● 经典的开放Gould-Broström术式一直被视为治疗慢性踝关节不稳的金标准
● 研究发现,慢性踝关节不稳的患者常常合并有关节内的其他病变,需要一并处理(Ferkel报道占93%,Hintermann报道占66%)
● 大多数学者提倡对每个慢性踝关节不稳患者都应进行关节镜探查
资料来源:
Komenda, GA, Ferkel, RD. Arthroscopic findings associated with the unstable ankle. Foot Ankle Int, 1999, 20(11):708 – 713.
Hintermann B, Boss A, Schafer D. Arthroscopic findings in patients with chronic ankle instability. Am J Sports Med, 2002, 30(3):402–409.
● 据文献报道,Hawkins最先采用Staple在距骨侧紧缩距腓前韧带获得了良好的效果(特别感谢香港亚洲专科江少华教授提供原文)
资料来源:
Hawkins RB. Arthroscopic stapling repair for chronic lateral instability. Clin Podiatr Med Surg, 1987, 4(4):875–883.
Corte-real, NM, Moreira RM. Arthroscopic repair of chronic lateral ankle instability. Foot & Ankle International, 2009, 3(3): 213-217.
● 经前内侧入路观察,经前外侧入路进行清理和置入锚钉,经前外侧辅助入路做韧带复合体缝合修复(经皮操作)
资料来源:
Corte-real, NM, Moreira RM. Arthroscopic repair of chronic lateral ankle instability. Foot & Ankle International, 2009, 3(3): 213-217.
● 关节镜经前外侧入路监视,经前外侧辅助入路置锚钉,小切口缝合修复韧带残端和伸肌支持带
资料来源:
Nery C, Raduan F, Del Buono A, et al. Arthroscopic-assisted Broström-Gould for chronic ankle instability: a long-term follow-up. Am J Sports Med, 2011, 39(11):2381-8.
● 经前内侧入路监视,经前外侧入路缝合韧带残端并使用无结锚钉挤压固定
资料来源:
Vega J. All-inside arthroscopic lateral collateral ligament repair for ankle instability with a knotless suture anchor technique. Foot Ankle Int, 2013, 34(12):1701-9.
● 经前内侧入路监视,经前外侧入路置入锚钉,采用缝线套索装置经皮缝合伸肌支持带
资料来源:
Cottom JM, Rigby RB. The 'All Inside' Arthroscopic Broström Procedure: A Prospective Study of 40 Consecutive Patients. J Foot Ankle Surg, 2013,52(5): 568-74.
● 经内侧中线入路(胫前肌腱内侧)监视(视野更好),经前外侧辅助入路置入锚钉(置钉方向更合理),采用2-0尼龙线穿过18号注射器针头作为缝线套索,来穿刺缝合韧带残端
● 作者术中并不常规做清理,而是通过术前MRI来判断关节内病损情况
资料来源:
Matsui K, Takao M, et al. Arthroscopic Broström repair with Gould augmentation via an accessory anterolateral port for lateral instability of the ankle. Arch Orthop Trauma Surg, 2014, 134(10):1461–1467.
● 经前内侧入路监视,经前外侧入路置入锚钉,采用缝合钩经皮缝合伸肌支持带,并提出“安全区”概念
资料来源:
Acevedo JI. Arthroscopic Brostrom Technique. Foot & Ankle International, 2015, 36(4): 465–473.
● 经前内侧入路监视,经皮缝合伸肌支持带,经前外侧入路在腓骨远端制作骨隧道,将伸肌支持带固定至腓骨远端
资料来源:
Lui TH. Modified arthroscopic Brostrom procedure. Foot Ankle Surg, 2015, 21(3):216–219.
资料来源:
Takao M, Matsui K, Stone JW, et al. Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle. Knee Surg Sports Traumatol Arthrosc, 2016, 24(4):1003–1006.
一项临床非随机对照研究结果(三级证据):
● 镜下修复和开放修复术后一年随访结果没有显著差异
● 镜下修复术后恢复更快
资料来源:
Matsui K, Takao M, Miyamoto W, et al. Early recovery after arthroscopic repair compared to open repair of the anterior talofibular ligament for lateral instability of the ankle. Arch Orthop Trauma Surg, 2016. 136(1):93-100.
一项临床随机对照研究结果(一级证据):
● 镜下修复和开放修复获得临床和影像学结果没有显著差异
● 镜下修复应合理选择患者
资料来源:
Yeo ED, Lee KT, Sung IH, et al. Comparison of all-inside arthroscopic and open techniques for the modified broström procedure for ankle instability. Foot Ankle Int, 2016, 37(10):1037-45.
生物力学测试结果显示镜下修复和开放修复没有显著差异:
资料来源:
Lee YK. All‑inside arthroscopic modified Broström operation for chronic ankle instability: a biomechanical study. Knee SurgSports Traumatol Arthrosc, 2016, 24(4):1096–1100.
关于单纯修复ATFL是否足够,一项生物力学测试(ATFL only VS ATFL+CFL)结果显示:
● 两组结果并没有显著差异
● 修复ATFL残端足矣
资料来源:
Lee KT, Lee JI, Sung KS, et al. Biomechanical evaluation against calcaneofibular ligament repair in the broström procedure: a cadaveric study. Knee Surg Sports Traumatol Arthrosc, 2008, 16(8):781-786.
单纯修复ATFL的解剖学依据
● ATFL、CFL与距跟韧带之间有筋膜连接
资料来源:
van Dijk. Ankle Arthroscopy. Springer.2014.
关于是否必须做IER加强缝合,研究结果显示:
● 结果并没有显著差异
● 是否做IER加强需要考虑ATFL残端的质量(术中探查情况)以及是否存在IER的变异情况
资料来源:
Behrens SB, Drakos M, Lee BJ, et al. Biomechanical analysis of Brostrom versus Brostrom-Gould lateral ankle instability repairs. Foot Ankle Int, 2013, 34(4):587-92.
目前的循证医学证据包括:
● 目前有关踝关节慢性不稳定微创手术的证据多为低等级证据(IV-V级)
● 大多数研究中每种微创手术方式的适应症并不清楚
● 采用镜下修复方式需要考虑的因素是韧带残端质量
● 绝大多数有关镜下修复的文献中报道仅修复ATFL,部分采用IER加强(Gould-Broström)
● 广泛采用的方式是锚钉修复,技术多种多样
● 广泛采用的方式是经前外侧辅助入路置钉和缝合韧带残端
资料来源:
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