踝关节骨折切开复位内固定术后踝关节镜手术的临床结果

目的研究踝关节骨折切开复位内固定(ORIF)手术后再次踝关节镜的疗效。 方法回顾性分析2011年1月至2014年12月在解放军第81集团军医院骨科因踝关节骨折ORIF手术后各种原因行踝关节镜手术66例患者,平均年龄(40±13)岁。纳入踝关节骨折ORIF术后因残余痛及其他各种原因行踝关节镜手术的患者,排除炎症性关节炎及下肢神经病变、合并精神疾病者。记录术前、术后4周、6月的疼痛视觉模拟评分(VAS)及美国足踝骨科协会踝－后足(AOFAS)评分,记录并发症及处理方法。组间比较采用单因素ANOVA方差分析。 结果术后早期无关节镜相关并发症发生。术后4周、6月VAS评分比术前显著改善(t＝2.783, P<0.05), AOFAS评分与术前相比明显升高(t＝6.271, P <0.01)。术后4年再次手术率为19.7%。 结论踝关节骨折ORIF手术后因各种原因行踝关节镜手术早期可以减轻疼痛、改善功能,但中期再手术率高。     

经皮微创内固定技术（MIPO）治疗踝关节骨折的疗效分析

目的比较经皮微创内固定技术（MIPO）与切开复位内固定术（ORIF）治疗踝关节骨折的疗效。方法自2009—01—2012—12对收治的88例成人踝关节骨折根据内固定方法不同分为闭合复位经皮微创空心钉及钢板内固定（MIPO组,38例）和传统切开复位内固定（ORIF组,50例）,比较2组手术时间、住院时间、骨折愈合时间、局部并发症发生情况及术后1年AOFAS评分。结果MIPO组在住院时间、切口感染发生率及骨折愈合时间方面明显优于ORIF组,差异有统计学意义（P〈O．05）。88例均获得随访6～36个月,平均18个月。结论与传统切开复位内固定相比,闭合复位经皮微创空心钉及钢板固定技术治疗踝关节骨折具有创伤小、切口美观、固定牢靠、骨折愈合率高、踝关节功能恢复满意的优点。     

切开复位内固定治疗后踝骨折的疗效分析

目的评价切开复位内固定治疗后踝骨折的手术方法及临床疗效。方法回顾分析2005年6月-2008年12月,46例采用切开复位内固定治疗并获完整随访的涉及后踝骨折的踝关节骨折患者临床资料。男29例,女17例;年龄19～76岁,平均47.7岁。扭伤17例,摔伤15例,交通事故伤12例,其他伤2例。左踝25例,右踝21例。单纯后踝骨折6例,外踝及后踝骨折13例,三踝骨折22例,外踝及后踝骨折伴三角韧带损伤5例。伴内踝或外踝骨折者根据Lauge-Hansen分型标准:旋后外旋Ⅲ度13例,Ⅳ度9例;旋前外旋Ⅳ度18例。后踝骨折按照Naoki分型:后外侧斜型29例,内侧延伸型11例,小块撕脱骨折型6例。7例急诊手术,39例择期手术。结果术后2例出现切口浅表感染,经加强换药后切口愈合;其余患者切口均Ⅰ期愈合。46例均获随访,随访时间18～63个月,平均37个月。骨折均于术后3～6个月愈合,平均4.3个月。术后1个月1例出现腓肠外侧皮神经损伤症状,未作特殊处理;末次随访时9例负重或行走时出现踝关节疼痛不适,加强康复锻炼及止痛药物治疗。末次随访时根据美国矫形足踝协会(AOFAS)踝与后足评分标准进行功能评估,获优17例,良21例,中8例,优良率为83%。患者疼痛视觉模拟评分(VAS)为0～5分,平均1.9分。结论切开复位内固定治疗后踝骨折可获得较好疗效,但应根据骨折类型选择手术方式和固定方法。     

后外侧入路切开复位内固定治疗三踝骨折

目的评价采用后外侧入路切开复位内固定治疗三踝骨折的价值。方法自2009-03—2012—06采用后外侧入路切开复位内固定治疗三踝骨折23例,处理外踝骨折时钢板放置于腓骨后侧或外侧,对后踝骨折行钢板或螺钉固定。观察术后切口及骨折愈合情况,术后3、12个月采用AOFAS踝一后足评分标准评价踝关节功能。结果术后3个月23例均获得随访,术后12个月2例失访。术后7d2例外侧和内侧切口周围同时出现张力性水泡．2例外侧切口周围出现张力性水泡,未出现切口感染。1例出现足背外侧麻木,术后3个月复诊时症状消失。术后3个月X线片显示23例骨折线均模糊,AOFAS评分：优12例,良8例,可2例,差1例,优良率86．96％。术后12个月X线片显示骨折线均消失,AOFAS评分：优17例,良2例,可2例,优良率90．48％。结论采用后外侧入路行切开复位内固定术治疗三踝骨折可以一次性复位固定外踝和后踝骨折,联合内侧切口可以一个体位下完成三踝骨折的治疗,对软组织破坏少,骨折可获得解剖复位,术后踝关节功能恢复佳、并发症少。     

Early weight-bearing in operatively fixed ankle fractures: A systematic review

BackgroundAnkle fractures are among the most common lower limb fractures and they can cause significant detrimental effects on quality of life and work.ObjectiveThe objective of the review was to evaluate if there is any advantage of early weight-bearing after open reduction and internal fixation of the ankle.MethodsElectronic databases, reference lists of included studies and relevant systematic reviews were searched for randomized and non-randomized controlled trials in adults comparing early and late weight-bearing after open reduction and internal fixation of the ankle. The search was inclusive up to February 2012.ResultsNine studies comprising 555 subjects were included for review. There were significantly better outcomes for improved early dorsiflexion, time to full weight-bearing, early return to previous work and shorter hospital stay (patient < 60 years of age) in the early weight-bearing group.ConclusionThe evidence base contained many methodological limitations and was generally poor, and so any conclusion drawn from the research must be done so with caution. The literature suggests that early weight-bearing may allow for quicker rehabilitation and earlier return to work. Future studies should focus on randomized controlled trials with narrow range of clinically useful outcome measures and consistent immobilization strategy between experimental groups.     

移位性踝关节骨折延迟性手术的术式选择

目的探讨移位性踝关节骨折延迟性手术的术式选择及疗效。方法对23例移位性踝关节骨折患者施行延迟性手术,16例行切开复位内固定术,7例行踝关节融合术,并应用AOFAS评分系统进行评价。结果随访25－173个月,平均80个月。骨折全部愈合,均获得无痛性可负重关节。延迟1－3个月者,切开复位内固定组的术后AOFAS评分有较大的提高。延迟3个月以上者,两种术式AOFAS评分提高的幅度相差不大。结论延迟1～3个月的骨折,如踝穴恢复完整并获得解剖复位,应选择切开复位内固定术,否则,可采用关节融合术。延迟3个月以上的骨折由于软骨和软组织的退变,获得解剖复位的难度增大,宜采用关节融合术。     

Locked intramedullary nailing provides superior functional outcomes and lower complication rates than plate fixation of distal fibula fractures. A systematic review and meta-analysis of comparative studies

PurposeThis study aims to provide an updated systematic review and meta-analysis of comparative studies on the outcomes and complications of locked IMNs in comparison to ORIF using plates and screws, while avoiding limitations of similar published reviews.MethodsFollowing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout May 2021 using the following keywords with their synonyms: “Ankle fracture fixation” AND “Open reduction and internal fixation”, “locked intramedullary nail”, or “complications”. The primary outcomes were (1) functional outcomes, (2) complications, and (3) reoperation, while the secondary outcomes were: (1) union rate, and (2) cost. Inclusion criteria: comparative studies on outcomes and complications of plate open reduction and internal fixation (ORIF) vs. locked intramedullary nailing (IMN) of ankle fractures reporting at least one of the following parameters: functional outcomes, complications (infection, dehiscence, reoperation etc.), union, and cost. Studies reporting on non-locked intramedullary fibular nails were also excluded.ResultsAfter the removal of duplicates, a total of 1461 studies were identified. After screening those records, 63 studies remained for full-text assessment. Out of those, four comparative studies with a total of 262 ankle fractures met the inclusion criteria for this meta-analysis. The mean 12 months postoperative Olerud and Molander Ankle Scores (OMAS) were reported by two studies, with a statistically significant difference in favor of IMNs (MD= 6.72, CI: 3.77–9.67, p <0.001, I²= 94%). In the ORIF group, the overall complication rate was 39/134 (29.1%) vs. 10/128 (7.8%) in the IMN group, with a statistically significant difference in favor of the IMN group (RR=3.23, CI:1.71–6.11, p<0.001, I²=34%). In the ORIF group, the overall infection rate was 11/134 (8.2%), while there were no infections in the IMN group, with a statistically significant difference in favor of the IMN group (RR=8.05, CI:1.51–42.82, p=0.01, I²=0%). In the ORIF group, the overall reoperation rate was 10/134 (7.5%) while the overall reoperation rate was 6/128 (4.7%) in the IMN group, with no statistically significant difference between groups (RR=1.49, CI: 0.60–3.70, p = 0.39, I²=0%).ConclusionLocked intramedullary nail fixation of distal fibula fractures could provide superior functional outcomes and lower complication rates in comparison to open reduction and plate fixation. Despite the high incidence of ankle fractures, the number of high-quality comparative studies remains limited in literature, especially on newer locked fibular nails, and large multicentric clinical trials are required before recommending locked IMNs as the new standard of care in distal fibula fractures.     

Complication rates following operative treatment of calcaneus fractures

Background

The purpose of this study is to report the short-term complication rates and mid-term subtalar fusion rates following operative management of calcaneal fractures.

Methods

This is a retrospective study of Californians undergoing operative treatment of a calaneus fracture from 1995 to 2005. The main outcomes reported are readmission for a short-term complication within 90 days of surgery and reoperation for subtalar fusion during the observation period.

Results

We identified 4481 patients who underwent open reduction and internal fixation of their fracture as inpatients within 30 days of the index admission. The short-term rate of complications included a 90-day rate of readmission of 1.03% for wound infection, 0.25% for thromboembolic disease, and 0.22% for mortality. The mid-term rate of subtalar fusion was 3.49% at 5 years post-operatively.

Conclusions

This study reports the short-term complication rates and mid-term subtalar fusion rates following operative management of calcaneal fractures using population-based data.     

关节镜辅助经皮内固定和切开复位内固定治疗Schatzker Ⅱ、Ⅲ型胫骨平台骨折的比较研究

目的比较关节镜辅助经皮内固定和切开复位内固定治疗SchatzkerⅡ、Ⅲ型胫骨平台骨折的疗效。方法 2006年8月-2010年4月,收治58例SchatzkerⅡ、Ⅲ型胫骨平台闭合骨折患者,根据治疗方法不同随机分为两组,其中38例采用关节镜辅助经皮内固定治疗(关节镜组),20例采用切开复位内固定治疗(对照组)。两组患者性别、年龄、病程、骨折类型、合并症比较,差异均无统计学意义(P>0.05),具有可比性。记录两组手术时间、切口长度、骨折愈合时间、术后并发症发生情况;按美国特种外科医院(HSS)评分标准行膝关节功能评分,测量关节活动度。结果术后两组患者切口均Ⅰ期愈合。关节镜组手术时间较对照组长,切口较对照组短,差异均有统计学意义(P<0.05)。两组患者均获12～14个月随访。术后6个月关节镜组膝关节HSS评分优于对照组,关节活动度大于对照组,差异均有统计学意义(P<0.05)。X线片检查示两组骨折均达骨性愈合,关节镜组愈合时间较对照组短,但差异无统计学意义(t=2.14,P=0.41)。关节镜组2例(5.3%)术后1周出现关节晨僵;对照组6例(30.0%)术后1周出现关节疼痛,其中3例伴关节僵直;均经对症处理后症状缓解。两组并发症发生率比较,差异有统计学意义(χ2=6.743,P=0.016)。结论关节镜辅助经皮内固定治疗SchatzkerⅡ、Ⅲ型胫骨平台骨折与切开复位内固定相比,具有术后功能恢复快、并发症少等优点。     

不同内固定方式对踝关节骨折的疗效分析

目的比较不同内固定方式对踝关节骨折的疗效,以期为临床提供依据。方法回顾性分析治疗的踝关节骨折患者38例,其中接受闭合复位内固定手术的患者22例,设为闭合复位组;接受传统切开复位内固定手术的患者16例,设为切开复位组。术后对患者进行随访,比较两组患者治疗优良率及术后并发症发生率。结果闭合复位组患者术后优良率86.36%(19/22),并发症发生率9.09%(2/22);切开复位组术后优良率为75%(12/16),并发症发生率为18.75%(3/16)。闭合复位组治疗优良率显著高于切开复位组,闭合复位组并发症发生率显著低于切开复位组,两组比较差异有统计学意义(P0.05)。结论与传统的切开复位内固定术相比,闭合复位经皮空心螺钉内固定法能够有效提升治疗效果并减少并发症发生率,减轻患者负担、提高患者生存质量,值得在临床上推广应用。     

Cost description of inpatient treatment for ankle fracture

Background

The study estimated the hospital costs associated with the surgical fixation of ankle fractures by either open reduction internal fixation (ORIF) or external fixation.

Method

A retrospective review of the clinical records of all 264 patients admitted with an ankle fracture requiring surgical stabilisation between 1 March 2007 and 29 February 2008. Patient records were examined for a minimum of 6 months after primary admission. A mean cost per patient was calculated based on patient-level hospital resource use. This included all procedures received during both their primary hospitalisation and subsequent re-admissions.

Results

Approximately equal numbers of males and females (mean age 46.2 years) were admitted, and males were significantly younger than females. The mean length of stay was 10.8 days (SD 9.1); however, ORIF (which was performed in the vast majority of cases, 94.7%) was associated with a much shorter mean length of stay compared with external fixation (10.4 days; SD 8.9 vs. 17.4 days; SD 10.2). The mean total hospital cost per patient including was £4730.28 (SD £2340.73) with a higher mean cost for those who received external fixation as the primary procedure (£9453.92; SD £3391.84) compared with ORIF (£4465.76; SD £1965.10). Patients with severe health problems had significantly higher costs than fit and healthy patients (£5982.65; SD £28 77.74 vs. £4375.00; SD £1957.65).

Conclusions

The results highlight the considerable hospital costs associated with the surgical fixation of an ankle fracture, thus providing valuable information for resource planners. Future research should broaden the perspective of the economic analysis to include rehabilitation costs and assess the cost-effectiveness of potential cost-saving strategies.     

可吸收螺钉治疗踝关节骨折

目的:探讨可吸收螺钉治疗踝关节骨折的临床疗效。方法:应用可吸收螺钉治疗踝关节骨折58例,男31例,女27例;平均年龄28岁。三踝骨折5例,内踝骨折27例,外踝骨折26例,其中内外踝骨折9例,合并下胫腓联合分离6例,合并腓骨下段骨折4例。单纯内、外踝骨折采用2枚可吸收螺钉固定;同时内外踝骨折各骨折分别用2枚可吸收螺钉固定;合并下胫腓联合分离者,从腓骨向胫骨拧入1枚可吸收拉力螺钉固定胫腓关节;内踝合并腓骨下段骨折者,内踝用1或2枚可吸收螺钉,腓骨骨折用重建钢板内固定;三踝骨折者据骨折片大小分别每一骨折用1或3枚螺钉内固定。结果:50例均获得随访,时间1～4年,平均26个月,经Kennedy踝关节功能标准评分,优30例,良20例。无骨折延迟愈合及骨折不愈合、固定钉松动、踝穴不稳定、畸形愈合,无明显创伤性关节炎等严重并发症。结论:可吸收螺钉是种新型内固定材料,内固定治疗踝关节骨折疗效好,可免除二次手术,值得推广。     

Fixation of ankle fragility fractures by tibiotalocalcaneal nail

Introduction Fragility fractures of the ankle are difficult to treat by conventional fixation due to poor bone quality, compromised soft tissues, and inherent instability. Conservative management of these patients also has its problems. Materials and methods We retrospectively reviewed 13 patients who underwent intramedullary nailing through the tibiotalocalcaneal joints in an attempt to achieve the dual aims of fracture control and early mobilisation. The Olerud and Molander scale was used as outcome measures. Results There were 12 females and 1 male with a mean age of 78.9 (range 64–93). Half of the patients were discharged from hospital within the first 2 weeks after the operation. All achieved a comparable function to their pre-operative state. The mean follow-up period was 11 months (range of 2–62 months). Six are now deceased from unrelated causes. The mean Olerud and Molander score was 50 (range 30–65). All the radiographs showed evidence of fracture union with no changes in the overall alignment of the joint. Conclusion Given the low survivorship of this frail group of patients the main objectives are achieving early mobilisation whilst maintaining good fracture position. In our experience, tibiotalocalcaneal nailing is a very useful and successful way of treating fragility fractures of the ankle because it has a low risk of complications and restores function with impressive patient satisfaction. The potential benefits of this technique, we believe, outweigh the disability ensued from subtalar joint fusion.     

Temporary vertical transarticular-pin fixation of unstable ankle fractures with critical soft tissue conditions

Unstable ankle fractures are demanding injuries to treat. Open reduction and internal fixation are accepted as standard care, however, in patients with severe soft tissue damage or serious medical conditions, this approach may not always be advisable. Closed reduction with temporary fixation using vertical transarticular pins is one method to maintain joint alignment until an open technique is possible. Fourteen patients (median age: 59.5 years) with unstable ankle fractures, including three type-2 open fractures, were included in the study. Open reduction and fixation was delayed because of severe soft tissue damage, and a temporary transarticular pin fixation using two Kirschner wires was performed. After a median of 8.4 days, an open reduction and internal fixation was carried out in all patients. No complications related to the temporary arthrodesis were observed during the acute phase, and follow-up at 24 months revealed no damage to the articular surface attributable to the pin insertion. The median Olerud-score was 33.43, but three patients showed signs of early post-traumatic arthritis which we felt were due to the initial fracture. We conclude that closed reduction and temporary fixation using vertical transarticular pins of unstable ankle fractures is a safe method of maintaining joint alignment until a definitive open approach is feasible.     

Treatment of distal tibia metaphyseal fractures; plating versus intramedullary nailing: A systematic review of recent evidence

IntroductionTreatment of distal tibia metaphyseal fractures is challenging. The purpose of this study was to systematically review the recent literature regarding management of extra-articular distal tibia fractures with a view to compare the outcome of intramedullary nailing with plate fixation.MethodsAdvanced literature search was performed using Medline (Ovid), Embase (Ovid) and Cochrane databases. Data were extracted regarding number of participants, fracture fixation devices, percentage of open fractures, malunions, nonunions, wound infections and metal removal etc.ResultsAfter inclusion, exclusion criteria, two RCTs and four retrospective comparative studies were deemed suitable for this review. The overall results showed relatively higher rate of infection in plating group as compared to intramedullary nailing. However malalignment was more common with intramedullary nailing.ConclusionBoth techniques can provide adequate treatments in appropriately selected patients. None of the studies had sufficient power to show clinically significant difference. Further studies are required to compare new locking plates with intramedullary nails.     

伴踝关节脱位胫骨pilon骨折的发病机制及治疗策略

目的 探讨伴踝关节脱位胫骨pilon骨折的发病机制及治疗策略.方法 2006年6月至2011年10月收治58例伴踝关节脱位胫骨pilon骨折患者,男47例,女11例;年龄17～76岁,平均48.1岁.骨折按AO分型:B2型8例,B3型17例,C3型33例.按踝关节脱位类型:内侧脱位13例,外侧脱位9例,前侧脱位11例,后侧脱位14例,纵向脱位11例.通过X线片观察术后骨折复位及脱位纠正情况,骨折愈合情况及内固定牢固程度,并定期接Kofoed踝关节评分标准对踝关节功能进行评估.结果 所有患者术后获4～ 27个月(平均12.6个月)随访.58例患者中获解剖复位39例,占67.2％;良好复位13例,占22 4％;不佳复位6例,占10.4％.后期无内固定松动、断裂等并发症发生,骨折全部获愈合,愈合时间为2～4个月,平均2.8个月.所有患者按Kofoed踝关节评分标准进行踝关节功能恢复情况评价优良率:B型84.0％,C型75.8％;内侧脱位76.9％,外侧脱位77.8％,前侧脱位81.8％,后侧脱位78.6％,纵向脱位81.8％. 结论 胫骨pilon骨折常伴有踝关节不同方向的脱位,治疗时应注意恢复原有解剖结构和力线关系,才能最大限度减少骨性关节炎等并发症的发生.     

可吸收螺钉在踝关节骨折中的应用

目的 探讨可吸收螺钉治疗踝关节骨折的疗效. 方法 2004年6月至2010年12月采用可吸收螺钉治疗16例踝关节骨折患者,男9例,女7例;年龄21～62岁,平均35岁;其中三踝骨折4例(AO分型:B型2例,C型2例),内外踝骨折8例(AO分型均为B型),单纯内踝骨折2例,单纯外踝骨折2例(1例为AO分型A型,另1例为外踝Maisonneuve骨折合并下胫腓联合和内侧三角韧带损伤).所有涉及外踝的骨折患者只有AO分型A型骨折采用2枚2.7 mm可吸收螺钉或1枚2.7mm可吸收螺钉辅助1枚1.5 mm可吸收棒固定,其余均采用接骨板螺钉固定.内踝骨折采用2～3枚3.5mm或4.0mm可吸收螺钉固定.1例下胫腓联合损伤采用2枚4.5 mm可吸收螺钉贯穿下胫腓固定.后踝骨折采用l～2枚4.0mm或4.5 mm可吸收螺钉从前向后固定.结果 16例患者术后获1.5～4.0年(平均28个月)随访.骨折愈合时间平均为3.0个月,无骨折延迟愈合及骨折不愈合,未出现伤口并发症.按美国足踝外科协会踝与后足功能标准评分评定疗效:优14例,良2例. 结论 可吸收螺钉内固定治疗踝关节骨折疗效好,无需行二次内固定取出手术,但要慎重选择骨折类型.     

踝部骨折的手术疗效

目的评价踝部骨折的手术治疗效果.方法41例分别应用拉力螺钉、1/3管型钢板、腓骨远端解剖型钢板内固定.结果41例随访1～3年,优24例,良14例,差3例.结论踝部骨折手术治疗应遵循踝关节的生理特点,强调恢复外踝及下胫腓联合的解剖关系、踝关节的稳定、合理有效内固定和早期功能锻炼.