Schmidt R, Cordier E, Bertsch C, Eils E, Neller S, Benesch S, Herbst A, Rosenbaum D, Claes L
Military Hospital, Surgical Department, Ulm, Germany.
Foot Ankle Int. 2004 Jan;25(1):31-6. doi: 10.1177/107110070402500107.
If conservative therapy fails, the standard treatment for chronic ankle instability is surgical reconstruction of the lateral ligaments. For the last seventy years, the tenodesis principles have been used for reconstruction. Recently however, surgical reconstructions--respecting the intact joint anatomy--have been developed, thus called "anatomical reconstruction principles".
This study focused on the investigation of the range of motion of the ankle and the subtalar joint following anatomical reconstruction surgery. Three different types of anatomical reconstruction procedures were compared: Direct ligament repair, tendon graft and carbon-fiber implant.
All procedures restored the original range of motion of the subtalar joint, except for the plantarflexed/dorsiflexed positions. As for the talocrural joint, the tendon graft and the carbon fiber implant left a small laxity for movements of inversion/eversion and internal/external rotation. The direct repair procedure achieved a more accurate result and restored the physiologic kinematics almost completely. During each procedure the insertion points and the direction of the original ligaments were maintained. However, the different results for the procedure of direct ligament repair compared to the other two anatomical reconstruction procedures showed that this condition alone is not sufficient to perfectly restore the kinematics of the talocrural and subtalar joints. It is important to note that none of the procedures caused a restriction of the range of motion.
The maintenance of the range of hindfoot motion decreases the risk of osteoarthritis as well as chronic pain or problems for the patient to walk on uneven surface. Therefore, we believe that standard therapy for chronic instability of the ankle should include direct surgical reconstruction of the ligaments. If this direct procedure cannot be performed because of poor quality of the ligaments an alternative anatomical reconstruction procedure should be considered.
若保守治疗失败，慢性踝关节不稳的标准治疗方法是外侧韧带的手术重建。在过去七十年里，一直采用腱固定原则进行重建。然而，近年来，已开发出尊重完整关节解剖结构的手术重建方法，即“解剖重建原则”。
本研究聚焦于解剖重建手术后踝关节和距下关节的活动范围调查。比较了三种不同类型的解剖重建手术：直接韧带修复、肌腱移植和碳纤维植入。
除跖屈/背屈位置外，所有手术均恢复了距下关节的原始活动范围。对于胫距关节，肌腱移植和碳纤维植入在内翻/外翻及内旋/外旋运动时留有轻微松弛。直接修复手术取得了更精确的结果，几乎完全恢复了生理运动学。在每个手术过程中，均维持了原韧带的附着点和方向。然而，与其他两种解剖重建手术相比，直接韧带修复手术的不同结果表明，仅这一条件不足以完美恢复胫距关节和距下关节的运动学。需要注意的是，所有手术均未导致活动范围受限。
维持后足运动范围可降低骨关节炎风险以及患者在不平整地面行走时的慢性疼痛或问题。因此，我们认为慢性踝关节不稳的标准治疗应包括韧带的直接手术重建。若因韧带质量差无法进行这种直接手术，则应考虑替代性的解剖重建手术。
