝關節(jié)疼痛、功能障礙、甚至最終發(fā)生創(chuàng)傷性骨關節(jié)炎2。下脛腓前韌帶是構成下脛腓聯(lián)合的重要結構之一,它呈多束復合結構,生物力學研究認為該韌帶為下脛腓聯(lián)合提供約35%的穩(wěn)定性。然而長期以來,臨床上對下脛腓前韌帶損傷的處理卻是消極而冷淡的。事實上,許多基礎研究的證據(jù)表明3,下脛腓前韌帶非常重要,而且自我修復能力比較差。首先,下脛腓前韌帶由平行排列的致密膠原纖維構成,這一組織學特性是與該韌帶需要承受較大應力相適應的。其次,運動學研究發(fā)現(xiàn),當踝關節(jié)完成最大跖屈到最大背伸的運動時,下脛腓聯(lián)合中腓骨的運動是輕微外移、后移和外旋,下脛腓前韌帶對于這三向運動都有非常直接的保護和限制作用。再次,血管造影研究發(fā)現(xiàn)4,大多數(shù)人(63%)下脛腓前韌帶的血供僅僅來源于腓動脈的前支。腓動脈的前支在踝關節(jié)面近端3cm處穿骨間膜到達前方,此血管在踝關節(jié)骨折的同時極有可能已經(jīng)斷裂,這注定下脛腓前韌帶的愈合非常困難。另一方面,目前下脛腓聯(lián)合損傷的最常用治療方法——下脛腓聯(lián)合螺釘受到了越來越深刻的反思5,6。人們越來越在意它過高的畸形復位率,越來越不希望犧牲可運動的下脛腓聯(lián)合關節(jié)的正常生理活動,越來越不愿承受二期需要取出該螺釘?shù)拇鷥r。踝關節(jié)的解剖性固定是既恢復下脛腓聯(lián)合穩(wěn)定而又避免使用下脛腓聯(lián)合螺釘?shù)南Ｍ�。舊理論認為,當一個穩(wěn)定環(huán)僅存在一處斷裂時,該系統(tǒng)仍然是穩(wěn)定的。但該理論僅適用于剛性結構的穩(wěn)定環(huán);而由多處韌帶連接的柔性穩(wěn)定環(huán),哪怕只殘留一處斷裂,依然可能造成整個系統(tǒng)的不穩(wěn)定。下脛腓聯(lián)合正是如此。因此,下脛腓前韌帶的損傷修復不應繼續(xù)缺席,而應作為一個重要的環(huán)節(jié)發(fā)揮作用。本研究詳細測量了國人下脛腓前韌帶的解剖學參數(shù);通過有限元分析闡明下脛腓前韌帶對于維持下脛腓聯(lián)合的穩(wěn)定,主要是外旋應力下的穩(wěn)定性作用非常重要;對尸體標本的動作捕捉研究進一步證實和強化了這一結論。本研究還證明,動畫絲攻試驗特異性優(yōu)異的同時還大大提高了術中診斷下脛腓聯(lián)合不穩(wěn)的敏感性,從而找到了理想的術中診斷方法。我們設計了踝關節(jié)外側勺形切口,以保障處理后踝骨折的同時可以探查下脛腓前韌帶,并且切開在直視下復位下脛腓聯(lián)合。在應用該切口進行臨床治療的過程中,我們對下脛腓前韌帶的損傷進行了觀察和分類,將其分為3型。Ⅰ型為脛骨或腓骨側韌帶止點處較大塊的撕脫性骨折;Ⅱ型為韌帶從止點骨面處剝脫,可伴有極小塊的撕脫性骨折;Ⅲ型為韌帶體部的斷裂。我們制定了Ⅰ型以2.5mm空心雙頭加壓螺釘復位固定撕脫骨塊、Ⅱ型以錨釘或借助鋼板的縫合孔縫合修復、Ⅲ型予縫線端端吻合修復的治療策略,療效滿意。通過隨機對照研究,我們證實重建下脛腓前韌帶的穩(wěn)定性與使用下脛腓聯(lián)合螺釘相比,畸形復位率較低,無需二次手術,并且療效相當,可以作為一項很有價值的治療選擇。
[Abstract]:Lower tibiofibular joint injury is more common in clinic and can exist alone, and more cases are associated with ankle joint fracture with 1. lower tibiofibular joint instability which will produce ankle pain, dysfunction, and even final traumatic osteoarthritis of the 2. lower tibiofibular ligament is one of the most important structures of the lower tibiofibular joint. The composite structure, biomechanical study suggests that the ligament provides about 35% of the stability of the lower tibiofibular joint. However, for a long time, the treatment of the anterior tibiofibular ligament injury is negative and cold. In fact, many basic research evidence suggests that 3, the anterior tibiofibular ligament is very important, and the ability of self repair is poor. First, lower. The anterior tibiofibular ligament is composed of a compact collagenous fiber arranged in parallel, which is adapted to the need for greater stress in the ligament. Secondly, the kinematic study found that when the ankle joint completes the maximum flexion to the maximum extension movement, the movement of the lower tibiofibular joint fibula is slightly outward, backward and external, and the anterior tibia and fibula are toughened. The band has a very direct protective and restrictive effect on these three movements. Again, the angiography study found that 4, most people (63%) the blood supply of the anterior tibiofibular ligament is only from the anterior branch of the peroneal artery. The anterior branch of the peroneal artery passes the interosseous membrane at the proximal 3cm of the ankle joint to the front, and this vessel is extremely likely to have been fractured at the ankle joint. The healing of the anterior tibiofibular ligament is very difficult by fracture. On the other hand, the most commonly used treatment of the joint tibiofibular joint injury, the lower tibiofibular joint screw, is becoming more and more deeply introspection 5,6. people are more and more concerned about its high deformity reduction rate, and more and more do not want to sacrifice the movement of the joint joint of the lower tibia and fibula. There is a growing reluctance to withstand the cost of the two phase of the screw. The anatomical fixation of the ankle is the hope of restoring the joint stability of the lower tibiofibula and avoiding the use of the lower tibiofibular joint screws. The old theory holds that the system is still stable when a stable ring only exists in one fracture. The stable ring of the rigid structure, and the flexible stable ring connected by the multiple ligaments, even a single residual fracture, may still cause the whole system instability. The lower tibiofibular joint is the same. Therefore, the repair of the anterior tibiofibular ligament should not continue to be absent, and should be used as an important link. This study has measured in detail. The anatomical parameters of the anterior tibiofibular ligament of the tibia and the anterior tibiofibular ligament were analyzed by the finite element analysis. The stability of the anterior tibiofibular ligament for maintaining the stability of the lower tibiofibular joint was important. The action capture study of the cadaver specimens further confirmed and strengthened this conclusion. This study also proved that the animated tapping test was specific. The sensitivity of intraoperative diagnosis of tibiofibular instability was greatly enhanced and an ideal diagnostic method was found. We designed a spoon - shaped incision in the lateral ankle to ensure the treatment of the posterior fracture of the ankle and the anterior tibiofibular ligament, and the incision was made under direct reduction for the lower tibiofibular joint. The incision was applied to the incision. In the course of clinical treatment, we observe and classify the injury of the anterior tibia and peroneal ligament, and divide it into 3 types. Type I is the avulsion fracture at the end of the tibial or the fibula side ligament; type II is ligaments exfoliate from the point of the point of the bone and can be accompanied by a very small avulsion fracture; type III is a fracture of the ligamentous body. Type I was repositioned with 2.5mm hollow double head compression screw and fixed avulsion block. Type II was repaired with anchors or suture with steel plate suture. The treatment strategy of type III end-to-end anastomosis repair was satisfactory. Through a randomized controlled study, we confirmed that the stability of the anterior tibiofibular ligament reconstruction was compared with the use of the lower tibiofibular screw. The reduction rate is low, no two operations are needed, and the curative effect is comparable. It can be regarded as a valuable therapeutic option.
【學位授予單位】：南京醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2017
【分類號】：R687.4

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