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劉子桃主治醫(yī)師 廣東省中醫(yī)院 骨科 大家好，我是劉醫(yī)生，今天有個朋友問我，他說他的腳踝扭傷已經(jīng)半年了，當時也去做過X光片檢查，沒有發(fā)現(xiàn)骨折，但是半年以來，這個腳踝老是好的不徹底，反反復復的，每當走路走多了，或者是運動之后，就覺得踝關節(jié)不舒服，現(xiàn)在要不要再進一步的檢查？那么像他這種情況的話，我們首先要考慮有沒有踝關節(jié)周圍韌帶的問題，所以我建議他先去做一個踝關節(jié)的彩超，因為踝關節(jié)彩超可以很方便的診斷，診斷出韌帶有沒有拉長，或者韌帶有沒有撕裂的情況，但是呢，踝關節(jié)彩超它對骨骼以及踝關節(jié)的軟骨，它的顯影就沒那么好了，所以如果想做好一點再進一步，那么可以去做一個踝關節(jié)的和磁共振，因為磁共振對踝關節(jié)周圍的軟組織以及骨骼都有一個比較好的顯眼。 對于踝關節(jié)扭傷之后的常見問題，比如說韌帶的斷裂啊，踝關節(jié)軟骨的損傷啊，踝關節(jié)周圍的一些腱鞘炎啊，以及踝關節(jié)周圍的轉擊引起的一些問題，它都可以診斷的出來。但是這兩個檢查的話，踝關節(jié)彩超相對來說就比較便宜了，100多塊錢就可以了，而華光業(yè)的施共振的話就需要800多塊錢，所以大家可以根據(jù)自己的情況，可以先做一個基本的檢查，排除有沒有踝關節(jié)韌帶的問題，如果沒發(fā)現(xiàn)問題，那么我們可以再做一個踝關節(jié)的磁共2022年06月15日
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2022年05月22日427
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2022年04月04日1326
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亓恒濤副主任醫(yī)師 山東省立醫(yī)院 超聲醫(yī)學科 1、踝關節(jié)扭傷常見嗎？ 答：踝關節(jié)扭傷是臨床常見的疾病，在關節(jié)及韌帶損傷中是發(fā)病率最高的疾病。踝關節(jié)是人體距離地面最近的負重關節(jié)，也就是說踝關節(jié)是全身負重最多的關節(jié)。踝關節(jié)的穩(wěn)定性對于日常的活動和體育運動的正常進行起重要的作用。踝關節(jié)周圍的韌帶損傷都屬于踝關節(jié)扭傷的范疇。 2、腳踝扭傷后應該關注什么？ 答：腳踝扭傷后最容易損傷的是踝關節(jié)周圍的韌帶，特別是踝關節(jié)的外側韌帶，除了韌帶以外也可以造成踝關節(jié)的骨折和關節(jié)錯位，所以踝關節(jié)扭傷我們需要關注的是踝關節(jié)骨質有無異常（骨折或者錯位），踝關節(jié)韌帶有無異常（撕裂或者斷裂）。 3、踝關節(jié)扭傷后應該怎么處理？ 答：發(fā)生踝關節(jié)扭傷后應立即至醫(yī)院急診就診，在就診前如有條件可按PRICE原則進行處理，PRICE原則包括protect保護，盡量不要繼續(xù)行走或奔跑；rest休息，近一步理解就是免除負重，ice冰敷，compression加壓包扎，elevation抬高患肢。就診后由醫(yī)生對傷情進行評估決定治療方案。 4、踝關節(jié)扭傷后應該做什么檢查？ 答：一般到醫(yī)院后，為了快速了解踝關節(jié)扭傷是否存在骨折，往往會讓您先做X線或者CT檢查，明確踝關節(jié)是否存在骨折，但X線是重疊影像，一些小的骨折往往不能顯示，且X線和CT對韌帶損傷無能為力。為了明確韌帶損傷位置及程度，往往需要超聲的檢查。 5、超聲檢查踝關節(jié)扭傷的優(yōu)勢？ 答：超聲對踝關節(jié)韌帶檢查有很高的分辨率，特別對于距腓前韌帶、跟腓韌帶及分歧韌帶等顯示清晰，對于是否存在撕脫骨折也可一并評價，比如腓骨、舟骨、跟骨前結節(jié)及第五跖骨等區(qū)域的撕脫骨折評估也非常準確。最重要的還可以實時動態(tài)觀察，特別對于鑒別韌帶的撕裂還是斷裂非常有幫助。2022年01月08日1094
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才禮揚副主任醫(yī)師 甘肅省人民醫(yī)院 手足外科 急性踝關節(jié)外側韌帶損傷常常又被稱為踝扭傷。它是骨科門急診中最常見損傷之一。據(jù)統(tǒng)計：踝關節(jié)損傷占整個運動損傷的15％，而其中85％為外側韌帶損傷。 受傷機制：踝關節(jié)外側的韌帶主要有三條，由前向后分別是距腓前韌帶、跟腓韌帶和距腓后韌帶。 踝關節(jié)扭傷時最容易受傷的是距腓前韌帶，當足在跖屈、內翻位時，距腓前韌帶最先受到應力作用而發(fā)生撕裂，外力的繼續(xù)作用，跟腓韌帶繼之撕裂，最后可導致距腓后韌帶的損傷。 臨床表現(xiàn)踝關節(jié)扭傷后出現(xiàn)以下表現(xiàn)： 外踝腫脹 青紫瘀血 局部伴有疼痛、壓痛 踝關節(jié)前后方向不穩(wěn)定 急性損傷后患者局部腫脹疼痛，不能行走，嚴重時患足不能站立負重。 在急性損傷后，約有20－40％病人會出現(xiàn)長期反復的踝關節(jié)無力，扭傷，尤其是地面不平時，常會踝關節(jié)失去控制，發(fā)生內翻。 扭傷后可伴有或不伴有疼痛腫脹。部分患者可感到踝關節(jié)僵硬。此時即進入慢性不穩(wěn)定階段?；颊呖墒菣C械性不穩(wěn)定，也可是功能性不穩(wěn)定。 診斷：1）一般扭傷后都應由骨科醫(yī)生檢查損傷的范圍與程度，有無并發(fā)損傷的出現(xiàn)。 2）如果不能排除其他損傷和骨折，還應拍攝足與踝關節(jié)的正、側位X線。 3）醫(yī)師會詢問患者的病史，受傷原因（注意有無引起中足、下脛腓聯(lián)合損傷、跟骨骨折、腓骨肌腱脫位的致傷因素），患者是否是第一次受傷，有無反復受傷的經(jīng)歷或者足踝部位的疾病史。 目前在臨床上廣泛使用的踝關節(jié)韌帶損傷分類法是美國醫(yī)學會（AMA）的標準分類法，根據(jù)韌帶損傷程度分為： I 度：韌帶拉傷 即韌帶受到牽拉，但無明顯的撕裂。踝關節(jié)穩(wěn)定，輕度腫脹，功能基本不受影響。 II 度：韌帶部分撕裂 踝關節(jié)中度腫脹和壓痛，可有輕度到中度不穩(wěn)定，踝關節(jié)功能受到影響。 III 度：韌帶完全斷裂 有較明顯的腫脹、瘀癍以及不穩(wěn)定。 距腓前韌帶 踝扭傷后，距腓前韌帶最容易損傷，此韌帶損傷時在外踝的前內側可以有明顯的腫脹、壓痛，有時伴有局部的淤斑。腫脹不只限于外踝，還可能延伸至踝關節(jié)前側、后側及內側。 距腓前韌帶斷裂時，查體可見前抽屜試驗陽性。但是在急性損傷、伴有腫脹的患者檢查不便進行。 前抽屜試驗檢查時，一手握患者的小腿，一手握住跟骨結節(jié)，向前方抽拉足部，查看有無距骨的不穩(wěn)定或脫位，如果有距骨的活動超過2cm，或與對側相比，活動度明顯增加，則試驗為陽性。 跟腓韌帶 跟腓韌帶很少有撕裂與斷裂，作為踝外側最強大的韌帶，跟腓韌帶損傷時常常可在踝關節(jié)正位X線片上看到腓骨尖遠端的撕脫骨折。如果跟腓韌帶造成了撕脫骨折，有手術治療的可能。 急性腓骨肌腱脫位 伴有脫位的患者，疼痛位于踝關節(jié)的后方，當腓骨長肌對抗外力進行背伸、外展足部時可引起疼痛加劇。 骨折 有距骨三角骨的患者，扭傷可能造成三角骨骨折，引發(fā)長期的踝部不適，甚至后期導致脛后肌腱無力。有跟距聯(lián)合的患者，可能因扭傷造成跟距聯(lián)合骨折、疼痛長期不緩解。 治療：急診處理 急性損傷后主要問題是踝關節(jié)的腫脹、疼痛。扭傷后急診的治療方法是“POLICE”原則： protest：保護 optimal loading：適當負重 ice：冰敷 compression：加壓包扎 elevation：抬高患肢 休息的時間為1周，關節(jié)護具佩帶的時間為6至12周。傷后需要進行關節(jié)康復性訓練，恢復肌肉力量，以及關節(jié)的本體感覺。一方面穩(wěn)定關節(jié)，一方面要避免再次損傷。 制動： 1. 踝關節(jié)急性扭傷后，最重要的是制動，避免進一步活動。如果扭傷后不能行走，一定要到醫(yī)院進行檢查，以確定有無骨折。如可以行走，可根據(jù)腫脹的情況進行自我護理。 2. 通常急性損傷1周至2周后可恢復無痛狀態(tài)，此時可以先進行輕體力運動，如果沒有疼痛，踝關節(jié)沒有失控感，可以再恢復以前的體育運動。但是在此過程中建議在6周之內佩帶支具。 固定： 目前有很多成熟的專業(yè)的踝關節(jié)固定支具，可以代替?zhèn)鹘y(tǒng)的石膏。具有穿戴方便、重量輕、美觀的優(yōu)點，但是費用高。 1. 扭傷后如沒有石膏，或患者不接受。在患者僅為前距腓韌帶損傷的前提下，可以全粘彈力繃帶8字固定。固定時注意不要刻意加壓，否則隨腫脹加重，容易固定過緊。 2. 伴有下脛腓聯(lián)合損傷的患者，需石膏固定，或使用專門的支具固定。 踝關節(jié)扭傷的危害：關節(jié)扭傷后可能因為治療不徹底，可引發(fā)包括： 關節(jié)松弛：可能造成拉傷或是斷裂的韌帶不能修復，或是變長，從而失去了穩(wěn)定關節(jié)的作用。 關節(jié)撞擊：踝關節(jié)松弛后會造成周圍關節(jié)的撞擊。 關節(jié)內軟骨損傷：如果傷后沒有及時制動，再次進行活動，容易造成關節(jié)異?；顒樱斐申P節(jié)內的軟骨損傷，關節(jié)周圍其他關節(jié)損傷，引發(fā)長期的疼痛。 關節(jié)炎：長期的慢性踝關節(jié)不穩(wěn)會造成內翻性踝關節(jié)炎。 當你被崴腳困擾時，向專業(yè)的足踝外科醫(yī)生求助是非常明智的決定。2022年01月05日722
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2021年10月17日914
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忻慰主治醫(yī)師 上海長征醫(yī)院 關節(jié)外科 在我們平時生活中會經(jīng)常聽到有人“崴腳”，而“崴腳”后我們一般會進行以下兩種處理狀態(tài)：（1）靜養(yǎng)，噴點云南白藥或敷點“中藥黑藥膏”；（2）第二種情況會稍微重視點，去醫(yī)院拍了張X線后發(fā)現(xiàn)沒有骨折，于是就不把“它”當回事，就靜待自己消腫恢復。一般來說，過了2周左右踝關節(jié)的腫脹就自己慢慢好轉了，疼痛也會逐漸好轉。但是很多“崴腳”并不是真的好了，很多人會感覺崴腳之后進行劇烈運動或長時間行走后踝關節(jié)酸脹不適，甚至有些人還容易反復崴腳，影響生活質量。那就讓我們來了解下這個常見情況的常見問題。那我們首先要了解何為崴腳？其實崴腳就是我們常說的踝關節(jié)扭傷。它是我們運動或日間生活中極為常見的損傷之一，尤其在我們有氧運動、打籃球、排球、戶外運動及攀巖時容易發(fā)生。踝關節(jié)扭傷就是踝關節(jié)在某個特定方向過度扭轉，導致起踝關節(jié)穩(wěn)定作用的韌帶牽拉過度甚至撕裂。常見類型如下圖。踝關節(jié)扭傷后會引起什么樣的癥狀？踝關節(jié)扭傷后最常見的癥狀就是腳踝疼痛、壓痛、腫脹及瘀斑，踝關節(jié)可能還會出現(xiàn)活動受限，甚至無法負重。但踝關節(jié)扭傷后病情不一，有些可能很輕微，有些癥狀卻很重。一般踝關扭傷分為I-III級：I級：有輕度腫脹和壓痛，能夠負重和行走，只伴輕微疼痛。II級：有中度疼痛、腫脹、壓痛和淤斑。關節(jié)活動度受到一定限制，且有功能損失，負重和行走時疼痛。III級：有重度疼痛、腫脹、壓痛和淤斑，嚴重的功能和活動度下降，不能負重和行走。踝關節(jié)扭傷后何時需要去醫(yī)院就診呢？當踝關節(jié)扭傷后出現(xiàn)下面情況就要及時就診了：（1）踝關節(jié)出現(xiàn)明顯的疼痛及腫脹（2）受傷的踝關節(jié)無法負重（3）腳踝出現(xiàn)歪斜或畸形時（4）腳踝出現(xiàn)不穩(wěn)定，如在走樓梯時出現(xiàn)“打軟腿”的情況當然，如果你無法確定自己的病情，穩(wěn)妥起見，也需及時就診，尤其是出現(xiàn)上文提到的II-III級損傷的癥狀。到了醫(yī)院會有針對踝關節(jié)扭傷的檢查嗎？有針對的檢查，但是否進行需看當時受傷的具體情況。醫(yī)生會問診和查體來判斷是否有扭傷，他可能會向不同方向轉動患足，以觀察你的疼痛情況并鑒別腳踝松弛程度（檢查過程中可能會有較明顯的疼痛，如有不適，需及時提出）。同時根據(jù)受傷情況，可能會加做X線檢查以排除骨折可能。有些還會安排超聲檢查，以確定有無韌帶損傷及損傷程度的判斷。踝關節(jié)扭傷后該怎么辦呢？在扭傷早期，比較公認的治療方法就是“RICE”療法。R，Rest，休息---使用拐杖或停止足部活動以便休息腳踝。I，Ice，冷敷---使用冰袋或冷毛巾敷腳踝，每1-2小時1次，一次15分鐘。冰袋和皮膚之間需要敷層毛巾。損傷后應該至少冷敷6小時，甚至2日內都可以冷敷，直至腫脹緩解。C，Compression，加壓---使用彈性繃帶加壓包裹踝關節(jié)，以減輕踝關節(jié)腫脹并加強踝關節(jié)穩(wěn)定性。需要在醫(yī)師指導下使用，以免壓力過大壓迫血管。D，Elevation，抬高患肢---抬高患足高于心臟平面，躺臥時用枕頭或毯子墊足，坐著時將患足放在桌子或椅子上。同時可在醫(yī)師指導下口服藥物消炎鎮(zhèn)痛，如對乙酰氨基酚、布洛芬、萘普生、塞來昔布等。輕微的扭傷通常無需夾板固定患踝和患足，嚴重時可能需要。有些損傷嚴重的踝關節(jié)扭傷甚至需要手術修復扭傷引起的韌帶撕裂。踝關節(jié)扭傷既然沒有骨折，為什么醫(yī)生還推薦打石膏固定呢？對于較嚴重的的韌帶損傷，固定足踝是很有必要的治療方式，不單單有助于減緩疼痛和腫脹，同時有助于促進受傷韌帶的恢復（尤其是在正確的位置上恢復），減少之后出現(xiàn)慢性踝關節(jié)不穩(wěn)的發(fā)生。固定足踝的方式通常有加壓繃帶、支具和石膏固定。許多研究表明，石膏固定相較于其他兩種固定方式，功能改善更快，同時能更快重返工作和運動。雖然打石膏后生活有諸多不便，但它的性價比是最高的，所以如果有醫(yī)生讓你打石膏也不要覺得意外。既然踝關節(jié)扭傷大多可通過保守治療治愈，那為何有些人還要進行手術呢？雖然大多數(shù)扭傷能通過保守治療完全治愈，但是還有近1/3的患者存在一定程度的踝關節(jié)慢性不穩(wěn)，表現(xiàn)為6個月后出現(xiàn)踝關節(jié)復發(fā)扭傷、復發(fā)性踝關節(jié)疼痛及腫脹、踝關節(jié)出現(xiàn)打軟腿、有不穩(wěn)定感、不敢進行之前的體育運動，甚至因此改變生活方式。這時候醫(yī)生會先進行功能鍛煉、佩戴支具及本體感覺訓練等保守治療，如果保守無效并且發(fā)現(xiàn)受傷的韌帶明顯松弛的話，就需要進行進一步的手術治療。踝關節(jié)扭傷后何時能復工呢？首先受傷的程度決定了恢復運動和工作能力的時間，正確的制動和康復訓練可縮短這一時間。具體復工時間需咨詢?？漆t(yī)師。2021年08月25日5101
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陶可主治醫(yī)師 北京大學人民醫(yī)院 骨關節(jié)科 踝關節(jié)炎：診斷和手術治療的綜述譯者：陶可（北京大學人民醫(yī)院骨關節(jié)科）北京大學人民醫(yī)院骨關節(jié)科陶可關鍵點： 目前踝關節(jié)炎非手術治療的標準包括使用非甾體抗炎藥、皮質類固醇注射、矯形器和腳踝支具。其他方式，包括透明質酸注射、物理療法、經(jīng)皮神經(jīng)電刺激、按摩療法，但缺乏高質量的研究來描述其使用的適當性和有效性。 終末期退行性踝關節(jié)炎手術干預的金標準仍然是關節(jié)融合術，但越來越多的證據(jù)表明，全踝關節(jié)置換術在功能結果方面的等效性甚至優(yōu)越性。 未來幾年將使我們能夠做出更準確的決定，并且通過更多前瞻性的高質量研究，可以確定最適合進行全踝關節(jié)置換術的患者群體。文獻出處：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介紹踝關節(jié)是身體中最常受傷的關節(jié)，每平方厘米吸收的應力比任何其他關節(jié)都要多。然而，踝關節(jié)炎的發(fā)病率卻是膝關節(jié)和髖關節(jié)癥狀性關節(jié)炎的九分之一。1 與膝關節(jié)和髖關節(jié)關節(jié)炎不同，踝關節(jié)關節(jié)炎最常見于創(chuàng)傷后，而原發(fā)性關節(jié)炎卻不常見。在 13 年期間對 639 名患者樣本追蹤隨訪中，Saltzman 及其同事 2 報告了 7.2% 的原發(fā)性踝關節(jié)炎與 70% 的創(chuàng)傷后踝關節(jié)炎，其中11.9% 的患者患有類風濕性關節(jié)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解剖學/病理生理學踝關節(jié)創(chuàng)傷，包括 Weber A 到 C 骨折、pilon 骨折和距骨的骨軟骨損傷（剝脫性骨軟骨炎 [OCD]）以及退行性改變的外側踝關節(jié)。5 一項研究中發(fā)現(xiàn)創(chuàng)傷后踝關節(jié)炎的平均潛伏期為 20.9年。6 患者的年齡（即老年患者）以及骨折治療期間的并發(fā)癥與踝關節(jié)炎發(fā)作的較短潛伏期有關。6 距骨頸骨折也可導致脛距骨關節(jié)炎的發(fā)生，文獻中描述的發(fā)生率為 47% 至 97%。7 距骨的骨軟骨損傷（OCD病變），無論是在踝關節(jié)骨折脫位時獲得的還是特發(fā)性的，都會使患者易患踝關節(jié)炎。這些病變最好通過磁共振成像 (MRI) 掃描來診斷。據(jù)估計，與膝關節(jié)骨關節(jié)炎相比，有癥狀的踝關節(jié)骨關節(jié)炎少 8 到 9 倍。1,8 這一估計意味著在美國進行的全膝關節(jié)置換術是全踝關節(jié)置換術的 24 倍。1 在一項尸體研究中使用 50 個樣本，在 76% 的踝關節(jié)中發(fā)現(xiàn)了2、3 或 4 級退行性變化，而膝關節(jié)退變則為 95%。9不同關節(jié)之間的軟骨特性也存在差異。與髖關節(jié)或膝關節(jié)軟骨相比，踝關節(jié)軟骨更薄。10 范圍從小于 1 毫米到大約 2 毫米。11 與膝關節(jié)和髖關節(jié)的接觸面積相比，踝關節(jié)的表面接觸面積也更?。?50 平方毫米），12分別為 1120 mm2 和 1100 mm2。1 大部分負荷通過距骨上部傳遞，踝關節(jié)承受的負荷高達人體重的 5 倍。13 在背屈時，與距骨的接觸面積最大，跖屈時減少18%。這一發(fā)現(xiàn)與單位面積應力的增加有關。 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?臨床表現(xiàn)疼痛和功能受限是踝關節(jié)炎患者最常見的癥狀。 17 Coughlin 及其同事 17 建議應詢問所有患者以下問題：1. 有外傷史嗎？2. 哪些活動會加重腳踝疼痛和導致踝關節(jié)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病史外傷史，即使是很早以前的外傷史，也有助于診斷創(chuàng)傷后踝關節(jié)炎。17 還應詢問患者是否有復發(fā)性扭傷，他們可能不會立即回憶起或與外傷史相關聯(lián)。接下來，需要詢問他們的醫(yī)學合并癥，包括類風濕性關節(jié)炎、糖尿病、血友病、感染、缺血性壞死和既往踝關節(jié)手術史。 17 糖尿病以及低骨密度使患者易患 Charcot關節(jié)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活動度接下來，應詢問患者導致其踝關節(jié)疼痛加重并限制其功能的活動。爬坡時加重的疼痛可能與前踝有關，而下坡疼痛與后踝有關。17 不平坦地面的疼痛通常與距下關節(jié)的疾病有關，而后內側關節(jié)的疼痛通常由后踝引起。脛骨肌腱功能障礙 (PTTD)，與踝關節(jié)炎的相關性較小。17 腓骨下或后外側踝關節(jié)疼痛可由腓骨肌腱或跟骨與距骨或腓骨之間的撞擊引起。這一發(fā)現(xiàn)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.臨床發(fā)現(xiàn)完整的體格檢查包括對患者站立和坐位的檢查。17 此外，步態(tài)檢查是必要的，以及檢查患者的后足對齊（即內翻/外翻足跟）。醫(yī)生需要注意沿下肢力線、從髖關節(jié)到膝關節(jié)以及沿脛骨軸線看到的任何排列不齊。在步態(tài)檢查過程中，檢查者需要注意腳跟撞擊時前腳掌的位置。在檢查扁平足畸形和 PTTD 患者時，需要測試單趾和雙趾上升。后足對齊的糾正或缺乏，表明晚期 PTTD。當后足在足跟抬高期間保持外翻時，可以診斷出固定或第 3 期 PTTD。在這些患者中，通常需要進行融合手術治療。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坐位檢查在這部分檢查期間，評估所有踝關節(jié)韌帶的穩(wěn)定性，包括前距腓韌帶 (ATFL) 和跟腓韌帶 (CFL)。ATFL 在跖屈時檢查，CFL 在輕微背屈時檢查。17 記錄踝關節(jié)的運動范圍并進行 Silfverskild 試驗，檢查跟腱和腓腸肌攣縮。膝關節(jié)屈曲時背屈改善表明腓腸肌攣縮，而膝關節(jié)伸直和屈曲時背屈受限表明跟腱攣縮。這部分檢查特別重要，因為它可以改變一個人的手術計劃。 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皮膚和血管 仔細的皮膚和血管檢查記錄脈搏、毛細血管再充盈以及潰瘍或老繭的存在是完整體檢的必要組成部分。皮膚變化可能表明血管炎，例如類風濕性關節(jié)炎或復雜的局部疼痛綜合征。 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診斷性影像學檢查踝關節(jié)的平片(X線片)仍然是最初成像方式的金標準。首選腳踝站立片，檢查前后位、mortise位和側位。如果計劃將后足或中足的作為手術治療的一部分，足部的 X 線片也包括在內。17 Saltzman 及其同事 2 還關注后足對齊，以進行診斷和手術計劃。在坐位中，后足可以通過 Harris位拍攝輕松實現(xiàn)。最近，一項研究 20 報告說，后足的長軸位可能比后足對齊位具有更好的觀察者間可靠性。計算機斷層掃描 (CT) 和 MRI 掃描的高級成像適用于特定環(huán)境。CT 掃描可用于更好地了解脛距關節(jié)、骨不連處的創(chuàng)傷后變化，以及復雜畸形或保留硬件的情況。與 MRI 相比，CT 掃描不太容易受到硬件偽影和運動偽影的影響。MRI掃描不如X線片和CT更多地用于診斷踝關節(jié)炎。MRI掃描的主要優(yōu)點在于對周圍軟組織的表征(如韌帶、軟骨、骨髓水腫等)。它還可以揭示導致創(chuàng)傷后關節(jié)炎發(fā)展的損傷機制。21 對于創(chuàng)傷后患者和下肢明顯畸形的患者，MRI掃描可以幫助做出正確的診斷和治療決策。踝關節(jié)炎可以根據(jù)解剖結構和根本病因進行分類。在解剖學方面，踝關節(jié)炎可以是廣泛性的（整個脛距關節(jié)都受到影響）或局部性的（關節(jié)面的特定部分受到影響）。 17 踝關節(jié)炎的根本病因可分為 3 大類：創(chuàng)傷后、骨關節(jié)炎、和類風濕性關節(jié)炎；Charcot 關節(jié)病和血色病；或由腫瘤引起的退行性變化。 1 踝關節(jié)骨關節(jié)炎可以使用影像學參數(shù)進行分級描述：0期：正常關節(jié)或軟骨下硬化；1期：存在骨贅但無關節(jié)間隙變窄（圖 3）；2期：關節(jié)間隙變窄，有或沒有骨贅；3期：關節(jié)間隙次全或全部消失或變形（圖4）。最近，加拿大足踝矯形協(xié)會 (COFAS) 對終末期踝關節(jié)炎的分類進行了描述。26 COFAS 分類已被證明具有良好的觀察者間可靠性 (=0.62) 和觀察者內可重復性 (=0.72)。采用COFAS 分期制定了術后分類，具有更高的觀察者間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預后與年齡匹配的對照組相比，踝關節(jié)炎會減少患者每天的總步數(shù)以及高強度步數(shù)，并且與較慢的步行速度相關。 28 這種情況可能對患者的日常生活（ADL）活動產生不利影響。踝關節(jié)炎的預后可能是自限性的，但一些患者的活動水平會持續(xù)下降，疼痛會增加。除了患者行走的步數(shù)減少之外，研究還發(fā)現(xiàn)在步態(tài)分析過程中踝關節(jié)活動范圍減小，跖屈力度減小。 28MANAGEMENT GOALSThe goal of management is pain control, improvement of patients function and ADLs, and a decrease in their level of pain.控制目標控制目標是管理疼痛、改善患者的功能和 日?；顒覣DL，并降低他們的疼痛水平。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.藥理學策略非甾體抗炎藥解決踝關節(jié)炎最常見的藥理學策略是非甾體抗炎藥 (NSAIDs)。NSAIDs 的副作用在開具處方和使用前需被充分考慮。這些副作用可能包括胃腸道出血、中風和心血管風險增加。 29 最近的建議側重于局部使用非甾體抗炎藥，特別是局部骨關節(jié)炎的高危患者。 29 所有患者在開始治療前都需要仔細篩查合并癥17,29 根據(jù)我們的臨床經(jīng)驗，NSAID 的療效各不相同，并且取決于患者。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.皮質類固醇注射劑和粘性補充劑用皮質類固醇注射脛距關節(jié)仍然是一種最終的非手術選擇，在NSAIDs治療和活動調整失敗后，患者可以在診室中獲得治療。盡管注射皮質類固醇仍然是金標準，但越來越多的研究文章研究了透明質酸(玻璃酸鈉注射液)在踝關節(jié)炎治療中的作用。23,24,30 在最近的一項研究中，31 每周注射 3 次透明質酸可緩解疼痛，減少對乙酰氨基酚的使用，以及平衡測試的改進。對患者進行了長達 6 個月的隨訪，注意到他們的美國矯形足踝協(xié)會 (AOFAS) 評分有所改善。需要向患者解釋注射的風險并回答所有問題。這些風險包括注射部位反應、感染、關節(jié)軟骨損傷的風險和永久性皮膚色素脫失。32 一些臨床醫(yī)生經(jīng)歷過永久性皮膚變色的不愉快影響以及隨之而來的患者不滿。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.非藥物策略自我管理策略活動調整可能是早期踝關節(jié)炎最有效的策略之一。 17 通過避免不平坦的平臺（即距下關節(jié)炎）、爬坡（前踝關節(jié)炎）以及使用跑步機或繼續(xù)保持使用橢圓機，患者可以達到一定的疼痛控制。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.矯形器另一種有效的策略似乎是關節(jié)的機械卸載。17 該策略可以通過基于踝關節(jié)或小腿韌帶的足踝矯形器來實現(xiàn)。33 系帶式踝關節(jié)支撐對于經(jīng)歷不穩(wěn)定或機械錯位的患者尤其有效。 1 可以穿帶有實心腳踝緩沖鞋跟的翹底鞋。34 其他策略包括臨時石膏或玻璃纖維模型，或使用 CAM 步行靴?？梢愿鶕?jù)患者的偏好和經(jīng)濟條件來選擇這些項目。其他非手術、非藥物選擇包括物理治療方式、脊椎按摩療法和針灸療法。關于這些模式的同行評審研究或評論很少。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手術技術當患者的保守治療選擇失敗時，可以考慮手術治療踝關節(jié)炎。最常見的手術選擇包括：1. 踝關節(jié)鏡；2. 矯正截骨術；3. 牽引關節(jié)成形術；4. 踝關節(jié)融合術；5. 全踝關節(jié)置換術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.手術的目標類似于非手術治療：緩解疼痛和改善或穩(wěn)定功能。根據(jù)關節(jié)炎的分期和位置（全身與局部）以及患者人口統(tǒng)計數(shù)據(jù)，手術選擇包括踝關節(jié)鏡清創(chuàng)術、踝關節(jié)上截骨術、牽引關節(jié)成形術、踝關節(jié)融合術和全踝關節(jié)成形術。 1,17有許多技術和方法可施行脛距關節(jié)融合術，沒有明確的經(jīng)驗證據(jù)表明一種技術在結果方面優(yōu)于其他技術。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關節(jié)鏡踝關節(jié)鏡檢查和清創(chuàng)術在踝關節(jié)炎中有多種適應癥。身體(韌帶)松弛、早期退行性關節(jié)炎改變和骨軟骨病變的患者可能適合進行關節(jié)鏡檢查。17 此外，撞擊產生的骨贅通?？梢酝ㄟ^踝關節(jié)鏡檢查解決。最近對現(xiàn)有研究證據(jù)的回顧提供了以下踝關節(jié)鏡檢查的適應證：踝關節(jié)撞擊癥、骨軟骨病變和踝關節(jié)融合術后的關節(jié)鏡檢查。35 禁忌癥包括：單純的晚期踝關節(jié)炎，而不包括導致撞擊的特定病變或骨贅的存在。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 (關節(jié)炎的骨折畸形愈合和下肢力線不齊。此外，在創(chuàng)傷后關節(jié)炎中，可見于部分或完全踝關節(jié)受累的骨折，踝關節(jié)上截骨術可能是有益的。1 內翻踝關節(jié)排列可以采用內側開口楔形截骨術或外側閉合楔形截骨術治療。術前距骨傾斜度較低 (關節(jié)炎。未來需要使用長期、高質量設計的進一步研究來指導我們的臨床實踐。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關節(jié)固定術脛距關節(jié)融合術脛距關節(jié)固定術可能是終末期脛距關節(jié)炎最成熟和研究最充分的手術治療方法之一。踝關節(jié)融合的主要指征是對頑固性疼痛或踝關節(jié)畸形患者的保守治療失敗。1,17 創(chuàng)傷后骨關節(jié)炎仍然是最常見的潛在原因。1,45 其他原因包括特發(fā)性骨關節(jié)炎、缺血性壞死、病史骨髓炎（非活動性）、全踝關節(jié)置換術失敗、46,47 脊髓灰質炎后綜合征、先天性畸形 17 和類風濕性關節(jié)炎 1。Thomas 和 Daniels1 不建議將關節(jié)固定術作為急性創(chuàng)傷的主要挽救手術。關節(jié)固定術的主要優(yōu)點之一是手術成功后疼痛緩解的可靠性。此外，關節(jié)固定術減少了對植入物或硬件移除的需求。踝關節(jié)融合術可以通過開放式、關節(jié)鏡或使用 Ilizarov 技術來完成。不管用于融合腳踝的特定方法如何，成功手術的最重要因素是腳踝位置和軟組織處理。 17 關節(jié)固定術中的踝關節(jié)位置 目前接受的踝關節(jié)位置是背屈中立、后足外翻 5和外旋 5 到 10 .1,48 其他研究人員推薦了一種模仿對側肢體旋轉的外旋位置。在足跟著地時，正常步態(tài)下中足跖屈 10。49 腳踝融合在中立位置時，允許發(fā)生這種運動。馬蹄足的融合導致足跟撞擊時步態(tài)異常的發(fā)展，因為中足不能背屈。 Hefti 及其同事 48 還建議將距骨相對于脛骨向后放置，并在 5 到 10 次外旋時融合。該策略具有通過自然旋前機制改進推離的理論優(yōu)勢。 軟組織處理 軟組織處理在進行關節(jié)融合術時至關重要。該過程包括小心牽開，并在每一個機會釋放牽開器以減少對軟組織的傷害，避免瘢痕攣縮和紅斑區(qū)域。17 需要盡可能保護皮神經(jīng)，有計劃的切口和細致的解剖技術是最重要的。對于前關節(jié)切開術，腓淺神經(jīng)的分支最危險，而外側入路和外踝周圍的腓腸神經(jīng)處于危險之中。 內固定與外固定 內固定仍然是大多數(shù)患者關節(jié)固定術的首選。相對于外固定架的優(yōu)勢包括更高的融合率和減少對患者的不便。50 內固定的不愈合率為 5%，而外固定架組為 21%。50 感染在外固定架組中也更常見， 28 名患者中有 5 名（針跡感染），而內固定組沒有淺表或深部感染。 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.鋼板與螺釘先前的幾項研究表明，與鋼板固定相比，使用螺釘可改善壓力。51-55 與鋼板相比，螺釘?shù)牧硪粋€優(yōu)點是減少了軟組織剝離。1 T 型鋼板固定用于融合可能在某些情況下具有優(yōu)勢。56 Cadaver生物力學測試表明，與螺釘固定或腓骨支柱移植物相比，T形鋼板固定提供了最大的剛性強度。56,57 在骨質減少的病例中，在前外側和前內側位置使用2塊鋼板的選擇可能會提供更好的固定強度和融合率。58 在1項Cadaver研究中，58 與使用單個前方鋼板相比，2塊鋼板的選擇使得彎曲剛度提高了1.5 到 2 倍。目前市場上可供選擇的有前方、外側和后方鋼板。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.螺釘配置與平行螺釘相比，使用2個交叉螺釘可提高剛度。59 我們機構使用的一種可能的螺釘配置如圖 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螺釘數(shù)量研究表明，與2枚螺釘相比，3枚螺釘可提供更高的剛度。60 使用腓骨支柱移植物可以進一步增強融合的穩(wěn)定性。61 已經(jīng)描述了用于特定方法和螺釘配置的幾種技術。Holt 及其同事 52 描述了使用 3 顆螺釘和腓骨截骨術。Kish 及其同事 62 描述了一種使用空心螺釘固定的技術。這種技術允許在導針的幫助下放置 3 到 4 個螺釘，以確保滿意的對齊和矯正整個融合部位的畸形應力（圖 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/器外固定架的主要適應癥是活動性感染期間和軟組織受損的患者。1此外，在嚴重的骨質疏松癥中，可能會減少螺釘?shù)氖褂煤腿诤喜课坏膽?，外固定架可能是首選方式。1 這該技術允許在可耐受的情況下立即負重，并可用作補救方法。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內固定與外固定與外固定相比，內固定有幾個優(yōu)點，包括更高的融合率和減少對患者的不便。50 內固定的不愈合率為 5%，而外固定組為 21%。50 感染也更常見外固定器組。28 名患者中有 5 名（針眼感染），而內固定組沒有淺表或深部感染。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踝關節(jié)融合術后的步態(tài)分析Thomas 和 Daniels1 對有關步態(tài)周期變化的要點進行了全面審查?？傮w而言，踝關節(jié)融合術后步行時的能量消耗增加了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.全踝關節(jié)置換術目前，美國食品和藥物管理局 (FDA) 批準了四種用于全踝關節(jié)置換術的器械：Agility、Salto、Scandinavian全踝關節(jié)置換術 (STAR) 和 INBONE。第三代全踝關節(jié)置換術正在使用中。踝關節(jié)置換術的使用始于 1970 年代 1。它在北美越來越普遍，但在歐洲已經(jīng)流行和成熟。在美國以外使用的大多數(shù)踝關節(jié)置換物是活動平臺，而在美國境內使用的大多數(shù)是固定平臺。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.全踝關節(jié)置換術的適應癥當前的挑戰(zhàn)之一是該程序的適應癥和確定將在短期和長期受益的最合適的患者方面存在爭議。手術患者是經(jīng)過數(shù)月保守治療失敗并患有晚期踝關節(jié)退行性疾病的成年患者。應滿足以下先決條件：(1)有足夠的血管流向遠端；(2) 足踝周圍有足夠的軟組織包膜，以允許傷口愈合和術后開始物理治療和踝關節(jié)在一定范圍內運動。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全踝關節(jié)置換術的禁忌癥全踝關節(jié)置換術的禁忌癥包括感染、距骨骨壞死、嚴重力線不正、軟組織受損、嚴重踝關節(jié)松弛和神經(jīng)功能障礙。1 Coetzee 和 Deorio 69 建議外翻畸形超過20不能進行全踝關節(jié)置換術。這些研究人員還建議，足部畸形需要在關節(jié)成形術時或之前進行處理和治療，因為足部畸形會導致早期植入失敗。嚴重的外翻畸形，如終末期成人獲得性扁平足畸形，可以在全踝關節(jié)置換術時解決。對于先前在中足或后足進行過融合手術的患者尤其如此（圖7）。全踝關節(jié)置換術的類型（全踝關節(jié)置換術可以根據(jù)幾個不同的參數(shù)進行分類）70：I.固定：固定可以是骨水泥或非骨水泥型；II.組件數(shù)量：組件數(shù)量從2到3不等；這些 組件可以是一致的或不一致的；不一致的（滑車、雙球形、凹/凸）到一致性的（球形、圓柱形、圓錐形）；III.限制性：限制、半限制或非限制；IV.組件形狀：非解剖與解剖；V.平臺：固定或活動。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踝關節(jié)置換Agility踝關節(jié)置換是一個帶有固定平臺的兩部分組件的設計系統(tǒng)。這是一個半限制裝置，允許60次運動。71 這種設計包括聯(lián)合融合，目的是防止脛骨組件下沉。70 距骨和脛骨都是非解剖結構，具有多孔涂層距骨。Claridge 和 Sagherian 72 回顧了 Agility 踝關節(jié)的一些中期結果。AOFAS評分從術前到術后分別從34.9提高到76.4。研究人員擔心并發(fā)癥的發(fā)生率很高，從淺到深的感染、醫(yī)源性骨折和需要游離皮瓣覆蓋的患者的動脈損傷。在9年的隨訪中，11%的患者需要翻修（回顧了126名患者的 132 例關節(jié)置換術）。其他研究報告的5年生存率為80% 至 95%，10 年生存率為63%。73,74 兩部分踝關節(jié)置換系統(tǒng)最有希望的結果包括 85% 的 10 年生存率。75 距下關節(jié)炎的發(fā)病率為19%，16%的患者患有進行性距舟關節(jié)炎。72 在 8% 的患者中，看到關節(jié)不愈合。76 Salto 這是自 1997 年以來在歐洲使用的移動平臺的踝關節(jié)置換系統(tǒng)（圖 8）。該系統(tǒng)包括一個用釘固定的錐形距骨和一個帶棘突固定的扁平脛骨組件。70 一項研究報告了6.8 年 65% 的存活率，該研究包括92名患者的96個植入物。導致再次手術失敗的最常見原因包括骨囊腫(骨囊性改變)（11名患者）、聚乙烯折斷（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 是一種非骨水泥、羥基磷灰石涂層的全踝關節(jié)假體(生物型)（圖 9）。該系統(tǒng)包括一個圓柱形距骨和一個扁平脛骨組件。78 它于 2009 年 5 月 27 日獲得 FDA 批準。該假體的 5 年生存率為 70% 66 至 89.5%，10 年生存率為 71.1 %.79 Zhao 和同事79 警告說，在他們的研究中，STAR 假體的松動率更高。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這種 2 組件系統(tǒng)于 2005 年獲得 FDA 批準。它包括以鈦為主成分的脛骨組件和以鈷鉻為主成分距骨。脛骨組件包括一個髓內柄。80 這種設計特征需要在透視下進行髓內鉆孔和用于手術的專用腳架。這種名為 Prophecy 的假體的新設計形式已經(jīng)面市。使用這種假體，患者術前踝關節(jié)CT掃描，可用于3D打印，以制作患者特定設計，從而減少手術時間和提高截骨精度。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全踝關節(jié)置換術與踝關節(jié)融合術(踝關節(jié)固定術)在特定的患者組中，與踝關節(jié)固定術相比，全踝關節(jié)置換術可能獲得安全、等效的結果，甚至可能導致與融合術相比的功能改善。66,80 Haddad 及其同事 67 研究了全踝關節(jié)置換術和關節(jié)固定術之間的差異。該檢查包括 852 名全踝關節(jié)置換患者和 1262 名踝關節(jié)融合患者。踝關節(jié)置換術后總體翻修率為7%，與踝關節(jié)融合術的9%翻修率相比并不顯著。還比較了挽救性治療流程，1%的全踝關節(jié)置換患者需要膝關節(jié)下截肢(BKA)，而踝關節(jié)融合組為5%。67 與關節(jié)固定術相比，踝關節(jié)置換術的運動范圍也可能得到改善。78 與踝關節(jié)固定術相比，踝關節(jié)置換術的相鄰關節(jié)的退行性關節(jié)變化率也更小。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.手術并發(fā)癥在所有足部和踝關節(jié)開放手術中，淺表和深部感染仍然是一個問題。感染率從低于 2% 55 到 2.5% 51 甚至到超過 20% 不等。83 延遲傷口愈合和感染可以通過細致的軟組織處理、減少牽開器的力量和時間，同時關閉伸肌支持帶來解決和預防。1 該策略在全踝關節(jié)置換術中尤為重要，因為傷口裂開可能會導致假體裸露。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 踝關節(jié)置換術的并發(fā)癥Moeckel 及其同事 50 將踝關節(jié)固定術最常見的并發(fā)癥描述為“骨不連、延遲愈合、應力性骨折、感染”。骨不連或假關節(jié)的發(fā)生率從 0% 到 41% 不等。4,17,53 在其他幾項研究中，據(jù)報道骨不連率低于 10%。84,85 吸煙是最公認的導致骨不連的因素之一。吸煙可導致骨不連的風險增加 4 倍。86 與骨不連有關的其他因素包括感染、不遵守術后負重限制、距骨缺血性壞死和外科醫(yī)生手術操作技術。1,86 Frey 及其同事 4 還確定了醫(yī)源性合并癥和開放性骨折史是骨不連的誘發(fā)危險因素。后足和中足的神經(jīng)血管損傷和鄰近關節(jié)的關節(jié)炎也有報道。1 距下關節(jié)退行性變的放射學證據(jù)經(jīng)常可見，但臨床上通常無癥狀。1 在隨訪7年研究時，可觀察到距下骨關節(jié)炎發(fā)生率高達 30% 。87 雖然同側足部經(jīng)常受累，但同側膝關節(jié)似乎不受與踝關節(jié)融合相關的退行性變化的影響。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.關節(jié)鏡手術的并發(fā)癥關節(jié)鏡融合術中最常見的并發(fā)癥是植入物相關性疼痛，導致二次手術移除。17,88 在一項針對 42 名患者的研究中，Crosby 及其同事 89 檢查了關節(jié)鏡下關節(jié)融合術的并發(fā)癥，其中包括不愈合 (7%)、醫(yī)源性骨折 (4.8%)、關節(jié)鏡穿刺部位感染 (9.5%) 和植入物相關性疼痛 (9.5%)，以及距下關節(jié)疼痛 (9.5%)，總體并發(fā)癥發(fā)生率為55%。在最近的文獻綜述分析中，對 244 名患者的 90 項結果進行了分析。其中，不愈合率為8.6%。在這些患者中，66.7% 的患者因骨不連出現(xiàn)癥狀。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踝關節(jié)置換術的并發(fā)癥最常見的全踝關節(jié)置換術失敗的并發(fā)癥和原因包括無菌性松動、力線不齊和深部感染 (1%)。79,91 在一項文獻研究回顧中，上述3種并發(fā)癥約占所見全部失敗原因的 50%。無菌性松動和假體失敗是多因素的。在許多情況下，四肢和后足畸形可能是一個加速因素。1 之前已經(jīng)提出了關于全踝關節(jié)置換術中力線問題的指南。1 這些指南包括仔細檢查術前 X 光片以確定后足的外翻/內翻畸形。在踝關節(jié)置換術時解決這些問題對于確保假體的使用壽命至關重要。獲取全長站立片以尋找膝關節(jié)和脛骨力線不正也很重要。以前曾建議對大于 10 的脛骨遠端畸形進行踝關節(jié)上方截骨術。92 全踝關節(jié)置換術的失敗會給患者帶來嚴重的后果。假體的深部感染通常需要移除假體、沖洗和清創(chuàng)、長期使用抗生素、可能放置抗生素間隔器并考慮多種挽救方案。 1 與踝關節(jié)融合術相比，在踝關節(jié)置換術期間進行更廣泛的截骨，并且修復流程和搶救選項必須考慮到這種減少的骨量。這種情況在全踝關節(jié)置換術（包括關節(jié)置換翻修術、踝關節(jié)融合術和BKA）失敗后通常會留下更少的選擇。 93,94 最近的薈萃分析檢查了失敗的全踝關節(jié)置換術向踝關節(jié)融合術的轉化，Haddad 和他的同事 67 報告了 5.1 % 的轉化率，Stengel 及其同事報告了 6.3%的轉化率。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.評估、調整、復發(fā)全踝關節(jié)置換術和踝關節(jié)融合術都可以減輕(踝關節(jié))疼痛并改善患者(踝關節(jié))功能。在最近的一項研究中，成功的手術與患者體重指數(shù)的下降無關，這些患者被歸類為超重或肥胖。96 對于全踝關節(jié)置換術，預期的翻修手術無需更換假體，已被許多足踝外科醫(yī)生接受為現(xiàn)實。這些再次手術可能包括骨囊腫切除、由于疼痛或撞擊而導致的外側或內側清創(chuàng)，以及由于磨損而更換聚乙烯墊片。78 如果癥狀持續(xù)存在，可以開始使用紅細胞沉降率和C反應蛋白等實驗室標記物進行感染檢查。 如果這些測試結果為陰性，可以考慮全踝關節(jié)置換翻修術，同時考慮骨量和軟組織條件。骨質溶解和聚乙烯磨損會影響全踝關節(jié)置換術（圖10）。Coughlin 及其同事 17 建議對溶骨性病變進行聚乙烯墊片置換、刮除和骨移植，并檢查假體表面是否有不規(guī)則磨損，這可能需要完全移除和修復假體。對于踝關節(jié)融合術，癥狀在12個月后持續(xù)存在，需要檢查可能的骨不連或感染。如果結果為陰性，CT掃描成像可以闡明細微的骨不連，而這可能在平片上不明顯。內翻或外翻畸形愈合可以通過閉合楔形截骨術解決，其功能是不拉伸神經(jīng)并為融合部位提供額外的骨量。17 距下關節(jié)的相鄰關節(jié)關節(jié)炎可以通過距下關節(jié)融合術解決，盡管Coughlin 及其同事 17標準的一枚螺釘固定方法可能不足以用于先前存在的踝關節(jié)融合術的患者。如果患者既往踝關節(jié)置換術失敗、踝關節(jié)融合失敗以及距下關節(jié)出現(xiàn)晚期退行性變，可能的挽救手術是脛距融合術。97 該手術可以通過逆行髓內釘實現(xiàn)脛距關節(jié)融合，同時使用距下關節(jié)的互鎖螺釘或刀片機制（圖 11）。并發(fā)癥包括脛骨假體周圍接近于螺釘近端的骨折報告。術中骨折也有報道。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.討論/總結本文回顧了踝關節(jié)炎的診斷和治療選擇。圖12提供了踝關節(jié)炎不同階段的治療選擇流程圖。目前非手術治療的標準包括使用非甾體抗炎藥、皮質類固醇注射、矯形器或踝關節(jié)支具。其他方式，包括透明質酸注射、物理療法、經(jīng)皮電神經(jīng)刺激裝置、按摩療法，但都缺乏高質量的研究來清楚地描述其使用的適當性和有效性。終末期退行性關節(jié)炎手術干預的金標準仍然是踝關節(jié)固定術，但越來越多的證據(jù)表明，全踝關節(jié)置換術在功能結果方面的等效性甚至優(yōu)越性。未來幾年將使我們能夠做出更準確的決定，并且通過更多前瞻性的高質量研究，可以確定最適合全踝關節(jié)置換術的患者群體。Fig. 1. Anteroposterior radiograph of comminuted, high-energy pilon fracture.圖 1. 粉碎的高能 Pilon 骨折的前后位 X 線片。Fig. 2. Open ankle fracture with exposed tibial plafond.圖 2. 脛骨平臺暴露的開放性踝關節(jié)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.圖 3. 右踝關節(jié)前后位X線片。內側骨贅被圈出。這是具有退行性變的第 1 階段踝關節(jié)的示例，存在無關節(jié)間隙變窄的骨贅。Fig. 4. Anteroposterior and lateral radiograph of an ankle with stage 3 degenerative changes. Subtotal or total disappearance or deformation of joint space.圖 4. 具有第 3 階段退行性變的踝關節(jié)的前后位 X 線片。關節(jié)間隙幾乎全部或全部消失或變形。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.圖 5. 脛距關節(jié)融合術。使用 3 枚部分空心螺釘固定技術。在軟骨被剝除并準備好融合骨床后，進行力線校正。使用克氏針進行初始固定，然后是 (1) 內側到外側：內側到外側方向，從上到下瞄準。導針在透視下保持在原位。測深尺進行測量。使用此螺釘?shù)膲|圈將螺釘置于受壓狀態(tài)。退出導絲。(2)從前到后：從脛骨前方進入距骨后方。(3)聯(lián)合螺釘：為了增加穩(wěn)定性，做一個外側小切口，將外側腓骨置于內側距骨螺釘，穩(wěn)定聯(lián)合。該螺釘通過小切口經(jīng)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.圖 6. 脛距關節(jié)融合術。使用3枚部分空心螺釘固定技術。術后16周的X線片。注意到橫跨踝關節(jié)的實心融合塊，具有完整的骨性結構(注：踝關節(jié)融合成功的標志)。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.圖 7. 踝關節(jié)炎，之前有中足融合，距下關節(jié)也已融合。目前存在外翻畸形，主要是脛距、距下和中足關節(jié)。在這種情況下，距下關節(jié)和足中關節(jié)融合并穩(wěn)定。這種情況使我們能夠通過踝關節(jié)置換術解決外翻畸形以及脛距關節(jié)的終末期關節(jié)炎，而不是脛距融合術。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.圖 8. 使用 Salto假體的全踝關節(jié)置換術。這是一個活動平臺系統(tǒng)。距骨呈圓錐形，并用釘子固定。脛骨組件是扁平的，包括一個用于固定的棘突。 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.圖 9. 使用 STAR假體的全踝關節(jié)置換術。距骨具有更加圓柱形的形狀。脛骨組件是平坦的。這是一種非骨水泥假體，涂有羥基磷灰石。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.圖 10. 患有創(chuàng)傷后脛距關節(jié)炎患者的右踝關節(jié)Mortise位X線片，既往切開復位內固定腓骨和脛骨。踝關節(jié)置換術，外側和內側有廣泛的骨質溶解。注意到假體周圍的扇形、射線透亮帶。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.圖 11. 伴有 Charcot 關節(jié)病的踝關節(jié)炎。涉及脛距、距下和中足關節(jié)。還存在內翻畸形。這種畸形可以通過脛距融合術解決。顯示了術前 (A) 和術后 (B) X線片。Fig. 12. Flowchart of treatment options at the different stages of ankle arthritis. TTC, tibiotalocalcaneal fusion.圖 12. 踝關節(jié)炎不同階段的治療方案流程圖。TTC，脛距融合術。2021年06月20日2806
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顧文奇副主任醫(yī)師 上海市第六人民醫(yī)院 骨科 Q：踝關節(jié)扭傷了怎么辦？A：急性踝關節(jié)扭傷可出現(xiàn)患肢腫脹、疼痛及不同程度活動受限的情況，此時應立即避免患側肢體負重及行走，抬高肢體，聯(lián)合冷敷消腫。若肢體腫脹、疼痛及活動受限明顯，應及時去醫(yī)院就診。Q：急性踝關節(jié)扭傷是否需要拍X光片？A：我們建議常規(guī)拍攝X光片，以排除任何可能的踝部骨折。外踝、跟骨前外側及距骨外側突都可能存在撕脫骨折，往往可以通過攝片明確；對于更嚴重的損傷，?？蓪е迈钻P節(jié)骨骨折；高位踝扭傷?？赡茉斐上旅勲杪?lián)合損傷，往往容易漏診，因此拍攝時應包括脛腓骨全長片，同時還應加拍足部正斜位片，以排除第5跖骨基骨折及其他足部骨折可能。Q：是否需要急診磁共振？A：我們認為無必要進行急診磁共振檢查，首先，急性期存在明顯的關節(jié)周圍水腫，大量水腫信號會影響磁共振讀片；其次，即使明確存在韌帶撕裂，對于指導治療并無太大意義，因為急性期（2周內）不！建！議！手！術！Q：為什么醫(yī)生要我打石膏？A：踝關節(jié)扭傷的早期制動非常重要，規(guī)范的制動及免負重對于減少遠期并發(fā)癥有一定的作用，石膏固定于外翻位有助于韌帶的修復。一般，對于無骨折的患者，通常需要固定7-14天，然后進行早期康復鍛煉；對于明確有撕脫骨折的患者，則需要固定4-6周，然后再進行康復；對于移位的踝關節(jié)骨折或第5跖骨基骨折，則需要手術治療。需要指出的是，隨著支具技術的發(fā)展，采用踝關節(jié)固定支具亦可提供良好的固定效果。Q：康復要點是什么？A：康復早期先進行一些踝關節(jié)背伸及外翻的力量練習，然后進階至負重、平衡、本體感覺等練習，通常一個月后可進行內翻內旋跖屈練習。Q：急性踝關節(jié)扭傷是否需要手術？A：目前原則是，急性期的踝關節(jié)扭傷不需要手術！所謂的急性期是受傷2周內。即使明確韌帶損傷，急性期也不建議手術。大部分患者可以通過制動及隨后的康復獲得良好的恢復。只有明確存在關節(jié)不穩(wěn)且保守治療無效的情況下才考慮手術，臨床報道也證明急性期手術療效并不優(yōu)于后期。但如果存在移位的踝關節(jié)骨折，則需要手術復位及固定。2021年05月09日711
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