2023盘点|足踝运动损伤诊疗新进展

2024-01-22   文章来源:复旦大学附属华山医院运动医学科   作者:李宏云,华英汇 点击量:263 我要说

2023盘点|足踝运动损伤诊疗新进展

作者:李宏云,华英汇

来源:复旦大学附属华山医院运动医学科


足踝运动医学是近年来逐渐兴起并蓬勃发展的新兴学科,主要聚焦于足踝部韧带、肌腱、软骨损伤的诊断和治疗。我们搜索了2023年发表于下述14本杂志中关于足踝运动损伤的相关文献:《American Journal of Sports Medicine》《British Journal of Sports Medicine》《Internal journal of sports medicine》《Arthroscopy : the journal of arthroscopic related surgery》《Knee surgery》《sports traumatology》《arthroscopy》《The Journal of bone and joint surgery (American volume)》《Clinical Orthopaedics and Related Research》《Arthroscopy Foot and Ankle International》《Foot and Ankle Surgery》《Journal of the American Medical Association(JMJA)》《The New England Journal of Medicine》《the Journal of the American Academy of Orthopaedic Association》,并做一综述。共搜索到足踝运动医学相关文献110篇,其中踝关节内外侧副韧带损伤相关文献42篇,跟腱腱病及损伤相关文献26篇,踝关节软骨损伤20篇,下胫腓联合损伤相关文献11篇,跖筋膜炎6篇,其他7篇。从2023年已发表的文献来看,踝关节不稳、内外侧副韧带损伤仍然是研究的热点,占所有文章的38.2%,其次是跟腱腱病及损伤和踝关节软骨损伤,分别占所有发表文章的23.6%和18.2%。值得注意的是,下胫腓联合损伤的诊断,跖筋膜炎的治疗仍然具有相当的关注度。

一、踝关节不稳

1.1 解剖与生物力学

自从有学者将距腓前韧(Anterior Talofibular Ligament,ATFL)分为上束和下束,并认为下束与跟腓韧带(Calcaneal Fibular Ligament,CFL)存在紧密连接之后,相关的解剖和生物力学研究又有了新的进展。Nunes GA等[1]的解剖学研究进一步证实,ATFL下束、CFL、距腓后韧带(posterior talofibular ligament,PTFL)在外踝内侧有一个共同的、连续的止点,其面积约为4.8cm2。Dalmau-Pasto M等[2]的生物力学研究证实,仅仅切断ATFL上束并不会引起显著的踝关节不稳。该研究提示我们,对于ATFL上束损伤的患者,需要更加精细的MRI和临床体检来发现这类患者。这些研究提示我们,在慢性踝关节不稳(Chronic Ankle Instability,CAI)患者的诊断和治疗上,应当注意区分不同类型的亚损伤,并做出相应的治疗方案。

1.2 影像诊断

在CAI的诊断方面,Hong CC等[3]认为,应用3D MRI可精确区分距腓前韧带的上束和下束,这对识别ATFL上束损伤非常有帮助。对于仅存在ATFL上束损伤的“微不稳”患者,我们不能忽视,因为这些“微不稳”患者可能随着时间的推移,出现显著的踝关节慢性不稳,并出现其他踝关节损伤。在一项系统综述和meta分析中,Wijnhoud EJ等[4]研究发现,高达三分之一的慢性踝关节不稳患者会出现软骨损伤。因此,对于慢性踝关节不稳应当引起临床医生的重视,尽量做到早期诊断、早期治疗。

另外,既往的多项研究已证实MRI诊断ATFL和CFL损伤的灵敏度和特异度并不高,因此,有必要采用一些间接的影像学征象,用于提高MRI诊断的准确率。Kim J等[5]发现,在CAI的患者中,ATFL-CFL夹角显著下降(小于100度)。当ATFL-CFL夹角小于70度时,应当考虑同时存在距下关节不稳。超声研究中,Yokoe T等[6]发现,在全身多韧带松弛的年轻人群中,其ATFL 比率(内翻应力位ATFL长度/中立位ATFL长度)高于普通人群。

1.3 手术治疗

在手术治疗方面,大部分学者比较了不同手术技术的临床疗效,有学者还提出了新的手术技术。

在以往的临床实践中,手术治疗主要是针对CAI患者,踝关节急性扭伤的患者首先考虑保守治疗,3-6个月保守治疗无效再考虑手术治疗。Hong CC等[7]随访了147名外侧副韧带三度损伤并在急性期行手术修复的精英运动员,最少随访2年。他们的研究结果发现,这些精英运动员在术后9-10周可重返运动,平均69天可恢复伤前运动水平,再次扭伤率仅为2%。他们认为,对于存在踝关节外副韧带三度损伤的精英运动员可考虑急性期修复手术。

虽然开放手术仍然被认为是治疗慢性踝关节不稳的金标准,但其地位逐渐受到关节镜手术的挑战,越来越多的临床医生开始采用关节镜下外侧副韧带修复或重建技术。Guelfi M等[8]五年的临床随访发现,全关节镜下踝关节外侧副韧带修复治疗CAI可获得与开放手术相当、甚至更好的临床疗效。他们认为,外科医生应当逐步考虑采用关节镜下外侧副韧带修复或重建术。Su T[9]等研究发现,与切开手术相比,全关节镜下外侧副韧带重建患者可更早负重、更早恢复活动,同时在术后3-6个月时疼痛程度更低、临床评分更佳。另外研究也发现,对于特殊类型的病人,比如需求较高[10]、全身多韧带松弛[11]、肥胖[12]的病人,关节镜下外侧副韧带修复和切开手术相比,无论在临床疗效和术后影像学比较上均无差异。Cao S等[13]研究证实,关节镜下外侧副韧带修复术可明显改善患者术后的动态平衡稳定性和肌肉激活状态。Mortada-Mahmoud A等[14]的研究也发现,关节镜下ATFL修复术可获得良好的临床疗效。Feng SM等[15]的研究则发现,关节镜下ATFL修复时无论采用1枚还是2枚双线锚钉,均可获得良好的临床疗效。该研究提示我们,在行关节镜下ATFL修复术时,使用1枚双线锚钉进行缝合即可达到良好的临床功能。Guo H等[16]的研究发现,关节镜下ATFL修复术采用Lasso‑loop技术和单纯缝合术在临床功能评分、病人满意度、关节稳定性、并发症发生率以及MRI表现方面均无明显差别。他们认为,在行ATFL修复术时,采用单纯缝合技术即可获得满意的临床疗效。

除了关节镜与开放手术的比较外,近年来采用线带增强技术(Internal-brace)来修复ATFL也是大家关注的焦点之一。Comfort SM等[17]一项随访五年的研究发现,线带增强技术与常规修复相比,在CAI患者术后的满意度及功能评分方面均无明显差异。这项研究提示,除了特殊人群(全身多韧带松弛、肥胖、运动需求较高等),在普通CAI患者中,同时行Internal-brace增强重建并无必要。

在外侧副韧带重建技术方面,也有相关研究发表。Wang Z等[18]提出了一种新的重建ATFL的手术技术。他们应用部分自体腓骨短肌腱双束重建ATFL,并获得了良好的临床疗效。他们认为双束重建技术是一种更加符合解剖的ATFL重建技术。但这项技术在临床开展可能存在一定难度,需要更长时间和更大样本量的临床研究来评估其临床有效性和可重复性。Liu CX等[19]的一项尸体研究证实,在解剖重建踝关节外侧副韧带时,腓骨骨道与腓骨纵轴呈45度时损伤腓骨肌腱的风险最低,同时也可获得满意的隧道长度。Wang A等[20]的尸体研究发现,下胫腓联合前韧带下束可作为关节镜下外侧副韧带解剖重建的标志点,ATFL、CFL以及这二条韧带的联合中点距下胫腓联合前韧带下束最低点的距离分别为6.0到7.1mm、11.5到13.2mm、9.0到10.0mm。

除此以外,有不少学者还关注了影响踝关节稳定术临床疗效的一些相关因素。

Su T等[21]发现,在CAI手术患者中,下胫腓联合的宽度与临床疗效存在明显负相关。在踝关节外侧副韧带修复后,当下胫腓联合的宽度大于4mm时,提示临床疗效相对较差。他们认为,对于这类患者,可能需要同时行下胫腓联合稳定术。Xiong S等[22]发现,存在距骨侧撕脱骨折的ATFL损伤患者,解剖修复韧带后术后疼痛会更加严重,但临床疗效与无撕脱的患者相比并无显著差异。Yoshimoto K等[23]发现,后足内翻的患者行踝关节稳定术后临床评分会较低。该研究提示我们,术前对患者进行精细的评估是获得良好的临床疗效的基础。Yoshimoto K等[24]应用MRI和关节镜评估ATFL的质量。他们发现,MRI T2系列上ATFL表现为高信号的患者,其手术后的复发率要高于低信号的患者,另外,关节镜下韧带明显松弛的患者,其术后复发率也较高。他们认为,应当重视术前的MRI评估和关节镜下ATFL的残端质量。Luthfi APWY等[25]的研究发现,ATFL残端质量较差、术前运动水平低、未对CFL损伤进行处理是踝关节外侧副韧带修复术失败主要危险因素。Li H等[26]的研究发现,对于存在旋转不稳的CAI患者,同时行三角韧带修复可获得更好的临床疗效。

二、跟腱腱病及相关损伤

2.1 急性跟腱断裂

对于急性跟腱断裂,保守还是手术治疗仍然存在一定争议。Hansen MS等[27]的一项研究将急性跟腱断裂患者随机分成三组,第一组根据哥本哈根跟腱断裂治疗守则(Copenhagen Achilles Rupture Treatment Algorithm,CARTA)进行处理,根据B超检查结果采取手术或保守治疗。如果B超检查发现跟腱断端重叠小于25%或断端重叠大于25%但跟腱延长超过7%(与对侧相比),则考虑手术治疗,否则考虑保守治疗。第二组行保守治疗。第三组采用手术治疗。结果发现,三组患者在术后1年时踝关节肌力、步态、跟腱延长方面均无明显差异。Seow D等[28]的一项系统综述与重叠meta分析共纳入了34项meta分析,他们发现,手术治疗的再次断裂率明显低于保守治疗,但并发症的发生率(肥肠神经损伤与伤口感染)要显著高于保守治疗。Attia AK等[29]在一项meta分析中比较了开放与小切口技术治疗急性跟腱断裂临床疗效。他们共纳入了10项随机对照研究,结果发现,开放手术的手术时间更长,浅表感染及踝关节僵硬的发生率更高;而小切口技术腓肠神经麻木的发生率更高。两者的再断裂率和功能评分无明显差异。Stake IK等[30]比较了经皮技术与切开技术治疗急性跟腱中段断裂,发现两者在功能评分与患者满意度及再断裂方面无显著差异。DeShazo S等[31]的研究证实,尼古丁依赖患者在跟腱修补术后伤口感染与不愈合的风险要显著增加。

跟腱断裂后腓肠肌延长是影响患者功能恢复的并发症之一。Hong CC等[32]采用自体半腱肌重建技术治疗腓肠肌延长,随访2年,获得了满意的临床疗效和功能评分。他们将自体半腱肌对折,近端固定于腓肠肌腱腹结合部,远端固定于跟骨。作者认为这项技术是一项安全可靠的技术。

手术技术方面,Chuckpaiwong B等[33]的生物力学研究发现,开放Krackow修复技术相比经皮非锁边技术的强度更高,多次循环后缝合断端之间形成的间隙更小。这项研究提示我们,开放Krackow修复技术在术后早期可以进行更加积极的康复训练。

2.2 慢性跟腱断裂

超过4周的跟腱断裂即为慢性跟腱断裂,有不同的手术技术进行治疗,包括V-Y翻瓣、肌腱移植、踇长屈肌腱转位术等。Xu T等[34]采用关节镜辅助下改良Krackow结合V-Y翻瓣技术治疗慢性跟腱断裂,29例病人随访两年,获得了满意的临床疗效。Mafulli N等[35]的一篇系统综述评估了肌腱移植治疗慢性跟腱断裂的临床疗效和重返运动能力。他们纳入了22篇文献,368名患者,术后可获得良好的功能评分,78.1%的患者完全恢复运动。Yoshida K等[36]、Schneebeli A等[37]发现可将超声波弹性成像技术应用于评估跟腱断裂后的愈合情况,为临床制订个性化的康复方案提供科学依据。

2.3 跟腱腱病

对于跟腱止点行腱病,有截骨术、止点重建术等不同手术技术。有学者比较了各种手术技术的临床疗效。Poutoglidou F等[38]的一项系统综述与meta分析证实,Zadek截骨术治疗跟腱止点性腱病可获得良好的临床疗效,同时并发症的发生率也较低。Karaismailoglu B等[39]的一项meta分析比较了背侧闭合跟骨截骨与止点重建术治疗跟腱止点性腱病的临床疗效,发现两者的临床疗效和并发症发生率无明显差异。Purnell J等[40]采用腓肠肌松解术治疗跟腱止点性腱病,可获得良好的临床疗效,并发症的发生率与再手术率都较低。Tay AYW等[41]采用跟腱中间纵行劈开术行跟腱清理和Haglund畸形切除术,随访2年,可获得良好的临床疗效。

三、软骨损伤

距骨软骨损伤的治疗方法包括骨髓刺激术、骨软骨移植术、胶原支架填充术等,不同的作者报道了他们的临床研究结果。

Bachir RM等[42]的一项系统综述评估了骨髓抽吸浓缩技术(Bone Marrow Aspirate Concentrate)治疗距骨软骨损伤,发现可获得良好的临床疗效、改善功能、减轻疼痛。Rikken QGH等[43]评估了关节镜下骨髓刺激术治疗距骨软骨损伤的疗效。51例患者平均随访8.8年,可获得良好的临床疗效。损伤面积与疼痛评分正相关,而双极损伤并不影响临床疗效。Huang M等[44]的一项系统综述与meta分析发现,微骨折术联合PRP注射可获得良好的临床疗效。Chen X等[45]发现,距骨骨囊肿会影响骨髓刺激术的临床疗效。当囊肿面积大于90.91mm2、深度大于7.56mm、体积大于428.13mm3时,提示临床疗效不佳。

Winkler PW 等[46]评估了自体骨软骨移植治疗距骨软骨损伤的长期疗效。35例患者最小随访18年,可获得较好的临床疗效,20年生存率达到80%,他们认为这项技术是一项安全、有效的手术技术。对于不同部位的距骨软骨损伤,其临床疗效可能存在差异。Choi SM等[47]比较了自体骨软骨移植治疗距骨内侧和外侧软骨损伤的临床疗效。他们发现,内侧距骨软骨损伤术后需要更长时间恢复,同时发生骨关节炎的风险更高。Amouyel T等[48]的一项多中心研究则发现,术前踝关节活动度更好的距骨软骨损伤患者术后的功能评分更好。Li Y等[49]采用带骨膜自体骨移植治疗伴有巨大骨囊肿形成的距骨软骨损伤,75例患者平均随访6.3年,可获得良好的临床疗效。Dahmen J等[50]采用带骨膜的髂骨移植治疗距骨软骨损伤,随访2年后获得良好的临床疗效,所有移植物均存活。Huber T等[51]采用逆向钻孔联合自体植骨术治疗2-3期距骨软骨损伤,平均随访89个月,可获得良好的临床疗效。

Vannini F等[52]采用胶原支架结合微骨折术治疗距骨软骨损伤,101例患者最小随访10年,可获得良好的临床疗效。作者同时也发现,随着时间推移,患者的满意度会有所下降。Rikken QGH等[53]采用关节镜下Lift-Drill-Fill-Fix(LDFF)技术治疗距骨软骨损伤,平均随访7年,获得了良好的临床疗效。

Buck TMF等[54]的系统综述评估了保守治疗距骨软骨损伤的临床疗效。30例研究、868例患者纳入,中位随访37个月。保守治疗的有效率为45%, 9-12%的患者会出现影像学进展。

四、下胫腓联合损伤

下胫腓联合损伤的诊断一直较为困难。在过去的一年,不少学者提出了更加精确诊断下胫腓联合损伤的方法。Mei N等[55]提出一种诊断慢性下胫腓联合损伤的方法。他们应用带气囊的支具固定于下胫腓联合处,当气囊充气后患者稳定性得到改善,则提示患者可能存在下胫腓联合损伤。Hagemeijer NC等[56]则提出可采用便携式超声诊断下胫腓联合损伤。他们在尸体研究中证实,当踝关节施加4.5Nm的外旋应力时,即可测量到2.6mm的间隙。Peiffer M等[57]提出了在负重位CT上施加外旋应力的方法,发现可提高诊断下胫腓联合损伤的精确性。Chans-Veres J等[58]、Rodrigues JC等[59]的研究也证实,负重位CT联合施加踝关节旋转应力可提高诊断下胫腓联合损伤的精确性。Borjali A等[60]则认为,采用电脑深度学习的方法可提高负重位CT诊断慢性下胫腓联合损伤的精确性。Bhimani R等[61]通过尸体研究证实,考虑到下胫腓联合韧带的走向,在关节镜下评估下胫腓联合稳定时,探勾应当向后倾斜15°来测量下胫腓间隙宽度。

手术技术方面,Baumbach SF等[62]通过CT研究,提出了采用可调袢钢板固定下胫腓联合时骨隧道钻取的方向。他们认为,腓骨侧的安全区位于腓骨外侧骨皮质。胫骨侧安全区位于胫前肌腱后内侧与胫后肌腱沟前方之间。Dong QY等[63]介绍了一种新的弹性固定下胫腓联合损伤的手术技术。他们在胫骨上钻取一前一后两个平行的骨隧道,随后将一根高强线穿过两个隧道,环抱腓骨后进行打结固定。67例患者平均随访37个月,临床评分与影像学表现均明显改善。

五、足底筋膜炎

关于足底筋膜炎,大部分学者关注的焦点还是治疗方面。Ruiz-Hernández IM等[64]比较了肉毒素与PRP注射治疗足底筋膜炎的临床疗效。他们发现,两者均能改善疼痛症状,肉毒素在治疗早期(1月)效果更佳,而PRP在长期(1年)时效果更佳。Koz G等[65]则比较了低剂量激光与冲击波治疗足底筋膜炎的临床疗效。他们的研究结果显示,两者均能改善患者功能、减轻疼痛,低剂量激光在减轻疼痛方面效果更佳。Sugino Y等[66]的研究则发现,拉伸练习可明显改善跖筋膜的弹性。该项研究提示我们拉伸练习在治疗足底筋膜炎的重要作用。

Riiser MO等[67]的一项随机对照研究显示,在随访6年后,近端腓肠肌内侧头松解联合拉伸锻炼比单纯跖筋膜拉伸的临床疗效更佳。Sanchez T等[68]也发现,腓肠肌松解可显著减轻慢性足底筋膜炎患者的疼痛,并获得满意的临床评分。Johannsen T等[69]的研究提示,内镜下跖筋膜松解1年后,可改善足部应力及临床症状。

六、其他

Paget LDA 等[70]的随机对照研究显示,与安慰剂相比,RPP注射一年后并不能改善踝关节退行性关节炎的症状和功能评分。他们的另外一项的系统综述与meta分析[71]也提示,玻璃酸钠、PRP、肉毒素注射均不能改善踝关节炎患者的临床疗效。Nishimura A等[72]的一项影像学研究发现,腓骨短肌肌腹较小、腓骨肌腱沟肌肉容积增加是引起腓骨肌腱脱位的风险因素,腓骨肌腱沟的骨性形态与腓骨肌腱脱位无明显相关。Desomer L等[73]采用PRP注射联合行走靴固定治疗慢性胫前肌腱腱病,随访12周,发现可明显改善患者的临床功能、减轻疼痛。

总结

在2023年,足踝运动医学聚焦于CAI、距骨软骨损伤、跟腱损伤及跟腱腱病等常见疾病的诊断、治疗及不同手术方式的比较,为今后的研究、诊断及治疗提供了新的思路。

作者简介

华英汇,主任医师,教授,博士生导师,复旦大学附属华山医院运动医学科主任

学术任职:国家卫健委职业健康司职业病诊断与技术指导委员会委员,中华医学会运动医疗分会委员,中国医师协会运动医学医师分会委员,中国康复医学会运动健康与产业发展分会副主任委员,上海医师协会运动医学医师分会副会长等。

获国家科技进步二等奖(排名第2)、中华医学科技二等奖、第二届国之名医、上海市优秀人才计划、上海市临床康复优秀学科带头人等荣誉称号及奖项。担任AP-SMART副主编、J-ISAKOS副主编、ASM、OJSM、Sports·Health(Am)Burns&·Trauma、《中国运动医学杂志》等多本杂志编委。

李宏云,主任医师,医学博士,硕士生导师

学术任职:中国医师协会骨科医师分会关节镜学组委员兼秘书,中华医学会运动医疗分会足踝工作委员会常务委员兼青年委员会副主任委员,中华医学会运动医疗分会下肢创伤学组委员,中国骨科菁英会运动医学专业委员等。

获得上海康复医学科技奖二等奖、中国体育科学学会科学技术奖三等奖、上海中西医结合科学技术奖三等奖等奖项。以第一作者或通讯作者发表论文40余篇,其中SCI收录论文17篇,参编、参译专著4部,独立承担3项科研基金,并作为主要成员参加4项国家自然科学基金的研究工作。

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