动态与静态固定2种方式在治疗伴下胫腓联合损伤的踝关节骨折中的疗效比较

目的比较动态与静态2种固定方式治疗伴下胫腓联合损伤的踝关节骨折的疗效。方法笔者回顾分析自2012-01—2015-06采用动态与静态固定方式行手术治疗的35例伴有下胫腓联合损伤的踝关节骨折,其中动态固定组16例,静态固定组19例。比较2组术后并发症、下胫腓联合复位满意程度、AOFAS评分和踝关节伸屈活动度。结果动态固定组与静态固定组在手术并发症及下胫腓联合复位满意程度方面,差异无统计学意义(P0.05)。术后3个月动态固定组AOFAS评分优于静态固定组,差异有统计学意义(P0.05),而术后6、12个月2组比较差异无统计学意义(P0.05)。踝关节伸屈活动度方面,术后3个月随访时2组差异无统计学意义(P0.05);而6、12个月随访时动态固定组优于静态固定组,差异有统计学意义(P0.05)。结论动态固定方法在治疗伴有下胫腓联合损伤的踝关节骨折中疗效可靠,与静态固定方法相比,可以早期负重活动,改善踝关节伸屈功能,同时可避免二次手术取出。     

Suture button versus syndesmosis screw constructs for acute ankle diastasis injuries: A meta-analysis and systematic review of randomised controlled trials

BackgroundAnkle syndesmotic injuries can be surgically managed with syndesmosis screws (SS) or suture button (SB) fixation. We performed a meta-analysis of randomized controlled trials (RCTs) aiming to compare the clinical and complication profiles of both modalities.MethodsA multi-database search up to 4th of March 2018 was performed according to PRISMA guidelines. All RCTs comparing both techniques and published in English were included.ResultsFive RCTs with a total of 280 patients (140 SB, 140 SS) were included for analysis. SB had a statistically significant higher AOFAS score at 1 year (mean difference = 5.46, 95% CI = 0.40–10.51, p = 0.03) and lower implant failure rate (OR = 0.03, 95% CI = 0.01–0.15, p < 0.001). Infection and wound issues were marginally higher with SB (OR = 1.4, 95% CI = 0.4–4.85, p = 0.60). No other parameters showed statistically significant difference.ConclusionsBoth constructs yielded similar clinical outcomes. The 1 year AOFAS score was higher in SB but clinical significance is unlikely. SB had significantly fewer implant failures.Level of evidence: Level I.     

锁扣带袢钛板与传统螺钉治疗踝关节骨折伴下胫腓联合损伤疗效比较

目的:比较锁扣带袢钛板与传统螺钉治疗踝关节骨折伴下胫腓联合损伤的临床效果。方法:对2014年5月至2016年2月采用锁扣带袢钛板重建和传统螺钉固定治疗的68例踝关节骨折伴下胫腓联合损伤患者的临床资料进行回顾性分析。根据治疗方法分为锁扣带袢钛板组和传统螺钉组,锁扣带袢钛板组33例采用锁扣带袢钛板重建下胫腓联合,其中男18例,女15例;年龄20~55岁,平均(32.4±5.2)岁;Lauge-Hansen分型为旋前外旋Ⅲ度12例,Ⅳ度21例。传统螺钉组35例采用传统螺钉固定下胫腓联合治疗,其中男19例,女16例;年龄21~54岁,平均(32.8±5.5)岁;Lauge-Hansen分型为旋前外旋Ⅲ度13例,Ⅳ度21例,旋前外展1例。观察并比较两组患者手术复位固定下胫腓联合的时间、并发症情况,并于术后3、6个月及末次随访采用AOFAS评分进行功能评价。结果:所有病例获得随访,时间8~24个月,平均(16.3±3.8)个月。下胫腓联合固定时间锁扣带袢钛板组(10.1±2.8)min,传统螺钉组(9.5±2.3)min,两组比较差异无统计学意义(P0.05)。两组患者并发症比较差异有统计学意义(P0.05)。两组患者术后3、6个月AOFAS评分比较差异有统计学意义(P0.05)。末次随访锁扣带袢钛板组优23例,良9例,中1例;传统螺钉组优18例,良12例,中5例;两组比较差异无统计学意义(P0.05)。结论:锁扣带袢钛板治疗下胫腓联合韧带损伤,操作方便,可早期负重锻炼而无断钉风险,为治疗踝关节骨折伴下胫腓联合损伤提供了新的选择。但仍需进一步研究总结纽扣钢板置入的角度、方向及张力的调节。     

螺钉固定与Tight-rope固定治疗下胫腓前联合损伤的初步有限元分析

目的 :建立下胫腓前联合损伤(anterior inferior tibiofibular syndesmosis injuries,AITSI)螺钉固定及Tightrope固定(TR)模型,比较其受力及位移情况,为临床诊治提供依据。方法 :选取1例正常人的踝关节CT图像建立3D模型。然后建立AITSI损伤模型,对损伤模型置入螺钉得到螺钉固定模型,使用Tight-rope固定得到TR模型。分析各模型单脚站立时的中立位、踝关节内旋以及外旋3种受力情况,观察胫腓骨及距骨关节面应力变化,以及胫腓骨远端位移情况。结果:AITSI导致胫腓骨及距骨关节面受力增加,胫腓骨位移增加。使用螺钉固定及TR均能有效减少AITSI导致的胫腓骨远端过度位移,但在螺钉固定模型中,胫腓骨位移明显小于正常模型,且胫腓骨远端及距骨关节面受力增大,螺钉受力集中。螺钉固定模型中的胫骨及腓骨最大受力为TR模型的1.3倍以上,距骨关节面接触力为1.8倍,螺钉固定模型中下胫腓前韧带胫骨附着点位移约为正常模型的0.6倍,而TR模型中该数据约为正常模型的1.1倍,但TR对于腓骨位移控制欠佳。结论:严重的下胫腓前联合损伤将改变踝关节受力及位移情况,应该行内固定治疗。下胫腓联合螺钉及TR都能有效地治疗下胫腓前联合分离,Tight-rope固定相较于螺钉固定在骨骼受力、踝关节微动及内固定物断裂方面具有优势,但存在腓骨旋转控制欠佳的劣势。伴有Weber C型踝关节骨折以及肥胖的患者更适合螺钉固定。     

Flexible stabilization of the distal tibiofibular syndesmosis: clinical and biomechanical considerations: a review of the literature

Syndesmotic rupture is present in 10 % of ankle fractures and must be recognized and treated to prevent late complications. The method of fixation is classically rigid fixation with one or two screws. Knowledge of the biomechanics of the syndesmosis has led to the development of new dynamic implants to restore physiologic motion during walking. One of these implants is the suture-button system. The purpose of this paper is to review the orthopaedic trauma literature, both biomechanical and clinical, to present the current state of knowledge on the suture-button fixation and to put emphasis on the advantages and disadvantages of this technique. Two investigators searched the databases of Pubmed/Medline, Cochrane Clinical Trial Register and Embase independently. The search interval was from January 1980 to March 2011. The search keys comprised terms to identify articles on biomechanical and clinical issues of flexible fixation of syndesmotic ruptures. Ninety-nine publications met the search criteria. After filtering using the exclusion criteria, 11 articles (five biomechanical and six clinical) were available for review. The biomechanical studies involved 90 cadaveric ankles. The suture-button demonstrated good resistance to axial and rotational loads (equivalent to screws) and resistance to failure. Physiologic motion of the syndesmosis was restored in all directions. The clinical studies (149 ankles) demonstrated good functional results using the AOFAS score, indicating faster rehabilitation with flexible fixation than with screws. There were few complications. Preliminary results from the current literature support the use of suture-button fixation for syndesmotic ruptures. This method seems secure and safe. As there is no strong evidence for its use, prospective randomized controlled trials to compare the suture-button to the screw fixation for ankle syndesmotic ruptures are required.     

Endobutton与螺钉内固定治疗下胫腓联合分离的临床疗效分析

目的 :探讨采用Endobutton纽扣钢板线缆系统与皮质骨螺钉内固定治疗下胫腓联合韧带损伤分离的临床疗效。方法:回顾性分析2011年10月至2013年10月,手术治疗的38例踝关节骨折合并下胫腓联合分离者患者,按术中内固定材料,分为皮质螺钉内固定(A组)和Endobutton纽扣钢板线缆系统固定(B组)。其中A组26例,男16例,女10例;年龄19~63岁,平均(37.90±4.67)岁;左侧14例,右侧12例;按Danis-Weber分型:B型8例,C型18例;按照Lauge-Hanson分型:旋后外旋(SER)9例,旋前外展(PAB)10例,旋前外旋(PER)7例。B组12例,男7例,女5例;年龄20~55岁,平均(38.70±6.03)岁;左侧6例,右侧6例;按Danis-Weber分型:B型4例,C型8例;按Lauge-Hanson分型:旋后外旋3例,旋前外展2例,旋前外旋7例。记录并比较两组患者手术时间、术中出血量、手术费用、住院时间、术后1个月疼痛评分、创口愈合情况及术后负重时间,定期复查X线片评估两组患者骨折愈合情况。术后采用美国足踝外科协会(AOFAS)踝与后足评分系统对患者进行踝关节功能评价。结果:38例患者获得随访,时间8~18个月,平均13.5个月。术后A组比B组的手术时间更长、经济费用更高(P0.05);两组患者术中失血量、住院时间、术后1个月疼痛评分、负重时间比较差异无统计学意义(P0.05);两组的胫腓骨重叠宽度、胫腓骨间隙、内踝间隙比较差异无统计学意义(P0.05)。术后X线片随访,A组骨折愈合良好,1例患者术后8周螺钉断裂,踝穴无移位,B组病例骨折愈合良好,无装置脱落,踝穴无移位。术后AOFAS评分:A组(87.50±8.67)分,优18例,良4例,可4例;B组(86.23±7.42)分,优7例,良4例,可1例。两组AOFAS评分比较差异无统计学意义(P0.05)。结论 :Endobutton纽扣钢板线缆系统是一种治疗下胫腓联合韧带损伤分离的弹性固定装置,其固定效果与螺钉内固定相似,但避免了螺钉断裂风险,术后无须常规取出,有利于患者提前进行负重功能锻炼。     

AO外固定架在不稳定性骨盆骨折中的临床应用

目的探讨AO外固定架对不稳定性骨盆骨折治疗的疗效和经验。方法回顾性分析24例(13例结合内固定治疗)AO外固定架治疗不稳定性骨盆骨折患者,总结该治疗方法的经验及体会。结果除1例因腹腔脏器破裂大量失血在固定后1d死于失血性休克外,其余23例平均随访13个月,按Matta评定标准,优良率达87.5%。结论①多数情况下单纯外固定架可改善骨盆的稳定性,也可作为终极治疗手段,必要时与内固定结合可增加骨盆的稳定性;②单纯外固定架固定可用于绝大多数B型及部分C型骨折的治疗;③对那些严重损伤,骨盆稳定性差,合并有其它脏器损伤患者,急诊期骨盆外固定架治疗效果显著。     

外固定支架生物学固定在胫腓骨骨折中的应用

目的探讨胫腓骨外固定支架生物学固定的临床效果。方法20例胫腓骨开放性骨折患者行Bastiani外固定支架固定，2周拆线后开始微动，每2周复查X线至有大量骨痂停止微动，观察骨折愈合情况。结果术后6周已有少量骨痂生长，10～12周有较多骨痂生长，5个月已达临床骨愈合。结论外固定支架生物学固定胫腓骨骨折，能明显缩短骨愈合时间，提高骨折愈合质量，且操作方便，值得推广。     

克氏针外固定架联合固定治疗Lisfranc损伤

<正>2002年2月~2011年7月,笔者应用克氏针外固定架联合固定治疗32例Lisfranc损伤患者,疗效确切,报道如下。1材料与方法 1.1病例资料本组32例,男22例,女10例,年龄18~65岁。闭合伤28例,开放伤4例。单纯Lisfranc损伤24例,合并Chopart关节损伤8例;按照Myerson分型[1]:单纯内侧柱损伤14例,内侧柱合并中柱损伤12例,三柱损伤6     

下胫腓联合损伤螺钉内固定治疗新进展

下胫腓联合对维持踝关节的稳定性、对重量的传导和行走都很重要。治疗不当易造成踝关节慢性不稳定、长期疼痛和创伤性关节炎。下胫腓联合损伤治疗方法较多,目前临床上应用最多的是用AO皮质骨螺钉行胫腓横向固定,但是对于如何运用螺钉横向固定下胫腓联合仍有争议。本文综述了下胫腓螺钉固定的技术现状,为临床应用提供实践指导。     

分类应用螺钉固定下胫腓联合在踝部骨折中的应用

目的:探讨分类应用螺钉固定下胫腓联合分离的手术方式及其在治疗踝关节骨折中的作用。方法:2001-2003年间收治踝部骨折伴下胫腓联合损伤110例,男46例,女64例;年龄18～70岁,平均40岁。按AODanisWeber分型:B型85例,C型25例。采用拉力螺钉固定95例,位置螺钉固定15例。结果:110例均得到随访,随访时间1.5～3年。根据踝关节症状与功能评分的Mazur标准,本组优60例,良38例,可12例,差0例,优良率达90%。无一例断钉。结论:分类应用拉力螺钉或位置螺钉固定下胫腓联合,是一种更科学的手术方法,临床疗效满意。     

Unstable fragility fractures of the ankle in the elderly: Transarticular Steinmann pin or external fixation

IntroductionBecause of poor skin conditions and comorbidity, open reduction and internal fixation in ankle fractures is frequently contra-indicated in the elderly. This study reports the results of two temporary fixation types in fragility fractures in the older patient: transarticular Steinmann pin fixation and external fixation.MethodsPatients aged over 60 treated with a Steinmann pin or external fixation were retrospectively included. Patient, fracture and treatment characteristics were collected.ResultsFifteen patients were included. Nine were managed using a Steinmann pin and six by external fixation. All reached fracture consolidation. Patients treated with a Steinmann pin underwent a median of 2 operations and the pin was left in situ for 80 days. Three patients suffered from superficial wound infection. X-ray showed malreduction in 67% and only two patients returned to pre-injury mobility.A median of 2 operations with 32 fixation days was reported in the external fixation group. This group showed one deep infection. In 50% there was malreduction, one patient experienced disability in ambulation at the end of treatment.ConclusionBoth techniques show few complications, but have, as expected, poor results in fracture reduction and functional outcome. External fixation and subsequent internal fixation could result in better functional outcome.     

Acute syndesmotic injuries in ankle fractures: From diagnosis to treatment and current concepts

A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment.     

组合式外固定器治疗合并患肢短缩的足踝部畸形

背景：传统的足踝部畸形的矫正需要通过手术来完成,术后需要“静态”的维持。Ilizarov技术遵循的“张力-应力法则”和“牵拉组织再生技术”,在一定程度上打破了传统的矫形模式。目的：探讨Ilizarov技术治疗合并患肢短缩的足踝部畸形的临床疗效。方法：回顾分析2006年8月至2012年10月采用Ilizarov技术治疗的17例下肢及足踝部畸形患者的临床资料。其中男10例,女7例,年龄20~37岁,平均27.5岁。脊髓灰质炎后遗症导致患肢短缩合并足踝负重位外翻畸形患者5例,先天性马蹄内翻足合并患肢短缩7例,高弓足合并患肢短缩3例,跟腱挛缩、仰趾畸形合并患肢短缩2例。所有患者在有限手术重建足踝部软组织平衡或者截骨矫正畸形后安装Ilizarov组合式外固定支架,同时做胫骨的延长。结果：17例患者佩戴Ilizarov支架的时间是16~44周,足踝部矫形支架在3~6个月矫形满意、骨融合确实后单独拆除,骨延长支架根据需要继续佩戴。所有患者都获得随访,随访时间6~48个月,患肢延长2~6 cm,延长段骨矿化满意,足踝部矫形满意。足踝功能参照AOFAS评分：术前（43±5.1）分,术后（76±7.2）分。结论：对于各种原因导致的合并下肢短缩的足踝部畸形的矫治,Ilizarov技术灵活的器械组合可同时完成多方向的畸形矫正,在矫正畸形的同时实施骨延长术。     

外固定支架结合克氏针治疗陈旧性肱骨髁间C型骨折的疗效观察

目的 探讨陈旧性肱骨髁间C型骨折的有效治疗方法.方法 2005年1月至2010年1月收治13例陈旧性肱骨髁间C型骨折,受伤至手术时间为3～5周,采用铰链式肘关节外固定支架+克氏针切开复位内固定进行治疗.结果 术后全部患者获得11～24个月(平均15个月)的随访,骨折临床愈合时间为4～7个月,平均5个月.肘关节经功能锻炼后的平均活动范围:伸直(19.4±6.5)°,屈曲(90.0±10.3)°;前臂旋前(50.0±6.0)°,旋后(65.0±6.0)°.按照HSS肘关节功能评分标准评定:术前(30.4±8.6)分,术后上升至(75.7±8.3)分,两者差异有统计学意义(P＜0.01);优5例,良4例,可3例,差1例.结论 采用切开复位内固定治疗陈旧性肱骨髁间C型骨折,术后在铰链式外固定支架辅助下活动肘关节,早期进行功能锻炼,有利于肘关节功能的恢复,疗效尚可,是一种有效的治疗方法.     

LCP钢板与外固定架治疗C型桡骨远端骨折的疗效比较

  目的 比较LCP钢板与外固定架治疗C型桡骨远端骨折的疗效。方法 回顾性分析2007年10月至2010年10月分别采用LCP钢板和外固定架治疗C型桡骨远端骨折的病例。其中LCP组38例,男13例,女25例;年龄23~65岁,平均45.1岁;按AO/OTA分型：C1型15例,C2型18例,C3型5例。外固定组26例,男12例,女14例;年龄25~60岁,平均47.1岁;按AO/OTA分型：C1型11例,C2型13例,C3型2例。比较两组术后影像学指标、功能指标,并采用Gartland-Werley功能评分标准对术后疗效进行评估。结果 所有患者均获得随访,随访时间LCP组12~36个月,平均23.8个月;外固定组12~44个月,平均31.2个月。X线片均显示两组骨折全部愈合。两组患者尺偏角、桡骨高度、腕关节背伸、掌屈、尺偏、桡偏、旋前、旋后及Gartland-Werley评分均无显著性差异。LCP组掌倾角11.71°±3.02°,外固定组掌倾角7.15°±2.98°,LCP组优于外固定组。LCP组伤口感染2例,正中神经损伤1例,固定松动1例;外固定组钉道感染3例,固定松动1例,腕关节僵硬2例。结论 两种固定方式治疗C型桡骨远端骨折均可达到较为满意的临床效果,LCP钢板术后影像学结果稍好,固定可靠。临床可根据患者具体情况选择治疗方式。     

Analysis of the uninjured tibiofibular syndesmosis using conventional CT-imaging and axial force in different foot positions

BackgroundSyndesmosis measurments and indices have been controversial and showed interindividual variability. The purpose of this study was to analyze, by conventional axial computed tomography images and a simulated load device, the uninjured tibiofibular syndesmosis under axial force and forced foot positions.MethodsA total of 15 healthy patients (30 ankles) were studied using adjustable simulated load device (ASLD). This device allowed to perform bilateral ankle CT scans in two forced foot and ankle positions (30° of plantar flexion, 15° of inversion, 20° of internal rotation and 15° of dorsal flexion, 15° of eversion, 30° of external rotation). Axial load was applied simultaneously in a controlled manner (70% body weight). Measurements on the axial image of computed tomography were: syndesmotic area (SA), fibular rotation (FR), position of the fibula in the sagittal plane (FPS), depth of the incisura (ID) and direct anterior difference (ADD), direct middle difference (MDD) and direct posterior difference (PDD).ResultsIn patients without injury to the tibiofibular syndesmosis, the application of axial load and forced foot and ankle positions showed statistically significant differences on the distal tibiofibular measurements between the stressed and the relaxed position, it also showed interindividual variability : SA (median = 4.12 [IQR = 2.42, 6.63]) (p < 0.001), ADD (0.67 [0.14, 0.67]) (p < 0.001), MDD(0.45, [0.05, 0.9]) (p < 0.001), PDD (0.73 [?0.05, 0.73]) (p < 0.002). However, it did not detect statistically significant differences when the tibiofibular differences between the stressed and the relaxed position in one ankle were compared with the contralateral side: SA (?0.14, SD = 4.33 [95% CI = ?2.53, 2.26]), ADD (?0.42, 1.08 [?1.02, 0.18]), MDD (0.29, 0.54 [?0.01, 0.59]), PDD (?0.1, 1.42 [?0.89, 0.68]). Interobserver reliability showed an Intraclass correlation coefficient of 0.990 [95% CI = 0.972, 0.997].ConclusionsWide interindividual variability was observed in all syndesmotic measurements, but no statistically significant differences were found when comparing one ankle to the contralateral side. Measuring syndesmosis alignment parameters, may only be of value, if those are compared to the contralateral ankle.     

可吸收螺钉联合克氏针固定治疗部分踝关节骨折的疗效评价

目的 探讨可吸收螺钉联合克氏针固定治疗部分踝关节骨折的疗效. 方法 2003年7月至2007年5月.对42例踝关节骨折患者采用可吸收螺钉联合克氏针固定治疗部分踝关节骨折,男27例,女15例;年龄20～70岁,平均39.2岁.术中于可吸收螺钉附近加用1～2枚克氏针,术后4周左右,于门诊拔除克氏针,后逐渐行功能锻炼,分析其治疗效果. 结果 所有患者术后平均随访24个月(14～38个月).骨折全部骨性愈合,无一例出现骨折移位、伤口感染等现象.根据英国足踝外科协会(AOFAS)制定的踝关节评定标准:优35例,良6例,可1例,优良率达97.6%.结论可吸收螺钉联合克氏针固定治疗部分踝关节骨折,骨折愈合率高,踝关节功能恢复良好,并可免除二次手术取内固定,值得推广.     

有限内固定结合踝关节外固定架治疗复杂开放性踝关节骨折46例

目的探讨有限内固定结合踝关节外固定架治疗复杂开放性踝关节骨折的手术方法及临床疗效。方法采用后外侧入路有限内固定结合踝关节外固定架手术治疗的复杂开放性踝关节骨折患者46例,其中男25例,女21例;年龄15~72岁,平均年龄39.3岁,并对其疗效进行分析。结果 46例患者均获完整随访,时间3~21个月。根据美国足与踝关节协会(AOFAS)评分:优24例,良18例,可4例,优良率为91.3%。结论对于复杂开放性踝关节骨折,采用后外侧入路有限内固定结合踝关节外固定架治疗,既可以保证踝关节获得较为满意的复位,又可以最大限度地避免内固定感染的发生。     

带关节的超关节外固定架结合有限内固定治疗Pilon骨折

目的应用带关节的超关节外固定架结合有限内固定治疗Pilon骨折，并评估其疗效。方法2002年2月～2004年6月采用单边带关节的超踝关节T型外固定架结合有限内固定治疗19例（21侧）Pilon骨折患者。支架远端螺钉固定于距骨或跟骨，近端螺钉固定于胫骨骨折近端，使踝关节可以距下关节为中心在一定范围内活动。依据伤口软组织情况在术后2～3周松动外固定支架关节开始踝关节功能锻炼。结果19例患者全部获得随访10～18个月，平均13个月。临床效果满意，无切口、伤口及钉道感染，无神经、血管损伤，无骨不连等并发症。踝关节骨折复位情况（Burwell＆charnley踝关节骨折复位评分法）为C1型5例全部达解剖复位；C2型达解剖复位7例，一般2例，C3型达解剖复位4例，一般1例，复位差2例。踝关节症状和功能评分（Baird＆Jackson评分法）为72～98分，平均92分；优4侧，良12侧，可3侧，差2侧，优良率为84．2％。结论带关节的超关节外固定支架结合有限内固定治疗Pilon骨折可避免伤口并发症和骨不连的发生，能更好地恢复关节面的解剖关系，有利于踝关节早期活动，避免关节僵硬，是治疗Pilon骨折的理想方法之一。