合并下胫腓联合分离的踝关节骨折手术治疗

目的 探讨切开复位内固定治疗合并下胫腓联合分离的踝关节骨折的疗效.方法 52例合并下胫腓韧带损伤的踝关节骨折脱位的患者,采用切开复位内固定,下胫腓联合采用单个或双螺钉固定,手术后用石膏外固定6周.术后根据Baird-Jackson系统评分标准进行疗效评估.结果 本组52例患者术后平均随访4.5年(6个月～8年),骨折愈合良好,无切口感染发生.根据Baird-Jackson评定标准,本组优26例,良21例,可3例,差2例,优良率为90.38%.结论 骨折的解剖复位,胫距之间正常的对合关系,应依据不同骨折类型处理下胫腓韧带损伤,是取得满意结果 的关键.     

可吸收螺钉治疗踝关节骨折伴下胫腓联合分离的效果:48例报告

目的探讨可吸收螺钉治疗踝关节骨折伴下胫腓联合分离中的应用。 方法2009年8月~2014年8月治疗踝关节骨折150例,皆行切开复位内固定术,其中伴有下胫腓分离者48例,内固定术后,行C臂机透视,如发现下胫腓联合仍然分离者,行可吸收螺钉横向固定。 结果全病例经跟踪得到6个月~4年9个月随访,平均2年4个月。根据美国足踝外科协会（AOFAS）制定的踝关节评定标准,优37例,良9例,可1例,差1例。优良率达95.8%。 结论可吸收螺钉治疗踝关节骨折伴有下腓分离,具有良好的内固定特性及组织相容性,能早期进行功能锻炼,减少了拆除横向螺钉手术过程再次手术的痛苦,避免金属螺钉断裂的风险。      

下胫腓钩板固定器的生物力学特征

背景:以往治疗下胫腓联合分离伴腓骨骨折患者采用石膏或夹板等外固定及螺钉、骨栓及钢板螺钉等内固定术式,但存在固定不牢靠、对合不良等弊端。目的:通过采用自行研制的新型内固定器--下胫腓钩板固定器治疗下胫腓联合分离伴腓骨骨折患者的初步临床疗效,观察下胫腓钩板固定器的生物力学特征。设计:自身前后对照观察。对象:选者2001-10/2004-03扬州大学临床医学院附属医院骨科就诊的下胫腓联合分离伴腓骨骨折的患者23例,根据Lauge-Hansen分类,旋后外旋型11例,旋前外旋型7例,旋前外展型5例。其中双踝骨折14例,三踝骨折9例。方法:采用下胫腓钩板固定器治疗23例下胫腓联合分离伴腓骨骨折。术后常规摄X射线片。1周即可进行距小腿关节功能锻炼,2个月左右即可部分负重行走。功能测评根据改良Mazur标准进行评价(分为优,良,可,差)。主要观察指标:①胫腓联合分离伴腓骨骨折患者术后愈合时间及功能测评。②不良事件及副反应。结果:23例患者平均随访11个月,均进入结果分析。①患者胫腓联合分离伴腓骨骨折术后愈合时间及功能测评结果:骨折愈合的时间为12～18周;优16例,良5例,可2例。②不良事件及副反应:患者下胫腓间隙无分离,内、外踝与距骨之间的距离对称,术后内固定无松动、断裂现象。结论:应用下胫腓钩板固定器治疗胫腓联合分离伴腓骨骨折患者,术后无并发症,并能恢复距小腿关节(踝关节)功能,其内固定稳定,生物力学性能较好。     

Sled fixation for horizontal medial malleolus fractures

BackgroundHorizontal fractures of the medial malleolus occur through exertion of various rotational forces on the ankle, including supination­-external rotation, pronation-­external rotation, and pronation-abduction. Many methods of fixation are employed for these fractures, but the optimal fixation construct remains unclear.MethodsHorizontal medial malleolus osteotomies were performed in synthetic distal tibiae and randomized into two fixation groups: 1) two parallel unicortical cancellous screws or 2) medial malleolar sled fixation. Specimens were subjected to offset axial tension loading and tracked using high-resolution video. Clinical failure was defined as 2 mm of articular displacement.FindingsThere were statistically significant increases in mean stiffness (127% higher, P = 0.0007) and mean force to clinical failure (52% higher, P = 0.0002) with the medial malleolar sled. The mean stiffness in offset tension loading was 232 (SD 83) N/mm for medial malleolar sled and 102 (SD 20) N/mm for parallel unicortical cancellous screws. The mean force to clinical failure was 595 (SD 112) N for medial malleolar sled and 392 (SD 34) N for unicortical screws. In addition, the medial malleolar sled demonstrated elastic recoil to pre-testing alignment while the unicortical screws did not.InterpretationMedial malleolar sled fixation was significantly stiffer and required more force to clinical failure than parallel unicortical cancellous screws. A medial malleolar sled requires more dissection to apply surgically, but provides significantly more initial fixation strength. Additionally, a medial malleolar sled acts like a tension band in its ability to capture comminuted fragments while being low profile enough to minimize soft tissue irritation.     

Suture-button fixation and anterior inferior tibiofibular ligament augmentation with suture-tape for syndesmosis injury: A biomechanical cadaveric study

BackgroundSuture-button (SB) fixation has been widely performed for syndesmosis injuries, but it has been reported unstable in some biomechanical studies. The purpose of this study was to evaluate the stability of the syndesmosis using SB fixation with anterior inferior tibiofibular ligament augmentation using suture-tape (ST).MethodsEight normal fresh-frozen cadaveric legs were used. After initial tests of intact and injured models, SB fixation, SB fixation with ST augmentation, ST augmentation alone, and screw fixation were performed sequentially for each specimen. Loading tests stimulating dorsiflexion, inversion, and external rotation of the ankle joint were performed for each model. The tibiofibular diastasis (TFD) and the fibular rotational angle related to the tibia (FRA) were measured using a magnetic tracking system.FindingsIn the injured model, both TFD and FRA increased significantly compared with the intact model in all directions (P < .05). In the SB fixation model, TFD and FRA generally showed significant increases (P < .05, except for TFD in external rotation). In the SB fixation with ST augmentation model and ST augmentation alone, TFD and FRA were not significantly different compared with the intact model (P > .05). In the screw fixation model, FRA with inversion force at the ankle was significantly decreased compared with the intact model (P = .027).InterpretationSB fixation alone did not provide stability of the syndesmosis, and screw fixation became too rigid compared with the intact model. Using ST augmentation achieved dynamic stability similar to the intact model for syndesmotic injuries.     

拉力螺钉1/3管状钢板在三踝骨折合并下胫腓联合分离治疗中的应用

目的：探讨三踝骨折合并下胫腓联合分离的手术治疗。方法：回顾分析25例三踝骨折合并下胫腓联合分离采用拉力螺钉1／3管状钢板治疗的临床资料。结果：25例患者随访1～3年，优17例，良4例，可4例，其中3例患者复诊时拉力螺钉断裂，但功能均优。结论：拉力螺钉1／3管状钢板固定牢固，有利于早期功能锻炼。     

踝关节腓骨旋转角测量：术中判断下胫腓骨联合复位的成功率

背景：CT在诊断下胫腓联合方面优于X射线平片,但是判断下胫腓联合旋转失匹配的CT诊断标准目前还缺乏研究。目前国内外下胫腓关节三维失匹配还缺乏系统研究,特别是对旋转关系的测量。目的：用CT测量正常人群的下胫腓联合的腓骨相对胫骨的旋转角度。方法：在符合条件的志愿者中随机抽取21名男性及21名女性进行测试,用CT随机扫描单侧踝关节。轴位CT测量包括胫腓前间隙、胫腓后间隙、腓骨旋转角、胫腓前关节面切线角、胫腓后关节面切线角。为了确保可靠性,2个研究者在3个不同的场合独立鉴定、评价每个CT数据。结果与结论：42例踝关节纳入到数据分析。下胫腓联合胫骨面形状大致分为深弧形、浅弧形、浅坡形及平直形,其中以深弧形对称型多见。腓骨形状可大致分为三角形、圆形、椭圆形,以三角形最多见。各测量指标95％置信区间：胫腓前间隙2．10-2．25mm、胫腓后间隙4．14—4．29mm、腓骨旋转角103．97°-106．30°、胫腓前关节面切线角21．88°-26．64°、胫腓后关节面切线角33．03°-36．63°。其中腓骨旋转角测量变异系数最小,相对波动小,更具有代表性。下胫腓联合CT测量的众多指标中腓骨旋转角是一个更为稳定的指标。这些数据为下胫腓联合的精确复位提供数据基础。     

Radiographic parameters of the normal ankle syndesmosis: Comparison between hindfoot alignment view and anteroposterior view

ObjectiveTo compare the parameters associated with the normal ankle syndesmosis between the hindfoot alignment view (HAV) and anteroposterior (AP) view and determine which view is more accurate for comparing the left and right ankles.MethodsThis study involved 61 subjects without syndesmosis injury who had radiographs of both ankles. The tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS) were measured in each view. Intraclass correlation coefficients were used to assess the agreement between the two ankles. Difference ratios for the measured parameters between the ankles were also compared.ResultsThe agreement for TFCS showed wide disparity between the two ankles (AP view, 0.576; HAV, 0.858). The highest degree of agreement was seen for TFO (AP view, 0.733; HAV, 0.926). The agreement for MCS was low in both groups. The mean difference ratio for TFCS was also lower in the HAV group (9.9%) than in the AP view group (16.4%); a similar result was observed for TFO (16.4% vs. 25.8%).ConclusionsFor evaluation of the syndesmosis, use of the HAV showed increased accuracy and few measurement errors when comparing the left and right ankles relative to use of the AP view.     

The effect of ankle distraction on arthroscopic evaluation of syndesmotic instability: A cadaveric study

BackgroundTo assist with visualization, orthopaedic surgeons often apply ankle distraction during arthroscopic procedures. The study aimed to investigate whether ankle distraction suppresses fibular motion in cadaveric specimens with an unstable syndesmotic injury.MethodsFourteen fresh-frozen above knee specimens underwent arthroscopic assessment with 1) intact ligaments, 2) after sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, and the posterior inferior tibiofibular ligament, and 3) after sectioning of the deep and superficial deltoid ligament. In all scenarios, the lateral hook test, anterior-posterior hook test, and posterior-anterior hook test were applied. Each test was performed with and without ankle distraction. Coronal plane anterior and posterior tibiofibular diastasis as well as sagittal plane tibiofibular translation due to the applied load were arthroscopically measured.FindingsTibiofibular diastasis in the coronal plane, as measured at both the anterior and posterior third of the incisura, was found to be significantly less when ankle distraction was applied, as compared to arthroscopic evaluation in the absence of distraction. In contrast, measurement of sagittal plane tibiofibular translation was not affected by ankle distraction.InterpretationSince arthroscopic findings of syndesmotic instability are subtle the differential values of the syndesmotic measurements taken on and off distraction are clinically relevant. To optimally assess syndesmotic instability one should evaluate the syndesmosis without distraction or focus on fibular motion in the sagittal plane when distraction is required.     

Treatment of lower part of glenoid fractures through a novel axillary approach: A case report

BACKGROUNDBased on the location and size of the fracture block, open reduction and internal fixation can be employed or assisted for shoulder arthroscopy in the treatment of glenoid fractures. However, the treatment of lower part of glenoid fractures through a novel axillary approach has not been reported so far. CASE SUMMARYA 22-year-old right-handed man was transferred to our outpatient clinic because of right shoulder injury during a traffic accident. X-ray examination after admission suggested the fracture of the lower part of the right glenoid and an ipiselial proximal humeral fracture. Three-dimensional (3D) computed tomography (CT) further suggested that the size of the fracture block of the lower part of the right glenoid was 3.4 mm × 16.2 mm. The patient was diagnosed as the fracture of the lower part of the glenoid, also known as bony Bankart lesion without shoulder dislocation. After general anesthesia, the patient was surgically treated with the open reduction internal fixation through a novel axillary approach. 3D CT and shoulder joint function were reexamined at 12 mo of follow-up, showing acceptable recovery.CONCLUSIONThis case report describes a novel axillary approach adopted in an open reduction with cannulated screw and wire anchor internal fixation. After a follow-up for more than 12 mo, 3D CT and shoulder joint function examinations display a good recovery.     

踝部骨折治疗效果与距骨生物力学的关系

背景距小腿(踝)关节的解剖结构并不复杂,但其生物力学关系十分重要.距骨参与组成3个关节,对距小腿关节功能起极其重要作用.因此恢复踝穴的解剖关系,稳定距骨在其中的位置甚为重要.目的探讨踝部骨折的治疗与距骨生物力学的关系.设计非随机非对照的研究.地点和对象1985-01/2000-10中国医科大学附属第一医院收治距小腿关节骨折患者95例.收集患者因恶性肿瘤截肢后小腿标本3只.干预通过离体小腿标本,对距骨在踝部骨折中生物力学关系做简要观察,并对95例距小腿关节骨折治疗后的临床及X射线加以分析.主要观察指标①观察不同骨折类型受力情况.②观察距小腿关节恢复的临床疗效与距骨生物力学变化的关系.结果随访65例,优41例,良12例,尚可7例,差5例.生物力学结果双踝骨折时,头颈压缩0.48 cm;外踝骨折,垂直压力时外踝面受力大于内踝面,腓骨下1/3骨折,内翻位时距骨外踝面受力轻于内踝面.结论距小腿关节骨折不论手法复位外固定或手术复位内固定,均应注意距骨在踝穴内解剖关系,并注意下胫腓关节间隙距离.恢复踝穴和距骨的生物力学关系是极为重要的治疗标准.     

踝关节镜辅助3孔钢板双螺钉固定下胫腓联合术对Maisonneuve骨折患者足踝功能及疼痛应激反应的影响

目的探讨踝关节镜辅助3孔钢板双螺钉固定下胫腓联合术对Maisonneuve骨折患者足踝功能及疼痛应激反应的影响。方法选取2017年8月至2019年8月收治的Maisonneuve骨折患者76例,以抽签法将其随机分为对照组和观察组,各38例。对照组采用传统切开复位下胫腓双螺钉固定术,观察组采用踝关节镜辅助3孔钢板双螺钉固定下胫腓联合术。比较两组疼痛应激反应指标、凝血功能指标、足踝功能和疼痛程度。结果术后1 d,观察组的E、Cor、CRP水平均低于对照组(P<0.05)。术后1 d,观察组的PT、APTT长于对照组,FBG水平低于对照组(P<0.05)。术后6个月,观察组的AOFAS评分高于对照组,VAS评分低于对照组(P<0.05)。结论临床采用踝关节镜辅助3孔钢板双螺钉固定下胫腓联合术治疗Maisonneuve骨折,能够有效减轻疼痛应激反应,改善凝血功能,促进患者足踝功能快速恢复。     

解剖型锁定钢板治疗股骨粗隆间骨折的效果

目的探讨股骨上段解剖型锁定钢板锁定股骨颈内侧皮质在治疗各型股骨粗隆间骨折中的效果。方法 2008年6月—2010年3月,我科对13例股骨粗隆间骨折病人,采用闭合复位解剖型锁定钢板内固定术治疗,骨折近端采用3枚自攻长锁定螺钉固定,其中1枚拧入股骨颈内,余2枚经股骨颈并穿出内侧皮质;远端采用自攻锁定螺钉和普通螺钉固定。结果 13例病人获得3～12月随访,骨折均愈合,无明显髋内翻畸形及内固定物松动、断裂等;根据股骨粗隆间骨折的SANDERS创伤性髋关节评定标准：优12例,良1例,优良率100%。结论解剖型锁定钢板锁定股骨颈内侧皮质治疗股骨粗隆间骨折,创伤小,手术时间短,固定可靠,并发症少,骨折愈合率高,病人能早期活动,临床效果优良。     

Ⅳ度旋前外旋型踝关节骨折的手术治疗体会

目的探讨Ⅳ度旋前外旋型踝关节骨折的手术治疗方法及临床效果。方法回顾分析自2006年1月至2009年12月采用手术治疗的Ⅳ度旋前外旋型踝关节骨折35例。Ⅳ度旋前外旋型踝关节骨折则采用改良的腓骨后外侧弧形联合切口,按后踝-外踝-内踝-下胫腓联合顺序进行复位固定。结果所有患者随访6～24个月,平均18个月,平均骨性愈合时间12周,根据Baird-Jackson系统评分:优31例,良3例,可1例,差0例,优良率97.1%。本组1例踝关节活动轻度受限,长距离行走时出现疼痛症状。结论通过切开复位内固定可使Ⅳ度旋前外旋型踝关节骨折的踝关节恢复正常解剖关系,最大限度恢复踝关节功能,获得最佳临床效果。     

Biomechanical study of Proximal humeral fracture fixation: Locking plate with medial support screw vs. locking plate with intramedullary fibular graft

BackgroundThe purpose of this study was to evaluate the biomechanical properties of two different fixation constructs in varus collapse proximal humerus fracture, locking plate with medial support screw and locking plate with intramedullary fibular graft.MethodsWe used 8 pairs of undamaged fresh-frozen humen cadaveric humeri and fibula from patients ranging in age from 62 to 81 years. We simulated a proximal humerus fracture with medial comminution using wedge shaped osteotomy. One group was fixed with locking plate with medial support screws, the other group with locking plate with intramedullary fibular graft. Biomechanical test was carried out using servohydraulic material testing system. We measured displacement of specimens under cyclic load test, maximum failure load, initial stiffness, and mode of failure under increasing load test.FindingsUnder cyclic loading, the displacement of the specimen was significantly less in the locking plate with fibular strut graft group than in the locking plate with medial support screws group. (p = 0.012) Under increasing load test, the Locking plate with fibular strut graft group showed higher values in both maximum failure load and initial stiffness than the Locking plate with medial support screws group, and this was statistically significant. (p = 0.012, p = 0.001).InterpretationIn biomechanical study, the locking plate with fibular strut graft showed significantly better results in all of the maximum failure load, initial stiffness, and gap depletion compared to the locking plate with medial support screws.Level of evidenceLevel IV.     

Fracture of the scapular neck combined with rotator cuff tear: A case report

BACKGROUNDScapular fracture has a low incidence rate, accounting for 0.4%-0.9% of all fractures, and scapular neck fractures are extremely rare, comprising approximately 7%-25% of all scapular fractures. Scapular neck fractures are often studied as case reports mostly accompanied by other injuries, thus leading to confusion. All previous cases of scapular neck fractures are not associated with rotator cuff injuries.CASE SUMMARYA 62-year-old man was admitted to our emergency department 6 h after his right shoulder and back were impacted by heavy objects. The patient presented chest tightness and shortness of breath. Chest computed tomography (CT) showed pneumohemothorax, multiple rib fractures, and right scapula fractures. Three-dimensional CT reconstruction of the right shoulder joint showed a trans-spinous scapular neck fracture with a glenohumeral joint dislocation. Rotator cuff injury was suspected because the patient had a glenohumeral joint dislocation and was then confirmed by shoulder magnetic resonance imaging. A staged surgery was performed, including open reduction and internal fixation of the right scapula fracture and repairing of rotator cuff by right shoulder arthroscopy. At the 5-mo follow-up, the fracture line was blurred and the shoulder joint function was good.CONCLUSIONFracture of the scapular neck combined with rotator cuff tear is rare and the rotator cuff injury should not be ignored in clinical work. Stable internal fixation combined with secondary arthroscopic repair of rotator cuff tear can achieve good results.     

后踝骨折切开复位螺钉置入过程中直视观察法与X射线透视法的比较

背景：既往后踝骨折的复位与固定过程中采用的传统X射线透视观察法,内踝脱位法及外踝截骨法等都存在不同程度的不满意之处。直视观察法可从另一种途径提供观察隐蔽的后踝。目的：观察在后踝骨折切开复位螺钉置入过程中直视观察法与X射线透视法的优劣。方法：选择2006-01/12北京积水潭医院创伤骨科收治的踝关节骨折患者26例,按照性别、年龄、骨折类型、受伤至手术时间等分为2组,每组13例。X射线透视组采用传统X射线透视法观察后踝骨折复位固定情况,直视组组采用直视法。结果与结论：直视组随访时间17~29个月,平均23个月;X射线透视组17~28个月,平均22.5个月。所有病例均获得骨性愈合,后踝关节面复位良好。直视组后踝复位及固定时间平均（8.08±1.55）min;X射线透视组平均（20.15±4.22）min,差异有显著性意义（P〈0.01）。直视组平均术中后踝X射线透视1次;X射线透视组为3~8次,平均（5.38±1.76）次,差异有显著性意义（P〈0.01）。直视组和X射线透视组AOFAS评分均为86~100分,平均96分,其中优各11例,良各2例。提示直视法观察后踝骨折复位及固定情况优于传统X射线透视法。     

Floating elbow combining ipsilateral distal multiple segmental forearm fractures: A case report

BACKGROUNDFloating elbow along with ipsilateral multiple segmental forearm fracture is a rare and high-energy injury, although elbow dislocation or fracture of the ulna and radius may occur separately.CASE SUMMARYWe report the case of a 37-year-old woman with open (IIIA) fracture of the right distal humerus with multiple shaft fractures of the ipsilateral radius and ulna with a history of falling from a height of almost 20 m from a balcony. After providing advanced trauma life support, damage control surgery was performed to debride the arm wound and temporarily stabilize the right upper limb with external fixators in the emergency operating room. Subsequently, one-stage internal fixation of multiple fractures was performed with normal values of biochemical indicators and reduction in limb swelling. The patient achieved good outcome at the 7 mo follow-up.CONCLUSIONOne- or two-stage treatment must be performed according to the type of injury; we efficiently used the “damage control principle.”     

Modified cannulated screw fixation in the treatment of Pauwels type III femoral neck fractures: A biomechanical study

BackgroundAchieving satisfactory internal fixation for patients with Pauwels type III femoral neck fractures has become a critical problem. The purpose of this study was to compare a common standard internal reduction and fixation method for femoral neck fractures to the modified fixation methods.MethodsA computed tomography scan of the femur was performed to make a Three-dimensional (3D) model, and a fracture line was simulated in the femoral neck. 3Dfinite element analysis was carried out for different insertion methods of cannulated tension screws. Six healthy femur specimens were harvested from three formalin-fixed cadavers, and Pauwels type III femoral neck fracture was artificially created in bilateral femurs. The right side was treated with the inverted triangle construct method and the left side by the modified screw fixation method. After fixation, uniaxial compression and maximum load experiments on the bilateral femoral necks were carried out using the non-contact full-field dynamic strain measurement system (VIC-3D) on a pressure testing machine.FindingsBoth 3D finite element analysis and biomechanical study showed that the modified screw fixation method(group D) provided better anti-shearing and anti-rotation properties for Pauwels type III femoral neck fractures, and offered better interfragmentary compression. Therefore, this modified screw fixation method can offer patients a better option for treatment of Pauwels type III femoral neck fractures.InterpretationChanging the placement of the anterosuperior screw in the inverted triangle construct as perpendicular to the fracture line has the advantages in anti-shearing, anti-rotation and increasing interfragmentary compression.     

踝关节镜下距腓前韧带重建联合内固定治疗旋后内收Ⅱ度踝关节损伤的临床疗效

【目的】探讨踝关节镜下距腓前韧带重建联合内固定治疗旋后内收Ⅱ度踝关节损伤的临床疗效。【方法】回顾性分析2014年1月至2018年6月在本院诊治的102例旋后内收Ⅱ度踝关节损伤患者,按照治疗方法不同分为观察组(踝关节镜下距腓前韧带重建联合支撑钢板内固定)和对照组(切开复位联合支撑钢板内固定),每组51例。比较两组围手术期指标、临床疗效和并发症发生率。【结果】观察组手术时间、术中出血量显著高于对照组,但骨折愈合时间、术后完全负重时间小于对照组,其差异均有统计学意义(均P<0.05)。末次随访,观察组Maryland评分中疼痛、功能、对线评分均显著高于对照组,AOFAS评分优良率显著高于对照组,并发症发生率显著低于对照组,其差异均有统计学意义(均P<0.05)。【结论】踝关节镜下距腓前韧带重建联合内固定治疗旋后内收Ⅱ度踝关节损伤恢复时间短,术后踝关节功能恢复佳,并发症发生率低,值得临床推广应用。