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張銀昌主任醫(yī)師 皖南醫(yī)學(xué)院第一附屬醫(yī)院 骨科 運(yùn)動(dòng)中崴了腳怎么辦？發(fā)生踝關(guān)節(jié)扭傷后，很多人第一反應(yīng)就是活動(dòng)活動(dòng)腳腕，若沒有疼痛或只是輕微疼痛，就不在意了；甚至有人認(rèn)為扭到腳踝只是小傷，熱敷或用繃帶包扎下就好了。 但這些做法都是錯(cuò)的。腳腕扭傷后，雖沒有骨折，但外側(cè)韌帶可能已經(jīng)撕裂。如不立即有效固定、制動(dòng)，受傷的韌帶會在異常位置修復(fù)，減弱維持踝關(guān)節(jié)穩(wěn)定的力量，致使習(xí)慣性踝關(guān)節(jié)扭傷，有的人一年甚至?xí)脦状?。 另外還有人會落下踝關(guān)節(jié)疼的毛病，早期可能是韌帶撕裂處疼，但由于踝關(guān)節(jié)長期不正常受力，將導(dǎo)致創(chuàng)傷性關(guān)節(jié)炎。 崴腳后應(yīng)如何應(yīng)對？ 第一是止疼。立即停止行走，使損傷的足踝部得到休息，從而減輕因?yàn)閾p傷引起的疼痛和不適。有人崴腳后忍痛行走，認(rèn)為活動(dòng)活動(dòng)就好了，這是錯(cuò)誤的觀念。忍痛行走或活動(dòng)會加重?fù)p傷，不利于損傷組織的恢復(fù)。 第二是冷敷。可以用冰袋或者其他溫度比較低的物品放在損傷的踝關(guān)節(jié)部位，降低局部的溫度。冷敷的目的是使損傷部位的毛細(xì)血管收縮，達(dá)到減少出血和滲出，防止局部腫脹的目的。同時(shí)，冷敷有減輕疼痛的作用。 冷敷應(yīng)在受傷后立即進(jìn)行，一般持續(xù)做1～3天，即傷后48到72小時(shí)內(nèi)，損傷的局部不用熱敷，而用冷敷來止痛和防止腫脹。 第三是做損傷足踝關(guān)節(jié)的加壓包扎和固定。目的是通過局部纏繃帶的方法壓迫損傷的血管，減少出血和滲出，從而減輕組織的腫脹和疼痛。同時(shí)，加壓包扎也起到踝關(guān)節(jié)局部固定作用，可減輕疼痛和因?yàn)榫植坎环€(wěn)定或者活動(dòng)產(chǎn)生的組織再次損傷。 第四是在充分休息、避免活動(dòng)的基礎(chǔ)上抬高患肢，促進(jìn)受傷肢體的血液回流和減少受傷組織的淤血，達(dá)到減輕腫脹的目的?？梢詫⑹軅闹w抬高10到20厘米，也就是說，如果人在平躺狀態(tài)，把患肢抬高10到20厘米，高于心臟的水平，就可以達(dá)到促進(jìn)血液回流，減輕踝關(guān)節(jié)腫脹的目的。 面對扭傷，要引起重視： 1、即使沒有骨折，扭傷后也該制動(dòng)2~3周，使受損的韌帶在正常位置修復(fù)、愈合; 2、冷敷，用冰袋敷于患處; 3、適當(dāng)加壓包扎，減輕腫脹，防止水泡產(chǎn)生; 4、抬高患肢，讓腫脹消退; 5、當(dāng)合并皮膚損傷時(shí)，千萬別自行處理。 如何有效預(yù)防扭傷？ 圖片 1、進(jìn)行適量運(yùn)動(dòng)，保持肌肉的力量和柔韌性，且在運(yùn)動(dòng)前要熱身; 2、在濕滑地面上時(shí)，要小心行走; 3、在不平路面活動(dòng)時(shí)，為保護(hù)踝關(guān)節(jié)，盡量穿高幫鞋或靴子; 4、不要穿鞋底被磨損不平的鞋子; 5、在黑暗中容易發(fā)生踝關(guān)節(jié)扭傷，夜間活動(dòng)要注意照明。 崴腳5大誤區(qū) 誤區(qū)1：熱敷消腫 崴腳后由于韌帶軟組織撕裂、小血管出血、組織液滲出增多，局部出現(xiàn)疼痛腫脹，且逐漸加重。有些人崴腳后，立即采用局部熱敷的辦法減輕疼痛，雖然暫時(shí)舒適些，但這樣做反而造成出血及滲液增加，進(jìn)一步加劇腫脹程度。 正確的做法是24小時(shí)內(nèi)應(yīng)冷敷，冷敷可收縮血管，減少出血水腫，24小時(shí)后才能熱敷。 誤區(qū)2：白酒擦洗 民間不少地方有用白酒點(diǎn)火擦洗的做法，認(rèn)為白酒活血化瘀、消腫止痛，酒洗的同時(shí)采用局部按摩，其實(shí)這種做法是十分有害。 崴腳急性期應(yīng)禁忌按摩，更切忌剛扭傷就馬上用白酒點(diǎn)火擦洗。這樣做往往適得其反，會進(jìn)一步加劇出血腫脹、皮膚瘀斑，甚至造成皮膚燒傷起水泡。 誤區(qū)3：不愿外固定 由于踝關(guān)節(jié)扭傷多為內(nèi)翻損傷，所以80%以上的崴腳會導(dǎo)致外側(cè)韌帶的撕裂或斷裂，致使腳踝兩側(cè)韌帶的拉力不平衡。不少人認(rèn)為崴腳后采用外固定很麻煩，影響行走活動(dòng)，不愿固定。 其實(shí)崴腳后固定制動(dòng)有助于消腫、減輕疼痛，促進(jìn)軟組織損傷恢復(fù)。 誤區(qū)4：不及時(shí)就醫(yī) 一些人認(rèn)為，崴腳是個(gè)小毛病，不用上醫(yī)院，掉以輕心，延誤病情，比如有些撕脫骨折患者耽誤了早期治療，給踝關(guān)節(jié)功能恢復(fù)埋下隱患。 崴腳后腳踝腫痛者應(yīng)立即到醫(yī)院骨科就診，拍片排除踝關(guān)節(jié)骨折，如果是韌帶損傷，要給予適當(dāng)?shù)墓潭?，如選用彈力繃帶、硬紙板、支具或高分子石膏固定。 如果檢查有骨折，還需要根據(jù)情況進(jìn)一步內(nèi)固定或外固定。 誤區(qū)5：不注意休息 有的人傷后不休息 認(rèn)為骨折后休息與否不重要 俗話說“傷筋動(dòng)骨一百天”，雖然不能一概而論，但也不無道理。 其中休息是踝關(guān)節(jié)韌帶恢復(fù)的其中一個(gè)環(huán)節(jié)。崴腳較輕者盡量少走;崴腳較重者不應(yīng)下地走路，還要抬高傷足踝;如果繼續(xù)過多行走不利于腫脹消退和韌帶的修復(fù)，會使損傷的外踝韌帶拉長、松弛，愈合不良。 因此，適當(dāng)?shù)男菹?，抬高傷足，有助于早日恢?fù)正常功能。 專家簡介： 張銀昌，醫(yī)學(xué)博士，副主任醫(yī)師，講師，南京鼓樓醫(yī)院，德國，上海六院研修關(guān)節(jié)置換及運(yùn)動(dòng)醫(yī)學(xué)，擅長：人工髖關(guān)節(jié)置換，人工膝關(guān)節(jié)置換。關(guān)節(jié)鏡下膝關(guān)節(jié)前后交叉韌帶重建、半月板成形術(shù)、半月板縫合術(shù)、習(xí)慣性髕骨脫位手術(shù)治療等微創(chuàng)手術(shù)。關(guān)節(jié)鏡治療肩關(guān)節(jié)凍結(jié)肩，肩袖損傷，肩關(guān)節(jié)脫位等，踝關(guān)節(jié)外傷不穩(wěn)，撞擊癥及慢性退變性疾病。 皖南醫(yī)學(xué)院弋磯山醫(yī)院關(guān)節(jié)骨科，每周二下午，周五上午門診2021年07月07日
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陶可主治醫(yī)師 北京大學(xué)人民醫(yī)院 骨關(guān)節(jié)科 踝關(guān)節(jié)炎：診斷和手術(shù)治療的綜述譯者：陶可（北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科）北京大學(xué)人民醫(yī)院骨關(guān)節(jié)科陶可關(guān)鍵點(diǎn)： 目前踝關(guān)節(jié)炎非手術(shù)治療的標(biāo)準(zhǔn)包括使用非甾體抗炎藥、皮質(zhì)類固醇注射、矯形器和腳踝支具。其他方式，包括透明質(zhì)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(zhì)量的研究來描述其使用的適當(dāng)性和有效性。 終末期退行性踝關(guān)節(jié)炎手術(shù)干預(yù)的金標(biāo)準(zhǔn)仍然是關(guān)節(jié)融合術(shù)，但越來越多的證據(jù)表明，全踝關(guān)節(jié)置換術(shù)在功能結(jié)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(zhǔn)確的決定，并且通過更多前瞻性的高質(zhì)量研究，可以確定最適合進(jìn)行全踝關(guān)節(jié)置換術(shù)的患者群體。文獻(xiàn)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(guān)節(jié)是身體中最常受傷的關(guān)節(jié)，每平方厘米吸收的應(yīng)力比任何其他關(guān)節(jié)都要多。然而，踝關(guān)節(jié)炎的發(fā)病率卻是膝關(guān)節(jié)和髖關(guān)節(jié)癥狀性關(guān)節(jié)炎的九分之一。1 與膝關(guān)節(jié)和髖關(guān)節(jié)關(guān)節(jié)炎不同，踝關(guān)節(jié)關(guān)節(jié)炎最常見于創(chuàng)傷后，而原發(fā)性關(guān)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(bào)告了 7.2% 的原發(fā)性踝關(guān)節(jié)炎與 70% 的創(chuàng)傷后踝關(guān)節(jié)炎，其中11.9% 的患者患有類風(fēng)濕性關(guān)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(xué)/病理生理學(xué)踝關(guān)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(cè)踝關(guān)節(jié)。5 一項(xiàng)研究中發(fā)現(xiàn)創(chuàng)傷后踝關(guān)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(guān)節(jié)炎發(fā)作的較短潛伏期有關(guān)。6 距骨頸骨折也可導(dǎo)致脛距骨關(guān)節(jié)炎的發(fā)生，文獻(xiàn)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(guān)節(jié)骨折脫位時(shí)獲得的還是特發(fā)性的，都會使患者易患踝關(guān)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(jì)，與膝關(guān)節(jié)骨關(guān)節(jié)炎相比，有癥狀的踝關(guān)節(jié)骨關(guān)節(jié)炎少 8 到 9 倍。1,8 這一估計(jì)意味著在美國進(jìn)行的全膝關(guān)節(jié)置換術(shù)是全踝關(guān)節(jié)置換術(shù)的 24 倍。1 在一項(xiàng)尸體研究中使用 50 個(gè)樣本，在 76% 的踝關(guān)節(jié)中發(fā)現(xiàn)了2、3 或 4 級退行性變化，而膝關(guān)節(jié)退變則為 95%。9不同關(guān)節(jié)之間的軟骨特性也存在差異。與髖關(guān)節(jié)或膝關(guān)節(jié)軟骨相比，踝關(guān)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(guān)節(jié)和髖關(guān)節(jié)的接觸面積相比，踝關(guān)節(jié)的表面接觸面積也更小（350 平方毫米），12分別為 1120 mm2 和 1100 mm2。1 大部分負(fù)荷通過距骨上部傳遞，踝關(guān)節(jié)承受的負(fù)荷高達(dá)人體重的 5 倍。13 在背屈時(shí)，與距骨的接觸面積最大，跖屈時(shí)減少18%。這一發(fā)現(xiàn)與單位面積應(yīng)力的增加有關(guān)。 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(guān)節(jié)炎患者最常見的癥狀。 17 Coughlin 及其同事 17 建議應(yīng)詢問所有患者以下問題：1. 有外傷史嗎？2. 哪些活動(dòng)會加重腳踝疼痛和導(dǎo)致踝關(guān)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(guān)節(jié)炎。17 還應(yīng)詢問患者是否有復(fù)發(fā)性扭傷，他們可能不會立即回憶起或與外傷史相關(guān)聯(lián)。接下來，需要詢問他們的醫(yī)學(xué)合并癥，包括類風(fēng)濕性關(guān)節(jié)炎、糖尿病、血友病、感染、缺血性壞死和既往踝關(guān)節(jié)手術(shù)史。 17 糖尿病以及低骨密度使患者易患 Charcot關(guān)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(dòng)度接下來，應(yīng)詢問患者導(dǎo)致其踝關(guān)節(jié)疼痛加重并限制其功能的活動(dòng)。爬坡時(shí)加重的疼痛可能與前踝有關(guān)，而下坡疼痛與后踝有關(guān)。17 不平坦地面的疼痛通常與距下關(guān)節(jié)的疾病有關(guān)，而后內(nèi)側(cè)關(guān)節(jié)的疼痛通常由后踝引起。脛骨肌腱功能障礙 (PTTD)，與踝關(guān)節(jié)炎的相關(guān)性較小。17 腓骨下或后外側(cè)踝關(guān)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(nèi)翻/外翻足跟）。醫(yī)生需要注意沿下肢力線、從髖關(guān)節(jié)到膝關(guān)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(shí)前腳掌的位置。在檢查扁平足畸形和 PTTD 患者時(shí)，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(dāng)后足在足跟抬高期間保持外翻時(shí)，可以診斷出固定或第 3 期 PTTD。在這些患者中，通常需要進(jìn)行融合手術(shù)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(guān)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(shí)檢查，CFL 在輕微背屈時(shí)檢查。17 記錄踝關(guān)節(jié)的運(yùn)動(dòng)范圍并進(jìn)行 Silfverskild 試驗(yàn)，檢查跟腱和腓腸肌攣縮。膝關(guān)節(jié)屈曲時(shí)背屈改善表明腓腸肌攣縮，而膝關(guān)節(jié)伸直和屈曲時(shí)背屈受限表明跟腱攣縮。這部分檢查特別重要，因?yàn)樗梢愿淖円粋€(gè)人的手術(shù)計(jì)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(xì)的皮膚和血管檢查記錄脈搏、毛細(xì)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(fēng)濕性關(guān)節(jié)炎或復(fù)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(xué)檢查踝關(guān)節(jié)的平片(X線片)仍然是最初成像方式的金標(biāo)準(zhǔn)。首選腳踝站立片，檢查前后位、mortise位和側(cè)位。如果計(jì)劃將后足或中足的作為手術(shù)治療的一部分，足部的 X 線片也包括在內(nèi)。17 Saltzman 及其同事 2 還關(guān)注后足對齊，以進(jìn)行診斷和手術(shù)計(jì)劃。在坐位中，后足可以通過 Harris位拍攝輕松實(shí)現(xiàn)。最近，一項(xiàng)研究 20 報(bào)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(jì)算機(jī)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(guān)節(jié)、骨不連處的創(chuàng)傷后變化，以及復(fù)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(yùn)動(dòng)偽影的影響。MRI掃描不如X線片和CT更多地用于診斷踝關(guān)節(jié)炎。MRI掃描的主要優(yōu)點(diǎn)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(dǎo)致創(chuàng)傷后關(guān)節(jié)炎發(fā)展的損傷機(jī)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(guān)節(jié)炎可以根據(jù)解剖結(jié)構(gòu)和根本病因進(jìn)行分類。在解剖學(xué)方面，踝關(guān)節(jié)炎可以是廣泛性的（整個(gè)脛距關(guān)節(jié)都受到影響）或局部性的（關(guān)節(jié)面的特定部分受到影響）。 17 踝關(guān)節(jié)炎的根本病因可分為 3 大類：創(chuàng)傷后、骨關(guān)節(jié)炎、和類風(fēng)濕性關(guān)節(jié)炎；Charcot 關(guān)節(jié)病和血色??；或由腫瘤引起的退行性變化。 1 踝關(guān)節(jié)骨關(guān)節(jié)炎可以使用影像學(xué)參數(shù)進(jìn)行分級描述：0期：正常關(guān)節(jié)或軟骨下硬化；1期：存在骨贅但無關(guān)節(jié)間隙變窄（圖 3）；2期：關(guān)節(jié)間隙變窄，有或沒有骨贅；3期：關(guān)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(guān)節(jié)炎的分類進(jìn)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(nèi)可重復(fù)性 (=0.72)。采用COFAS 分期制定了術(shù)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(yù)后與年齡匹配的對照組相比，踝關(guān)節(jié)炎會減少患者每天的總步數(shù)以及高強(qiáng)度步數(shù)，并且與較慢的步行速度相關(guān)。 28 這種情況可能對患者的日常生活（ADL）活動(dòng)產(chǎn)生不利影響。踝關(guān)節(jié)炎的預(yù)后可能是自限性的，但一些患者的活動(dòng)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(guān)節(jié)活動(dòng)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(biāo)控制目標(biāo)是管理疼痛、改善患者的功能和 日?；顒?dòng)ADL，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(xué)策略非甾體抗炎藥解決踝關(guān)節(jié)炎最常見的藥理學(xué)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(fēng)和心血管風(fēng)險(xiǎn)增加。 29 最近的建議側(cè)重于局部使用非甾體抗炎藥，特別是局部骨關(guān)節(jié)炎的高?；颊?。 29 所有患者在開始治療前都需要仔細(xì)篩查合并癥17,29 根據(jù)我們的臨床經(jīng)驗(yàn)，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(zhì)類固醇注射劑和粘性補(bǔ)充劑用皮質(zhì)類固醇注射脛距關(guān)節(jié)仍然是一種最終的非手術(shù)選擇，在NSAIDs治療和活動(dòng)調(diào)整失敗后，患者可以在診室中獲得治療。盡管注射皮質(zhì)類固醇仍然是金標(biāo)準(zhǔn)，但越來越多的研究文章研究了透明質(zhì)酸(玻璃酸鈉注射液)在踝關(guān)節(jié)炎治療中的作用。23,24,30 在最近的一項(xiàng)研究中，31 每周注射 3 次透明質(zhì)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(jìn)。對患者進(jìn)行了長達(dá) 6 個(gè)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(fēng)險(xiǎn)并回答所有問題。這些風(fēng)險(xiǎn)包括注射部位反應(yīng)、感染、關(guān)節(jié)軟骨損傷的風(fēng)險(xiǎn)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(dòng)調(diào)整可能是早期踝關(guān)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(guān)節(jié)炎）、爬坡（前踝關(guān)節(jié)炎）以及使用跑步機(jī)或繼續(xù)保持使用橢圓機(jī)，患者可以達(dá)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(guān)節(jié)的機(jī)械卸載。17 該策略可以通過基于踝關(guān)節(jié)或小腿韌帶的足踝矯形器來實(shí)現(xiàn)。33 系帶式踝關(guān)節(jié)支撐對于經(jīng)歷不穩(wěn)定或機(jī)械錯(cuò)位的患者尤其有效。 1 可以穿帶有實(shí)心腳踝緩沖鞋跟的翹底鞋。34 其他策略包括臨時(shí)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(jì)條件來選擇這些項(xiàng)目。其他非手術(shù)、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(guān)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(shù)技術(shù)當(dāng)患者的保守治療選擇失敗時(shí)，可以考慮手術(shù)治療踝關(guān)節(jié)炎。最常見的手術(shù)選擇包括：1. 踝關(guān)節(jié)鏡；2. 矯正截骨術(shù)；3. 牽引關(guān)節(jié)成形術(shù)；4. 踝關(guān)節(jié)融合術(shù)；5. 全踝關(guān)節(jié)置換術(shù)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(shù)的目標(biāo)類似于非手術(shù)治療：緩解疼痛和改善或穩(wěn)定功能。根據(jù)關(guān)節(jié)炎的分期和位置（全身與局部）以及患者人口統(tǒng)計(jì)數(shù)據(jù)，手術(shù)選擇包括踝關(guān)節(jié)鏡清創(chuàng)術(shù)、踝關(guān)節(jié)上截骨術(shù)、牽引關(guān)節(jié)成形術(shù)、踝關(guān)節(jié)融合術(shù)和全踝關(guān)節(jié)成形術(shù)。 1,17有許多技術(shù)和方法可施行脛距關(guān)節(jié)融合術(shù)，沒有明確的經(jīng)驗(yàn)證據(jù)表明一種技術(shù)在結(jié)果方面優(yōu)于其他技術(shù)。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(guān)節(jié)鏡踝關(guān)節(jié)鏡檢查和清創(chuàng)術(shù)在踝關(guān)節(jié)炎中有多種適應(yīng)癥。身體(韌帶)松弛、早期退行性關(guān)節(jié)炎改變和骨軟骨病變的患者可能適合進(jìn)行關(guān)節(jié)鏡檢查。17 此外，撞擊產(chǎn)生的骨贅通?？梢酝ㄟ^踝關(guān)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(guān)節(jié)鏡檢查的適應(yīng)證：踝關(guān)節(jié)撞擊癥、骨軟骨病變和踝關(guān)節(jié)融合術(shù)后的關(guān)節(jié)鏡檢查。35 禁忌癥包括：單純的晚期踝關(guān)節(jié)炎，而不包括導(dǎo)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(guān)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(guān)節(jié)炎中，可見于部分或完全踝關(guān)節(jié)受累的骨折，踝關(guān)節(jié)上截骨術(shù)可能是有益的。1 內(nèi)翻踝關(guān)節(jié)排列可以采用內(nèi)側(cè)開口楔形截骨術(shù)或外側(cè)閉合楔形截骨術(shù)治療。術(shù)前距骨傾斜度較低 (關(guān)節(jié)炎。未來需要使用長期、高質(zhì)量設(shè)計(jì)的進(jìn)一步研究來指導(dǎo)我們的臨床實(shí)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(guān)節(jié)固定術(shù)脛距關(guān)節(jié)融合術(shù)脛距關(guān)節(jié)固定術(shù)可能是終末期脛距關(guān)節(jié)炎最成熟和研究最充分的手術(shù)治療方法之一。踝關(guān)節(jié)融合的主要指征是對頑固性疼痛或踝關(guān)節(jié)畸形患者的保守治療失敗。1,17 創(chuàng)傷后骨關(guān)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(guān)節(jié)炎、缺血性壞死、病史骨髓炎（非活動(dòng)性）、全踝關(guān)節(jié)置換術(shù)失敗、46,47 脊髓灰質(zhì)炎后綜合征、先天性畸形 17 和類風(fēng)濕性關(guān)節(jié)炎 1。Thomas 和 Daniels1 不建議將關(guān)節(jié)固定術(shù)作為急性創(chuàng)傷的主要挽救手術(shù)。關(guān)節(jié)固定術(shù)的主要優(yōu)點(diǎn)之一是手術(shù)成功后疼痛緩解的可靠性。此外，關(guān)節(jié)固定術(shù)減少了對植入物或硬件移除的需求。踝關(guān)節(jié)融合術(shù)可以通過開放式、關(guān)節(jié)鏡或使用 Ilizarov 技術(shù)來完成。不管用于融合腳踝的特定方法如何，成功手術(shù)的最重要因素是腳踝位置和軟組織處理。 17 關(guān)節(jié)固定術(shù)中的踝關(guān)節(jié)位置 目前接受的踝關(guān)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(cè)肢體旋轉(zhuǎn)的外旋位置。在足跟著地時(shí)，正常步態(tài)下中足跖屈 10。49 腳踝融合在中立位置時(shí)，允許發(fā)生這種運(yùn)動(dòng)。馬蹄足的融合導(dǎo)致足跟撞擊時(shí)步態(tài)異常的發(fā)展，因?yàn)橹凶悴荒鼙城?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(shí)融合。該策略具有通過自然旋前機(jī)制改進(jìn)推離的理論優(yōu)勢。 軟組織處理 軟組織處理在進(jìn)行關(guān)節(jié)融合術(shù)時(shí)至關(guān)重要。該過程包括小心牽開，并在每一個(gè)機(jī)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(hù)皮神經(jīng)，有計(jì)劃的切口和細(xì)致的解剖技術(shù)是最重要的。對于前關(guān)節(jié)切開術(shù)，腓淺神經(jīng)的分支最危險(xiǎn)，而外側(cè)入路和外踝周圍的腓腸神經(jīng)處于危險(xiǎn)之中。 內(nèi)固定與外固定 內(nèi)固定仍然是大多數(shù)患者關(guān)節(jié)固定術(shù)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(nèi)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(nèi)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(xiàng)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€(gè)優(yōu)點(diǎn)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(xué)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(qiáng)度。56,57 在骨質(zhì)減少的病例中，在前外側(cè)和前內(nèi)側(cè)位置使用2塊鋼板的選擇可能會提供更好的固定強(qiáng)度和融合率。58 在1項(xiàng)Cadaver研究中，58 與使用單個(gè)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(cè)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(gè)交叉螺釘可提高剛度。59 我們機(jī)構(gòu)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(jìn)一步增強(qiáng)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(shù)。Holt 及其同事 52 描述了使用 3 顆螺釘和腓骨截骨術(shù)。Kish 及其同事 62 描述了一種使用空心螺釘固定的技術(shù)。這種技術(shù)允許在導(dǎo)針的幫助下放置 3 到 4 個(gè)螺釘，以確保滿意的對齊和矯正整個(gè)融合部位的畸形應(yīng)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(yīng)癥是活動(dòng)性感染期間和軟組織受損的患者。1此外，在嚴(yán)重的骨質(zhì)疏松癥中，可能會減少螺釘?shù)氖褂煤腿诤喜课坏膽?yīng)力，外固定架可能是首選方式。1 這該技術(shù)允許在可耐受的情況下立即負(fù)重，并可用作補(bǔ)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(nèi)固定與外固定與外固定相比，內(nèi)固定有幾個(gè)優(yōu)點(diǎn)，包括更高的融合率和減少對患者的不便。50 內(nèi)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(nèi)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(guān)節(jié)融合術(shù)后的步態(tài)分析Thomas 和 Daniels1 對有關(guān)步態(tài)周期變化的要點(diǎn)進(jìn)行了全面審查?？傮w而言，踝關(guān)節(jié)融合術(shù)后步行時(shí)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(guān)節(jié)置換術(shù)目前，美國食品和藥物管理局 (FDA) 批準(zhǔn)了四種用于全踝關(guān)節(jié)置換術(shù)的器械：Agility、Salto、Scandinavian全踝關(guān)節(jié)置換術(shù) (STAR) 和 INBONE。第三代全踝關(guān)節(jié)置換術(shù)正在使用中。踝關(guān)節(jié)置換術(shù)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(guān)節(jié)置換物是活動(dòng)平臺，而在美國境內(nèi)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(guān)節(jié)置換術(shù)的適應(yīng)癥當(dāng)前的挑戰(zhàn)之一是該程序的適應(yīng)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(shù)患者是經(jīng)過數(shù)月保守治療失敗并患有晚期踝關(guān)節(jié)退行性疾病的成年患者。應(yīng)滿足以下先決條件：(1)有足夠的血管流向遠(yuǎn)端；(2) 足踝周圍有足夠的軟組織包膜，以允許傷口愈合和術(shù)后開始物理治療和踝關(guān)節(jié)在一定范圍內(nèi)運(yùn)動(dòng)。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(guān)節(jié)置換術(shù)的禁忌癥全踝關(guān)節(jié)置換術(shù)的禁忌癥包括感染、距骨骨壞死、嚴(yán)重力線不正、軟組織受損、嚴(yán)重踝關(guān)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(jìn)行全踝關(guān)節(jié)置換術(shù)。這些研究人員還建議，足部畸形需要在關(guān)節(jié)成形術(shù)時(shí)或之前進(jìn)行處理和治療，因?yàn)樽悴炕螘?dǎo)致早期植入失敗。嚴(yán)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(guān)節(jié)置換術(shù)時(shí)解決。對于先前在中足或后足進(jìn)行過融合手術(shù)的患者尤其如此（圖7）。全踝關(guān)節(jié)置換術(shù)的類型（全踝關(guān)節(jié)置換術(shù)可以根據(jù)幾個(gè)不同的參數(shù)進(jìn)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(dòng)。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(guān)節(jié)置換Agility踝關(guān)節(jié)置換是一個(gè)帶有固定平臺的兩部分組件的設(shè)計(jì)系統(tǒng)。這是一個(gè)半限制裝置，允許60次運(yùn)動(dòng)。71 這種設(shè)計(jì)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(jié)構(gòu)，具有多孔涂層距骨。Claridge 和 Sagherian 72 回顧了 Agility 踝關(guān)節(jié)的一些中期結(jié)果。AOFAS評分從術(shù)前到術(shù)后分別從34.9提高到76.4。研究人員擔(dān)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(dòng)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(guān)節(jié)置換術(shù)）。其他研究報(bào)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(guān)節(jié)置換系統(tǒng)最有希望的結(jié)果包括 85% 的 10 年生存率。75 距下關(guān)節(jié)炎的發(fā)病率為19%，16%的患者患有進(jìn)行性距舟關(guān)節(jié)炎。72 在 8% 的患者中，看到關(guān)節(jié)不愈合。76 Salto 這是自 1997 年以來在歐洲使用的移動(dòng)平臺的踝關(guān)節(jié)置換系統(tǒng)（圖 8）。該系統(tǒng)包括一個(gè)用釘固定的錐形距骨和一個(gè)帶棘突固定的扁平脛骨組件。70 一項(xiàng)研究報(bào)告了6.8 年 65% 的存活率，該研究包括92名患者的96個(gè)植入物。導(dǎo)致再次手術(shù)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(guān)節(jié)假體(生物型)（圖 9）。該系統(tǒng)包括一個(gè)圓柱形距骨和一個(gè)扁平脛骨組件。78 它于 2009 年 5 月 27 日獲得 FDA 批準(zhǔn)。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(dòng)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(zhǔn)。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(gè)髓內(nèi)柄。80 這種設(shè)計(jì)特征需要在透視下進(jìn)行髓內(nèi)鉆孔和用于手術(shù)的專用腳架。這種名為 Prophecy 的假體的新設(shè)計(jì)形式已經(jīng)面市。使用這種假體，患者術(shù)前踝關(guān)節(jié)CT掃描，可用于3D打印，以制作患者特定設(shè)計(jì)，從而減少手術(shù)時(shí)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(guān)節(jié)置換術(shù)與踝關(guān)節(jié)融合術(shù)(踝關(guān)節(jié)固定術(shù))在特定的患者組中，與踝關(guān)節(jié)固定術(shù)相比，全踝關(guān)節(jié)置換術(shù)可能獲得安全、等效的結(jié)果，甚至可能導(dǎo)致與融合術(shù)相比的功能改善。66,80 Haddad 及其同事 67 研究了全踝關(guān)節(jié)置換術(shù)和關(guān)節(jié)固定術(shù)之間的差異。該檢查包括 852 名全踝關(guān)節(jié)置換患者和 1262 名踝關(guān)節(jié)融合患者。踝關(guān)節(jié)置換術(shù)后總體翻修率為7%，與踝關(guān)節(jié)融合術(shù)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(guān)節(jié)置換患者需要膝關(guān)節(jié)下截肢(BKA)，而踝關(guān)節(jié)融合組為5%。67 與關(guān)節(jié)固定術(shù)相比，踝關(guān)節(jié)置換術(shù)的運(yùn)動(dòng)范圍也可能得到改善。78 與踝關(guān)節(jié)固定術(shù)相比，踝關(guān)節(jié)置換術(shù)的相鄰關(guān)節(jié)的退行性關(guān)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(shù)并發(fā)癥在所有足部和踝關(guān)節(jié)開放手術(shù)中，淺表和深部感染仍然是一個(gè)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(xì)致的軟組織處理、減少牽開器的力量和時(shí)間，同時(shí)關(guān)閉伸肌支持帶來解決和預(yù)防。1 該策略在全踝關(guān)節(jié)置換術(shù)中尤為重要，因?yàn)閭诹验_可能會導(dǎo)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(guān)節(jié)置換術(shù)的并發(fā)癥Moeckel 及其同事 50 將踝關(guān)節(jié)固定術(shù)最常見的并發(fā)癥描述為“骨不連、延遲愈合、應(yīng)力性骨折、感染”。骨不連或假關(guān)節(jié)的發(fā)生率從 0% 到 41% 不等。4,17,53 在其他幾項(xiàng)研究中，據(jù)報(bào)道骨不連率低于 10%。84,85 吸煙是最公認(rèn)的導(dǎo)致骨不連的因素之一。吸煙可導(dǎo)致骨不連的風(fēng)險(xiǎn)增加 4 倍。86 與骨不連有關(guān)的其他因素包括感染、不遵守術(shù)后負(fù)重限制、距骨缺血性壞死和外科醫(yī)生手術(shù)操作技術(shù)。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(xiǎn)因素。后足和中足的神經(jīng)血管損傷和鄰近關(guān)節(jié)的關(guān)節(jié)炎也有報(bào)道。1 距下關(guān)節(jié)退行性變的放射學(xué)證據(jù)經(jīng)?？梢姡R床上通常無癥狀。1 在隨訪7年研究時(shí)，可觀察到距下骨關(guān)節(jié)炎發(fā)生率高達(dá) 30% 。87 雖然同側(cè)足部經(jīng)常受累，但同側(cè)膝關(guān)節(jié)似乎不受與踝關(guān)節(jié)融合相關(guān)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(guān)節(jié)鏡手術(shù)的并發(fā)癥關(guān)節(jié)鏡融合術(shù)中最常見的并發(fā)癥是植入物相關(guān)性疼痛，導(dǎo)致二次手術(shù)移除。17,88 在一項(xiàng)針對 42 名患者的研究中，Crosby 及其同事 89 檢查了關(guān)節(jié)鏡下關(guān)節(jié)融合術(shù)的并發(fā)癥，其中包括不愈合 (7%)、醫(yī)源性骨折 (4.8%)、關(guān)節(jié)鏡穿刺部位感染 (9.5%) 和植入物相關(guān)性疼痛 (9.5%)，以及距下關(guān)節(jié)疼痛 (9.5%)，總體并發(fā)癥發(fā)生率為55%。在最近的文獻(xiàn)綜述分析中，對 244 名患者的 90 項(xiàng)結(jié)果進(jìn)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(guān)節(jié)置換術(shù)的并發(fā)癥最常見的全踝關(guān)節(jié)置換術(shù)失敗的并發(fā)癥和原因包括無菌性松動(dòng)、力線不齊和深部感染 (1%)。79,91 在一項(xiàng)文獻(xiàn)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(dòng)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(gè)加速因素。1 之前已經(jīng)提出了關(guān)于全踝關(guān)節(jié)置換術(shù)中力線問題的指南。1 這些指南包括仔細(xì)檢查術(shù)前 X 光片以確定后足的外翻/內(nèi)翻畸形。在踝關(guān)節(jié)置換術(shù)時(shí)解決這些問題對于確保假體的使用壽命至關(guān)重要。獲取全長站立片以尋找膝關(guān)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(yuǎn)端畸形進(jìn)行踝關(guān)節(jié)上方截骨術(shù)。92 全踝關(guān)節(jié)置換術(shù)的失敗會給患者帶來嚴(yán)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(guān)節(jié)融合術(shù)相比，在踝關(guān)節(jié)置換術(shù)期間進(jìn)行更廣泛的截骨，并且修復(fù)流程和搶救選項(xiàng)必須考慮到這種減少的骨量。這種情況在全踝關(guān)節(jié)置換術(shù)（包括關(guān)節(jié)置換翻修術(shù)、踝關(guān)節(jié)融合術(shù)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(guān)節(jié)置換術(shù)向踝關(guān)節(jié)融合術(shù)的轉(zhuǎn)化，Haddad 和他的同事 67 報(bào)告了 5.1 % 的轉(zhuǎn)化率，Stengel 及其同事報(bào)告了 6.3%的轉(zhuǎn)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(diào)整、復(fù)發(fā)全踝關(guān)節(jié)置換術(shù)和踝關(guān)節(jié)融合術(shù)都可以減輕(踝關(guān)節(jié))疼痛并改善患者(踝關(guān)節(jié))功能。在最近的一項(xiàng)研究中，成功的手術(shù)與患者體重指數(shù)的下降無關(guān)，這些患者被歸類為超重或肥胖。96 對于全踝關(guān)節(jié)置換術(shù)，預(yù)期的翻修手術(shù)無需更換假體，已被許多足踝外科醫(yī)生接受為現(xiàn)實(shí)。這些再次手術(shù)可能包括骨囊腫切除、由于疼痛或撞擊而導(dǎo)致的外側(cè)或內(nèi)側(cè)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(xì)胞沉降率和C反應(yīng)蛋白等實(shí)驗(yàn)室標(biāo)記物進(jìn)行感染檢查。 如果這些測試結(jié)果為陰性，可以考慮全踝關(guān)節(jié)置換翻修術(shù)，同時(shí)考慮骨量和軟組織條件。骨質(zhì)溶解和聚乙烯磨損會影響全踝關(guān)節(jié)置換術(shù)（圖10）。Coughlin 及其同事 17 建議對溶骨性病變進(jìn)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(fù)假體。對于踝關(guān)節(jié)融合術(shù)，癥狀在12個(gè)月后持續(xù)存在，需要檢查可能的骨不連或感染。如果結(jié)果為陰性，CT掃描成像可以闡明細(xì)微的骨不連，而這可能在平片上不明顯。內(nèi)翻或外翻畸形愈合可以通過閉合楔形截骨術(shù)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(guān)節(jié)的相鄰關(guān)節(jié)關(guān)節(jié)炎可以通過距下關(guān)節(jié)融合術(shù)解決，盡管Coughlin 及其同事 17標(biāo)準(zhǔn)的一枚螺釘固定方法可能不足以用于先前存在的踝關(guān)節(jié)融合術(shù)的患者。如果患者既往踝關(guān)節(jié)置換術(shù)失敗、踝關(guān)節(jié)融合失敗以及距下關(guān)節(jié)出現(xiàn)晚期退行性變，可能的挽救手術(shù)是脛距融合術(shù)。97 該手術(shù)可以通過逆行髓內(nèi)釘實(shí)現(xiàn)脛距關(guān)節(jié)融合，同時(shí)使用距下關(guān)節(jié)的互鎖螺釘或刀片機(jī)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(bào)告。術(shù)中骨折也有報(bào)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(jié)本文回顧了踝關(guān)節(jié)炎的診斷和治療選擇。圖12提供了踝關(guān)節(jié)炎不同階段的治療選擇流程圖。目前非手術(shù)治療的標(biāo)準(zhǔn)包括使用非甾體抗炎藥、皮質(zhì)類固醇注射、矯形器或踝關(guān)節(jié)支具。其他方式，包括透明質(zhì)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(zhì)量的研究來清楚地描述其使用的適當(dāng)性和有效性。終末期退行性關(guān)節(jié)炎手術(shù)干預(yù)的金標(biāo)準(zhǔn)仍然是踝關(guān)節(jié)固定術(shù)，但越來越多的證據(jù)表明，全踝關(guān)節(jié)置換術(shù)在功能結(jié)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(zhǔn)確的決定，并且通過更多前瞻性的高質(zhì)量研究，可以確定最適合全踝關(guān)節(jié)置換術(shù)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(guān)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(guān)節(jié)前后位X線片。內(nèi)側(cè)骨贅被圈出。這是具有退行性變的第 1 階段踝關(guān)節(jié)的示例，存在無關(guān)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(guān)節(jié)的前后位 X 線片。關(guān)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(guān)節(jié)融合術(shù)。使用 3 枚部分空心螺釘固定技術(shù)。在軟骨被剝除并準(zhǔn)備好融合骨床后，進(jìn)行力線校正。使用克氏針進(jìn)行初始固定，然后是 (1) 內(nèi)側(cè)到外側(cè)：內(nèi)側(cè)到外側(cè)方向，從上到下瞄準(zhǔn)。導(dǎo)針在透視下保持在原位。測深尺進(jìn)行測量。使用此螺釘?shù)膲|圈將螺釘置于受壓狀態(tài)。退出導(dǎo)絲。(2)從前到后：從脛骨前方進(jìn)入距骨后方。(3)聯(lián)合螺釘：為了增加穩(wěn)定性，做一個(gè)外側(cè)小切口，將外側(cè)腓骨置于內(nèi)側(cè)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(guān)節(jié)融合術(shù)。使用3枚部分空心螺釘固定技術(shù)。術(shù)后16周的X線片。注意到橫跨踝關(guān)節(jié)的實(shí)心融合塊，具有完整的骨性結(jié)構(gòu)(注：踝關(guān)節(jié)融合成功的標(biāo)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(guān)節(jié)炎，之前有中足融合，距下關(guān)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(guān)節(jié)。在這種情況下，距下關(guān)節(jié)和足中關(guān)節(jié)融合并穩(wěn)定。這種情況使我們能夠通過踝關(guān)節(jié)置換術(shù)解決外翻畸形以及脛距關(guān)節(jié)的終末期關(guān)節(jié)炎，而不是脛距融合術(shù)。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(guān)節(jié)置換術(shù)。這是一個(gè)活動(dòng)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(gè)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(guān)節(jié)置換術(shù)。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(guān)節(jié)炎患者的右踝關(guān)節(jié)Mortise位X線片，既往切開復(fù)位內(nèi)固定腓骨和脛骨。踝關(guān)節(jié)置換術(shù)，外側(cè)和內(nèi)側(cè)有廣泛的骨質(zhì)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(guān)節(jié)病的踝關(guān)節(jié)炎。涉及脛距、距下和中足關(guān)節(jié)。還存在內(nèi)翻畸形。這種畸形可以通過脛距融合術(shù)解決。顯示了術(shù)前 (A) 和術(shù)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(guān)節(jié)炎不同階段的治療方案流程圖。TTC，脛距融合術(shù)。2021年06月20日2858
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朱文輝副主任醫(yī)師 復(fù)旦大學(xué)附屬華山醫(yī)院 運(yùn)動(dòng)醫(yī)學(xué)科 剛下手術(shù)就看到一條新聞，新聞上說北京時(shí)間6月14日，籃網(wǎng)與雄鹿的比賽進(jìn)行到第二節(jié)還有六分鐘的時(shí)候，NBA球員歐文上來落地時(shí)右腳踩到巨部的右腳上，導(dǎo)致了右腳踝受傷。如果我們碰到這種情況，為了讓傷情控制在最小范圍內(nèi)，急性期的處理很重要，主要是遵循一個(gè)防外側(cè)原則，我們應(yīng)該立即保護(hù)受傷部位，讓受傷部位開動(dòng)休息，立即冰敷，抬高受傷部位的肢體，及時(shí)進(jìn)行安全的轉(zhuǎn)運(yùn)。2021年06月15日855
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趙會副主任醫(yī)師 北京朝陽醫(yī)院 骨科 韌帶撕裂可以發(fā)生在任何關(guān)節(jié)，但最常見的發(fā)生在腳踝、膝蓋或手腕關(guān)節(jié)。多數(shù)韌帶撕裂都有局部壓痛，可伴局部疼痛、腫脹、瘀斑、肌肉痙攣、肌肉無力等，如果大關(guān)節(jié)不穩(wěn)定則提示韌帶斷裂比較嚴(yán)重（或脫位，可能自發(fā)修復(fù)）。韌帶撕裂一般是指關(guān)節(jié)內(nèi)外韌帶由于各種力量被拉扯或發(fā)生撕裂，多是由于外界損傷突然迫使關(guān)節(jié)活動(dòng)超出其正常范圍而引起的。屬于韌帶損傷的一種。急性韌帶撕裂是在外力的作用下，突然迫使關(guān)節(jié)運(yùn)動(dòng)超出其正常范圍而不能代償?shù)臅r(shí)候發(fā)生的。如果出現(xiàn)韌帶撕裂傷后，首先應(yīng)該到醫(yī)院去，讓醫(yī)生做臨床查體，同時(shí)還要拍一張核磁共振片，通過醫(yī)生的查體和核磁共振片來明確韌帶撕裂的程度，當(dāng)腳踝韌帶撕裂后，治療方法可分為兩種。第一種是保守治療，保守治療主要是針對腳踝韌帶損傷不嚴(yán)重，沒有影響到踝關(guān)節(jié)的穩(wěn)定性，是這個(gè)時(shí)候選擇保守治療，保守治療主要是給予石膏或者支具托外固定。另外，局部腫脹者，可對癥的給予一些消腫止痛的藥進(jìn)行治療，一般固定三周左右韌帶，就可以修復(fù)，然后拆除石膏或者支具，逐步行功能鍛煉。第二種，如果是腳踝韌帶撕裂比較嚴(yán)重，影響到踝關(guān)節(jié)的穩(wěn)定性，那么這個(gè)時(shí)候往往需要手術(shù)治療。手術(shù)可行韌帶的修補(bǔ)術(shù)，韌帶修補(bǔ)后，予石膏或支具托外固定四周到六周的時(shí)間，然后拆除石膏，逐步行功能鍛煉。2021年05月26日2580
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趙會副主任醫(yī)師 北京朝陽醫(yī)院 骨科 第一步，如果崴到腳，腳踝立刻就腫脹，而且很痛，建議首先到醫(yī)院拍張片子看一下有沒有傷到骨頭。如果是傷到骨頭，要聽從醫(yī)生的進(jìn)行治療。如果沒有傷到骨頭，就可以在家進(jìn)行下面的處理了。第二步，如果是輕微的扭傷，也不要太不當(dāng)一回事了。崴到的這只腳暫時(shí)不要活動(dòng)，最好把它架起來防止再次活動(dòng)造成損傷。第三步，取冷水，用毛巾對崴到的部位進(jìn)行冷敷。這是在崴到腳的一天之內(nèi)，敷五到六為宜。這是為了把毛細(xì)血管內(nèi)的出血盡快控制住。第四步，如果比較痛，可以使用一些噴霧來幫助止痛，有一些還能幫助止血。第五步，一天過后就可以開始進(jìn)行熱敷了。其實(shí)這個(gè)流程也是有名的R.I.C.E.處理原則，也就Rest(休息),Ice（冰敷）,Compression（壓迫）,Elevation(抬高)的首字母。當(dāng)然，后來RICE發(fā)展為PRICE，加入了P（Protection,保護(hù)），即避免患處再次受傷。再后來發(fā)展為POLICE，即去掉了Rest(休息)，改為OL（optimalloading,最適符合），鼓勵(lì)指利用合適的康復(fù)設(shè)施（如彈力繃帶、石膏、拐杖等）提供最佳的機(jī)械負(fù)荷。一般來說，輕度踝扭傷，可用彈力繃帶固定踝關(guān)節(jié)2-4周，重度損傷者需用U型石膏或硬性支具固定踝關(guān)節(jié)包括小腿一個(gè)月，利于韌帶修復(fù)。并進(jìn)行適當(dāng)?shù)目祻?fù)訓(xùn)練。所以，繼續(xù)回到時(shí)間線上，在約3天之后，腳大概可以下地行走，便應(yīng)該使用彈力繃帶，護(hù)具等保護(hù)并提供最佳負(fù)荷，進(jìn)行早期的康復(fù)鍛煉。2021年05月25日814
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趙會副主任醫(yī)師 北京朝陽醫(yī)院 骨科 崴腳這種事情，在所難免。那如何最快的康復(fù)呢？我整理了一個(gè)時(shí)間線。第0小時(shí)：超級痛，此時(shí)你需要休息，從球場下來，停止繼續(xù)運(yùn)動(dòng)。第1小時(shí)，沒那么疼了，但你的腳踝開始肉眼可見的腫脹，此時(shí)應(yīng)該立即冰敷。沒有冰怎么辦？廚房凍著的肉，牛奶都可以替代。注意冰敷的時(shí)候裹上一層毛巾，每次十分鐘，一小時(shí)一次。同樣的第1小時(shí)，第一次冰敷后就加壓包扎，用繃帶（秋褲，女朋友的絲襪，彈力褲）加壓包扎腳踝。第4小時(shí)，從球場回了家，盡量不要活動(dòng)崴傷的腳，回家后繼續(xù)之前的冰敷和加壓包扎，并抬高腳踝，高于心臟。不要到處走動(dòng)。第12小時(shí)，要睡覺了。冰敷和加壓包扎繼續(xù)，晚上睡覺的時(shí)候墊幾個(gè)枕頭在腳下，維持腳高于心臟。今晚最痛了，可以吃點(diǎn)布洛芬緩解疼痛。不要走動(dòng)，不要下床。第24小時(shí)～48小時(shí)，次日醒來，看情況而定，如果還在繼續(xù)腫脹，則可以延長休息，冰敷和抬高的時(shí)間。再過一個(gè)24小時(shí)候應(yīng)會逐漸好轉(zhuǎn)。48小時(shí)之后，可以按摩，熱敷和使用跌打損傷藥啦，也可以嘗試慢慢活動(dòng)腳踝，進(jìn)行功能性康復(fù)。這樣下來差不多一周左右，主要是早期（前六小時(shí)一定要休息，冷敷+加壓包扎，前24小時(shí)重復(fù)這些行為），否則容易在腫脹期出現(xiàn)二次損傷，讓崴腳遷延不愈。其實(shí)這個(gè)流程也是有名的R.I.C.E.處理原則，也就Rest(休息),Ice（冰敷）,Compression（壓迫）,Elevation(抬高)的首字母。當(dāng)然，后來RICE發(fā)展為PRICE，加入了P（Protection,保護(hù)），即避免患處再次受傷。再后來發(fā)展為POLICE，即去掉了Rest(休息)，改為OL（optimalloading,最適符合），鼓勵(lì)指利用合適的康復(fù)設(shè)施（如彈力繃帶、石膏、拐杖等）提供最佳的機(jī)械負(fù)荷。一般來說，輕度踝扭傷，可用彈力繃帶固定踝關(guān)節(jié)2-4周，重度損傷者需用U型石膏或硬性支具固定踝關(guān)節(jié)包括小腿一個(gè)月，利于韌帶修復(fù)。并進(jìn)行適當(dāng)?shù)目祻?fù)訓(xùn)練。所以，繼續(xù)回到時(shí)間線上，在約3天之后，腳大概可以下地行走，便應(yīng)該使用彈力繃帶，護(hù)具等保護(hù)并提供最佳負(fù)荷，進(jìn)行早期的康復(fù)鍛煉。如這些：(1)足趾屈伸活動(dòng)：一天可進(jìn)行數(shù)次，每次20-30個(gè)。(2)股四頭肌靜力性練習(xí)：仰臥位，雙下肢伸直，患側(cè)大腿繃緊，6-10秒/個(gè)，30個(gè)/次，6-10次/日。(3)腘繩肌等長練習(xí)：仰臥位，下肢伸直，患側(cè)膝關(guān)節(jié)下墊小枕頭，用力下壓枕頭，6-10秒/個(gè)，30個(gè)/次，6-10次/日。2021年05月19日1829
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沈彤主治醫(yī)師 天津中醫(yī)藥大學(xué)第一附屬醫(yī)院 推拿科 外傷后可千萬別熱敷，今天來了一位老患者，一瘸一拐的來了，就是在兩天之前啊，下樓的時(shí)候扭傷了踝關(guān)節(jié)，他順帶了拉傷了小腿腓腸肌的肌肉，他的一個(gè)好心的朋友呢，對他進(jìn)行了一個(gè)局部的按摩，當(dāng)時(shí)呢，覺得好點(diǎn)了，但是今天已經(jīng)是走路都費(fèi)勁了，這個(gè)問題可以說是老生常談了，但是很多患者朋友還是不太清楚，就是在出現(xiàn)這種輕度的扭傷拉傷，還沒有損傷骨骼的情況下，在開始到24到48小時(shí)之間，一定要先進(jìn)行冷敷，這樣才可以減少局部毛細(xì)血管的滲血，開始這兩天還要注意避免局部的過度活動(dòng)，在兩天之后呢，可以進(jìn)行一下熱敷，貼膏藥或者一些按摩的手法治療，這個(gè)時(shí)候局部的滲血已經(jīng)停止了，才適合進(jìn)行一下熱敷，改變局部的血液循環(huán)，加快它的恢復(fù)，如果過早的熱敷按摩，活動(dòng)局部的關(guān)節(jié)和肌肉的話，反而會加重局部的腫脹，甚至產(chǎn)生血。 這個(gè)大家一定要注意。2021年05月14日666
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趙會副主任醫(yī)師 北京朝陽醫(yī)院 骨科 腳踝扭傷在日常生活中很常見，有些人走路走著走著就不小心崴到腳了，就會造成腳踝扭傷，對于腳踝扭傷，我們一般該怎么處理呢？在通常情況下，腳踝扭傷分為三個(gè)病理期，分別為炎癥期、增生期和重建期。我們先來說炎癥期，炎癥期就是所謂的腳踝有了炎癥，它會出現(xiàn)變紅、發(fā)熱、疼痛、腫脹，就是我們平常所說的“紅腫熱痛”，這個(gè)時(shí)期一般會維持4-7天左右的時(shí)間，這時(shí)候我們應(yīng)該采取制動(dòng)處理，就是不要患處受力，在48-72小時(shí)內(nèi)采取冰敷，時(shí)間過后采取熱敷的方法進(jìn)行處理，促進(jìn)水腫的消散，在休息的時(shí)候需要抬高患肢，同時(shí)還需要及時(shí)去醫(yī)院進(jìn)行影像學(xué)檢查，避免腳踝骨折等可能。在炎癥期過后的5周，就是我們所說的增生期，在增生期的時(shí)候，腳踝周圍受傷的纖維組織會進(jìn)行自我生長和重建，在這個(gè)期間我們可以進(jìn)行適當(dāng)?shù)挠?xùn)練，如足背屈等動(dòng)作，當(dāng)然這些訓(xùn)練需要在無痛的狀態(tài)下進(jìn)行，避免二次傷害。在增生期過后的半年內(nèi)，我們就到達(dá)了我們的重建期，重建期的患者這時(shí)候是差不多已經(jīng)恢復(fù)了正常運(yùn)動(dòng)的，我們這時(shí)需要注重身體本體的感受和平衡穩(wěn)定能力，可以適當(dāng)?shù)倪M(jìn)行相關(guān)的運(yùn)動(dòng)，促進(jìn)腳踝部位的康復(fù)。對于腳踝扭傷的患者來說，康復(fù)以后需要注意一些事項(xiàng)，防止二次扭傷，比如運(yùn)動(dòng)前需要做適當(dāng)?shù)纳煺埂⒆⒁庹_的姿勢，必要時(shí)需要訓(xùn)練自身的平衡能力，同時(shí)穿適合自己的鞋、護(hù)具也能預(yù)防腳踝的扭傷。2021年05月14日1377
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