【作者】 丁晶；

【导师】 徐达传；

【作者基本信息】 第一军医大学 ， 人体解剖学， 2001， 博士

【摘要】 研究目的 研究踝关节外侧韧带和距下关节韧带的形态特点及其临床意义，踝关节外侧韧带和距下关节韧带损伤的生物力学机理，评价应力试验X光片、CT、MRI和关节镜对踝关节外侧韧带和距下关节韧带损伤的诊断价值。 材料与方法 1．经防腐处理、灌注乳胶的成人小腿足标本32侧，观测踝关节外侧韧带、距下关节韧带和用作移植的肌腱和韧带的起、止、走行和长、宽、厚。小腿动脉铸型标本4侧，墨汁灌注小腿标本1侧，动脉造影1例观测踝部血管网。干骨标本25侧，观测跗骨窦形态特点。 2．新鲜小腿足标本8侧，3侧选取足体表标志和标志点间连线为标志线，解剖定位韧带。5侧用于研究后足的手术入路和模拟韧带损伤修复重建术。 3．新鲜小腿足标本7侧置于MTS实验机上，4侧踝跖屈15°，3侧踝背屈10°，在5秒内压力逐渐增加到1000N，使踝、距下关节内翻，观察韧带内翻损伤的过程。新鲜踝关节标本6侧，踝关节固定在中立位，置于三维运动试验机上，测量距下关节韧带切断前后的活动度。 4．新鲜小腿标本8侧，保留胫腓连结和骨间膜的完整，置于SWD10实验机上，以1mm/min的速度施加载荷，记录胫腓连结切断前和切断后用普通螺丝钉、拉力螺丝钉和“U”形钉固定的活动度。 5．在MTS上以内翻暴力造成踝关节外侧韧带、距下关节韧带损伤的小腿足标本6侧，行前抽屉试验、内翻应力踝穴位、Merrill位拍摄X光片和关节镜检查，2侧标本行踝、距下关节CT、MRI扫描。标本解剖检查作为金标准对照影像检查结果。踝关节外侧韧带损伤患者4例，拍摄前抽屉试验、内翻应力试验踝穴位、Merrill位X光片和CT检查，与手术探查对照。 结 果 ①距胖前韧带起自外踝尖前上 Icm的范困内，韧带向远内侧行，与内、外踝连线成26”～30”角，与外踝尖至第5 M骨基底的连线成50”角，止于距骨颈外上颈韧带止点上4mm处：跟胖韧带起自外踝尖端，与用滑纵线成 130“～145“角，与外踝至跟鲢止点连线成 20”角，向内、后、远侧走行，止于跟骨外侧面中部，止点离距下关节面 12～15nun，韧带向前上的延长线通过外踝前距胖前韧带的起点；颈韧带居附骨窦内，起于跟骨上面的颈峪，呈45”角向上、内行，止于距骨颈下外的结节，距胖前韧带止点下前4nun，韧带延长线外侧通过外踝尖至第5肠骨基底的连线的中点；距跟骨间韧带位于附骨管内，由前、后两束交叉组成，前束附于跟骨前和距骨关节面后方，行向前外，止于距骨颈下面，后束起于跟骨后、距骨关节面前，行向上后外，止于距骨后、跟关节面前，韧带延长线向足背经过内、外踝连线与足纵线的交点，向足底经跷健膜的止点与足纵线在足背的投影线成90”角。小趾趾长伸肌健、第三跳骨肌健、胖骨短肌腾、伸肌下支持带解剖位置恒定，与踝关节外侧韧带和距下关节韧带相毗邻，具有一定的长、宽、厚度，便于移位移植。 ②跑骨窦位于足背外侧，距下关节前后关节面之间，内有伸肌下支持带、颈韧带、距跟骨间韧带和附骨窦动、静脉等，各结构间由脂肪组织填充。 ③踝部血供总体上可以胖骨外侧缘中线、胚骨内侧中线和腿健后面中线分为前区、后外侧区、后内侧区3个区。前区以腔前动脉为主，后外侧区以脓动脉为主，后内侧区以胚后动脉后主，各区之间有丰富的吻合。临床应用17例，创面愈合满意。 ④踝、距下关节在厢屈位内翻时，韧带断裂的顺序是：前距胖韧带一跟脓韧带一颈韧带；背屈位内翻时韧带断裂顺序是：跟胖韧带一距脓前韧带一颈韧带。距下关节在韧带切断后活动度明显加大，与切断前比相差非常显著（P＜0刀1人 2 ⑤腔胖连结正常的生理活动度为：前一后 1．83 i 0．83nun、后一前 L89土0．d0M、外一内1．42士0．34一 内一外1．36士0．65M。用普通 螺丝钉和拉力螺钉固定胜胖连结，外踝的活动明显受限，与正常比较相 差非常显著（p＜0刀1人 用‘儿”形钉固定后，活动度与正常比较相差不：显著（p＞0．05） ③影像检查中前抽屉试验6侧标本5侧阳性，阳性率为83．3％，4 例患者2例阳性，阳性率50％；内翻应力踝穴位片5侧阳性，阳性率为 83．3％，l例患者为假阴性；距下关节韧带损伤，Merr ifl位片阳性率 50％； 经关节镜可检查到距胖前韧带和距跟骨k椰带后束，在新鲜损伤，或关 节囊有撕裂时跟脓韧带可检查到，颈韧带经关节镜难以探查到：2侧标 本、4例患者行 CT检查均无阳性结果；2侧标本 MR检查除 1侧颈韧带 损伤未查到外，其余均为阳性。 结 论 ①踝关节外侧韧带和距下关节韧带结合足体表标志均能精确地解剖 定位?更多还原

【Abstract】 ObjectiveThe purpose of this thesis is to acquire better knowledge of ankle-subtalar ligaments injuries, discuss the anatomy and the clinical significance of ankle-subtalar ligaments, study the mechanism of ankle-subtalar ligaments inversion injuries evaluate the value of stress test plain X-ray film, CT, MRI and arthroscopy in the diagnosis of ankle-subtalar ligaments injuries. Three approaches were used: anatomy, biomechanics and imagine. The knowledge is intended to serve as a basis development of diagnosis and reconstruction of ankle-subtalar ligaments injuries.Materials and MethodsIn the anatomic approach, the ankle lateral ligaments, subtalar ligaments and related reconstructive tendons and ligaments that could be transferred were studied on 32 leg-foot specimens. 25 dry foot bone specimens were used. The artery supply around ankle joint and sinus tarsi were studied in the same time. Several reconstuctive operations were imitated in the cadaver. In the biomechanical approach, 7 cases of fresh-frozen ankle- foot specimens were injured imitated the clinical injury of ankle-subtalar joint inversion in the MTS, the 3-D dimension motion of the subtalar joint of 6 cases of fresh injured specimens in the 3-D motion apparatus, the inferior tibia-fibular syndesmosis injury were studied on 8 cases fresh leg specimens in SWD10 material test apparatus. In the imaging approach, the 6 cases injured ankle-subtalar complexes specimens were examined with X-ray, CT, MRI and arthroscrpy, The results were compared with anatomy of the injured specimens, and 4 cases patients of ankle inversion injured were examined with X-ray, CT compared with found during operation.ResultAnterior talofibular ligament areas of attachments is located in the range 1 cm of superior-anterior lateral malleolus, forward and medially, to the superior-lateral neck of talus, in front of its lateral articular facet. The calcaneofibular ligament, the longest of the three, is a narrow, rounded cord,running from the apex of the fibular malleolus downward and slightly backward to a tubercle on the lateral surface of the calcaneus. It is covered by the tendons of the Peronasi longus and birevis. Cervical ligament extends from the front and lateral surface of the neck of the talus to the superior surface of the calcaneus. It forms the posterior boundary of the talocalcaneonavicular joint, and is sometimes described as the anterior interosseous ligament. The posterior talocalcaneal ligament connects the lateral tubercle of the talus with the upper and medial part of the calcaneus; it include two crass short band, and its fibers radiate from their narrow attachment to the talus.The locations of the extensor longus tendon of little toe, the peroneus brevis tendon, the peroneus tertius tendon and the inferior extensor retinaculum were near the lateral ankle and subtalar ligaments; There were enough of length, width and thickness to reconstruct the lateral ankle and subtalar ligaments.The sinus tarsi is a conical shaped cavity located between the anterosuperior surface of the calcaneus and the inferior aspect of the neck of the talus. It opens laterally, anterior to the fibular malleolus and terminates posteromedially directly behind the sustentaculum tali. The contents of the sinus tarsi include interosseous talocalcaneal ligament and cervical ligament, medial, inferior and lateral roots of the inferior extensor retinaculum,artery and venous of the tarsal canal, filled with fat tissue.The ankle artery supply could be divided into the anterior, lateral- posterior and medial-posterior three areas, there are sufficient communicating branches among three areas.In the ankle-subtalar joint inversion injuries, the Anterior talofibular ligament was injured firstly when ankle was plantarflexion, second was calcaneofibular ligament, when ankle joint was dorsiflexion, calcaneofibular ligament was injured firstly, secondly was talofibular ligament, the last injured in both situation were subtalar ligaments. The 3-D motion of subtalar joint更多还原