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宋斌副主任醫(yī)師 中山六院 關(guān)節(jié)外科/運(yùn)動(dòng)醫(yī)學(xué)科 專家簡(jiǎn)介：宋斌，副主任醫(yī)師，醫(yī)學(xué)博士，師從李衛(wèi)平教授，現(xiàn)任職于中山大學(xué)孫逸仙紀(jì)念醫(yī)院運(yùn)動(dòng)醫(yī)學(xué)科。擅長(zhǎng)運(yùn)動(dòng)醫(yī)學(xué)，關(guān)節(jié)鏡，四肢關(guān)節(jié)運(yùn)動(dòng)損傷及康復(fù),尤其對(duì)膝關(guān)節(jié)、髖關(guān)節(jié)、踝關(guān)節(jié)運(yùn)動(dòng)損傷的診斷以及治療。崴腳太常見了，據(jù)統(tǒng)計(jì)百分之就是以上的人都有過崴腳的經(jīng)歷。但是崴過腳以后的康復(fù)情況卻有很大差別，一般說來有幾種情況。1、受傷比較輕，適當(dāng)控制或者休息后好轉(zhuǎn)；2、受傷稍嚴(yán)重，經(jīng)過藥物、支具固定等好轉(zhuǎn)；3、以上兩種情況表面好轉(zhuǎn)，但是出現(xiàn)頻繁崴腳；4、從第一次崴腳就一直不好，反復(fù)疼痛腫脹；其中大約有六成的人屬于1、2，也就是百分之六十的人在經(jīng)過治療后可以達(dá)到較好效果，剩下四成可能有不同的癥狀是什么造成這些差別？1、肯定是受傷程度，崴腳引起踝關(guān)節(jié)周圍韌帶損傷，有時(shí)候還有骨折，一般程度越重恢復(fù)越慢；2、是否經(jīng)過妥善治療，一般來說踝關(guān)節(jié)周圍韌帶一旦損傷雖然非常難自愈，但是通過妥善治療很多可以恢復(fù)踝關(guān)節(jié)穩(wěn)定性，所以早看早好，不能拖延3、治療的周期是否足夠，很多扭傷經(jīng)過休息制動(dòng)后很快就可以消腫，很多人就以為好了，該干啥干啥，高跟鞋又穿上了，結(jié)果造成二次損傷，要知道韌帶組織生長(zhǎng)通常需要6周以上的時(shí)間，所以要進(jìn)行足夠時(shí)間的治療；4、康復(fù)不夠，很多人受傷了以為就是養(yǎng)，等于不動(dòng)，其實(shí)這也是認(rèn)識(shí)上的誤區(qū)，合理積極的康復(fù)才能加快恢復(fù)。要想好得快，千萬(wàn)不要諱疾忌醫(yī)2021年09月13日
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張耀國(guó)康復(fù)師 北京康復(fù)醫(yī)院 骨科中心 腳踝扭傷不是病，痛起來卻要人命！相信不少人都有過腳踝扭傷的慘痛經(jīng)驗(yàn)。扭傷要好得快，首先要做的是冰敷而非熱敷，再搭配適度的腳踝運(yùn)動(dòng)，消除水腫瘀青，水腫一消扭傷自然恢復(fù)得快。 此外，由于韌帶拉傷至少需要1個(gè)月的時(shí)間，才能夠完全恢復(fù)，若扭傷后沒有適當(dāng)保護(hù)患處，還去推拿按摩，萬(wàn)一出問題，恐怕會(huì)拉長(zhǎng)復(fù)原時(shí)間。 韌帶彈性不佳 快速大力拉扯易撕裂 如果將腳踝內(nèi)翻外翻，各做一次，就會(huì)發(fā)現(xiàn)內(nèi)翻比外翻要容易一些，這是因?yàn)槟_踝外翻時(shí)，受到較大的韌帶限制。而韌帶是連接兩塊骨頭的結(jié)締組織，主要是用來穩(wěn)定結(jié)構(gòu)，不具任何收縮能力。 韌帶是連接兩塊骨頭之間的結(jié)締組織，主要是用來穩(wěn)定結(jié)構(gòu)，不具任何收縮能力 換句話說，韌帶就像是卡車上用來固定貨物的繩索一樣，因此韌帶的彈性不佳，只要發(fā)生意外事故，如踩到別人的腳，或是下樓梯時(shí)不平衡跌倒，都會(huì)使腳踝受到快速且大力的拉扯，讓韌帶像是支撐不住重量的繩子一樣，產(chǎn)生嚴(yán)重的撕裂傷。輕則單條韌帶撕裂，導(dǎo)致腳踝外側(cè)腫脹瘀青；重則多條韌帶撕裂，腳踝內(nèi)外側(cè)與背側(cè)都瘀青；再嚴(yán)重一點(diǎn)的，韌帶全斷或骨折，必須要手術(shù)。 在進(jìn)行戶外運(yùn)動(dòng)時(shí)，不可避免會(huì)發(fā)生運(yùn)動(dòng)損傷，踝關(guān)節(jié)扭傷在運(yùn)動(dòng)損傷中發(fā)生率最高，占所有運(yùn)動(dòng)損傷的40%以上，當(dāng)發(fā)生這種狀況時(shí)，我們?cè)撛趺刺幚恚? 請(qǐng)謹(jǐn)記 POLICE原則 崴腳之后如何康復(fù)訓(xùn)練？ 經(jīng)過了一段時(shí)間養(yǎng)傷，炎癥是減輕了，但腳踝的靈活性、穩(wěn)定性、力量難以通過養(yǎng)傷養(yǎng)好，還需要進(jìn)行康復(fù)訓(xùn)練。被動(dòng)休息治療結(jié)合主動(dòng)康復(fù)訓(xùn)練才能最大限度恢復(fù)受損的功能。 Step1 鍛煉踝關(guān)節(jié)的靈活性（傷后1周左右開始） 如果沒有骨折等問題，受傷后48～72小時(shí)以后，就要開始進(jìn)行簡(jiǎn)單的康復(fù)訓(xùn)練。長(zhǎng)時(shí)間休息不活動(dòng)會(huì)導(dǎo)致腳踝關(guān)節(jié)粘連、肌肉萎縮、力量下降等一系列并發(fā)癥。首先需要做的是放松小腿及踝關(guān)節(jié)附近緊張的肌肉，恢復(fù)關(guān)節(jié)靈活性。 轉(zhuǎn)腳踝練習(xí) 初期小范圍踝關(guān)節(jié)環(huán)繞練習(xí)。移動(dòng)腳踝完成整個(gè)范圍內(nèi)的運(yùn)動(dòng)（上下，前后，繞環(huán)），整個(gè)過程中保證腿部不動(dòng)，只移動(dòng)腳踝，可以想象在寫字，如圖： 提踵練習(xí) 提踵能夠提高踝關(guān)節(jié)的穩(wěn)定性和靈活性。 足尖寫字練習(xí) 用腳拇指當(dāng)做鉛筆寫字。移動(dòng)踝和足，在地板上字母。小腿伸直，膝關(guān)節(jié)和踝關(guān)節(jié)不要伸直。這字母開始較小，隨著踝關(guān)節(jié)功能的改善就會(huì)變得大了。 Step2 鍛煉小腿肌肉軟組織的力量 崴腳本身就跟腳踝力量不足有關(guān)，因此，恢復(fù)腳踝力量是康復(fù)最重要的環(huán)節(jié)之一。腳踝力量練習(xí)需要做以下練習(xí)，但一定記住遵循“無(wú)痛原則”，只要感覺疼痛就立馬停止。 勾腳尖練習(xí) 雙腳做勾腳尖動(dòng)作，盡可能勾腳至最大幅度，可重復(fù)30～50次，直至小腿前側(cè)有酸脹感。 提踵離心練習(xí) 找一個(gè)臺(tái)階或者凳子，腳前掌踩在上面，做快起慢落的練習(xí)，要求提踵1～2秒，而還原落下6～8秒。找一個(gè)臺(tái)階或凳子的目的是讓腳跟懸空，下落時(shí)可以讓腳跟落至低于腳前掌的位置。 抗阻勾腳練習(xí) 以彈力帶為阻力，遠(yuǎn)端固定(或握在手中)，套在腳上，從伸直位盡量用力勾到屈曲位，稍作停頓，慢慢放開，反復(fù)做20次，休息30秒，共做4-6組，每天1-2次。 外翻練習(xí) 坐在床上或凳子上，用皮筋（腳踝訓(xùn)練帶）套住兩腳，患腳用力外翻，反復(fù)做15次，休息30秒，共做4-6 組，每天1-2 次； 內(nèi)翻練習(xí) 姿勢(shì)同抗阻足外翻，皮筋在遠(yuǎn)端固定，用力內(nèi)翻，數(shù)量和要求同抗阻踝外翻。 Step3 平衡能力訓(xùn)練 當(dāng)腳踝具有了一定力量，接下來就可以進(jìn)行平衡能力訓(xùn)練。平衡訓(xùn)練本質(zhì)就是腳踝穩(wěn)定性訓(xùn)練。需要注意的是，平衡訓(xùn)練本身具有一定危險(xiǎn)性，一定是從低難度開始，循序漸進(jìn)。 ?靜態(tài)平衡1級(jí)難度：睜眼雙手側(cè)平舉單腳站立，目標(biāo)60秒； ?靜態(tài)平衡2級(jí)難度：睜眼雙手抱胸前單腳站立，目標(biāo)45秒； ?靜態(tài)平衡3級(jí)難度：閉眼雙手抱胸前單腳站立，目標(biāo)20秒。 站在平衡軟踏上，腿伸直，挺胸抬頭，重心盡量往上提，用一條腿的力量控制身體平衡，每次3-5分鐘，休息30秒，共做2-3次每組，1-2組每天。如果力量尚不能保證安全，可以在身旁尋求他人或扶手保護(hù)。如果力量很好完成無(wú)困難，可以手持重物完成動(dòng)作或在板\墊上0至45度半蹲起以增加難度。 訓(xùn)練要持之以恒，盡管很枯燥，甚至很痛苦，但堅(jiān)持鍛煉后所獲得的結(jié)果收益會(huì)讓你為既往的付出感動(dòng)欣慰。 練習(xí)目標(biāo)：走路穩(wěn)定、輕快，才能停止。 預(yù)防腳踝扭傷四注意 對(duì)于腳踝曾扭傷過的人來說，預(yù)防再度扭傷非常重要。在平時(shí)的工作、生活和運(yùn)動(dòng)中，孫得海主任醫(yī)師提醒大家注意以下四點(diǎn)，可大大減少踝關(guān)節(jié)扭傷的幾率。 1. 合適的鞋子：鞋子介于人體腳板與地面之間，緩沖下肢對(duì)地面間的沖擊力，提供下肢適當(dāng)?shù)姆€(wěn)定性與貼地性。在運(yùn)動(dòng)之時(shí)，適宜選擇鞋底柔軟的高幫鞋。 2. 良好的場(chǎng)地：良好場(chǎng)地的維護(hù)往往比選擇一雙合適的鞋子更重要。因此在運(yùn)動(dòng)前，要認(rèn)真清除運(yùn)動(dòng)場(chǎng)地上的磚瓦、石塊、沙礫，填平坑洼。 3. 腳踝的保護(hù)：運(yùn)動(dòng)前需做充分的準(zhǔn)備活動(dòng)，當(dāng)踝關(guān)節(jié)充分活動(dòng)開以后，再進(jìn)行劇烈的活動(dòng)；跑步、跳高、滑冰、打球等要講究正確的姿勢(shì)，不要用力過猛，防止腳掌內(nèi)外翻，要使整個(gè)腳掌平著落地。 4. 加強(qiáng)功能鍛煉：再多外在的保護(hù)，不如自己有能力控制預(yù)防腳踝扭傷的再發(fā)生。所以，平時(shí)要注重踝關(guān)節(jié)周圍肌肉的鍛煉，增強(qiáng)踝關(guān)節(jié)的穩(wěn)定性。如經(jīng)常練習(xí)負(fù)重提重、提重蹲跳、上下坡跑步及踮著腳尖走路。這些練習(xí)可增強(qiáng)踝關(guān)節(jié)的力量，預(yù)防腳踝反復(fù)扭傷。 【注意事項(xiàng)】 在康復(fù)過程中，如果出現(xiàn)以下一些情況，需要及時(shí)來醫(yī)院就診，以免耽誤病情： 1）急性扭傷后腫痛非常明顯，且伴有大量皮膚瘀青，有明顯壓痛和活動(dòng)受限； 2）休息制動(dòng)后腫痛慢慢消退，但是走路活動(dòng)多時(shí)會(huì)有疼痛，伴關(guān)節(jié)腫脹（在不平的地面或樓梯上活動(dòng)更容易發(fā)生）； 3）腫痛好轉(zhuǎn)，但正常走路或者運(yùn)動(dòng)時(shí)常出現(xiàn)“打軟腿”，并可能伴跌倒等不穩(wěn)癥狀； 4）曾經(jīng)有踝關(guān)節(jié)扭傷史，運(yùn)動(dòng)中再次扭傷，且容易有反復(fù)扭傷或者關(guān)節(jié)松動(dòng)不穩(wěn)病史： 5）繼發(fā)出現(xiàn)整個(gè)足踝部發(fā)紅發(fā)熱伴疼痛，可能發(fā)展為慢性疼痛或復(fù)雜性局域疼痛綜合癥（CRPS）。2021年08月27日1382
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劉恒副主任醫(yī)師 北京大學(xué)第一醫(yī)院 骨科 很多踝關(guān)節(jié)扭傷的患者老是會(huì)抱怨，為什么都幾個(gè)月了，還是走路不舒服，甚至是走路多了腳踝還腫脹，疼痛？我們先來看看踝關(guān)節(jié)扭傷時(shí)到底是怎么回事，我們的身體哪些部件出了問題？大部分的踝關(guān)節(jié)扭傷都是像上圖中所顯示的那樣，是腳心沖內(nèi)側(cè)的一個(gè)扭傷。這個(gè)時(shí)候踝關(guān)節(jié)外側(cè)維持關(guān)節(jié)穩(wěn)定性的韌帶會(huì)發(fā)生損傷（由輕到重會(huì)有距腓前韌帶和跟腓韌帶的拉傷，撕裂傷，甚至是完全斷裂），還有一些人會(huì)出現(xiàn)踝關(guān)節(jié)內(nèi)部距骨和對(duì)應(yīng)的脛骨遠(yuǎn)端關(guān)節(jié)面的軟骨損傷。甚至?xí)幸恍┤顺霈F(xiàn)腓骨的撕脫骨折（距腓前韌帶本身沒有損傷，而是它在腓骨尖端的附著點(diǎn)的骨頭發(fā)生骨折），以至于再嚴(yán)重的會(huì)出現(xiàn)腓骨、脛骨遠(yuǎn)端的骨折。所以我們經(jīng)常會(huì)建議發(fā)生嚴(yán)重踝關(guān)節(jié)扭傷的朋友應(yīng)該及時(shí)就醫(yī)，讓醫(yī)生判斷你是骨折，還是一個(gè)單純的踝關(guān)節(jié)韌帶損傷。但即使是去急診照完X線沒有發(fā)現(xiàn)骨折，只是一個(gè)單純的踝關(guān)節(jié)韌帶損傷，也有很多朋友會(huì)長(zhǎng)時(shí)間的出現(xiàn)踝關(guān)節(jié)行走后疼痛、腫脹，甚至是有人會(huì)在之后經(jīng)常性的出現(xiàn)受傷的踝關(guān)節(jié)再次扭傷。這往往是初次扭傷時(shí)沒有很好的治療和康復(fù)造成的。如果您被診斷為單純的扭傷造成的踝關(guān)節(jié)韌帶損傷，醫(yī)生會(huì)根據(jù)您的韌帶受傷程度給您做一段時(shí)間的固定（支具甚至是石膏固定，沒錯(cuò)，即使沒有骨折，有時(shí)候也是要支具或者石膏固定的）（一般是2-6周）。受傷的早期會(huì)輔助冰敷，適當(dāng)?shù)募訅?，保護(hù)下的負(fù)重等一些輔助手段。固定結(jié)束后，就需要一個(gè)正規(guī)的康復(fù)訓(xùn)練，來恢復(fù)或增強(qiáng)踝關(guān)節(jié)的穩(wěn)定性及關(guān)節(jié)的靈活性。只有這樣，才能讓受傷的踝關(guān)節(jié)韌帶愈合，且愈合在一個(gè)接近于受傷前的狀態(tài)。讓踝關(guān)節(jié)的功能及穩(wěn)定性恢復(fù)到受傷前的狀態(tài)。下面兩個(gè)視頻是美國(guó)Mayo醫(yī)院制作的關(guān)于踝關(guān)節(jié)扭傷后的康復(fù)視頻。很簡(jiǎn)單的幾個(gè)動(dòng)作，大家可以按照這個(gè)視頻學(xué)習(xí)踝關(guān)節(jié)扭傷后的康復(fù)鍛煉。如果在鍛煉后仍然存在踝關(guān)節(jié)的疼痛或是反復(fù)的踝關(guān)節(jié)扭傷，那么您還需要就醫(yī)，讓醫(yī)生判斷是否存在合并的軟骨損傷或是出現(xiàn)慢性踝關(guān)節(jié)不穩(wěn)定。那可能需要進(jìn)一步的康復(fù)治療或是手術(shù)治療。2021年08月12日1467
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2021年08月03日1047
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寧長(zhǎng)青醫(yī)師 上海市東方醫(yī)院 傷科 踝關(guān)節(jié)內(nèi)側(cè)有內(nèi)側(cè)副韌帶（三角韌帶），比較堅(jiān)韌不容易發(fā)生撕裂，外側(cè)有側(cè)副韌帶（主要包括距腓前韌帶、腓跟韌帶、距腓后韌帶），比較薄弱，所以容易造成損傷。很多人踝關(guān)節(jié)扭傷后自己判斷沒有骨折，所以自己處理了，當(dāng)遲遲不見恢復(fù)的時(shí)候才會(huì)去看醫(yī)生。據(jù)統(tǒng)計(jì)約70%的人會(huì)出現(xiàn)踝關(guān)節(jié)不穩(wěn)，不僅增加再次或反復(fù)踝關(guān)節(jié)扭傷的風(fēng)險(xiǎn)，同時(shí)還可能遺留有關(guān)節(jié)韌帶的松弛，加速骨關(guān)節(jié)炎的發(fā)生。（門診經(jīng)常聽到病人說走路多了疼痛、或者天氣變化時(shí)腳踝不舒服甚至經(jīng)常反復(fù)扭腳）2021年06月30日768
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2021年06月27日776
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鄭鑫副主任醫(yī)師 臺(tái)州市立醫(yī)院 骨科 很多人受傷的時(shí)候不方便來醫(yī)院，今天我教大家在家里自我評(píng)估崴腳的方法一疼痛的程度，如果崴腳的時(shí)候痛一下之后就不痛了，說明傷的不嚴(yán)重。 如果平地走路不痛，上下樓梯或掂腳的時(shí)候會(huì)痛，那有可能是傷到韌帶，需要到醫(yī)院配個(gè)護(hù)踝保護(hù)一下。 如果疼痛很劇烈，甚至無(wú)法走路，建議馬上去醫(yī)院拍個(gè)X光片，看看是否有骨折。 二腫脹程度。 傷得越重，腫得越厲害。 但容易被我們忽略的一種情況是剛受傷的時(shí)候不腫，過了一段時(shí)間才腫起來，其實(shí)這也是腳踝扭傷的一種表現(xiàn)，也需要重視，建議及時(shí)到醫(yī)院就診。 這日子么。2021年06月27日737
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鄭鑫副主任醫(yī)師 臺(tái)州市立醫(yī)院 骨科 今天向大家科普一個(gè)疾病，他在日常的生活和運(yùn)動(dòng)中非常常見，每個(gè)人都會(huì)遇到，他在腳踝扭傷也叫崴腳，雖然他很常見，但每個(gè)人在處理上普遍存在很多誤區(qū)，處理不當(dāng)會(huì)導(dǎo)致習(xí)慣性崴腳，腳踝的慢性疼痛。 崴腳之后發(fā)生了什么？我們?cè)撊绾握_處理？然我們比較常見的內(nèi)翻型崴腳來說，當(dāng)我們的腳踝處在一個(gè)內(nèi)翻的位置，附載在骨表面的韌帶啊，會(huì)受到牽拉甚至斷裂，導(dǎo)致腳踝扭傷，嚴(yán)重的會(huì)導(dǎo)致骨折。 因此，崴腳之后，我們一定要重視早發(fā)現(xiàn)、早診斷、早治療，以免留下后遺癥。2021年06月27日575
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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(duì) 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(wú)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(huì)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(guó)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(jí)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?。?50 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(huì)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(huì)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(duì)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(duì)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(cè)試單趾和雙趾上升。后足對(duì)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(píng)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(duì)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(zhǎng)軸位可能比后足對(duì)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(jí)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(duì)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(duì)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?。换蛴赡[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(jí)描述：0期：正常關(guān)節(jié)或軟骨下硬化；1期：存在骨贅但無(wú)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(huì) (COFAS) 對(duì)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(duì)照組相比，踝關(guān)節(jié)炎會(huì)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(duì)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(huì)持續(xù)下降，疼痛會(huì)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(duì)乙酰氨基酚的使用，以及平衡測(cè)試的改進(jìn)。對(duì)患者進(jìn)行了長(zhǎng)達(dá) 6 個(gè)月的隨訪，注意到他們的美國(guó)矯形足踝協(xié)會(huì) (AOFAS) 評(píng)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(tái)（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(duì)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(píng)審研究或評(píng)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(duì)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：?jiǎn)渭兊耐砥邗钻P(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(zhǎng)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(duì)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(duì)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(duì)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(duì)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(shì)。 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(huì)釋放牽開器以減少對(duì)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(duì)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(duì)于外固定架的優(yōu)勢(shì)包括更高的融合率和減少對(duì)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(shì)。56 Cadaver生物力學(xué)測(cè)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(huì)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(chǎng)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(duì)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(huì)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(duì)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(duì)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(guó)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(guó)以外使用的大多數(shù)踝關(guān)節(jié)置換物是活動(dòng)平臺(tái)，而在美國(guó)境內(nèi)使用的大多數(shù)是固定平臺(tái)。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(zhǎng)期受益的最合適的患者方面存在爭(zhēng)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?huì)導(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(duì)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(tái)：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(tái)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(píng)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(tái)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(huì)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(wú)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(duì) 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(duì) 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(wú)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(wú)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(duì)于確保假體的使用壽命至關(guān)重要。獲取全長(zhǎng)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(duì)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(huì)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(zhǎng)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(huì)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(píng)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(wú)關(guān)，這些患者被歸類為超重或肥胖。96 對(duì)于全踝關(guān)節(jié)置換術(shù)，預(yù)期的翻修手術(shù)無(wú)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(cè)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(huì)影響全踝關(guān)節(jié)置換術(shù)（圖10）。Coughlin 及其同事 17 建議對(duì)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(duì)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(tái)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(wú)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(cè)深尺進(jìn)行測(cè)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(tái)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2834
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楊睿主任醫(yī)師 中山大學(xué)孫逸仙紀(jì)念醫(yī)院 骨外科 2021年5月22日在甘肅省黃河石林景區(qū)舉辦的馬拉松百公里越野賽，突受極端天氣影響，氣溫驟降，參賽人員出現(xiàn)不同程度的身體不適、失溫等情況，截止目前為止已確定有21位國(guó)內(nèi)頂尖的跑馬運(yùn)動(dòng)者因?yàn)椤笆亍痹僖病芭懿换貋砹恕薄?什么是“失溫”？“失溫”為何如此恐怖！ 當(dāng)身體散發(fā)的熱量超過其吸收或產(chǎn)生的熱量，使身體無(wú)法產(chǎn)生足夠的熱量來供應(yīng)體內(nèi)平衡和正常的身體功能時(shí)，就會(huì)出現(xiàn)失溫。失溫，常出現(xiàn)于嚴(yán)寒的地區(qū)；但是經(jīng)過這次教訓(xùn)，我們發(fā)現(xiàn)失溫并不局限于嚴(yán)寒的地區(qū)或時(shí)間，也可能發(fā)生在較溫和的氣候。失溫可以導(dǎo)致人的意識(shí)喪失、心跳呼吸停止，如沒得到恰當(dāng)?shù)母深A(yù)，死亡在所難免（致敬逝世的21位跑者）。原本，失溫是可以避免的。如果天氣冷，不要在外面呆太久（就如被牧羊人救起的6位跑者）；如果在這種嚴(yán)酷的氣候下外出，合適的著裝是關(guān)鍵；如果衣服濕了，趕緊把它們換掉。當(dāng)然，馬拉松遇上“失溫”極其罕見，但馬拉松遇上運(yùn)動(dòng)性損傷卻非常常見。來自中山大學(xué)孫逸仙紀(jì)念醫(yī)院運(yùn)動(dòng)醫(yī)學(xué)科的楊睿教授、博士生導(dǎo)師將帶來跑馬運(yùn)動(dòng)者常見運(yùn)動(dòng)損傷的介紹及其處置。馬拉松所致的運(yùn)動(dòng)性損傷包括：抽筋（肌肉痙攣）、脛前疼痛、足踝扭傷、髕股關(guān)節(jié)疼痛、腰臀痛、跟腱炎以及足底筋膜炎等。一、肌肉痙攣腿肌肉痙攣俗稱抽筋，是肌肉在長(zhǎng)時(shí)間劇烈運(yùn)動(dòng)后肌肉突然、不自主僵直收縮的現(xiàn)象；此時(shí)可出現(xiàn)肌肉僵硬、疼痛難忍，同時(shí)伴有肌肉持續(xù)緊張或抽搐，通常持續(xù)數(shù)十秒至數(shù)分鐘甚至更長(zhǎng)。常見的原因有：1.長(zhǎng)時(shí)間運(yùn)動(dòng)造成肌肉疲勞；2.環(huán)境溫度的突然改變（比如此次的失溫情況）；3.水份、鹽份的急慢性流失過多導(dǎo)致體內(nèi)電解質(zhì)失衡；4.運(yùn)動(dòng)姿勢(shì)不當(dāng)造成的肌肉協(xié)調(diào)不良；5.本身即有系統(tǒng)性性疾病等。抽筋了該怎么辦呢？1.需立刻停止運(yùn)動(dòng)；2.順著抽筋肌肉的方向緩慢的拉長(zhǎng)肌肉；3.不可以突然拉長(zhǎng)肌肉、或用力過猛，以免拉傷肌肉造成二次傷害；4.等抽筋部位緩解后，再輕輕按摩直到肌肉舒緩為止。二、脛前疼痛脛前疼痛，通常是小腿肌肉的過度使用所造成的傷害，常見于需要長(zhǎng)時(shí)間跑步的運(yùn)動(dòng)（馬拉松、長(zhǎng)途急行軍等）。在脛前疼痛的處理上根據(jù)所處的時(shí)期不同，處理的方式也不同。在急性期（0～48小時(shí)）：休息、冰敷、 抬高患肢；亞急性期（第3天～第 6周）：行肌肉伸展、 肌力增強(qiáng)訓(xùn)練等；恢復(fù)期（約第7星期開始)：運(yùn)動(dòng)前熱身、肌肉伸展運(yùn)動(dòng)、熱敷，運(yùn)動(dòng)后冰敷、肌肉伸展運(yùn)動(dòng)、訓(xùn)練脛前肌等。三、足踝扭傷足踝扭傷是常見的跑馬運(yùn)動(dòng)性損傷之一， 80％的腳踝扭傷發(fā)生于外側(cè)，最常受傷的韌帶是前距腓韌帶。足踝扭傷該怎么辦呢？在排外骨折后通常在急性期（0～48h）內(nèi)主要予休息、冰敷、抬高患肢；過了急性期后后可予理療等減輕疼痛、增加血液循環(huán)促進(jìn)韌帶重新癒合，運(yùn)動(dòng)康復(fù)等。在這，中山大學(xué)孫逸仙紀(jì)念醫(yī)院運(yùn)動(dòng)醫(yī)學(xué)科的楊睿教授重點(diǎn)提醒各位跑者，大部分的踝關(guān)節(jié)急性扭傷均可行保守治療，但是踝關(guān)節(jié)急性扭傷沒有得到合適的處理或者是未處理，20～40%的踝關(guān)節(jié)急性扭傷患者將會(huì)演變成慢性踝關(guān)節(jié)不穩(wěn)定，最終告別跑馬生涯。四、髕股關(guān)節(jié)疼痛癥髕股關(guān)節(jié)疼痛癥是指髕骨前方或是周圍疼痛，尤其是在膝蓋彎曲伸直的活動(dòng)時(shí)候，疼痛會(huì)加??；常見于過度使用膝關(guān)節(jié)，如馬拉松長(zhǎng)跑等。對(duì)于髕股關(guān)節(jié)疼痛的處置，建議多休息，減少造成膝關(guān)節(jié)不舒服的活動(dòng)，避免長(zhǎng)時(shí)間將膝關(guān)節(jié)維持在固定或大角度的彎曲的姿勢(shì)；同時(shí)穿護(hù)膝或髕骨貼，訓(xùn)練股四頭肌的肌肉力量。五、腰臀部痛腰臀部痛在長(zhǎng)跑運(yùn)動(dòng)員中也很常見。這是因?yàn)榕荞R的人群中，可能存在雙足的足弓高低不一，造成兩腿在功能上的長(zhǎng)短不一 ；或是腹、臀及下背的肌肉力量弱；或是背、大腿后肌、及骼脛帶的長(zhǎng)期繃緊導(dǎo)致慢性勞損等。跑馬運(yùn)動(dòng)員經(jīng)常腰臀疼該咋辦呢？1.多做改善足弓的肌肉練習(xí)；2.加強(qiáng)腹、背力量及耐力；3.增進(jìn)背肌–大腿后肌–骼脛帶–小腿后肌-跟腱的伸展運(yùn)動(dòng)；4.避免下坡跑。六、跟腱炎常以足跟部上方慢性疼痛為主，這也是跑馬運(yùn)動(dòng)者就醫(yī)時(shí)常見的主訴之一。對(duì)于跟腱炎的處理包括：1.冰敷（運(yùn)動(dòng)后，一日數(shù)次）；2.在跑鞋內(nèi)加入鞋跟墊；3.局部使用消炎止痛藥物；4.加強(qiáng)對(duì)跟腱伸展運(yùn)動(dòng)的鍛煉；七、足底筋膜炎跑馬者長(zhǎng)期超負(fù)荷運(yùn)動(dòng)，造成足底筋膜的急性或慢性損傷在所難免；這是引起足底筋膜炎的主要原因。足底筋膜炎表現(xiàn)為腳底的酸軟、痛，特別是在起床后的最初幾步，在步行一段距離后，癥狀會(huì)緩解。對(duì)于足底筋膜炎的處理，一般經(jīng)過休息、冰敷、使用消炎葯、腳踩筋膜放松按摩球等保守康復(fù)治療后均可自愈。最后，中山大學(xué)孫逸仙紀(jì)念醫(yī)院運(yùn)動(dòng)醫(yī)學(xué)科的楊睿教授強(qiáng)調(diào)，跑馬運(yùn)動(dòng)者的運(yùn)動(dòng)性損傷應(yīng)該是預(yù)防大于治療，一份預(yù)防大于十分治療，不治已病治未病。2021年05月25日1581
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