各位讀者，大家好！
近期，我們將制作一期來源于「河南足踝」和「山東足踝」的軟組織專輯，該專輯由鄭州市骨科醫(yī)院的王翔宇教授團(tuán)隊和山東大學(xué)第二醫(yī)院的胡勇教授團(tuán)隊，從多年臨床診療和經(jīng)驗積累出發(fā)，針對足踝部軟組織的臨床解剖、影像檢查等基礎(chǔ)知識、軟組織病損的臨床診斷和治療、手術(shù)治療中的術(shù)式及其組合應(yīng)用等，以及臨床典型病例分別進(jìn)行分享。
今天，由山東大學(xué)第二醫(yī)院的胡勇教授團(tuán)隊為大家?guī)淼摹?span>應(yīng)力位X線片在慢性踝關(guān)節(jié)不穩(wěn)中的應(yīng)用」。
本文引用兩篇文獻(xiàn)，復(fù)習(xí)了應(yīng)力位X線片在慢性踝關(guān)節(jié)不穩(wěn)中的應(yīng)用，并討論了應(yīng)力位X片的診斷效能。
前言
慢性踝關(guān)節(jié)不穩(wěn)的診斷，依靠患者自訴的癥狀、查體及輔助檢查手段。
其中，MRI是具有重要的診斷價值，而通過應(yīng)力位X線片中關(guān)節(jié)的非對稱性改變，我們也可以得到間接證據(jù)來輔助診斷。
當(dāng)然，應(yīng)力位X片的診斷價值因其間接性而具有一定的局限性，因而其診斷效能需要進(jìn)行一些討論。
討論
1、應(yīng)力位X線片與MRI中的韌帶損傷有沒有相關(guān)性？
2、應(yīng)力位X線片在診斷韌帶損傷中的準(zhǔn)確性如何？
一、文獻(xiàn)一
1
介紹
The aim of this study was to investigate the relationship between bone morphology and injured ligament of the ankle on imaging studies and laxity of the ankle on ankle stress radiographs in patients evaluated for lateral ankle instability .
Univariate and multiple regression analyses were used to evaluate the correlation between the findings of ankle stress radiographs and structural factors such as the bony configuration and degree of ligament injury around the ankle joint .
2
X線測量
▲Fig. 1 a Distal tibial articular surface angle (DTAS), bimalleolar tilt (BT), medial malleolar relative length (a/c), lateral malleolar relative length (b/c), medial malleolar slip angle (MMSA). b anterior inclination of the tibia (AI), and fibular position (d/e).
▲Fig. 2 Tibiotalar tilt angle on anteroposterior varus stress view a. Anterior translation of the talus on anterior drawer lateral view b.
? 距腓前韌帶-矢狀位
? 跟腓韌帶、距腓后韌帶、三角韌帶-冠狀位
3
分析
▲ Fig. 3 Inclusion and exclusion criteria.
▲ Table 1 Patient demographics.
▲ Table 2 Summary of measurements.
▲ Table 4 Factors affecting ankle stress radiographs by univariate analysis.
▲ Table 5 Factors affecting ankle stress radiographs by multiple regression analysis
According to our results, we may assume that younger female patients, who showed greater bimalleolar tilt angle and more posterior position of the fibula, had a poorer prognosis after ligament reconstruction .
4
結(jié)果和討論
In conclusion, although ankle stress radiographs have been widely used in patients with lateral ankle instability, various potential determinants including bony morphology of the ankle joint have been overlooked during interpretation of the measurements.
Based on our study, age, sex, degree of ATFL injury, and bimalleolar tilt were found to be factors significantly associated with tibiotalar tilt angle on the varus stress view, and the degree of PTFL injury and fibular position were factors significantly associated with anterior translation of the talus on the anterior drawer view.
These results suggest that differences in patient factors including age, sex, and bony anatomical structure of the ankle joint might predispose the outcomes of ankle stress radiographs.
We conclude that comparison of both ankles on stress radiographs is superior to applying fixed numerical values to the injured side in order to reduce the influence of patient factors when assessing surgical indications.
二、文獻(xiàn)二
1
介紹
本文研究了慢性踝關(guān)節(jié)不穩(wěn)病例的距腓前韌帶、跟腓韌帶的MRI影響和應(yīng)力位X線片之間的關(guān)系。
▲Table 1. Demographics of Patients Who Underwent Lateral Ankle Ligament Reconstruction Using Allograft or a Modified Brostrom Procedure.
2
ATFL和CFL的MRI分類
▲Figure 1. Four categories according to the thickness of the ATFL in CLAI patients: (A) normal-thickness ATFL; (B) nonvisualized ATFL; (C) attenuated ATFL; (D) thickened ATFL. ATFL, anterior talofibular ligament; CLAI, chronic lateral ankle instability
▲ Figure 2. Other morphologies of the ATFL observed in MRI of CLAI patients: (A) discontinuity of the ATFL; (B) wavy-shaped ATFL; (C) increased ATFL signal. ATFL, anterior talofibular ligament; CLAI, chronic lateral ankle instability; MRI, magnetic resonance imaging.
▲ Figure 3. Four categories according to the thickness of the CFL in CLAI patients: (A) normal-thickness CFL (B) nonvisualized CFL (C) attenuated CFL (D) thickened CFL. CFL, calcaneofibular ligament; CLAI, chronic lateral ankle instability.
▲ Figure 4. Other morphologies of the CFL observed in MRI of CLAI patients: (A) discontinuity of the CFL; (B) wavy-shaped CFL; (C) increased CFL signal. CFL, calcaneofibular ligament; CLAI, chronic lateral ankle instability; MRI, magnetic resonance imaging.
3
結(jié)果和討論
▲ Table 2. The Overall Incidences of ATFL and CFL Magnetic Resonance Imaging Findings in Chronic Lateral Ankle Instability.
▲Table 3. The Incidences of ATFL and CFL Patterns Based on the Degree of Thickness.
? 在慢性踝關(guān)節(jié)不穩(wěn)病例中，96％的距腓前韌帶和71％的跟腓韌帶存在厚度的異常。其中變薄是最常見的改變。
? 不連續(xù)的病例只有20%，相對于之前報道的急性踝關(guān)節(jié)損傷的病例中不連續(xù)的比例低很多。說明韌帶可以自行修復(fù)。
? 相關(guān)性分析表明抽屜位試驗中距骨前移距離跟韌帶的形態(tài)沒有關(guān)系。
? 內(nèi)翻位距骨傾斜角跟距腓前韌帶和跟腓韌帶的厚度都有關(guān)系。
? 應(yīng)力位X線片距骨傾斜角有助于術(shù)者在術(shù)前制定手術(shù)方式。（直接修復(fù)或重建）
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