旋前、后外旋型三踝骨折的手术治疗

目的总结旋前后外旋型（Ⅳ度)三踝骨折切开复位内固定的手术方法和疗效。方法1996年3月～2002年10月，对48例旋前、后外旋型（Ⅳ度)三踝骨折行切开复位内固定术．男27例，女21例；年龄l7～85岁．平均42.8岁。根据Lauge-Hansen分类．旋前外旋型Ⅳ度三踝骨折20例．旋后外旋Ⅳ度三躁骨折28例。受伤距手术时间2h～21d。内侧采用标准内踝切口显露内踝骨折，外侧采用腓骨后缘纵行切口显露外踝骨折。如需行后踝骨折处理．则将内踝的切口延长．外侧采用经腓骨的Gatellie-Chastang手术入路同时切开显露内、外及后踝。整复固定的顺序是后踝，内踝、外踝和下胫腓联合。骨折复位固定完成后，行踝部正侧位及踝榫(Mortise)位X线检查。满意复位的标准为：(1)踝榫的正常关系恢复，(2)踝的负重排列与下肢纵轴成直角．（3)关节面的外形轮廓光滑，结果仝部患者均获得随访，随访时间6～36个月．平均13个月，骨折愈台时间为12～16周。随访时疗效评定根据Baird-Jackson评分系统进行评定：优26例，良15例，可5例．差2例；优良率为85．4％。术后未发生感染、骨不连、骨折畸形愈合等并发症．但发生1例下胫腓三皮质固定螺钉断裂。结论躁关节的解剖复位可获得最佳的临床结果，采用切开复位内固定术治疗三踝骨折可保证踝关节获得解剖复位．最大限度地恢复踝关节功能。     

旋后-外旋型Ⅳ度踝关节骨折的手术治疗

目的探讨旋后-外旋型Ⅳ度踝关节骨折的手术治疗方法及疗效。方法自2011-03—2013-03诊治旋后-外旋型Ⅳ度踝关节骨折96例,单纯外踝骨折行内踝三角韧带探查修复及外踝骨折复位内固定;内外踝骨折或不需处理后踝的三踝骨折,分别行内外踝骨折复位内固定;三踝骨折中后踝骨折块超过关节面1/3者,行复位内固定治疗,外踝、后踝选择后外侧切口进入,复位顺序为外踝、后踝、内踝。结果本组手术时间1~3 h,平均2.3 h。所有患者均获得随访6~24个月,平均13个月。术后6个月行踝关节CT检查显示均获得骨性愈合。末次随访时踝关节功能Kofoed评分:优47例,良43例,可5例,差1例,优良率93.8%。结论旋后-外旋型Ⅳ度踝关节骨折手术治疗过程中合理的复位顺序可明显缩短手术时间、提高手术效果,术中应常规探查下胫腓关节情况;内、后踝需要同时固定的患者取后外侧单一切口即可满足手术显露需求。     

三踝骨折的分型与治疗

目的总结三踝骨折切开复位内固定的手术方法和疗效。探讨三踝骨折的分型与治疗。方法1996年9月至2007年2月，对56例三踝骨折行切开复位内固定术，男36例，女20例；年龄17～70岁，平均36岁。按Lauge—Hansen分类，旋前型三踝骨折9例，旋后型47例。结果全部患者均获得随访，随访时根据Baird—Jackson评分系统进行评定，优45例，良9例，可2例，差0例，优良率为96％。术后未发生感染、骨不连、骨折畸形愈合等并发症。结论根据骨折分型确定手术顺序，旋后型手术顺序是外踝、下胫腓联合、内踝、后踝。旋前型顺序是内踝、外踝、下胫腓联合、后踝。强调外踝固定的重要性，1／3管形钢板为有效方法之一。     

陈旧性三踝骨折的手术治疗

目的探讨陈旧性三踝骨折的手术治疗方法。方法2000年1月至2004年1月,手术治疗陈旧性三踝骨折患者58例,男41例,女17例;年龄19～61岁,平均43岁。手术时间为伤后29～76d,平均48d。骨折采用Lauge-Hansen分型,其中旋后外旋型37例,旋前外旋型21例。手术采用前内、前外双侧弧形切口,锐性探查内、外踝原始骨折线,清理骨折断端及踝(,外翻踝关节,直视显露后踝骨折块,清理后踝周围的瘢痕组织,用刀尖探查后踝原始骨折线。清理骨折断端,复位、固定后踝。以骨嵴为标志,恢复外踝的正常长度和力线,并用1/3管型钢板或普通钢板固定。内踝用螺钉或张力带固定。术后10～12周开始部分负重。结果58例均获随访,随访时间18～65个月,平均37个月。2例出现浅表皮缘坏死,4例出现伤口延迟愈合。骨折均一期愈合,愈合时间21～29周,平均25周。2例患者腓骨对位差。6例患者术后X线片显示踝关节间隙变窄,有创伤性关节炎改变,其中2例患者骨折复位良好。根据AOFAS评定标准,踝关节评分优31例,良22例,可5例,优良率91.4%。5例患者疼痛评分在20分,9例患者踝关节背伸活动受限<10°。结论手术治疗伤后76d内三踝骨折,锐性探查原始骨折线,直视下复位后踝骨折块,保留腓骨的正常长度、旋转和力线可以获得良好的复位和临床疗效。     

旋前-外旋型踝关节骨折中隐匿后踝骨折的漏诊原因分析及治疗

目的：探讨旋前-外旋型踝关节骨折中隐匿后踝骨折相关漏诊病例的原因及治疗。方法：自2002年3月至2010年6月,收治旋前-外旋型踝关节骨折103例,其中9例后踝骨折漏诊,男6例,女3例;年龄18～55岁,平均35.2岁;根据Lauge-Hansen分型均为旋前-外旋型损伤。术中经C形臂X线透视发现4例,术后住院期间发现2例,余3例为外院术后于门诊随访时发现。手术入路采用踝关节后外侧入路,直视下复位后采用空心螺钉或锁定钢板固定。手术后根据美国足踝外科医师协会（American Orthopaedic Foot and Ankle Society,AOFAS）踝-后足功能评分进行功能评定。结果：9例术后均获随访,时间14～30个月,平均17个月。无切口感染,切口均I期愈合。末次随访AOFAS踝-后足功能评分83.0±4.4,其中术中发现并处理4例平均分85.0±2.9,二次手术处理5例平均分81.0±5.3,差异无统计学意义。术后平均2.2个月经X线片证实全部病例骨性愈合,未发现内固定松动、退钉、断裂及血管神经损伤等并发症。结论：旋前-外旋型踝关节骨折可能合并隐匿性后踝骨折,临床医师需充分了解其暴力传导机制,仔细阅读X线侧位片,对可疑后踝损伤者可行CT或MRI检查;同时,术中内外踝固定满意后附加侧位透视有助于避免漏诊。     

腓骨远端干骺端钢板固定外踝和后踝治疗三踝骨折

目的探讨腓骨远端干骺端钢板用作支撑钢板固定外踝和后踝治疗三踝骨折的疗效及预后。方法 2008年1月至2010年1月,采用腓骨远端干骺端钢板用作支撑钢板固定外踝及后踝治疗三踝骨折23例,男10例,女13例;年龄20～65岁,平均45岁。左侧12例,右侧11例。根据Lange-Hansen分型,Ⅲ、Ⅳ度旋后-外旋型14例,Ⅳ度旋前-外旋型9例。直视下行骨折复位内固定,骨折复位固定顺序为外踝、后踝、内踝、下胫腓联合。术后随访观察骨折愈合及钢板稳定情况。结果所有病例得到随访,随访时间12～36个月,平均28.4个月。患肢均无畸形愈合,无骨不连,无钢板外露、松动、断裂,无伤口感染。根据Baird-Jackson评分系统进行评估,优17例,良4例,可2例,优良率为91%。结论腓骨远端干骺端钢板用作支撑钢板固定外踝及后踝治疗三踝骨折,其操作简便、对骨折固定可靠、踝关节功能恢复满意、并发症少,是治疗三踝骨折的有效方法。     

延期切开复位内固定治疗三踝骨折

[目的]探讨延期手术治疗三踝骨折(Cotton's fracture)的具体手术方法及疗效评价。[方法]2000年1月～2009年1月,三踝骨折延期行切开复位内固定术21例,术前均行踝关节X线片和三维CT检查。对于CT显示后踝骨折偏外侧或者骨块居中的患者,选用踝后外侧切口,同时暴露外踝(lateral malleolus)和后踝(posterior malleo-lus),手术次序为外踝-后踝-内踝(medial malleolus)。对于后踝骨折偏内侧的患者,利用踝后内侧切口同时暴露内踝和后踝,手术次序为外踝-内踝-后踝。对于伴下胫腓关节分离的患者采用1/3管形钢板和拉力螺钉固定。选择常规手术组行对照分析手术时间有无差异性,术后应用Baird评分结合踝关节活动度数对两组手术疗效行统计学分析。[结果]手术均达到解剖复位。延期手术组的手术时间为(101.67±37.991)min,常规手术组(85.29±34.26)min,差异无统计学意义(t=1.467,P=0.15);延期手术组Baird评分平均得分95.9±2.9,常规手术组平均得分96.3±3.0,差异无统计学意义(t=-0.46,P0.05);两组患者踝关节术后活动度数差异均无统计学意义。[结论]延期切开复位内固定术治疗三踝骨折,应根据后踝骨折移位情况选择显露后踝的切口,以及内踝、外踝、后踝的手术次序,以利于术中复位,缩短手术时间,有效恢复踝关节的功能。     

踝关节骨折28例内固定手术疗效报告

目的观察28例踝关节骨折手术治疗的临床疗效。方法本组28例病人均在连续硬膜外麻醉下进行切开复位内固定，开放骨折严格按照清创原则进行清创后再行内固定手术，术中尽可能做到解剖复位，恢复踝穴的解剖关系，双踝骨折先行外踝固定，再行内踝固定，三踝骨折则按外踝、后踝、内踝顺序整复固定。结果28例病人随诊5—34个月不等，根据病人主诉、踝关节外形、功能及X线征象做优、良、中、差四级评定，优良率占68％。结论踝关节骨折关键在于解剖复位，踝穴的微小变化，都会使距骨位置改变，故外踝的整复及下胫腓分离的固定是处理踝关节骨折的两个重要步骤。     

踝关节后踝骨折内固定治疗的疗效分析

目的通过对踝前小切口自前向后内固定治疗后踝骨折的操作技巧及疗效的回顾性研究,探讨后踝骨折内固定治疗的生物力学基础及临床应用。方法我科自2003年9月至2008年8月治疗波及后踝的踝关节骨折21例,其中男9例,女12例;年龄23～75岁,平均40.1岁。应用Lauge-Hansen和Danis-Weber分类法分类,旋后外型度5例,度10例,旋前外型5例;B型15例,C型5例,其中单纯后踝骨折未分类1例。术中应用踝外侧偏后和前方联合切口复位后踝,在维持良好复位下自前向后用4 mm钛质空心钉内固定骨折,然后复位固定外踝及内踝。结果术后平均随访25.8个月（11～68个月）,所有病例骨折均获得骨性愈合,临床愈合时间平均13.8周（10～16周）。依据Baird-Jackson踝关节评分系统评定,优13例,良6例,可1例,差1例,优良率达90.5%。结论后踝骨折解剖复位、坚强内固定符合生物力学要求,同时采用踝前小切口自前向后内固定,创伤小,是较为理想的内固定方式。     

经后内侧手术入路显露后踝治疗三踝骨折

目的探讨三踝骨折切开复位内固定的手术治疗方法。方法收治三踝骨折45例,采用标准外侧切口固定外踝,后内侧切口固定后踝及内踝。结果本组随访时间5～28个月,骨折愈合时间为11~16周。根据改良Baird的主客观评价标准:优26例,良11例,可5例,差3例,优良率为82.2%。结论三踝骨折需切开复位保证踝关节获得解剖复位,并最大限度地恢复踝关节功能,通过后内侧手术入路可以直视下固定后踝及内踝,是值得选择的手术入路。     

Frakturen des oberen Sprunggelenks

Malleolar fractures predominately result from a dislocation force at the ankle and are usually accompanied by injuries of the collateral ligaments and the tibiofibular syndesmosis. Forced abduction, adduction or external rotation of the foot against the tibia produce the typical sequence of bony and ligamentous injuries at the ankle joint. With the foot in supination at the time of injury, the deforming force acts first on the lateral malleolus, with the foot in pronation the force acts first on the medial malleolus. Fracture-dislocations must be reduced as an emergency under sufficient analgesia. Early stabilization is generally preferable for all displaced and unstable ankle fractures. With operative treatment, exact reconstruction of the articular surface, restoration of the length and rotational alignment of the fibula and fixation of osseous or ligamentous syndesmotic injuries are important prognostic factors. Non-operative, functional treatment leads to good long-term results in isolated, non-displaced fractures of the medial or lateral malleolus provided that instability of the ankle mortise has been definitely ruled out. Treatment of pediatric and adolescent malleolar fractures follows the same principles and has to respect the growth plate which ossifies over an 18 month period. Special attention has to be paid to hereditary or acquired neuropathy with dramatically increased healing times and complication rates.     

Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures

We studied the late results after bimalleolar and trimalleolar ankle fractures in thirty-four patients after an average follow-up of four years. Twenty-one patients had had open reduction and internal fixation of the medial malleolus only and thirteen, internal fixation of both the medial malleolus and the lateral malleolus. Twenty-four lesions were supination-external rotation fractures; six, pronation-external rotation; and four, supination-adduction fractures. All initial and post-reduction roentgenograms were evaluated, and the patients were re-evaluated two to seven years after fracture. Re-evaluation included physical examination as well as standardized and stress roentgenograms of both ankles. Criteria were developed for measuring the width of the syndesmosis and assessing the late roentgenographic, subjective, and objective results, as well as any late instability of the syndesmosis and osteoarthritis. Significant correlations were found between: (1) the adequacy of the reduction of the syndesmosis and late arthritis, (2) the adequacy of the initial reduction of the syndesmosis and the late stability of the syndesmosis, (3) the late stability of the syndesmosis and the final outcome, and (4) the adequacy of the reduction of the lateral malleolus and that of the syndesmosis. Based on the findings in this small series and on the evidence published in the literature, we concluded that adequate reduction of the syndesmosis is necessary to achieve a stable ankle following supination-external rotation and pronation-external rotation fractures of the ankle, and that the reduction of the syndesmosis will be unsatisfactory if the lateral malleolus is not well reduced.     

微创经皮内固定治疗复杂踝部骨折53例

目的：探讨微创内固定治疗复杂踝部骨折的手术方法和临床疗效。方法：自2007年1月至2011年12月,采用微创经皮内固定治疗53例复杂踝部骨折患者,男31例,女22例;年龄18-65岁,平均38．2岁。按Lauge-Hansen分型：旋后外旋型Ⅳ度32例,旋前外旋型Ⅲ、Ⅳ度13例,旋前外展型Ⅲ度5例,因腓骨骨折严重粉碎无法分类3例。Denis—Weber分类：A型4例,B型34例,C型15例。受伤至手术时间2h-14d,平均5d。骨折复位固定顺序为后踝、内踝、外踝和下胫腓联合。后踝骨折采用踝前切口间接复位固定,内外踝骨折采用经皮螺钉、接骨板或张力带固定,必要时螺钉固定下胫腓联合。术后采用Baird-Jackson评价系统进行疗效评价。结果：48例获随访,时间10-36个月,平均13个月。骨折全部愈合,愈合时间10-18周,平均12周。根据Baird-Jackson评价系统进行疗效评定,术后踝关节功能平均（94．7±4．2）分,其中优28例,良15例,可3例,差2例。1例发生皮肤浅表性感染,经换药治愈;2例发生下胫腓联合固定螺钉断裂。结论：采用微创经皮内固定治疗复杂踝部骨折可保证踝关节获得解剖复位,保护骨折端血运及软组织覆盖,最大限度地恢复踝关节功能,获得满意的临床疗效。     

踝关节骨折的手术治疗

目的探讨踝关节骨折切开复位内固定方法和治疗效果。方法2001年3月-2006年1月，采用手术治疗踝关节骨折85例。男65例，女20例；年龄17～65岁，平均36．5岁。根据Lauge—Hansen分型，旋前外旋型Ⅱ度12例、Ⅳ度9例，旋后外旋型Ⅱ度34例、Ⅳ度16例，旋后内收型Ⅱ度8例，旋前外展型6例。合并胫腓下联合分离10例。闭合性骨折21例，伤后予以简单手法复位石膏托固定后2h～10d手术；开放性骨折64例，急诊清创同时行骨折复位内固定。结果85例术后切口Ⅰ期愈合。患者均获随访6～36个月，平均10个月。术后未发生骨不连、畸形愈合、胫腓下联合处螺钉断裂等并发症。临床疗效按Baird-Jackson踝关节评分评定，优53例，良23例，可6例，差3例，优良率89．4％。骨折愈合时间平均150d。结论手术治疗踝关节骨折可取得满意的临床疗效，对骨折类型的准确判断及正确选择固定方法对于提高复位质量、改善远期疗效具有重要意义。     

Comparing Different Surgical Techniques for Addressing the Posterior Malleolus in Supination External Rotation Ankle Fractures and the Need for Syndesmotic Screw Fixation

Trimalleolar ankle fractures are unstable injuries with possible syndesmotic disruption. Recent data have described inherent morbidity associated with screw fixation of the syndesmosis, including the potential for malreduction, hardware irritation, and post-traumatic arthritis. The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. We hypothesized that fixation of a sizable posterior malleolar (PM) fracture in supination external rotation type IV (SER IV) ankle fractures would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. A retrospective review of trimalleolar ankle fractures surgically treated from October 2006 to April of 2011 was performed. A total of 143 trimalleolar ankle fractures were identified, and 97 were classified as SER IV. Of the 97 patients, 74 (76.3%) had a sizable PM fragment. Syndesmotic fixation was required in 7 of 34 (20%) and 27 of 40 (68%), respectively, when the PM was fixed versus not fixed (p = .0002). When the PM was indirectly reduced using an anterior to posterior screw, 7 of 15 patients (46.7%) required syndesmotic fixation compared with none of 19 patients when the PM fragment was fixated with direct posterior lateral plate fixation (p = .0012). Fixation of the PM fracture in SER IV ankle fractures can restore syndesmotic stability and, thus, lower the rate of syndesmotic fixation. We found that fixation of a sizable PM fragment in SER IV or equivalent injuries through posterolateral plating can eliminate the need for syndesmotic screw fixation.     

踝关节骨折的手术治疗

目的探讨踝关节移位骨折切开复位内固定的疗效。方法手术治疗踝关节移位骨折患者132例,根据Weber-Danis分型。整复固定顺序为后踝、外踝、内踝、下胫腓联合。结果随访6个月~3年,平均1·5年。骨折临床愈合时间12~18周。结论采取切开复位内固定治疗移位的踝关节骨折,可获得稳定固定;早期进行适当的功能锻炼,多数患者可恢复正常的踝关节功能。     

后外侧联合内侧入路急诊内固定治疗三踝骨折

目的探讨后外侧联合内侧入路急诊内固定治疗三踝骨折的疗效。方法对23例三踝骨折患者急诊采用后外侧入路行后踝骨折复位空心螺钉或支撑钢板内固定、外踝骨折复位钢板内固定,内侧入路行内踝骨折复位空心螺钉内固定。末次随访时采用AOFAS踝-后足功能评分标准评价疗效。结果患者均获得随访,时间10~32个月。切口均一期愈合。骨折均愈合,时间10~20周。无畸形愈合、螺钉松动、钢板断裂等并发症发生。末次随访时采用AOFAS踝-后足功能评分标准评价疗效:优19例,良3例,可1例,优良率22/23。结论后外侧联合内侧入路急诊内固定治疗三踝骨折,可较为轻松完成后踝—外踝—内踝骨折的复位和坚强固定,同时也可对下胫腓联合复位固定,临床效果满意。     

Posterior Malleolus Fracture Displacement Is Associated with Rotational Ankle Fracture Stability in Patients Without Medial Malleolar Fractures

Background

The optimal method for the determination of ankle stability remains controversial in rotational ankle fractures without medial bony injury.

Questions/Purposes

The purposes of this study were to (1) evaluate whether posterior malleolar (PM) fracture displacement is associated with deltoid ligament injury in supination-external rotation (SER) ankle fractures and (2) compare the diagnostic accuracy of PM displacement and magnetic resonance imaging (MRI) evaluation of the deep deltoid ligament in identifying fractures with deltoid ligament incompetence.

Methods

Patients with rotational bimalleolar injuries containing lateral malleolar and PM fractures without bony medial injury were included. After operative lateral and PM fixation, an external rotation stress test was performed to evaluate deltoid ligament stability. Operative dictations were reviewed to confirm injury pattern, stability on stress test, and visual inspection of the deltoid ligament. Maximum PM displacement was assessed on lateral X-ray. Pre-operative MRI of the ankle was performed following closed reduction and splinting.

Results

The final cohort consisted of 13 trimalleolar equivalent fractures (torn deltoid ligament) and 20 bimalleolar fractures (medial malleolus and deltoid ligament intact). Average PM displacement was significantly higher for SER trimalleolar equivalent patterns when measured on lateral X-ray. The sensitivity of detecting trimalleolar equivalent fracture was higher on all reported X-ray findings than the sensitivity obtained by the reported MRI findings of deltoid ligament injury.

Conclusion

PM displacement on X-ray is a useful adjuvant along with external rotation stress radiography and MRI evaluation of deep deltoid integrity to distinguish between stable and unstable fracture patterns and thus helps facilitate treatment decisions.

     

微创经皮内固定治疗三踝骨折

目的探讨微创经皮内固定治疗三踝骨折的临床疗效。方法2002年1月～2005年10月,对28例(平均38.7岁)三踝骨折采用微创切开复位经皮内固定,Gatellier-Chastang后外侧入路显露外踝及外踝后方。骨折复位固定顺序为后踝、内踝、外踝、下胫腓联合。术后进行石膏固定3～4周。结果所有患者均获得随访,随访6～36个月(平均18个月),骨折全部愈合,愈合时间2.8～4.5个月,平均3.2个月。根据Baird-Jackson评分系统评估疗效:优16例,良8例,可3例,差1例,优良率85.7%。结论三踝骨折的解剖复位、稳固内固定是治疗的关键;微创经皮内固定是治疗三踝骨折较好方法,切口小可以减少骨折段血运的破坏,提高骨折愈合率。     

Ankle syndesmotic injury

Ankle syndesmotic injury does not necessarily lead to ankle instability; however, the coexistence of deltoid ligament injury critically destabilizes the ankle joint. Syndesmotic injury may occur in isolation or may be associated with ankle fracture. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. Radiographic findings usually include increased tibiofibular clear space decreased tibiofibular overlap, and increased medial clear space. However, syndesmotic injury may not be apparent radiographically; thus, routine stress testing is necessary for detecting syndesmotic instability. The goals of management are to restore and maintain the normal tibiofibular relationship to allow for healing of the ligamentous structures of the syndesmosis. Fixation of the syndesmosis is indicated when evidence of a diastasis is present. This may be detected preoperatively, in the absence of fracture, or intraoperatively, after rigid fixation of the medial malleolus and fibula fractures. Failure to diagnose and stabilize syndesmotic disruption adversely affects outcome.