各位读者，大家好！
近期，我们将制作一期来源于「河南足踝」和「山东足踝」的软组织专辑，该专辑由郑州市骨科医院的王翔宇教授团队和山东大学第二医院的胡勇教授团队，从多年临床诊疗和经验积累出发，针对足踝部软组织的临床解剖、影像检查等基础知识、软组织病损的临床诊断和治疗、手术治疗中的术式及其组合应用等，以及临床典型病例分别进行分享。
今天，由山东大学第二医院的胡勇教授团队为大家带来的「应力位X线片在慢性踝关节不稳中的应用」。
本文引用两篇文献，复习了应力位X线片在慢性踝关节不稳中的应用，并讨论了应力位X片的诊断效能。
前言
慢性踝关节不稳的诊断，依靠患者自诉的症状、查体及辅助检查手段。
其中，MRI是具有重要的诊断价值，而通过应力位X线片中关节的非对称性改变，我们也可以得到间接证据来辅助诊断。
当然，应力位X片的诊断价值因其间接性而具有一定的局限性，因而其诊断效能需要进行一些讨论。
讨论
1、应力位X线片与MRI中的韧带损伤有没有相关性？
2、应力位X线片在诊断韧带损伤中的准确性如何？
一、文献一
1
介绍
The aim of this study was to investigate the relationship between bone morphology and injured ligament of the ankle on imaging studies and laxity of the ankle on ankle stress radiographs in patients evaluated for lateral ankle instability .
Univariate and multiple regression analyses were used to evaluate the correlation between the findings of ankle stress radiographs and structural factors such as the bony configuration and degree of ligament injury around the ankle joint .
2
X线测量
▲Fig. 1 a Distal tibial articular surface angle (DTAS), bimalleolar tilt (BT), medial malleolar relative length (a/c), lateral malleolar relative length (b/c), medial malleolar slip angle (MMSA). b anterior inclination of the tibia (AI), and fibular position (d/e).
▲Fig. 2 Tibiotalar tilt angle on anteroposterior varus stress view a. Anterior translation of the talus on anterior drawer lateral view b.
▶ 距腓前韧带-矢状位
▶ 跟腓韧带、距腓后韧带、三角韧带-冠状位
3
分析
▲ Fig. 3 Inclusion and exclusion criteria.
▲ Table 1 Patient demographics.
▲ Table 2 Summary of measurements.
▲ Table 4 Factors affecting ankle stress radiographs by univariate analysis.
▲ Table 5 Factors affecting ankle stress radiographs by multiple regression analysis
According to our results, we may assume that younger female patients, who showed greater bimalleolar tilt angle and more posterior position of the fibula, had a poorer prognosis after ligament reconstruction .
4
结果和讨论
In conclusion, although ankle stress radiographs have been widely used in patients with lateral ankle instability, various potential determinants including bony morphology of the ankle joint have been overlooked during interpretation of the measurements.
Based on our study, age, sex, degree of ATFL injury, and bimalleolar tilt were found to be factors significantly associated with tibiotalar tilt angle on the varus stress view, and the degree of PTFL injury and fibular position were factors significantly associated with anterior translation of the talus on the anterior drawer view.
These results suggest that differences in patient factors including age, sex, and bony anatomical structure of the ankle joint might predispose the outcomes of ankle stress radiographs.
We conclude that comparison of both ankles on stress radiographs is superior to applying fixed numerical values to the injured side in order to reduce the influence of patient factors when assessing surgical indications.
二、文献二
1
介绍
本文研究了慢性踝关节不稳病例的距腓前韧带、跟腓韧带的MRI影响和应力位X线片之间的关系。
▲Table 1. Demographics of Patients Who Underwent Lateral Ankle Ligament Reconstruction Using Allograft or a Modified Brostrom Procedure.
2
ATFL和CFL的MRI分类
▲Figure 1. Four categories according to the thickness of the ATFL in CLAI patients: (A) normal-thickness ATFL; (B) nonvisualized ATFL; (C) attenuated ATFL; (D) thickened ATFL. ATFL, anterior talofibular ligament; CLAI, chronic lateral ankle instability
▲ Figure 2. Other morphologies of the ATFL observed in MRI of CLAI patients: (A) discontinuity of the ATFL; (B) wavy-shaped ATFL; (C) increased ATFL signal. ATFL, anterior talofibular ligament; CLAI, chronic lateral ankle instability; MRI, magnetic resonance imaging.
▲ Figure 3. Four categories according to the thickness of the CFL in CLAI patients: (A) normal-thickness CFL (B) nonvisualized CFL (C) attenuated CFL (D) thickened CFL. CFL, calcaneofibular ligament; CLAI, chronic lateral ankle instability.
▲ Figure 4. Other morphologies of the CFL observed in MRI of CLAI patients: (A) discontinuity of the CFL; (B) wavy-shaped CFL; (C) increased CFL signal. CFL, calcaneofibular ligament; CLAI, chronic lateral ankle instability; MRI, magnetic resonance imaging.
3
结果和讨论
▲ Table 2. The Overall Incidences of ATFL and CFL Magnetic Resonance Imaging Findings in Chronic Lateral Ankle Instability.
▲Table 3. The Incidences of ATFL and CFL Patterns Based on the Degree of Thickness.
▶ 在慢性踝关节不稳病例中，96％的距腓前韧带和71％的跟腓韧带存在厚度的异常。其中变薄是最常见的改变。
▶ 不连续的病例只有20%，相对于之前报道的急性踝关节损伤的病例中不连续的比例低很多。说明韧带可以自行修复。
▶ 相关性分析表明抽屉位试验中距骨前移距离跟韧带的形态没有关系。
▶ 内翻位距骨倾斜角跟距腓前韧带和跟腓韧带的厚度都有关系。
▶ 应力位X线片距骨倾斜角有助于术者在术前制定手术方式。（直接修复或重建）
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