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陶可主治医师 北京大学人民医院 骨关节科 踝关节炎：诊断和手术治疗的综述译者：陶可（北京大学人民医院骨关节科）北京大学人民医院骨关节科陶可关键点： 目前踝关节炎非手术治疗的标准包括使用非甾体抗炎药、皮质类固醇注射、矫形器和脚踝支具。其他方式，包括透明质酸注射、物理疗法、经皮神经电刺激、按摩疗法，但缺乏高质量的研究来描述其使用的适当性和有效性。 终末期退行性踝关节炎手术干预的金标准仍然是关节融合术，但越来越多的证据表明，全踝关节置换术在功能结果方面的等效性甚至优越性。 未来几年将使我们能够做出更准确的决定，并且通过更多前瞻性的高质量研究，可以确定最适合进行全踝关节置换术的患者群体。文献出处：Robert Grunfeld, Umur Aydogan, Paul Juliano. Ankle arthritis: review of diagnosis and operative management. Med Clin North Am. 2014 Mar;98(2):267-89. doi: 10.1016/j.mcna.2013.10.005. Epub 2014 Jan 10. Review.Ankle arthritis: review of diagnosis and operative managementKEY POINTSThe current standard of care for nonoperative options include the use of nonsteroidal antiinflammatory drugs, corticosteroid injections, orthotics, and ankle braces. Other modalities, including hyaluronic injections, physical therapy, transcutaneous electrical nerve stimulation units, massage therapy, lack high-quality research studies to delineate the appropriateness and effectiveness of their use.The gold standard for operative intervention in end-stage degenerative arthritis remains arthrodesis, but evidence for the equivalence and perhaps even superiority in functional outcomes of total ankle arthroplasty is increasing.The next few years will enable us to make more informed decisions, and, with more prospective high-quality studies, the most appropriate patient population for total ankle arthroplasty can be identified.INTRODUCTIONThe ankle joint is the most commonly injured joint in the body and absorbs more force per square centimeter than any other joint. However, the incidence of ankle arthritis is 9 times less common than symptomatic arthritis in the knee and hip.1 Unlike arthritis in the knee and hip joint, ankle arthritis is most commonly posttraumatic, and primary arthritis remains uncommon. Saltzman and colleagues2 reported 7.2% of primary ankle arthritis compared with 70% of posttraumatic arthritis, in a sample of 639 patients across a 13-year period. Rheumatoid arthritis was seen in 11.9% of patients.2介绍踝关节是身体中最常受伤的关节，每平方厘米吸收的应力比任何其他关节都要多。然而，踝关节炎的发病率却是膝关节和髋关节症状性关节炎的九分之一。1 与膝关节和髋关节关节炎不同，踝关节关节炎最常见于创伤后，而原发性关节炎却不常见。在 13 年期间对 639 名患者样本追踪随访中，Saltzman 及其同事 2 报告了 7.2% 的原发性踝关节炎与 70% 的创伤后踝关节炎，其中11.9% 的患者患有类风湿性关节炎。2ANATOMY/PATHOPHYSIOLOGYTrauma to the ankle joint, including Weber A to C fractures, pilon fractures, and osteochondral injuries to the talus (osteochondritis dissecans [OCD]) as well as lateral ankle of degenerative changes.5 The mean latency time for the development of posttraumatic arthritis was 20.9 years in 1 study.6 Patients age (ie, older patients) as well as complications during the treatment of the fracture were related to a shorter latency in the onset of arthritis.6 Talar neck fracture can also lead to the development of tibiotalar arthritis, with rates of 47% to 97% described in the literature.7 Osteochondral injuries to the talus (OCDlesions), whether acquired at the time of an ankle fracture dislocation or of idiopathic origin, predispose patients to the development of ankle arthritis. These lesions are best diagnosed with magnetic resonance imaging (MRI) scans.It is estimated that symptomatic ankle arthritis is encountered 8 to 9 times less when compared with knee osteoarthritis.1,8 This estimate translates to 24 times more total knee replacements being performed in the United States compared with total ankle arthroplasty.1 In a cadaver study using 50 samples, grade 2, 3, or 4 degenerative changes were found in 76% of ankles, compared with 95% of knees.9There are also differences in cartilage properties between different joints. Ankle cartilage is thinner compared with hip or knee cartilage.10 It ranges from less than 1 mm to approximately 2 mm.11 The surface contact area for the ankle is also smaller (350 mm2),12 compared with that of the knee and hip, at 1120 mm2 and 1100 mm2, respectively.1 Most of the load is transmitted over the superior portion of the talus, and the ankle joint experiences loads up to 5 times of a persons body weight.13 In dorsiflexion, the contact area across the talus is largest, and it decreases by 18% in plantarflexion. This finding is associated with an increase in force per unit area.14解剖学/病理生理学踝关节创伤，包括 Weber A 到 C 骨折、pilon 骨折和距骨的骨软骨损伤（剥脱性骨软骨炎 [OCD]）以及退行性改变的外侧踝关节。5 一项研究中发现创伤后踝关节炎的平均潜伏期为 20.9年。6 患者的年龄（即老年患者）以及骨折治疗期间的并发症与踝关节炎发作的较短潜伏期有关。6 距骨颈骨折也可导致胫距骨关节炎的发生，文献中描述的发生率为 47% 至 97%。7 距骨的骨软骨损伤（OCD病变），无论是在踝关节骨折脱位时获得的还是特发性的，都会使患者易患踝关节炎。这些病变最好通过磁共振成像 (MRI) 扫描来诊断。据估计，与膝关节骨关节炎相比，有症状的踝关节骨关节炎少 8 到 9 倍。1,8 这一估计意味着在美国进行的全膝关节置换术是全踝关节置换术的 24 倍。1 在一项尸体研究中使用 50 个样本，在 76% 的踝关节中发现了2、3 或 4 级退行性变化，而膝关节退变则为 95%。9不同关节之间的软骨特性也存在差异。与髋关节或膝关节软骨相比，踝关节软骨更薄。10 范围从小于 1 毫米到大约 2 毫米。11 与膝关节和髋关节的接触面积相比，踝关节的表面接触面积也更小（350 平方毫米），12分别为 1120 mm2 和 1100 mm2。1 大部分负荷通过距骨上部传递，踝关节承受的负荷高达人体重的 5 倍。13 在背屈时，与距骨的接触面积最大，跖屈时减少18%。这一发现与单位面积应力的增加有关。 14CLINICAL PRESENTATIONPain and functional limitations are the most common presenting symptoms in patients with ankle arthritis.17 Coughlin and colleagues17 recommend that all patients should be asked the following:1. Is there a history of trauma? 2. What activities worsen the ankle pain and limit function?临床表现疼痛和功能受限是踝关节炎患者最常见的症状。 17 Coughlin 及其同事 17 建议应询问所有患者以下问题：1. 有外伤史吗？2. 哪些活动会加重脚踝疼痛和导致踝关节功能受到限制？Patient HistoryThe history of trauma, even remote, can be helpful in diagnosing posttraumatic ankle arthritis.17 The patient should also be asked about recurrent sprains, which they may not immediately recall or associate with a history of trauma. Next, patients need to asked about their medical comorbidities, including rheumatoid arthritis, diabetes, hemophilia, infection, avascular necrosis, and history of previous ankle procedures.17 Diabetes mellitus, as well as low-bone density, predispose patients to the development of Charcot arthropathy.18病史外伤史，即使是很早以前的外伤史，也有助于诊断创伤后踝关节炎。17 还应询问患者是否有复发性扭伤，他们可能不会立即回忆起或与外伤史相关联。接下来，需要询问他们的医学合并症，包括类风湿性关节炎、糖尿病、血友病、感染、缺血性坏死和既往踝关节手术史。 17 糖尿病以及低骨密度使患者易患 Charcot关节病 18ActivitiesNext, patients should be asked about activities that aggravate their pain and limit their function. Pain that worsens with uphill climbing may be related to the anterior ankle, whereas downhill pain is related to the posterior ankle.17 Pain on uneven ground is often related to disease in the subtalar joint, whereas pain in the posteromedial joint is often caused by posterior tibial tendon dysfunction (PTTD), and is less related to ankle arthritis.17 Subfibular or posterolateral ankle pain can be caused by peroneal tendons, or impingement between the calcaneus and talus or fibula. This finding may be seen in the aftermath of calcaneus fractures.19活动度接下来，应询问患者导致其踝关节疼痛加重并限制其功能的活动。爬坡时加重的疼痛可能与前踝有关，而下坡疼痛与后踝有关。17 不平坦地面的疼痛通常与距下关节的疾病有关，而后内侧关节的疼痛通常由后踝引起。胫骨肌腱功能障碍 (PTTD)，与踝关节炎的相关性较小。17 腓骨下或后外侧踝关节疼痛可由腓骨肌腱或跟骨与距骨或腓骨之间的撞击引起。这一发现可以在跟骨骨折的后果中看到。 19CLINICAL FINDINGSA complete physical examination includes examination of the patient in both a standing and a sitting position.17 In addition, gait examination is imperative, as well as examining the patient for hindfoot alignment (ie, varus/valgus heel). Physicians need to take note of any malalignment seen along the lower extremity axis, from hip to knee, and along the tibial shaft. During the gait examination, the examiner needs to note the position of the forefoot during heel strike. When examining patients with flatfoot deformity and PTTD, single and double toe rise needs to be tested. Correction of hindfoot alignment, or lack thereof, indicates late stage PTTD. When the hindfoot remains in valgus during heel rise, a fixed, or stage 3, PTTD can be diagnosed. In these patients, treatment with a fusion procedure is often then indicated.临床发现完整的体格检查包括对患者站立和坐位的检查。17 此外，步态检查是必要的，以及检查患者的后足对齐（即内翻/外翻足跟）。医生需要注意沿下肢力线、从髋关节到膝关节以及沿胫骨轴线看到的任何排列不齐。在步态检查过程中，检查者需要注意脚跟撞击时前脚掌的位置。在检查扁平足畸形和 PTTD 患者时，需要测试单趾和双趾上升。后足对齐的纠正或缺乏，表明晚期 PTTD。当后足在足跟抬高期间保持外翻时，可以诊断出固定或第 3 期 PTTD。在这些患者中，通常需要进行融合手术治疗。Sitting ExaminationDuring this part of the examination, the stability of all ankle ligaments is assessed, including anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). The ATFL is examined in plantarflexion and the CFL in slight dorsiflexion.17 The range of motion of the ankle is documented and the Silfverskio ld test is performed, examining for Achilles and gastrocnemius contracture. Improved dorsiflexion with the knee flexed indicates gastrocnemius contracture, whereas limited dorsiflexion with both the knee straight and in a flexed position indicates Achilles contracture. This part of the examination is of particular importance, because it can alter ones operative plan.17坐位检查在这部分检查期间，评估所有踝关节韧带的稳定性，包括前距腓韧带 (ATFL) 和跟腓韧带 (CFL)。ATFL 在跖屈时检查，CFL 在轻微背屈时检查。17 记录踝关节的运动范围并进行 Silfverskild 试验，检查跟腱和腓肠肌挛缩。膝关节屈曲时背屈改善表明腓肠肌挛缩，而膝关节伸直和屈曲时背屈受限表明跟腱挛缩。这部分检查特别重要，因为它可以改变一个人的手术计划。 17Skin and VascularA careful skin and vascular examination documenting pulses, capillary refill, and presence of ulcer or calluses is a mandatory component of a complete physical examination. Skin changes may indicate vasculitis, as, for example, in rheumatoid arthritis or complex regional pain syndrome.17皮肤和血管 仔细的皮肤和血管检查记录脉搏、毛细血管再充盈以及溃疡或老茧的存在是完整体检的必要组成部分。皮肤变化可能表明血管炎，例如类风湿性关节炎或复杂的局部疼痛综合征。 17DIAGNOSTIC IMAGINGPlain films of the ankle remain the gold standard for initial imaging modality. Standing films of the ankle are preferred, examining anteroposterior, mortise, and lateral views. Radiographs of the foot are also included if surgery in the hindfoot or midfoot is planned as part of the surgical treatment.17 Saltzman and colleagues2 also focused on the hindfoot alignment for diagnostic and operative planning purposes. Hindfoot imagining using the Harris view can be easily accomplished in the office setting. Recently, a study20 reported that the long-axis view of the hindfoot may have better interobserver reliability than the hindfoot alignment view. Advanced imaging with computed tomography (CT) and MRI scans is appropriate in select settings. CT scans may be used to gain an improved appreciation of posttraumatic changes at the tibiotalar joint, nonunions, and in cases of complex deformity or retained hardware. CT scans are less susceptible to hardware artifacts and motion artifacts compared with MRI. MRI is less frequently used for the diagnosis of ankle arthritis. Its main advantage lies in characterization of the surrounding soft tissues. It can also shed light on the mechanism of injury that led to the development of posttraumatic arthritis.21 For posttraumatic patients and patients with significant lower extremity deformity, a scanogram can assist in therapeutic and diagnostic decision making.Ankle arthritis can be classified based on anatomy and underlying cause. In terms of anatomy, arthritis can be global (where the entire tibiotalar joint is affected) or localized (specific portions of the articular surface are affected).17 The underlying cause of the arthritis can be classified into 3 broad categories: posttraumatic, osteoarthritis, and rheumatoid arthritis; Charcot arthropathy and hemochromatosis; or degenerative changes caused by tumor.1 The stages of osteoarthritis can be outlined using radiographic parameters:Stage 0: normal joint, or subchondral sclerosisStage 1: presence of osteophytes without joint space narrowing (Fig. 3)Stage 2: joint space narrowing, with or without osteophytesStage 3: subtotal or total disappearance or deformation of joint space (Fig. 4)More recently, the Canadian Orthopaedic Foot and Ankle Society (COFAS) classification for end-stage ankle arthritis has been described.26 The COFAS classification has been shown to have good interobserver reliability (k 5 0.62) and intraobserver reproducibility (k 5 0.72). A postoperative classification was developed for the COFAS stages, with even higher interobserver reliability and improved reliability.27诊断性影像学检查踝关节的平片(X线片)仍然是最初成像方式的金标准。首选脚踝站立片，检查前后位、mortise位和侧位。如果计划将后足或中足的作为手术治疗的一部分，足部的 X 线片也包括在内。17 Saltzman 及其同事 2 还关注后足对齐，以进行诊断和手术计划。在坐位中，后足可以通过 Harris位拍摄轻松实现。最近，一项研究 20 报告说，后足的长轴位可能比后足对齐位具有更好的观察者间可靠性。计算机断层扫描 (CT) 和 MRI 扫描的高级成像适用于特定环境。CT 扫描可用于更好地了解胫距关节、骨不连处的创伤后变化，以及复杂畸形或保留硬件的情况。与 MRI 相比，CT 扫描不太容易受到硬件伪影和运动伪影的影响。MRI扫描不如X线片和CT更多地用于诊断踝关节炎。MRI扫描的主要优点在于对周围软组织的表征(如韧带、软骨、骨髓水肿等)。它还可以揭示导致创伤后关节炎发展的损伤机制。21 对于创伤后患者和下肢明显畸形的患者，MRI扫描可以帮助做出正确的诊断和治疗决策。踝关节炎可以根据解剖结构和根本病因进行分类。在解剖学方面，踝关节炎可以是广泛性的（整个胫距关节都受到影响）或局部性的（关节面的特定部分受到影响）。 17 踝关节炎的根本病因可分为 3 大类：创伤后、骨关节炎、和类风湿性关节炎；Charcot 关节病和血色病；或由肿瘤引起的退行性变化。 1 踝关节骨关节炎可以使用影像学参数进行分级描述：0期：正常关节或软骨下硬化；1期：存在骨赘但无关节间隙变窄（图 3）；2期：关节间隙变窄，有或没有骨赘；3期：关节间隙次全或全部消失或变形（图4）。最近，加拿大足踝矫形协会 (COFAS) 对终末期踝关节炎的分类进行了描述。26 COFAS 分类已被证明具有良好的观察者间可靠性 (=0.62) 和观察者内可重复性 (=0.72)。采用COFAS 分期制定了术后分类，具有更高的观察者间可靠性和更高的可靠性。 27PROGNOSISAnkle arthritis reduces the number of total steps per day taken by patients, as well high-intensity steps, and is associated with a slower walking speed, when compared with age-matched controls.28 This situation can have a detrimental impact on patients activities of daily living (ADLs). The prognosis of ankle arthritis can be self-limiting, but some patients can experience a continued decline in their activity level and an increase in their pain. Besides a decrease in the number of steps taken by patients, studies have also found decreased ankle range of motion and decreased plantar flexion power during gait analysis.28预后与年龄匹配的对照组相比，踝关节炎会减少患者每天的总步数以及高强度步数，并且与较慢的步行速度相关。 28 这种情况可能对患者的日常生活（ADL）活动产生不利影响。踝关节炎的预后可能是自限性的，但一些患者的活动水平会持续下降，疼痛会增加。除了患者行走的步数减少之外，研究还发现在步态分析过程中踝关节活动范围减小，跖屈力度减小。 28MANAGEMENT GOALSThe goal of management is pain control, improvement of patients function and ADLs, and a decrease in their level of pain.控制目标控制目标是管理疼痛、改善患者的功能和 日常活动ADL，并降低他们的疼痛水平。PHARMACOLOGIC STRATEGIESNonsteroidal Antiinflammatory DrugsThe most common pharmacologic strategy addressing ankle arthritis is nonsteroidal antiinflammatory drugs (NSAIDs). The side effects of NSAIDs require judicious prescribing and use. These side effects can include gastrointestinal bleeding, stroke, and increased cardiovascular risks.29 Recent recommendations have focused on the use of topical NSAIDs, particular in high-risk patients for localized osteoarthritis.29 All patients need to be carefully screened for comorbidities before the initiation of an NSAID regimen.17,29 Based on our clinical experience, the efficacy of NSAIDs varies and is patient dependent.药理学策略非甾体抗炎药解决踝关节炎最常见的药理学策略是非甾体抗炎药 (NSAIDs)。NSAIDs 的副作用在开具处方和使用前需被充分考虑。这些副作用可能包括胃肠道出血、中风和心血管风险增加。 29 最近的建议侧重于局部使用非甾体抗炎药，特别是局部骨关节炎的高危患者。 29 所有患者在开始治疗前都需要仔细筛查合并症17,29 根据我们的临床经验，NSAID 的疗效各不相同，并且取决于患者。Corticosteroid Injections and ViscosupplementationTibiotalar joint injections with corticosteroids continue to be 1 final nonsurgical option that patients can be offered in the office setting after failing NSAID therapy and activity modifications. Although corticosteroid injections remain the gold standard, there are an increased number of research articles examining the role of viscosupplementation with hyaluronate in ankle arthritis.23,24,30 In a more recent study,31 3 weekly injections of hyaluronate resulted in pain relief, decreased acetaminophen consumption, and improvement of balance tests. Patients were followed up to 6 months, with improvements in their American Orthopaedic Foot and Ankle Society (AOFAS) scores noted.Risks of the injection need to be explained to the patient and all questions answered. These risks include injection site reactions, infections, risk of damage to articular cartilage, and permanent skin depigmentation.32 Several clinicians have experienced the unpleasant effect of permanent skin discoloration and the patient dissatisfaction that can accompany this.皮质类固醇注射剂和粘性补充剂用皮质类固醇注射胫距关节仍然是一种最终的非手术选择，在NSAIDs治疗和活动调整失败后，患者可以在诊室中获得治疗。尽管注射皮质类固醇仍然是金标准，但越来越多的研究文章研究了透明质酸(玻璃酸钠注射液)在踝关节炎治疗中的作用。23,24,30 在最近的一项研究中，31 每周注射 3 次透明质酸可缓解疼痛，减少对乙酰氨基酚的使用，以及平衡测试的改进。对患者进行了长达 6 个月的随访，注意到他们的美国矫形足踝协会 (AOFAS) 评分有所改善。需要向患者解释注射的风险并回答所有问题。这些风险包括注射部位反应、感染、关节软骨损伤的风险和永久性皮肤色素脱失。32 一些临床医生经历过永久性皮肤变色的不愉快影响以及随之而来的患者不满。NONPHARMACOLOGIC STRATEGIESSelf-Management StrategiesActivity modifications can be one of the most effective strategies in early ankle arthritis.17 By avoiding uneven platforms (ie, subtalar arthritis), uphill climbs (anterior ankle arthritis), and using treadmills or elliptical exercise machines to continue to stay active, patients can achieve some pain control.非药物策略自我管理策略活动调整可能是早期踝关节炎最有效的策略之一。 17 通过避免不平坦的平台（即距下关节炎）、爬坡（前踝关节炎）以及使用跑步机或继续保持使用椭圆机，患者可以达到一定的疼痛控制。OrthoticsAnother effective strategy seems to be mechanical unloading of the joint.17 This strategy can be accomplished via ankle foot orthosis, based on either ankle or calf lacers.33 Lace-up ankle support can be especially effective in patients who experience instability or mechanical misalignment.1 Rocker-bottom shoes with the addition of a solid ankle cushioned heel can be worn.34 Additional strategies include a temporary plaster or fiber-glass cast, or the use of a CAM walker boot. These options can be selected based on both patient preference and financial resources available. Other nonsurgical, nonpharmacologic options include physical therapy modalities, chiropractic care, and acupuncture. There are few peer-reviewed studies or reviews on these modalities.矫形器另一种有效的策略似乎是关节的机械卸载。17 该策略可以通过基于踝关节或小腿韧带的足踝矫形器来实现。33 系带式踝关节支撑对于经历不稳定或机械错位的患者尤其有效。 1 可以穿带有实心脚踝缓冲鞋跟的翘底鞋。34 其他策略包括临时石膏或玻璃纤维模型，或使用 CAM 步行靴。可以根据患者的偏好和经济条件来选择这些项目。其他非手术、非药物选择包括物理治疗方式、脊椎按摩疗法和针灸疗法。关于这些模式的同行评审研究或评论很少。SURGICAL TECHNIQUEWhen patients have failed conservative treatment options, surgical approaches to ankle arthritis can be considered. The most common surgical options include:1. Arthroscopy2. Corrective osteotomies3. Distraction arthroplasty4. Ankle arthrodesis5. Total ankle arthroplasty手术技术当患者的保守治疗选择失败时，可以考虑手术治疗踝关节炎。最常见的手术选择包括：1. 踝关节镜；2. 矫正截骨术；3. 牵引关节成形术；4. 踝关节融合术；5. 全踝关节置换术The goals of surgery are similar to nonsurgical options: pain relief and improve or stabilize function. Based on the stage and location of arthritis (global vs localized), as well as patient demographics, surgical options include arthroscopic debridement, supramalleolar osteotomy, distraction arthroplasty, arthrodesis, and total ankle arthroplasty.1,17 There are numerous techniques and approaches for tibiotalar arthrodesis, with no clear empiric evidence of 1 technique being superior in terms of outcomes compared with others.手术的目标类似于非手术治疗：缓解疼痛和改善或稳定功能。根据关节炎的分期和位置（全身与局部）以及患者人口统计数据，手术选择包括踝关节镜清创术、踝关节上截骨术、牵引关节成形术、踝关节融合术和全踝关节成形术。 1,17有许多技术和方法可施行胫距关节融合术，没有明确的经验证据表明一种技术在结果方面优于其他技术。ArthroscopyAnkle arthroscopy along with debridement has several indications in ankle arthritis. Patients with loose bodies, early degenerative changes, and osteochondral lesions may be suitable candidates for arthroscopy.17 In addition, impinging osteophytes can often be addressed with ankle arthroscopy. A recent review of the available evidence provides the following list of indications for ankle arthroscopy: ankle impingement, osteochondral lesions, and arthroscopy for ankle arthrodesis.35 Contraindications include isolated advanced ankle arthritis, excluding the presence of a specific lesion or osteophyte leading to impingement.3537关节镜踝关节镜检查和清创术在踝关节炎中有多种适应症。身体(韧带)松弛、早期退行性关节炎改变和骨软骨病变的患者可能适合进行关节镜检查。17 此外，撞击产生的骨赘通常可以通过踝关节镜检查解决。最近对现有研究证据的回顾提供了以下踝关节镜检查的适应证：踝关节撞击症、骨软骨病变和踝关节融合术后的关节镜检查。35 禁忌症包括：单纯的晚期踝关节炎，而不包括导致撞击的特定病变或骨赘的存在。3537Supramalleolar OsteotomySupramalleolar osteotomies address fracture malunions and malalignment of the lower extremity, which contribute to ankle arthritis.1 In addition, in posttraumatic arthritis, seen in fractures with partial or complete articular involvement, supramalleolar osteotomies can be of benefit.1 Varus ankle alignment can be treated with a medial opening-wedge osteotomy or a lateral closing-wedge osteotomy. Patients who had a lower preoperative talar tilt (关节炎的骨折畸形愈合和下肢力线不齐。此外，在创伤后关节炎中，可见于部分或完全踝关节受累的骨折，踝关节上截骨术可能是有益的。1 内翻踝关节排列可以采用内侧开口楔形截骨术或外侧闭合楔形截骨术治疗。术前距骨倾斜度较低 (关节炎。未来需要使用长期、高质量设计的进一步研究来指导我们的临床实践。ArthrodesisTibiotalar arthrodesisTibiotalar arthrodesis is perhaps one of the most established and well-studied operative treatments of end-stage tibiotalar arthritis. The main indication for fusion of the ankle joint is failed conservative therapy in patients with intractable pain or deformity of the ankle joint.1,17 Posttraumatic osteoarthritis remains the most common underlying cause.1,45 Other causes include idiopathic osteoarthritis, avascular necrosis, history of osteomyelitis (not active), failed total ankle arthroplasty,46,47 postpolio syndrome, congenital deformities,17 and rheumatoid arthritis.1 Thomas and Daniels1 do not recommend arthrodesis as a primary salvage procedure for acute trauma. One of the main advantages of arthrodesis is the reliability of pain relief after successful surgery. In addition, the need for implant or hardware removal is decreased with arthrodesis. Ankle arthrodesis can be accomplished via, open, arthroscopic or with the use of the Ilizarov technique. Regardless of the particular approach used to fuse the ankle, the most important factor in a successful operation is ankle position and soft tissue handling.17Ankle position during arthrodesis The currently accepted position of the ankle is neutral dorsiflexion, 5 of hindfoot valgus and external rotation in 5 to 10.1,48 Other researchers have recommended a position of external rotation that mimics the rotation of the contralateral extremity. At heel strike, the midfoot plantar flexes 10 during normal gait.49 With the ankle fused in a neutral position, this motion is allowed to occur. Fusion in equinus leads to the development of a gait abnormality during heel strike, because the midfoot is unable to dorsiflex. Hefti and colleagues48 also recommended placing the talus backward in relation to the tibia and fusing it in 5to 10 of external rotation. This strategy has the theoretic advantage of improved push-off via the natural pronation mechanism. Soft tissue handling Soft tissue handling is of vital importance when performing arthrodesis. This procedure includes careful retraction, and releasing retractors at every opportunity to decrease insult to the soft tissues, avoiding scar contractures and areas of erythema.17 Cutaneous nerves need to be protected whenever possible, and planned incision and meticulous dissection techniques are paramount. For the anterior arthrotomy, branches of the superficial peroneal nerve are most at risk, whereas the sural nerve is in danger during a lateral approach and around the lateral malleolus.Internal versus external fixation Internal fixation remains the first choice during arthrodesis for most patients. Advantages over external fixation include a higher fusion rate and decreased inconvenience for patients.50 The nonunion rate is cited as 5% for internal fixation, compared with 21%in the external fixation group.50 Infections were also more common in the external fixator group, at 5 of 28 patients (pin track infections), compared with no superficial or deep infections in the internal fixation group.50关节固定术胫距关节融合术胫距关节固定术可能是终末期胫距关节炎最成熟和研究最充分的手术治疗方法之一。踝关节融合的主要指征是对顽固性疼痛或踝关节畸形患者的保守治疗失败。1,17 创伤后骨关节炎仍然是最常见的潜在原因。1,45 其他原因包括特发性骨关节炎、缺血性坏死、病史骨髓炎（非活动性）、全踝关节置换术失败、46,47 脊髓灰质炎后综合征、先天性畸形 17 和类风湿性关节炎 1。Thomas 和 Daniels1 不建议将关节固定术作为急性创伤的主要挽救手术。关节固定术的主要优点之一是手术成功后疼痛缓解的可靠性。此外，关节固定术减少了对植入物或硬件移除的需求。踝关节融合术可以通过开放式、关节镜或使用 Ilizarov 技术来完成。不管用于融合脚踝的特定方法如何，成功手术的最重要因素是脚踝位置和软组织处理。 17 关节固定术中的踝关节位置 目前接受的踝关节位置是背屈中立、后足外翻 5和外旋 5 到 10 .1,48 其他研究人员推荐了一种模仿对侧肢体旋转的外旋位置。在足跟着地时，正常步态下中足跖屈 10。49 脚踝融合在中立位置时，允许发生这种运动。马蹄足的融合导致足跟撞击时步态异常的发展，因为中足不能背屈。 Hefti 及其同事 48 还建议将距骨相对于胫骨向后放置，并在 5 到 10 次外旋时融合。该策略具有通过自然旋前机制改进推离的理论优势。 软组织处理 软组织处理在进行关节融合术时至关重要。该过程包括小心牵开，并在每一个机会释放牵开器以减少对软组织的伤害，避免瘢痕挛缩和红斑区域。17 需要尽可能保护皮神经，有计划的切口和细致的解剖技术是最重要的。对于前关节切开术，腓浅神经的分支最危险，而外侧入路和外踝周围的腓肠神经处于危险之中。 内固定与外固定 内固定仍然是大多数患者关节固定术的首选。相对于外固定架的优势包括更高的融合率和减少对患者的不便。50 内固定的不愈合率为 5%，而外固定架组为 21%。50 感染在外固定架组中也更常见， 28 名患者中有 5 名（针迹感染），而内固定组没有浅表或深部感染。 50 Plates versus screwsSeveral previous studies have shown improved compression with the use of screws compared with plate fixation.5155 An additional advantage of screws is decreased soft tissue stripping compared with plates.1 T-plate fixation for fusions may offer advantages in certain situations.56 Cadaver biomechanical testing showed that T-plate fixation provided the greatest stiffness compared with screw fixation or fibular strut graft.56,57 In osteopenic bone, the option of using 2 plates in anterolateral and anteromedial positions may offer improved fixation strength and fusion rates.58 In 1 cadaver study,58 bending stiffness was improved by 1.5 to 2 times compared with using a single anterior plate. Commercial systems are available using anterior, lateral, and posterior plating options.钢板与螺钉先前的几项研究表明，与钢板固定相比，使用螺钉可改善压力。51-55 与钢板相比，螺钉的另一个优点是减少了软组织剥离。1 T 型钢板固定用于融合可能在某些情况下具有优势。56 Cadaver生物力学测试表明，与螺钉固定或腓骨支柱移植物相比，T形钢板固定提供了最大的刚性强度。56,57 在骨质减少的病例中，在前外侧和前内侧位置使用2块钢板的选择可能会提供更好的固定强度和融合率。58 在1项Cadaver研究中，58 与使用单个前方钢板相比，2块钢板的选择使得弯曲刚度提高了1.5 到 2 倍。目前市场上可供选择的有前方、外侧和后方钢板。Screw configurationThe use of 2 crossed screws produces increased rigidity compared with parallel screws.59 One possible screw configuration used at our institution is shown in Fig. 5.螺钉配置与平行螺钉相比，使用2个交叉螺钉可提高刚度。59 我们机构使用的一种可能的螺钉配置如图 5 所示。Number of screwsStudies have shown that 3 screws can provide increased stiffness compared with 2 screws.60 The stability of the fusion can further be enhanced with the use of a fibular strut graft.61 Several techniques for the specific approach and screw configuration have been described. Holt and colleagues52 described the use of 3 screws along with a fibular osteotomy. Kish and colleagues62 described a technique using cannulated screw fixation. This technique allows for 3 to 4 screws to be placed, with the aid of guidewires to ensure satisfactory alignment and correction of deformity compression across the fusion site (Fig. 6).63螺钉数量研究表明，与2枚螺钉相比，3枚螺钉可提供更高的刚度。60 使用腓骨支柱移植物可以进一步增强融合的稳定性。61 已经描述了用于特定方法和螺钉配置的几种技术。Holt 及其同事 52 描述了使用 3 颗螺钉和腓骨截骨术。Kish 及其同事 62 描述了一种使用空心螺钉固定的技术。这种技术允许在导针的帮助下放置 3 到 4 个螺钉，以确保满意的对齐和矫正整个融合部位的畸形应力（图 6）。63External FixationsThe main indication for external fixation is during active infections and in patients with compromised soft tissues.1 In addition, in severe osteoporosis, in which decreased screw purchase and compression across the fusion site is possible, external fixation may be the preferred modality.1 This technique allows for immediate weight bearing as tolerated and can be used as a salvage approach.64外固定架/器外固定架的主要适应症是活动性感染期间和软组织受损的患者。1此外，在严重的骨质疏松症中，可能会减少螺钉的使用和融合部位的应力，外固定架可能是首选方式。1 这该技术允许在可耐受的情况下立即负重，并可用作补救方法。64Internal Versus External FixationInternal fixation has several advantages over external fixation, including a higher reported fusion rate and decreased inconvenience for patients.50 The nonunion rate is cited as 5% for internal fixation, compared with 21% in the external fixation group.50 Infections were also more common in the external fixator group at 5 of 28 patients (pin track infections), compared with no superficial or deep infections in the internal fixation group.50内固定与外固定与外固定相比，内固定有几个优点，包括更高的融合率和减少对患者的不便。50 内固定的不愈合率为 5%，而外固定组为 21%。50 感染也更常见外固定器组。28 名患者中有 5 名（针眼感染），而内固定组没有浅表或深部感染。50Gait Analysis in Ankle ArthrodesisThomas and Daniels1 provide a thorough review of the main points with regards to alterations in the gait cycle. Overall, the energy expenditure during walking is increased by 3%.65踝关节融合术后的步态分析Thomas 和 Daniels1 对有关步态周期变化的要点进行了全面审查。总体而言，踝关节融合术后步行时的能量消耗增加了3%。65TOTAL ANKLE ARTHROPLASTYFour devices are currently approved by the US Food and Drug Administration (FDA) for total ankle arthroplasty: Agility, Salto, Scandinavian Total Ankle Replacements (STAR), and INBONE. The third generation of total ankle arthroplasty is in use. The use of ankle arthroplasty started in the 1970s.1 It is becoming widespread in North America, but has been popular and well established in Europe. Most ankle replacements used outside the United States are mobile bearing, whereas most used within the United States are fixed bearing.全踝关节置换术目前，美国食品和药物管理局 (FDA) 批准了四种用于全踝关节置换术的器械：Agility、Salto、Scandinavian全踝关节置换术 (STAR) 和 INBONE。第三代全踝关节置换术正在使用中。踝关节置换术的使用始于 1970 年代 1。它在北美越来越普遍，但在欧洲已经流行和成熟。在美国以外使用的大多数踝关节置换物是活动平台，而在美国境内使用的大多数是固定平台。INDICATIONSOne of the current challenges is controversy in the indications for this procedure and identifying the most appropriate patients who will benefit in the short-term and long-term. Surgical candidates are adult patients who have failed several months of conservative treatment and have end-stage degenerative joint disease of the ankle. The following prerequisites should be fulfilled: (1) adequate vascular flow to the extremity and (2) an adequate soft tissue envelope around the ankle to allow for wound healing and the initiation of physical therapy and ankle range of motion exercises postoperatively.全踝关节置换术的适应症当前的挑战之一是该程序的适应症和确定将在短期和长期受益的最合适的患者方面存在争议。手术患者是经过数月保守治疗失败并患有晚期踝关节退行性疾病的成年患者。应满足以下先决条件：(1)有足够的血管流向远端；(2) 足踝周围有足够的软组织包膜，以允许伤口愈合和术后开始物理治疗和踝关节在一定范围内运动。CONTRAINDICATIONS TO TOTAL ANKLE ARTHROPLASTYContraindications for total ankle arthroplasty include infection, osteonecrosis of the talus, severe malalignment, compromised soft tissue, severe laxity, and neurologic dysfunction.1 Coetzee and Deorio69 recommend that a valgus deformity of more than 20 is prohibitive for a total ankle replacement. These investigators also recommend that foot deformities need to be addressed and treated at or before the time of the arthroplasty, because foot deformities can lead to early implant failure. Severe valgus deformities, as seen in end-stage adult acquired flatfoot deformity, can be addressed at the time of total ankle replacement. This is especially the case in patients who had previous fusion procedures in the midfoot or hindfoot (Fig. 7).Types of total ankle replacement (total ankle arthroplasties can be classified along several different parameters)70: I. Fixation: fixation can be cemented or uncementedII. Number of components: the number of components ranges from 2 to 3; thesecomponents can be congruent or incongruent; congruency refers to incongruent(trochlear, bispherical, concave/convex) to congruent (spherical, cylindrical, conical)III. Constraint: constrained, semiconstrained, or nonconstrainedIV. Component shape: nonanatomic versus anatomicV. Bearing: fixed or mobile全踝关节置换术的禁忌症全踝关节置换术的禁忌症包括感染、距骨骨坏死、严重力线不正、软组织受损、严重踝关节松弛和神经功能障碍。1 Coetzee 和 Deorio 69 建议外翻畸形超过20不能进行全踝关节置换术。这些研究人员还建议，足部畸形需要在关节成形术时或之前进行处理和治疗，因为足部畸形会导致早期植入失败。严重的外翻畸形，如终末期成人获得性扁平足畸形，可以在全踝关节置换术时解决。对于先前在中足或后足进行过融合手术的患者尤其如此（图7）。全踝关节置换术的类型（全踝关节置换术可以根据几个不同的参数进行分类）70：I.固定：固定可以是骨水泥或非骨水泥型；II.组件数量：组件数量从2到3不等；这些 组件可以是一致的或不一致的；不一致的（滑车、双球形、凹/凸）到一致性的（球形、圆柱形、圆锥形）；III.限制性：限制、半限制或非限制；IV.组件形状：非解剖与解剖；V.平台：固定或活动。Agility AnkleThe Agility ankle is a 2-component design system with fixed bearings. This is a semiconstrained device and allows for 60 of motion.71 This design includes a syndesmotic fusion, with the goal to prevent subsidence of the tibial component.70 Both the talus and tibia are nonanatomic, with a porous coated talus. Claridge and Sagherian72 reviewed some of the intermediate-term results of the Agility ankle. Improvements in AOFAS score were seen from 34.9 to 76.4, preoperative to postoperative, respectively. The investigators were concerned regarding the high rate of complications, ranging from superficial to deep infections, iatrogenic fractures, and arterial injury to patients requiring free flap coverage. At a follow-up of 9 years, 11% of patients required revisions (132 arthroplasties in 126 patients were reviewed). Other studies reported survival rates range from 80% to 95% at 5 years and 63% at 10 years.73,74 The most promising results of 2-component systems include 85% survival at 10 years.75 The incidence of subtalar arthritis was 19%, and 16% of patients had progressive talonavicular arthritis.72 In 8% of patients, nonunion of the syndesmosis was seen.76 Salto This is a mobile-bearing system, used in Europe since 1997 (Fig. 8). This system includes a conical talus fixed with pegs and a flat tibial component with fin fixation.70 Survival rate of 65% at 6.8 years was reported in a study including 96 implants in 92 patients. The most common causes for failures resulting in reoperations included bone cysts (11 patients), polyethylene fractures (5 patients), and unexplained pain (3 patients).77踝关节置换Agility踝关节置换是一个带有固定平台的两部分组件的设计系统。这是一个半限制装置，允许60次运动。71 这种设计包括联合融合，目的是防止胫骨组件下沉。70 距骨和胫骨都是非解剖结构，具有多孔涂层距骨。Claridge 和 Sagherian 72 回顾了 Agility 踝关节的一些中期结果。AOFAS评分从术前到术后分别从34.9提高到76.4。研究人员担心并发症的发生率很高，从浅到深的感染、医源性骨折和需要游离皮瓣覆盖的患者的动脉损伤。在9年的随访中，11%的患者需要翻修（回顾了126名患者的 132 例关节置换术）。其他研究报告的5年生存率为80% 至 95%，10 年生存率为63%。73,74 两部分踝关节置换系统最有希望的结果包括 85% 的 10 年生存率。75 距下关节炎的发病率为19%，16%的患者患有进行性距舟关节炎。72 在 8% 的患者中，看到关节不愈合。76 Salto 这是自 1997 年以来在欧洲使用的移动平台的踝关节置换系统（图 8）。该系统包括一个用钉固定的锥形距骨和一个带棘突固定的扁平胫骨组件。70 一项研究报告了6.8 年 65% 的存活率，该研究包括92名患者的96个植入物。导致再次手术失败的最常见原因包括骨囊肿(骨囊性改变)（11名患者）、聚乙烯折断（5名患者）和不明原因的疼痛（3 名患者）。77STARSTAR is an uncemented, hydroxyapatite-coated total ankle prosthesis (Fig. 9). This system includes a cylindrical talus and a flat tibial component.78 It was approved by the FDA on May 27, 2009. The 5-year survival of this prosthesis ranges from 70% 66 to 89.5%, with a 10-year survival of 71.1%.79 The postoperative range of motion was found to be equivalent to the postoperative range of motion.79 Zhao and colleagues79 cautioned about the higher rate of loosening that is seen with the STAR prosthesis in their study. STARSTAR 是一种非骨水泥、羟基磷灰石涂层的全踝关节假体(生物型)（图 9）。该系统包括一个圆柱形距骨和一个扁平胫骨组件。78 它于 2009 年 5 月 27 日获得 FDA 批准。该假体的 5 年生存率为 70% 66 至 89.5%，10 年生存率为 71.1 %.79 Zhao 和同事79 警告说，在他们的研究中，STAR 假体的松动率更高。INBONEThis 2-component system was FDA approved in 2005. It includes a titanium-based tibial component with a cobalt-chromium talus. The tibial component includes an intramedullary stem.80 This design feature requires intramedullary reaming under fluoroscopy and a specialized foot holder for the procedure. A newly designed form of this prosthesis called Prophecy has been introduced into the market. With this implant, the ankle CT of the patient is used to produce patient-specific cutting guides using threedimensional printing and has the advantages of decreasing the operation time and increasing the accuracy of bone cuts.INBONE这种 2 组件系统于 2005 年获得 FDA 批准。它包括以钛为主成分的胫骨组件和以钴铬为主成分距骨。胫骨组件包括一个髓内柄。80 这种设计特征需要在透视下进行髓内钻孔和用于手术的专用脚架。这种名为 Prophecy 的假体的新设计形式已经面市。使用这种假体，患者术前踝关节CT扫描，可用于3D打印，以制作患者特定设计，从而减少手术时间和提高截骨精度。TOTAL ANKLE VERSUS ARTHRODESISIn select groups of patients, total ankle arthroplasty may achieve safe, equivalent results compared with arthrodesis and may even lead to improved functional outcomes compared with fusions.66,80 Haddad and colleagues67 examined differences between total ankle arthroplasty and arthrodesis. This examination included 852 patients with total ankles and 1262 with fusions. A revision rate of 7% in total ankle replacements compared with 9% in fusions was not found to be significant. Salvage procedures were also compared, and 1% of patients with total ankle replacements required a below knee amputation (BKA) compared with 5% in the fusion group.67 Range of motion may also be improved in ankle replacements compared with arthrodesis.78 There may also be a smaller rate of degenerative joint changes in adjacent joints with arthroplasty compared with arthrodesis.81,82全踝关节置换术与踝关节融合术(踝关节固定术)在特定的患者组中，与踝关节固定术相比，全踝关节置换术可能获得安全、等效的结果，甚至可能导致与融合术相比的功能改善。66,80 Haddad 及其同事 67 研究了全踝关节置换术和关节固定术之间的差异。该检查包括 852 名全踝关节置换患者和 1262 名踝关节融合患者。踝关节置换术后总体翻修率为7%，与踝关节融合术的9%翻修率相比并不显着。还比较了挽救性治疗流程，1%的全踝关节置换患者需要膝关节下截肢(BKA)，而踝关节融合组为5%。67 与关节固定术相比，踝关节置换术的运动范围也可能得到改善。78 与踝关节固定术相比，踝关节置换术的相邻关节的退行性关节变化率也更小。81,82SURGICAL COMPLICATIONSIn all open foot and ankle procedures, infections, both superficial and deep, remain a concern. Infection rates ranging from less than 2%55 to 2.5%51 and up to more than 20% have been described.83 Delayed wound healing and infection can be addressed and prevented through meticulous soft tissue handling, decreasing retractor force and time, as well as closing of the extensor retinaculum.1 This strategy can be especially important in total ankle arthroplasty, in which exposed hardware can occur as a result of wound dehiscence.手术并发症在所有足部和踝关节开放手术中，浅表和深部感染仍然是一个问题。感染率从低于 2% 55 到 2.5% 51 甚至到超过 20% 不等。83 延迟伤口愈合和感染可以通过细致的软组织处理、减少牵开器的力量和时间，同时关闭伸肌支持带来解决和预防。1 该策略在全踝关节置换术中尤为重要，因为伤口裂开可能会导致假体裸露。COMPLICATIONS OF ANKLE ARTHRODESISMoeckel and colleagues50 described the most common complications of arthrodesis as “nonunion, delayed union, stress fracture, infection.” Nonunion or pseudoarthrosis may occur with rates ranging from 0% up to 41%.4,17,53 In several other studies, nonunion rates of less than 10% have been reported.84,85 Smoking is one of the most recognized factors contributing to nonunion and is associated with a 4 times greater risk of nonunion.86 Other factors implicated in nonunion are infection, noncompliance with postoperative weight-bearing restrictions, avascular necrosis of the talus, and surgeon technique.1,86 Frey and colleagues4 also identified medical comorbidities and history of open fractures as predisposing risk factors for nonunions. Neurovascular injury and adjacent joint arthritis in the hindfoot and midfoot have also been reported.1 Radiographic evidence of degenerative changes in the subtalar joint is frequently observed but is commonly clinically asymptomatic.1 Rates of up to 30% of subtalar osteoarthritis have been observed at 7-year follow-up studies.87 Although the ipsilateral foot is often involved, the ipsilateral knee seems to be spared from degenerative changes related to the ankle fusion.82 踝关节置换术的并发症Moeckel 及其同事 50 将踝关节固定术最常见的并发症描述为“骨不连、延迟愈合、应力性骨折、感染”。骨不连或假关节的发生率从 0% 到 41% 不等。4,17,53 在其他几项研究中，据报道骨不连率低于 10%。84,85 吸烟是最公认的导致骨不连的因素之一。吸烟可导致骨不连的风险增加 4 倍。86 与骨不连有关的其他因素包括感染、不遵守术后负重限制、距骨缺血性坏死和外科医生手术操作技术。1,86 Frey 及其同事 4 还确定了医源性合并症和开放性骨折史是骨不连的诱发危险因素。后足和中足的神经血管损伤和邻近关节的关节炎也有报道。1 距下关节退行性变的放射学证据经常可见，但临床上通常无症状。1 在随访7年研究时，可观察到距下骨关节炎发生率高达 30% 。87 虽然同侧足部经常受累，但同侧膝关节似乎不受与踝关节融合相关的退行性变化的影响。82COMPLICATIONS OF ARTHROSCOPIC ARTHRODESISThe most common complication in arthroscopic fusion is painful hardware, resulting in secondary procedures for removal.17,88 In a study of 42 patients, Crosby and colleagues89 examined complications of arthroscopic arthrodesis, which included nonunion (7%), iatrogenic fractures (4.8%), pin site infections (9.5%), and painful hardware (9.5%), as well as painful subtalar joints (9.5%), for an overall complication rate of 55%. In a recent meta-analysis of the literature,90 results of 244 patients were analyzed. A nonunion rate of 8.6% was reported. Of these patients, 66.7% were symptomatic from their nonunion.关节镜手术的并发症关节镜融合术中最常见的并发症是植入物相关性疼痛，导致二次手术移除。17,88 在一项针对 42 名患者的研究中，Crosby 及其同事 89 检查了关节镜下关节融合术的并发症，其中包括不愈合 (7%)、医源性骨折 (4.8%)、关节镜穿刺部位感染 (9.5%) 和植入物相关性疼痛 (9.5%)，以及距下关节疼痛 (9.5%)，总体并发症发生率为55%。在最近的文献综述分析中，对 244 名患者的 90 项结果进行了分析。其中，不愈合率为8.6%。在这些患者中，66.7% 的患者因骨不连出现症状。COMPLICATIONS OF ANKLE ARTHROPLASTYThe most common complications and reasons for failure of total ankle replacements include aseptic loosening, malalignment, and deep infection (1%).79,91 These 3 complications accounted for approximately 50% of the failures seen in 1 study review of the literature.91Aseptic loosening and implant failure is multifactorial. Limb and hindfoot deformities can be a contributing factor in many cases.1 Guidelines have previously been proposed with regards to alignment issues in total ankle arthroplasty.1 These guidelines include careful examination of preoperative radiographs to identify valgus/varus deformities of the hindfoot. Addressing issues these either before or at the time of the ankle replacement is vital to ensuring longevity of the implant. Obtaining full-length standing films to look for knee and tibia malalignment is also important. Supramalleolar osteotomies for distal tibia deformities greater than 10 have previously been recommended.92Failure of total ankle arthroplasty can have drastic consequences for patients. Deep infection of a prosthesis often necessitates removal of the implant, irrigation and debridement, long-term antibiotics, possible antibiotic spacer placement, and consideration of several salvage options.1 Compared with ankle arthrodesis, more extensive bone cuts are made during ankle replacements, and revision procedures and salvage options must take this diminished bone stock into account. This situation often leaves fewer options available after failed total ankle arthroplasty, including revision arthroplasty, ankle arthrodesis, and BKA.93,94 Recent meta-analyses have examined the conversion of failed total ankle arthroplasty to ankle arthrodesis, with Haddad and colleagues67 reporting a 5.1% conversion rate, and Stengel and colleagues95, a 6.3% rate.95踝关节置换术的并发症最常见的全踝关节置换术失败的并发症和原因包括无菌性松动、力线不齐和深部感染 (1%)。79,91 在一项文献研究回顾中，上述3种并发症约占所见全部失败原因的 50%。无菌性松动和假体失败是多因素的。在许多情况下，四肢和后足畸形可能是一个加速因素。1 之前已经提出了关于全踝关节置换术中力线问题的指南。1 这些指南包括仔细检查术前 X 光片以确定后足的外翻/内翻畸形。在踝关节置换术时解决这些问题对于确保假体的使用寿命至关重要。获取全长站立片以寻找膝关节和胫骨力线不正也很重要。以前曾建议对大于 10 的胫骨远端畸形进行踝关节上方截骨术。92 全踝关节置换术的失败会给患者带来严重的后果。假体的深部感染通常需要移除假体、冲洗和清创、长期使用抗生素、可能放置抗生素间隔器并考虑多种挽救方案。 1 与踝关节融合术相比，在踝关节置换术期间进行更广泛的截骨，并且修复流程和抢救选项必须考虑到这种减少的骨量。这种情况在全踝关节置换术（包括关节置换翻修术、踝关节融合术和BKA）失败后通常会留下更少的选择。 93,94 最近的荟萃分析检查了失败的全踝关节置换术向踝关节融合术的转化，Haddad 和他的同事 67 报告了 5.1 % 的转化率，Stengel 及其同事报告了 6.3%的转化率。95EVALUATION, ADJUSTMENT, RECURRENCEBoth total ankle arthroplasty and ankle fusion have led to decrease in pain and improvement in patient function. In a recent study, successful surgery was not related to a decrease in patients body mass index, who were classified as overweight or obese.96For total ankle arthroplasty, anticipated revision surgery, without hardware exchange, is accepted by many foot and ankle surgeons as the reality. These reoperations may include cyst removal, lateral or medial gutter debridement because of pain or impingement, and polyethylene exchange because of wear.78 If symptoms persist, infection workup using erythrocyte sedimentation rate and C-reactive protein laboratory markers can be initiated. If these tests are negative, revision total ankle arthroplasty can be considered, taking bone stock and soft tissue envelope into account. Osteolysis and polyethylene wear can affect total ankle arthroplasty (Fig. 10). Coughlin and colleagues17 recommend polyethylene exchange, curettage and bone grafting of the osteolytic lesions, and implant inspection for irregular surface wear, which may necessitate complete implant removal and revision.For ankle arthrodesis, persistence of symptoms after the 12-month period warrants examination for possible nonunion or infection. If results are negative, advanced imaging with CT scans can elucidate subtle nonunion, which may not be evident on plain radiographs. Malunion in varus or valgus can be addressed with closing-wedge osteotomies, which has the function of not stretching nerves and providing additional bone for the fusion site.17 Adjacent joint arthritis in the subtalar joint can be addressed with subtalar arthrodesis, although Coughlin and colleagues17caution that the standard 1-screw approach may be insufficient in patients with a preexisting ankle arthrodesis.If patients have failed previous ankle arthroplasty and failed ankle fusions and advanced degenerative changes in the subtalar joint, a possible salvage procedure is tibiotalocalcaneal fusion.97 This procedure can be accomplished through a retrograde intramedullary nail, achieving tibiotalar fusion, along with an interlocking screw or blade option for the subtalar joint (Fig. 11). Complications have included several reports of periprosthetic fractures in the tibia, proximal to the nail. Intraoperative fracture have also been reported.评估、调整、复发全踝关节置换术和踝关节融合术都可以减轻(踝关节)疼痛并改善患者(踝关节)功能。在最近的一项研究中，成功的手术与患者体重指数的下降无关，这些患者被归类为超重或肥胖。96 对于全踝关节置换术，预期的翻修手术无需更换假体，已被许多足踝外科医生接受为现实。这些再次手术可能包括骨囊肿切除、由于疼痛或撞击而导致的外侧或内侧清创，以及由于磨损而更换聚乙烯垫片。78 如果症状持续存在，可以开始使用红细胞沉降率和C反应蛋白等实验室标记物进行感染检查。 如果这些测试结果为阴性，可以考虑全踝关节置换翻修术，同时考虑骨量和软组织条件。骨质溶解和聚乙烯磨损会影响全踝关节置换术（图10）。Coughlin 及其同事 17 建议对溶骨性病变进行聚乙烯垫片置换、刮除和骨移植，并检查假体表面是否有不规则磨损，这可能需要完全移除和修复假体。对于踝关节融合术，症状在12个月后持续存在，需要检查可能的骨不连或感染。如果结果为阴性，CT扫描成像可以阐明细微的骨不连，而这可能在平片上不明显。内翻或外翻畸形愈合可以通过闭合楔形截骨术解决，其功能是不拉伸神经并为融合部位提供额外的骨量。17 距下关节的相邻关节关节炎可以通过距下关节融合术解决，尽管Coughlin 及其同事 17标准的一枚螺钉固定方法可能不足以用于先前存在的踝关节融合术的患者。如果患者既往踝关节置换术失败、踝关节融合失败以及距下关节出现晚期退行性变，可能的挽救手术是胫距融合术。97 该手术可以通过逆行髓内钉实现胫距关节融合，同时使用距下关节的互锁螺钉或刀片机制（图 11）。并发症包括胫骨假体周围接近于螺钉近端的骨折报告。术中骨折也有报道。DISCUSSION/SUMMARYThe diagnostic and therapeutic options for ankle arthritis are reviewed. Fig. 12 provides a flowchart of treatment options at the different stages of ankle arthritis. The current standard of care for nonoperative options include the use of NSAIDs, corticosteroid injections, orthotics, or ankle braces. Other modalities, including hyaluronic injections, physical therapy, transcutaneous electrical nerve stimulation units, massage therapy, lack high-quality research studies to clearly delineate the appropriateness and effectiveness of their use. The gold standard for operative intervention in end-stage degenerative arthritis remains arthrodesis, but evidence for the equivalence and perhaps even superiority in functional outcomes of total ankle arthroplasty is increasing. The next few years will enable us to make more informed decisions and with more prospective high-quality studies, the most appropriate patient population for total ankle arthroplasty can be identified.讨论/总结本文回顾了踝关节炎的诊断和治疗选择。图12提供了踝关节炎不同阶段的治疗选择流程图。目前非手术治疗的标准包括使用非甾体抗炎药、皮质类固醇注射、矫形器或踝关节支具。其他方式，包括透明质酸注射、物理疗法、经皮电神经刺激装置、按摩疗法，但都缺乏高质量的研究来清楚地描述其使用的适当性和有效性。终末期退行性关节炎手术干预的金标准仍然是踝关节固定术，但越来越多的证据表明，全踝关节置换术在功能结果方面的等效性甚至优越性。未来几年将使我们能够做出更准确的决定，并且通过更多前瞻性的高质量研究，可以确定最适合全踝关节置换术的患者群体。Fig. 1. Anteroposterior radiograph of comminuted, high-energy pilon fracture.图 1. 粉碎的高能 Pilon 骨折的前后位 X 线片。Fig. 2. Open ankle fracture with exposed tibial plafond.图 2. 胫骨平台暴露的开放性踝关节骨折。Fig. 3. Anteroposterior view of a right ankle. A medial osteophyte is circled. This is an example of a stage 1 ankle with degenerative changes. Presence of osteophytes without joint space narrowing.图 3. 右踝关节前后位X线片。内侧骨赘被圈出。这是具有退行性变的第 1 阶段踝关节的示例，存在无关节间隙变窄的骨赘。Fig. 4. Anteroposterior and lateral radiograph of an ankle with stage 3 degenerative changes. Subtotal or total disappearance or deformation of joint space.图 4. 具有第 3 阶段退行性变的踝关节的前后位 X 线片。关节间隙几乎全部或全部消失或变形。Fig. 5. Tibiotalar arthrodesis. Technique using 3 cannulated, partially threaded screws. After cartilage is denuded and the fusion bed is prepared, alignment corrections are made. Initial fixation is performed using a K-wire, followed by (1) Medial to lateral: medial to lateral direction, aiming from superior to inferior. Guidewire is kept in place under fluoroscopy. Measure with depth gauge. Use a washer for this screw to place screw under compression. Back out guidewire. (2) Anterior to posterior: anterior tibia into posterior talus. (3) Syndesmotic screw: for additional stability, make a lateral stab incision, place lateral fibula to medial talar screw, stabilizing the syndesmosis. This screw is placed percutaneously through the stab incision.图 5. 胫距关节融合术。使用 3 枚部分空心螺钉固定技术。在软骨被剥除并准备好融合骨床后，进行力线校正。使用克氏针进行初始固定，然后是 (1) 内侧到外侧：内侧到外侧方向，从上到下瞄准。导针在透视下保持在原位。测深尺进行测量。使用此螺钉的垫圈将螺钉置于受压状态。退出导丝。(2)从前到后：从胫骨前方进入距骨后方。(3)联合螺钉：为了增加稳定性，做一个外侧小切口，将外侧腓骨置于内侧距骨螺钉，稳定联合。该螺钉通过小切口经皮放置。Fig. 6. Tibiotalar arthrodesis. Technique using 3 cannulated, partially threaded screws. Sixteen-week postoperative films obtained in the clinic. A solid fusion mass across the ankle joint is noted, with intact hardware.图 6. 胫距关节融合术。使用3枚部分空心螺钉固定技术。术后16周的X线片。注意到横跨踝关节的实心融合块，具有完整的骨性结构(注：踝关节融合成功的标志)。Fig. 7. A pantalar arthritis with previous midfoot fusions and an already fused subtalar joint. There is valgus malalignment and the tibiotalar, subtalar, and midfoot joints are involved. In this case, the subtalar joint and midfoot joints are fused and are stable. This situation enables us to address the valgus deformity as well as the end-stage arthritis at the tibiotalar joint with an ankle arthroplasty, as opposed to a tibiotalocalcaneal fusion.图 7. 踝关节炎，之前有中足融合，距下关节也已融合。目前存在外翻畸形，主要是胫距、距下和中足关节。在这种情况下，距下关节和足中关节融合并稳定。这种情况使我们能够通过踝关节置换术解决外翻畸形以及胫距关节的终末期关节炎，而不是胫距融合术。Fig. 8. Total ankle arthroplasty using the Salto implant. This is a mobile-bearing system. The talus has a conical shape and is fixed with pegs. The tibial component is flat and includes a fin for fixation.图 8. 使用 Salto假体的全踝关节置换术。这是一个活动平台系统。距骨呈圆锥形，并用钉子固定。胫骨组件是扁平的，包括一个用于固定的棘突。 Fig. 9. Total ankle arthroplasty using the STAR implant. The talus has a more cylindrical shape. The tibial component is flat. This is an uncemented prosthesis, coated in hydroxyapatite.图 9. 使用 STAR假体的全踝关节置换术。距骨具有更加圆柱形的形状。胫骨组件是平坦的。这是一种非骨水泥假体，涂有羟基磷灰石。Fig. 10. Mortise radiograph of right ankle of a patient with posttraumatic tibiotalar arthritis, previous open reduction and internal fixation fibula and tibia. Ankle arthroplasty with extensive osteolysis laterally and medially. Scalloping, radiolucent area around the prosthesis is noted.图 10. 患有创伤后胫距关节炎患者的右踝关节Mortise位X线片，既往切开复位内固定腓骨和胫骨。踝关节置换术，外侧和内侧有广泛的骨质溶解。注意到假体周围的扇形、射线透亮带。Fig. 11. Pantalar arthritis with Charcot arthropathy. The tibiotalar, subtalar, and midfoot joints are involved. There is also varus malalignment. This deformity can be addressed with a tibiotalocalcaneal fusion. Preoperative (A) and postoperative (B) radiographs are shown.图 11. 伴有 Charcot 关节病的踝关节炎。涉及胫距、距下和中足关节。还存在内翻畸形。这种畸形可以通过胫距融合术解决。显示了术前 (A) 和术后 (B) X线片。Fig. 12. Flowchart of treatment options at the different stages of ankle arthritis. TTC, tibiotalocalcaneal fusion.图 12. 踝关节炎不同阶段的治疗方案流程图。TTC，胫距融合术。2021年06月20日2693
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杨睿主任医师 中山大学孙逸仙纪念医院 骨外科 2021年5月22日在甘肃省黄河石林景区举办的马拉松百公里越野赛，突受极端天气影响，气温骤降，参赛人员出现不同程度的身体不适、失温等情况，截止目前为止已确定有21位国内顶尖的跑马运动者因为“失温”再也“跑不回来了”。 什么是“失温”？“失温”为何如此恐怖！ 当身体散发的热量超过其吸收或产生的热量，使身体无法产生足够的热量来供应体内平衡和正常的身体功能时，就会出现失温。失温，常出现于严寒的地区；但是经过这次教训，我们发现失温并不局限于严寒的地区或时间，也可能发生在较温和的气候。失温可以导致人的意识丧失、心跳呼吸停止，如没得到恰当的干预，死亡在所难免（致敬逝世的21位跑者）。原本，失温是可以避免的。如果天气冷，不要在外面呆太久（就如被牧羊人救起的6位跑者）；如果在这种严酷的气候下外出，合适的着装是关键；如果衣服湿了，赶紧把它们换掉。当然，马拉松遇上“失温”极其罕见，但马拉松遇上运动性损伤却非常常见。来自中山大学孙逸仙纪念医院运动医学科的杨睿教授、博士生导师将带来跑马运动者常见运动损伤的介绍及其处置。马拉松所致的运动性损伤包括：抽筋（肌肉痉挛）、胫前疼痛、足踝扭伤、髌股关节疼痛、腰臀痛、跟腱炎以及足底筋膜炎等。一、肌肉痉挛腿肌肉痉挛俗称抽筋，是肌肉在长时间剧烈运动后肌肉突然、不自主僵直收缩的现象；此时可出现肌肉僵硬、疼痛难忍，同时伴有肌肉持续紧张或抽搐，通常持续数十秒至数分钟甚至更长。常见的原因有：1.长时间运动造成肌肉疲劳；2.环境温度的突然改变（比如此次的失温情况）；3.水份、盐份的急慢性流失过多导致体内电解质失衡；4.运动姿势不当造成的肌肉协调不良；5.本身即有系统性性疾病等。抽筋了该怎么办呢？1.需立刻停止运动；2.顺着抽筋肌肉的方向缓慢的拉长肌肉；3.不可以突然拉长肌肉、或用力过猛，以免拉伤肌肉造成二次伤害；4.等抽筋部位缓解后，再轻轻按摩直到肌肉舒缓为止。二、胫前疼痛胫前疼痛，通常是小腿肌肉的过度使用所造成的伤害，常见于需要长时间跑步的运动（马拉松、长途急行军等）。在胫前疼痛的处理上根据所处的时期不同，处理的方式也不同。在急性期（0～48小时）：休息、冰敷、 抬高患肢；亚急性期（第3天～第 6周）：行肌肉伸展、 肌力增强训练等；恢复期（约第7星期开始)：运动前热身、肌肉伸展运动、热敷，运动后冰敷、肌肉伸展运动、训练胫前肌等。三、足踝扭伤足踝扭伤是常见的跑马运动性损伤之一， 80％的脚踝扭伤发生于外侧，最常受伤的韧带是前距腓韧带。足踝扭伤该怎么办呢？在排外骨折后通常在急性期（0～48h）内主要予休息、冰敷、抬高患肢；过了急性期后后可予理疗等减轻疼痛、增加血液循环促进韧带重新癒合，运动康复等。在这，中山大学孙逸仙纪念医院运动医学科的杨睿教授重点提醒各位跑者，大部分的踝关节急性扭伤均可行保守治疗，但是踝关节急性扭伤没有得到合适的处理或者是未处理，20～40%的踝关节急性扭伤患者将会演变成慢性踝关节不稳定，最终告别跑马生涯。四、髌股关节疼痛症髌股关节疼痛症是指髌骨前方或是周围疼痛，尤其是在膝盖弯曲伸直的活动时候，疼痛会加剧；常见于过度使用膝关节，如马拉松长跑等。对于髌股关节疼痛的处置，建议多休息，减少造成膝关节不舒服的活动，避免长时间将膝关节维持在固定或大角度的弯曲的姿势；同时穿护膝或髌骨贴，训练股四头肌的肌肉力量。五、腰臀部痛腰臀部痛在长跑运动员中也很常见。这是因为跑马的人群中，可能存在双足的足弓高低不一，造成两腿在功能上的长短不一 ；或是腹、臀及下背的肌肉力量弱；或是背、大腿后肌、及骼胫带的长期绷紧导致慢性劳损等。跑马运动员经常腰臀疼该咋办呢？1.多做改善足弓的肌肉练习；2.加强腹、背力量及耐力；3.增进背肌–大腿后肌–骼胫带–小腿后肌-跟腱的伸展运动；4.避免下坡跑。六、跟腱炎常以足跟部上方慢性疼痛为主，这也是跑马运动者就医时常见的主诉之一。对于跟腱炎的处理包括：1.冰敷（运动后，一日数次）；2.在跑鞋內加入鞋跟墊；3.局部使用消炎止痛药物；4.加强对跟腱伸展运动的锻炼；七、足底筋膜炎跑马者长期超负荷运动，造成足底筋膜的急性或慢性损伤在所难免；这是引起足底筋膜炎的主要原因。足底筋膜炎表现为脚底的酸软、痛，特別是在起床后的最初几步，在步行一段距离后，症状会缓解。对于足底筋膜炎的处理，一般经过休息、冰敷、使用消炎葯、脚踩筋膜放松按摩球等保守康复治疗后均可自愈。最后，中山大学孙逸仙纪念医院运动医学科的杨睿教授强调，跑马运动者的运动性损伤应该是预防大于治疗，一份预防大于十分治疗，不治已病治未病。2021年05月25日1468
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赵会副主任医师 北京朝阳医院 骨科 崴脚就是踝关节扭伤，多由于行走时突然踏在不平的地面上或上下楼梯，走坡路不慎踏空，或腾空向后足跖屈（即垫脚的动作）落地，足部受力不稳，而导致踝关节过度内翻或外翻造成的扭伤。一般分为内翻损伤和外翻损伤，那么以内翻损伤（外侧韧带的损伤）最为常见，这是由于踝关节解剖结构所决定的，外侧的韧带较内侧韧带薄弱，内翻肌群也比外翻肌群要强一些，内翻活动度比外翻大，而人在放松状态下就有内翻和脚尖向内的趋势。内翻损伤一般损伤外侧的韧带距腓前韧带距腓后韧带和跟腓韧带，以距腓前韧带损伤最多（外踝前下方的凹陷处）；外翻损伤则损伤内侧的三角韧带，三角形是最稳定的结构所以不容易撕裂，常常外翻损伤发生的是内踝的撕脱骨折。扭伤时，损伤处的韧带遭受超过其生理限度的强大外力，紧张性增高或发生纤维断裂等病理改变。有内翻损伤时，虽然外侧韧带损伤，但也可能引起内踝的挤压伤，要注意辨别。崴脚常见的症状有：疼痛或酸痛肿胀淤青行走困难关节僵硬以上这些症状因由崴伤程度的不同而严重不一，有过崴脚前科的患者有时会感觉不到疼痛和肿胀。相反的，他们可能只会感受到行走时摇晃和不稳，即使崴脚时没有疼痛或肿胀的症状，不管这是你第一次还是第五次崴脚，及时的治疗处理都同样尤为重要。2021年05月18日4690
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赵会副主任医师 北京朝阳医院 骨科 脚踝扭伤如果没有骨折，一般根据软组织损伤的程度、韧带损伤的程度分为Ⅰ度、Ⅱ度和Ⅲ度损伤，一般的情况下常见的脚踝扭伤多见于Ⅰ度和Ⅱ度损伤，韧带没有完全断裂，Ⅱ度是有一些撕裂，Ⅰ度是轻微的损伤。Ⅰ度的这种扭伤一般恢复需要制动，先冷敷，后热敷，抹药膏，贴膏药，吃些消炎止疼药，少走路，一般需要2-3周的时间来恢复。Ⅱ度也差不多，可能3-4周左右时间来恢复。Ⅲ度的脚踝韧带的撕裂，完全断裂的话，这种情况下一般要打石膏固定至少3-4周，等3-4周韧带长的差不多之后再开始把石膏拆掉，可以适当的进行脚踝的功能锻炼。所谓的恢复就是说对于Ⅰ度、Ⅱ度、轻度的，1-2周、2-3周韧带的地方修复的差不多，但是你走路疼不疼，能不能恢复到之前的运动还是因人而异。有些人脚踝扭伤他可能恢复需要3个月、6个月左右的时间，才能够彻底的恢复，有些人需要一年。因为这种损伤修复好了之后，虽然说修复好了，但是里面的软组织彻底的恢复有时候时间会比较长，所以我说的恢复一般都是指韧带基本上恢复了绝大部分。一般的软组织损伤这个脚踝3-4周就差不多了，像前面说的如果韧带完全断裂，Ⅲ度损伤一般需要固定4周，然后再康复3-4周，一般2-3个月的时间才能够恢复，建议期间注意休息，避免长时间走路，以免影响恢复。2021年05月17日3165
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赵会副主任医师 北京朝阳医院 骨科 踝关节作为人体距离地面最近的负重关节，踝关节扭伤俗称“崴脚”，约占所有运动损伤的40%，很多人对我们踝关节扭伤不了解、不重视，总觉得“休息制动”、“泡泡热水”、“上点红花油”就完事了，殊不知，正是因为“崴脚”后处理不及时、不得当，不少人最后不得不进行手术治疗，甚至留下后遗症，下面我们来聊聊常听说的误区有哪些？误区一：能活动，就绝不是骨折有不少人认为踝关节扭伤后，只要还能走就没事。事实上，有时即使骨折，你也可以行走。例如内外踝的撕脱骨折，一些当时没有移位的骨折都容易被忽视。误区二：脚扭伤了，赶紧用热毛巾敷一敷脚踝扭伤时，不要立即进行热敷。热敷会引起局部血管扩张，加重出血和局部软组织肿胀，加重炎性反应和疼痛，有的还会出现局部水泡。脚踝扭伤后，应立即冷敷，用毛巾包裹冰袋敷于受伤部位表面。误区三：勉力行走很多人比较坚强，踝关节损伤后会勉强坚持行走锻炼或带病工作，认为这样做可以帮助消肿止痛，促进患病肢体功能的恢复，这也是一种错误认识。很多人正是因为如此，扭伤的关节在行走时反复扭伤，最终造成关节软骨损伤和创伤性关节炎。误区四：扭伤后马上用药酒揉搓有人扭伤后，会马上用药酒揉搓患处，一是为了止痛，二是认为揉搓可以活血祛瘀，理筋通络，加快扭伤的恢复。实际上，过分用力揉搓患处，会加重软组织损伤，使肌肉间的组织液渗出增多，扭伤的关节肿胀疼痛加剧，会加重扭伤的症状。2021年05月17日1680
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刘子桃主治医师 广东省中医院 骨科 踝关节扭伤，也就是我们常说的崴脚，在日常生活中非常常见，有些人休息几天就没事了，但也有部分的人总是会有一些不舒服的症状，例如久行或运动后肿胀、疼痛或者反复扭伤等，虽然症状反反复复，但是觉得不严重也没有引起重视，但是真实的情况是不是这样呢？我们看一下这三个患者的X光：我们知道，随着年龄的增大，关节磨损也会越严重，出现关节炎的概率也就越高，但是上面的三个患者，反而年龄越大的关节越好，另外两个相对年轻的患者踝关节却出现增生、间隙狭窄等表现。其实，这主要是因为他们有慢性踝关节不稳的问题。慢性踝关节不稳是指踝关节周围韧带损伤，导致踝关节活动轨迹改变，踝关节不稳定，从而导致踝关节周围软骨的摩擦、软组织的炎症，出现疼痛、肿胀、反复崴脚等症状的疾病。是踝关节扭伤后最容易出现的并发症。打个比方，踝关节每天都需要活动，就好像汽车的轮子一样，如果轮子的轴承稳定，那么轮子就可以平稳地转动，磨损也就很少。但是，如果轮子不稳定，除了转动以外还有晃动，磨损自然也就加快。所以，慢性踝关节不稳，虽然短期内对日常生活影响不大，但是它的危害却尤如温水煮青蛙，往往在三五年甚至十年之后才越来越严重，但是这时候再来治疗就太晚了，所以，我们需要早期发现和处理慢性踝关节不稳。 首先，在踝关节扭伤的早期，应该按照RICE的原则进行处理，疼痛及肿胀严重者，建议至医院就诊，必要时完善X光检查排除有无骨折，韧带严重损伤的患者需要石膏或者支具固定制动。如果踝关节扭伤已经4周或者已经出现多次的踝关节扭伤，建议至足踝外科专科就诊。可完善踝关节彩超或者踝关节MRI检查进一步明确韧带情况。同时专科医生根据体格检查，亦可以很容易判断出踝关节是否稳定。慢性踝关节不稳应该怎样治疗，总体来说，慢性踝关节不稳可分为功能性不稳和机械性不稳。功能性不稳往往韧带是好的，医生通过查体可以判断踝关节是否稳定，此类不稳定可以通过功能锻炼、物理治疗等来改善症状。但是，如果有明确的韧带撕裂或者吸收，单纯保守治疗难以获得满意效果，这个时候就需要手术来修复断裂的韧带。既往这类手术需要切开较大的伤口，创伤大，恢复慢，随着技术的进步，目前可以在关节镜微创下进行韧带修复与增强手术，创伤小，术后第二天佩戴支具可下床活动，术后两周即可行走。术口更美观，可以更快恢复正常生活及工作。传统开放手术示意图及切口外观关节镜微创手术示意图图及切口外观。2021年04月28日2827
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侯辉歌副主任医师 暨南大学附属第一医院 关节外科与运动医学中心 “坚持选择微创手术果然是没错的！”来自内蒙古的张先生感叹道。之前，张先生从内蒙古飞到广州暨南大学附属第一医院，只为微创手术解决自己的脚踝问题。舍近求远的结果亦很理想，术后当晚便可下地走路，观察几天后顺利出院。 从北到南 跨越大半个中国来寻医张先生一个月前走路时不慎崴脚，当时脚踝立马肿起来，自行急性处理后，肿胀消去一部分但是疼痛还是明显。在内蒙古某地就医后，检查结果显示距腓前韧带损伤。要想彻底解决问题，唯有进行手术修复韧带。但是，当地医院医生告诉张先生，他们的手术方式是用关节镜探查然后开一条3~4公分的口子进行韧带修复。急需恢复工作的张先生不想接受创口较大的手术，所以决定寻求其他医院解决问题。 张先生先后去过北京部分医院，却未能提供让他满意的手术方案，在多地求医无果后，终于在网络上解到了暨南大学第一附属医院运动医学中心可以行全镜下的韧带修复手术，并且会根据患者的韧带损伤情况，从国内外七种最先进的缝合方案择优处理。当晚张先生便坐飞机来到广州，对自己的选择坚信不移。 骨关节与运动医学科的侯辉歌副主任医师接诊了张先生。在查体、阅片及询问病史后，发现张先生在一年前就有过崴脚经历，并且近一年有三次以上崴脚的情况。侯辉歌推断患者存在距腓前韧带损伤，并且伴有踝关节的不稳定。距腓前韧带损伤是造成踝关节不稳的主要原因。如果未解决这个问题，时间一长就会磨损到关节软骨，从而造成不可逆的损伤。手术治疗是彻底解决问题的有效方法。 张先生对手术方式还是心存顾虑：能否全程都是在镜下完成，手术创口会不会很大，术后多久可以下地走路，多久能恢复到正常生活。侯辉歌告诉患者：保证在全镜下进行韧带修复，并且会根据镜下韧带撕裂分度、残留部分质量及患者具体情况，选择个体化缝合方法进行精准医疗。手术只会有2~3个微小的创口，一般一周内就可回归日常生活。打消顾虑后，张先生做了最终决定。 微创治疗踝关节 3天左右即可出院在运动医学专家郑小飞副院长的组织下，运动医学手术团队进行了认真的术前讨论，反复论证手术方案。根据患者的术前查体以及术前的影像学检查，决定采用Internal brace技术对撕裂的距腓前韧带进行一个柔性增强修复。术后当晚患者自述疼痛明显减轻，术后当晚患者即可下地行走。张先生开心地表示：没想到来医院那么短时间就顺利解决问题，术后也没什么不舒服。当天就要求出院。考虑到患者实际情况，侯辉歌还是建议观察几天后再出院。目前患者已经顺利出院。 侯辉歌介绍，距腓前韧带损伤主要是由于日常生活中崴伤脚踝所导致的，后续就会出现脚踝的外侧不稳定，并且伴有本体感觉的缺失。长时间的不稳定就会引起软骨损伤，还会有软组织和骨性的增生会在关节内产生炎症和疼痛。如果出现这种情况的话，那就要积极治疗了，否则踝关节只会越来越糟糕。 侯辉歌表示，随着技术进步和设备的完善，距腓前韧带的治疗可在关节镜下操作，对关节的保护更加充分，创伤更小。同时对于这类患者，全程融入快速康复理念，促进患者快速功能康复，大大提高患者的生活质量。2021年04月19日1204
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