全层修复三角韧带与下胫腓联合内固定治疗Lauge-Hansen旋后外旋型Ⅳ度踝关节骨折

目的探讨全层修复三角韧带联合下胫腓联合螺钉固定治疗Lauge-Hansen旋后外旋型Ⅳ度踝关节骨折的临床疗效。方法回顾性分析自2013-03—2018-03手术治疗的31例Lauge-Hansen旋后外旋型Ⅳ度踝关节骨折,先取仰卧位内侧入路探查三角韧带并评估损伤程度,在三角韧带深层止点预置锚钉,再取侧卧位后外侧入路复位腓骨、后踝固定或不固定,再取仰卧位前外侧小切口探查清理下胫腓联合并行下胫腓联合螺钉固定,最后依次修复三角韧带深层、浅层。结果 31例均获得随访,随访时间平均31(18~48)个月。骨折完全愈合时间为12~48周,无骨折延迟愈合、下胫腓螺钉断裂发生。末次随访时踝-后足AOFAS评分平均91(72~97)分,优27例,良3例,可1例。结论全层修复三角韧带联合下胫腓联合螺钉内固定治疗合并下胫腓联合及三角韧带损伤的Lauge-Hansen旋后外旋型Ⅳ度踝关节骨折可降低踝关节复位不良发生率,恢复踝关节稳定性,有利于患者进行早期功能锻练,达到快速康复的目的。     

踝关节骨折合并三角韧带撕裂术中三角韧带不同修复方式的效果比较

目的比较踝关节骨折合并三角韧带撕裂术中三角韧带不同修复方式的临床效果。方法回顾性分析自2012-08—2017-10行切开复位内固定手术治疗的68例踝关节骨折合并三角韧带撕裂,16例修复浅层三角韧带(浅层修复组),18例修复深层三角韧带(深层修复组),22例修复浅层与深层三角韧带(完全修复组),12例不修复三角韧带(不修复组)。比较4组末次随访时内踝间隙、踝关节背伸活动度、骨折愈合时间,术后6、12、18个月疼痛VAS评分、AOFAS评分。结果 68例均获得至少18个月随访。4组骨折愈合时间、末次随访时内踝间隙,以及术后6、12个月疼痛VAS评分、AOFAS评分差异无统计学意义(P0.05)。深层修复组与完全修复组末次随访时踝关节背伸活动度大于浅层修复组与不修复组,而且完全修复组踝关节背伸活动度大于深层修复组,差异有统计学意义(P 0.05)。深层修复组与完全修复组术后18个月疼痛VAS评分低于浅层修复组与不修复组,AOFAS评分高于浅层修复组与不修复组,差异有统计学意义(P 0.05)。结论在合理选择适应证的前提下,踝关节骨折合并的三角韧带撕裂一期深层修复或浅层与深层完全修复有利于术后踝关节功能恢复、减少踝关节慢性疼痛发生。     

踝关节Logsplitter损伤内固定手术疗效观察

目的 观察内固定手术治疗踝关节Logsplitter损伤的临床疗效。方法 回顾性分析自2016-08—2018-08诊治的17例踝关节Logsplitter损伤,其中典型踝关节Logsplitter损伤8例（典型组）,非典型踝关节Logsplitter损伤9例（非典型组）。开放性损伤急诊行清创后外固定架固定,二期行内固定手术治疗,术中骨折内固定后检查下胫腓联合关节稳定性,行下胫腓联合关节固定或三角韧带修复,其中7例采用螺钉固定下胫腓联合关节,3例行内侧三角韧带深层带线铆钉修复,2例采用下胫腓联合关节袢钢板固定。结果 17例均获得随访,随访时间12～68个月,平均30.82个月。术后12个月踝关节AOFAS评分平均68.24分,末次随访平均73.76分。末次随访踝关节跖屈活动度平均33.06°,踝关节背伸活动度平均15.05°。非典型组术后1年踝关节AOFAS评分明显高于典型组,差异有统计学意义（P<0.05）,两组末次随访踝关节AOFAS评分差异无统计学意义（P>0.05）。非典型组末次随访踝关节跖屈活动度、背伸活动度均大于典型组,差异有统计学意义（P<0.05）。结...     

急性踝关节骨折伴三角韧带损伤术中诊断及治疗策略

目的探讨丝攻试验对三角韧带损伤的诊断价值,比较跨下胫腓联合螺钉固定与锚钉缝合修复三角韧带的疗效。方法 2011年6月至2013年12月,对我院收治的51例疑有三角韧带损伤的踝关节骨折患者进行丝攻试验,并将阳性患者随机分为锚钉缝合修补三角韧带组(A组)和跨下胫腓联合螺钉固定组(B组)。采用美国足踝骨科学会(AOFAS)踝-后足评分和疼痛视觉模拟评分(VAS)评价术后疗效。结果最终45例患者纳入统计学分析。A组21例,B组24例。A组有19例获得随访,平均随访14个月;B组有23例获得随访,平均随访18个月。末次随访时,A、B组患者均获得骨性愈合。A组AOFAS踝-后足评分和VAS评分分别为(87.50±6.30)分和(1.79±1.47)分,B组AOFAS踝-后足评分和VAS评分分别为(85.20±7.54)分和(1.56±1.20)分。两组AOFAS踝-后足评分和VAS评分差异无统计学意义。B组复位不良率达34.8%,A组仅为5.26%。结论三角韧带的完整性是影响下胫腓联合分离和内侧踝穴增宽的重要因素,修补三角韧带与跨下胫腓联合螺钉固定疗效相当,但其复位不良率低,且无二次取钉及断钉等问题。丝攻试验对于三角韧带损伤诊断和手术效果评估具有重要价值。     

踝关节骨折伴下胫腓联合分离的手术治疗及临床意义

目的探讨治疗踝关节骨折伴下胫腓联合分离的手术方法及临床意义。方法自2002年1月～2005年12月对112例伴踝关节骨折下胫腓联合分离行腓骨内固定或不固定,内踝内固定,三角韧带探查修复术。未固定下胫腓联合。术后随访6～36个月,平均20.8个月。结果用Mazur评分系统评估手术疗效:优98例,良14例。未见骨折不愈合、关节不稳及创伤性关节炎等并发症。结论对伴下胫腓联合分离的踝关节骨折行手术治疗时,除了固定内、外踝,还要修复三角韧带损伤。恢复了内、外侧所有结构的完整性后才能真正恢复下胫腓联合及踝关节的正常生物力学环境和稳定性,这时即使不固定下胫腓联合,也可以获得下胫腓联合的稳定。固定内、外踝和下胫腓联合,而三角韧带的损伤不修复,虽然下胫腓韧带可以获得愈合,但三角韧带会愈合不佳、韧带松弛及功能不良,最终仍会导致创伤性关节炎。     

合并下胫腓韧带损伤的踝关节骨折的治疗

目的探讨切开复位内固定治疗合并下胫腓韧带损伤的踝关节骨折的疗效。方法 54例合并下胫腓韧带损伤的踝关节骨折的患者分别接受切开复位、闭合复位治疗,术后定期随访,测量胫腓间隙宽度、内踝与距骨间隙宽度、后踝骨折块移位程度等。按Olerud评分、Tegner评分、疼痛评分系统评价术后踝关节的主观感受、日常生活功能及疼痛状况。结果手术组患者术后胫腓间隙宽度、后踝骨折块移位程度及Olerud评分、Tegner评分、疼痛评分与闭合复位组比较,效果较好（P〈0.05）,差异有统计学意义;内踝与距骨间隙宽度效果相似,差异无统计学意义。结论手术组术后踝关节解剖位置和患者主观功能感受均较闭合复位组好,切开复位内固定是治疗合并下胫腓韧带损伤的踝关节骨折的一种有效方法。     

伴三角韧带完全断裂的踝关节骨折的治疗

[目的]分析治疗伴三角韧带完全断裂的踝关节骨折的手术方法及临床意义.[方法]2002年1月-2007年12月对18例伴三角韧带完全断裂的踝关节骨折患者行腓骨内同定,后踝固定或未固定,三角韧带修复术,未固定下胫腓联合.术后随访6～36个月.平均20.2个月.[结果]用Mazur评分系统评估手术疗效,优8例,良8例,可2例.未见关节不稳及创伤性关节炎等并发症.[结论]踝关节骨折伴三角韧带完全断裂时,往往同时合并下胫腓联合分离,固定腓骨,修复三角韧带,就能够恢复踝关节的正常生物力学环境和稳定性,这时即使不固定下胫腓联合,也可以获得下胫腓联合的稳定.固定腓骨和下胫腓联合,而不修复三角韧带,虽然仍能恢复踝关节的稳定性,但三角韧带会愈合不佳、韧带松弛及功能不良,最终仍会导致创伤性踝关节炎.     

AO-B型踝关节骨折伴有下胫腓联合损伤诊断及治疗

目的探讨手术治疗 AO-B 型踝关节骨折伴有下胫腓联合损伤的诊断及治疗效果。方法2010年7月至2012年12月采用手术治疗AO-B型踝关节骨折伴有下胫腓联合损伤患者42例,其中三踝骨折30例,外后踝骨折伴有三角韧带断裂6例,单纯内外踝骨折6例。术中为先行外踝、后踝内固定,再行内踝内固定或内侧三角韧带修复,最后行下胫腓联合内固定。采用美国足踝骨科学会（AOFAS）踝-后足评分标准进行疗效评定。结果术后40例患者获得随访,平均随访时间为（14．3±0．5）个月（10～26个月）。所有患者骨折均愈合,其中伤口延迟愈合1例,无一例发生伤口感染及坏死。术后6、12个月AOFAS踝-后足评分分别为（87．1±2．16）分、（93．4±2．31）分,两者差异有统计学意义（P＜0．01）。末次随访时AOFAS踝-后足评分优26例（65．0％）,良10例（25．0％）,可6例（10．0％）,优良率为90．0％。结论对于AO-B型踝关节骨折,术前及术中准确判断是否伴有下胫腓联合损伤,并对其进行解剖复位及可靠内固定,可重建踝穴稳定性,促进踝关节功能恢复。     

Maisonneuve骨折诊治的临床特点

 目的 探讨Maisonneuve骨折诊断和治疗的临床特点。
方法 2005年8月至2009年8月,收治23例Maisonneuve骨折患者,男16例,女7例;年龄25~43岁,平均35.3岁;摔倒伤10例,运动相关损伤8例,车祸伤4例,高处坠落伤1例。所有骨折均为闭合性损伤;其中内踝骨折16例,后踝骨折6例,三角韧带撕裂7例;所有患者均有下胫腓联合分离和腓骨上1/4螺旋型骨折。手术采用固定内踝及后踝骨折、修复内侧三角韧带及固定修复下胫腓联合的方法进行治疗。术后采用Baird-Jackson踝关节功能评定标准对患者踝关节功能进行评价。结果23例患者中有9例在入院前发生漏诊,漏诊率为39.13%（9/23）,入院后经详细查体而明确诊断。22例患者获得随访,随访时间为12~25个月,平均16.8个月。术后患者踝关节均无疼痛、压痛及明显肿胀,踝关节活动度与对侧基本相同。术后4~7个月,平均5.3个月X线片示腓骨骨折及踝部骨折均骨性愈合,踝穴正常,腓骨长度恢复,无下胫腓螺钉断裂及创伤性关节炎发生。末次随访Baird-Jackson踝关节功能评分为85~100分,其中优11例、良8例、可3例,优良率为86.4%。22例患者中有19例已经恢复到伤前的活动水平。
结论 Maisonneuve骨折是容易产生漏诊的踝关节损伤,仅注意到受伤的局部情况和缺乏对这种少见骨折的认识是造成漏诊的主要原因;可采用固定内踝及后踝骨折、修复内侧三角韧带及固定下胫腓联合的方法进行治疗。     

锚钉治疗内侧三角韧带完全断裂的踝关节骨折脱位

目的分析利用锚钉治疗内侧三角韧带完全断裂的踝关节骨折脱位的手术方法及临床意义。方法对2007年1月至2011年8月收治的18例伴有三角韧带完全断裂的踝关节骨折脱位患者进行手术治疗，进行腓骨内固定，同时利用锚钉进行内侧副韧带修复15例．内踝钻孔可吸收线拉出固定3例；胫腓联合固定5例；后踝骨块超过1／4关节面的可予固定，其中固定3例。术后随访6．41个月，平均15．2个月。结果按刘云鹏等评定标准评价结果，优良16例，可2例，未见关节不稳及创伤性关节炎等并发症。结论踝关节骨折伴三三角韧带完全断裂时，往往同时合并下胫腓联合分离，固定腓骨，锚钉修复三角韧带，操作简便，固定坚强，能够直接恢复踝关节的正常生物力学环境和稳定性，获得下胫腓联合的稳定。     

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...     

内踝解剖型钩钢板治疗粉碎性内踝骨折的疗效分析

目的 评价内踝解剖型钩钢板治疗粉碎性内踝骨折的临床疗效。方法 对2015年3月至2017年6月采用内踝解剖型钩钢板治疗粉碎性内踝骨折的30例病人进行回顾性分析,其中男18例,女12例;年龄为21~50岁,平均34.5岁。受伤原因：扭伤10例,直接暴力骨折20例。左踝12例,右踝18例。30例病人均行切开复位内固定手术,内踝应用解剖型钩钢板固定,合并外踝及后踝骨折的病人,外踝应用解剖钢板固定,后踝应用空心螺钉或钢板固定。采用美国足踝外科医师协会（American Orthopedic Foot and Ankle Society, AOFAS）踝与后足功能评分系统、踝关节活动度和疼痛视觉模拟评分量表（visual analogue scale, VAS）评价术前及末次随访时病人的踝关节功能。结果 所有30例病人的随访时间为6~18个月,平均13.1个月。术后切口均一期甲级愈合,无感染、皮瓣坏死、骨折移位、内固定松动、骨不愈合等并发症出现。手术前后的AOFAS踝-后足评分分别为（12.0±10.0）分、（90.0±3.1）分,VAS评分分别为（5.4±1.0）分、（1.3±0.3）分,差异均有统计学意义（P均＜0.05）。末次随访时平均踝关节活动度为60.2°±6.2°。结论 采用内踝解剖型钩钢板治疗粉碎性内踝骨折,固定牢固,操作方便,病人术后功能恢复好,是治疗粉碎性内踝骨折有效的固定方法。     

Fractures of the fibula proximal to the distal tibiofibular syndesmosis.

Study of thirty-six cases of fracture of the fibula at levels proximal to the distal tibiofibular syndesmosis established that there are three types, distinguished by the direction of the fracture line, which are produced by different mechanisms: supination-external rotation, pronation-abduction, and pronation-external rotation. Advanced lesions that were seen were severe injuries of the ankle which included rupture of the deltoid ligament or fracture of the medial malleolus and complete diastasis of the distal tibiofibular syndesmosis in addition to the fracture of the fibula. Surgical treatment is necessary in most advanced lesions.     

Evaluation of Transsyndesmotic Fixation and Primary Deltoid Ligament Repair in Ankle Fractures With Suspected Combined Deltoid Ligament Injury

The present prospective study examined the utility of the intraoperative tap test/technique for distal tibiofibular syndesmosis in the diagnosis of deltoid ligament rupture and compared the outcomes of transsyndesmotic fixation to deltoid ligament repair with suture anchor. This diagnostic technique was performed in 59 ankle fractures with suspected deltoid ligament injury. The width of the medial clear space of 59 cases was evaluated to assess the sensitivity and specificity. Those with deltoid ligament rupture were randomly assigned to 2 groups and treated with deltoid ligament repair with a suture anchor or with syndesmosis screw fixation. All the patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, short-form 36-item questionnaire (SF-36), and visual analog scale (VAS). The tap test was positive in 53 cases. However, surgical exploration demonstrated that 51 cases (86.4%) had a combined deltoid ligament injury and fracture. The sensitivity and specificity of the tap test was 100.0% and 75.0%, respectively. Finally, 26 cases (96.3%) in the syndesmosis screw group and 22 (91.7%) in the deltoid repair group were followed up. No statistically significant differences were found in the AOFAS ankle-hindfoot scale score, SF-36 score, or VAS score between the 2 groups. The malreduction rate in the syndesmosis screw group was 34.6% and that in the deltoid repair group was 9.09%. The tap test is an intraoperative diagnostic method to use to evaluate for deltoid ligament injury. Deltoid ligament repair with a suture anchor had good functional and radiologic outcomes comparable to those with syndesmotic screw fixation but has a lower malreduction rate. We did not encounter the issue of internal fixation failure or implant removal.     

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.     

Deltoid ligament integrity in lateral malleolar fractures: a comparative analysis of arthroscopic and radiographic assessments

Foot and ankle surgeons often rely on the medial clear space to evaluate competency of the deep deltoid ligament when evaluating ankle fractures. This investigation assesses the integrity of the deep deltoid ligament after lateral malleolar fracture by using direct arthroscopic visualization and medial clear-space separation on plain film radiographs. The objectives of this study were to test the reliability of medial clear-space separation and the Lauge-Hansen classification scheme in predicting deep deltoid rupture in displaced lateral malleolar fractures. The medial clear space was measured on injury radiographs of 40 patients with an isolated displaced lateral malleolar fracture who underwent open reduction and internal fixation. Injury radiographs were classified according to the Lauge-Hansen scheme. Direct arthroscopic visualization was used to evaluate the deep deltoid ligament under manual stress before fracture reduction. The mean preoperative medial clear space in patients with a deep deltoid rupture (n = 13) was 6.6 +/- 2.4 mm (range, 4 to 12 mm), and in patients without a deep deltoid rupture (n = 26), it was 4.0 +/- 1.0 mm (range, 2.5 to 6 mm) (P =.002, 2-sample t test). At an injury medial clear space > or =3 mm, the false positive rate for deltoid rupture was 88.5% (P =.54, Fisher's exact test). At > or =4 mm, the false positive rate was 53.6% (P =.007). All fractures were rotational injuries according to the Lauge-Hansen system. Three fractures were not classifiable; another 3 fractures showed deltoid ligament integrity opposite the expected finding. The results indicate that, in isolated displaced fractures of the lateral malleolus, radiographic widening of the medial clear space is not a reliable indicator for deep deltoid rupture. Some fractures considered stable by the Lauge-Hansen classification may require careful scrutiny to rule out deep deltoid injury.     

False negative rate of syndesmotic injury in pronation-external rotation stage IV ankle fractures

Background:

To investigate false negative rate in the diagnosis of diastasis on initial static anteroposterior radiograph and reliability of intraoperative external rotational stress test for detection of concealed disruption of syndesmosis in pronation external rotation (PER) stage IV (Lauge-Hansen) ankle fractures.

Materials and Methods:

We prospectively studied 34 PER stage IV ankle fractures between September 2001 and September 2008. Twenty (59%) patients show syndesmotic injury on initial anteroposterior radiographs. We performed an intraoperative external rotation stress test in other 14 patients with suspicious PER stage IV ankle fractures, which showed no defined syndesmotic injury on anteroposterior radiographs inspite of a medial malleolar fracture, an oblique fibular fracture above the syndesmosis and fracture of the posterior tubercle of the tibia.

Results:

All 14 fractures showed different degrees of tibiofibular clear space (TFCS) and tibiofibular overlapping (TFO) on the external rotation stress test radiograph compared to the initial plain anteroposterior radiograph. It is important to understand the fracture pattern characterstic of PER stage IV ankle fractures even though it appears normal on anteroposterior radiographs, it is to be confirmed for the concealed syndesmotic injury through a routine intraoperative external rotational stress radiograph.     

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。     

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。     

S-Type Posterolateral Approach for Open Reduction and Internal Fixation of Pronation External Rotation Ankle Fractures: Improved Visualisation of the Posterior Joint and the Lateral Malleolus

Pronation external rotation (PER) fractures are unstable ankle fractures that require anatomically stable fixation. However, due to the long distance between the fibula and the posterior malleolus in PER IV, existing approaches may make it difficult for the fixation of the associated posterior joint and the lateral malleolus. We describe an S-type posterolateral approach for the open reduction and internal fixation of posterior malleolar fractures with an associated lateral malleolar fracture in PER IV.