三踝骨折及其手术治疗

从1986年5月～1996年1月收治三踝骨折24例,手法整复6例,余18例经开放整复内固定术治疗。采用螺丝钉固定内踝13例,外踝6例,后踝8例;外踝经克氏针固定5例,克氏针加钢丝固定1例。作者认为三踝骨折是复合性的踝关节骨折,应尽早手术,解剖复位和坚固内固定,才能保证踝关节功能恢复,防止创伤性关节炎发生。本文提出了先外踝,再后、内踝的整复次序,尽早整复固定下胫腓骨韧带联合分离,重视对外踝的正确处理。     

Immediate Weightbearing After Operative Treatment of Bimalleolar and Trimalleolar Ankle Fractures: Faster Return to Work for Patients with Nonsedentary Occupations

The goal of this study was to compare immediate weightbearing (IWB) and traditional weightbearing (TWB) postoperative protocols in unstable ankle fractures, as this has not been compared in prior works. We hypothesize that an immediate weightbearing protocol after ankle fracture fixation will lead to an earlier return to work. An ankle fracture registry was reviewed for operatively treated unstable bimalleolar and trimalleolar ankle fractures at an ambulatory surgery center and followed up at associated outpatient clinics. All fracture cases reviewed occurred from 2009 to 2015. Immediate weightbearing patients were placed into a controlled ankle motion (CAM) boot and allowed to fully bear weight the day of surgery. Traditional weightbearing patients were placed into a CAM boot with 6 weeks of non-weightbearing. Demographics, fixation technique, and injury characteristics were surveyed. Physical job demand was stratified for 69 patients meeting the inclusion criteria (34 IWB and 35 TWB). The main outcome of this study was measured as the time to return to work. Subgroup analysis of patients with nonsedentary jobs demonstrated a significantly earlier return to work for the IWB group (5.7 versus 10.0 weeks, p = .04). Multivariate regression analysis identified a statistically significant 2.25-week (p = .05) earlier return to work for the IWB group after adjustment for occupational physical demand, demographics, fracture characteristics, and participation in a light work period before full work return. In patients with nonsedentary jobs, an IWB protocol after operative management of bimalleolar and trimalleolar ankle fractures resulted in an earlier return to work compared with traditional protocols.     

Pilon骨折的手术治疗体会

目的回顾性分析了治疗Pilon骨折的适宜手术方法、最佳手术时机及其手术疗效。方法对1997年至2002年接受手术治疗的52例单侧Pilon骨折患进行随访，平均年龄37．8岁，伤后至手术时间平均6．8d。骨折类型：Ⅰ型4例、Ⅱ型36例、Ⅲ型12例。40例行切开复位三叶型(或T型)钢板内固定；12例行有限切开内固定并辅以外固定，其中应用外固定支架2例，辅以石膏托10例。术后平均随访28．4个月。结果采用Mazur评分系统评估手术疗效，52例患，优43例，良6例，可3例。术后并发症包括创面不愈合4例，感染2例，延迟愈合1例和关节退行性变7例。结论正确选择手术时机，根据骨折类型和条件灵活选择固定方式是取得良好手术效果的关键。     

胫骨Pilon骨折的手术治疗

目的 探讨胫骨Pilon骨折的治疗方法、手术时机、手术方法。方法 随访1997年～2002年治疗的胫骨Pilon骨折16例,平均随访28.2个月。骨折类型:Ⅰ型3例,Ⅱ型5例,Ⅲ型8例。手术方法:合并腓骨骨折12例,占80％,均用钢板固定。胫骨骨折:螺钉固定5例,三叶草钢板固定5例,胫骨远端钢板固定2例,一期行踝关节融合3例。结果 按Mazur踝关节症状与功能评分系统评分:优5例,良5例,可3例,差3例。总体优良率为64％,并发症为31％。结论 对大部分Pilon骨折主张施行有限手术、有限内固定。而对严重胫骨关节面粉碎骨折的Ⅲ型骨折宜一期融合。     

不稳定性踝部骨折的手术治疗体会

目的：探讨不稳定性踝部骨折的治疗方法，强调外踝、下胫腓联合的切开复位内固定的重要性，并分析如何减少和预防并发症的发生。方法：1996年－2000年期间手术治疗不稳定性踝部骨折43例。结果：经6－36个月随访，优良率达88．38％。结论：（1）对不稳定性踝部骨折，手术治疗可提高疗效，减少并发症；（2）重视外踝与腓骨的整复；（3）正确处理下胫腓联合分离并在术后3个月应取出内固定材料；（4）解剖复位，可靠的内固定，早期合理的功能锻炼，是提高疗效、减少和预防创伤性关节炎的关键。     

Reoperation After Operative Fixation of Proximal Interphalangeal Joint Fractures

Background: The purpose of this study was to determine the reoperation rate and what factors are associated with reoperation of proximal interphalangeal (PIP) joint fractures. Methods: We identified 161 surgically treated PIP joint fractures between 2004 and 2015 at 2 academic medical systems. Demographic, injury, radiographic, and treatment data that might be associated with reoperation were collected. Bivariate analysis was performed. Factors identified during bivariate analysis with a P < .10 were entered into a multivariable logistic regression analysis. Results: Of the 161 fingers, 25 underwent revision surgery. Open fracture was independently associated with revision surgery. The most common indication for reoperation was joint stiffness (35%). In a subanalysis of 111 closed fractures, no factors were associated with revision surgery. Conclusions: Soft tissue injury is a major factor in reoperation after PIP joint fracture dislocation. Specific attention should be paid to persistent subluxation because this may predispose to early arthrosis.     

不同术式治疗三踝骨折伴下胫腓联合分离的疗效

目的探讨不同术式治疗三踝骨折伴下胫腓联合分离的疗效。方法通过对下胫腓韧带解剖的研究,对30例三踝骨折伴下胫腓联合分离采取不同术式治疗,即腓骨短肌腱移位与腓骨骨膜转位修复下胫腓韧带损伤,对治疗效果进行比较分析。结果全部患者获得随访,随访时间8~22个月,平均13.5个月,30例骨折均愈合。对手术时间、骨折愈合时间、踝关节的功能进行观察,其中踝关节功能按Leeds等的临床评定标准,腓骨短肌腱移位组14例:优4例,良8例,差2例,优良率85.7%;腓骨骨膜转位组16例:优8例,良7例,差1例,优良率93.8%。结论三踝骨折伴下胫腓联合分离应用腓骨骨膜转位修复下胫腓韧带损伤优于腓骨短肌腱移位,是一种新的有效的微创治疗方法。     

临床应用改良Stoppa入路手术治疗髋臼骨折

目的报告改良Stoppa入路手术治疗髋臼骨折的临床效果。方法自2006年1月至2011年1月,应用改良Stoppa入路手术治疗髋臼骨折患者共28例,男17例,女11例;年龄25~52岁,平均36.5岁。损伤后手术时间3~9 d,平均7 d。骨折类型包括:前柱和前壁骨折、横形骨折以及双柱骨折。行耻骨联合上2 cm横行切口,长度约为12cm,从下向上将腹白线纵行切开,进入腹膜外。将腹直肌、髂腰肌、股神经及髂血管等结构向外向前牵开进入骨折部位。结果术后随访2.5~6年,平均4.5年。骨折8~12周愈合(平均10周)。没有发生医源性大血管和神经损伤以及异位骨化。没有出现与该项技术相关的并发症。按Matta等提出的髋臼骨折疗效评定标准评定,优18例,良7例,尚可2例,差1例,优良率为89.28%,取得了满意的效果。结论改良Stoppa入路对治疗髋臼骨折提供了一种新的手术方法,能改善髋臼骨折的复位与固定。     

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p?=?.432). No significant difference was found in the complication rate (p?=?.914) or the reoperation rate (p?=?.291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.     

Harvey Cushing's Early Operative Treatment of Skull Base Fractures

Objectives To review Dr. Harvey Cushing''s early surgical cases at the Johns Hopkins Hospital, revealing details of his operative approaches to fractures of the skull base. Design Following institutional review board approval and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files. Setting The Johns Hopkins Hospital, 1896 to 1912. Participants A total of 24 patients underwent operative treatment for suspected fractures of the skull base. Main Outcome Measures The main outcome measure was operative approach, postoperative mortality, and condition recorded at the time of discharge. Results Overall, 23 patients underwent operative treatment for suspected skull base fractures. The mechanisms of injury were known for 22 patients and included work-related injuries (41%), falls (23%), vehicle injuries (32%), and other trauma (5%). One patient had no mechanism of injury specified in the file. The outcome at the time of discharge from the hospital was “well” or “improved” in 12 patients (52%). The remaining 11 patients died during their admission. Conclusions Although Cushing''s experience with selected skull base pathology has been previously reported, the breadth of his contributions to operative approaches to the skull base has been neglected.     

Early Protected Weightbearing After Ankle Fractures in Patients With Diabetes Mellitus

The traditional protocol for treatment after ankle fracture in the diabetic patient involves a period of prolonged non-weightbearing to reduce the incidence of complications. The goal of the present study was to identify the risk factors and complications associated with early protected weightbearing after closed ankle fractures in patients with diabetes. The data from 73 diabetic patients with operatively and nonoperatively treated ankle fractures were retrospectively reviewed. All patients were allowed to begin protected weightbearing in a cast or removable boot at 2 weeks after the index injury or surgery. The mean follow-up period was 51 (range of 26 to 480) weeks. Complications occurred in 25% of the operative cases and 8% of the nonoperative cases. In both categories, the complication rate was less than that from existing reports using prolonged non-weightbearing. Wound dehiscence was the most common complication in the operatively treated patients (18.8%). A statistically significant difference was found in the complications rates for the patients aged >60 years (p = .0403). No statistically significant differences were identified according to hemoglobin A1c, the presence of peripheral neuropathy, smoking status, fracture type, or the presence of end-stage renal disease. The results of the present study suggest that early protected weightbearing after closed ankle fractures in diabetic patients is fairly safe, with an acceptable complication rate. However, the patients selected for early weightbearing had low comorbidity profiles, which might have accounted, in part, for the low complication rate.     

Pathologic Versus Native Hip Fractures: Comparing 30-day Mortality and Short-term Complication Profiles

BackgroundA large body of research on native hip fractures has resulted in several evidence-based guidelines aimed at improving postsurgical care for these patients. In contrast, there is a paucity of data on pathologic hip fractures, and whether native hip fracture protocols are generalizable to this population is unknown. The purpose of this study was to compare mortality rates and complication profiles between patients with pathologic and native hip fractures.MethodsUsing the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database, we identified patients who underwent surgical treatment for pathologic and native hip fractures from 2007 to 2017 and 2601 matched pairs were identified using propensity scoring. Baseline covariates were controlled for, and rates of 30-day postoperative complications and mortality were compared using McNemar’s test.ResultsPathologic hip fracture patients experienced significantly higher rates of death (6.3% vs 4.3%, P < .001), serious adverse events (17.3% vs 13.5%, P < .001), minor complications (34.3% vs 29.1%, P < .001), extended postoperative lengths of stay (30.2% vs 25.9%, P < .001), readmissions (11.9% vs 8.4%, P < .001), thromboembolic complications (3.0% vs 1.6%, P < .001), and perioperative transfusions (31.5% vs 26.4%, P < .001) compared to native hip fracture patients.ConclusionPathologic hip fractures result in significantly higher complication rates than native hip fractures after surgical treatment, suggesting that guidelines for native hip fractures may not be generalizable for pathologic hip fractures. Orthopedic surgeons should closely monitor these patients for deep vein thrombosis, utilize blood sparing techniques, and employ a multidisciplinary approach to help manage and prevent a more heterogenous profile of postsurgical complications.     

Clinical Comparison of Minifragment Plates Versus Conventional Semitubular Plates for Fixation of Distal Fibula Fractures

BackgroundAlthough operative stabilization of unstable distal fibula fractures is frequently performed and discussed, the ideal implant and technique for these injuries is still debated.Questions/PurposesThe purpose of this study was to determine if minifragment plating of distal fibula fractures would clinically provide equivalent fixation and cost and minimize hardware prominence when compared with standard one-third tubular plating.ResultsThe minifragment group demonstrated equivalency in maintenance of fracture reduction relative to standard tubular plating. Both groups were able to maintain the talocrural angle with less than 1° of change from initial postoperative to final postoperative radiographs. No significant differences were seen in postoperative hardware irritation between groups.ConclusionsUse of a minifragment plating system for displaced fibula fractures appears to be safe but comes with the significant potential added cost of the technology. Interestingly, no significant differences were seen in implant-related irritation or implant removal, but further investigation with a larger study population would help better determine these outcomes.     

Involvement of Residents Does Not Increase Postoperative Complications After Open Reduction Internal Fixation of Ankle Fractures: An Analysis of 3251 Cases

Ankle fractures are common injuries frequently treated by foot and ankle surgeons. Therefore, it has become a core competency for orthopedic residency training. Surgical educators must balance the task of training residents with optimizing patient outcomes and minimizing morbidity and mortality. The present study aimed to determine the effect of resident involvement on the 30-day postoperative complication rates after open reduction and internal fixation of ankle fractures. A second objective of the present study was to determine the independent risk factors for complications after this procedure. We identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who had undergone open reduction internal fixation for ankle fractures from 2005 to 2012. Propensity score matching was used to help account for a potential selection bias. We performed univariate and multivariate analyses to identify the independent risk factors associated with short-term postoperative complications. A total of 3251 open reduction internal fixation procedures for ankle fractures were identified, of which 959 (29.4%) had resident involvement. Univariate (2.82% versus 4.54%; p = .024) and multivariate (odds ratio 0.71; p = .75) analyses demonstrated that resident involvement did not increase short-term complication rates. The independent risk factors for complications after open reduction internal fixation of ankle fractures included insulin-dependent diabetes, increasing age, higher American Society of Anesthesiologists score, and longer operative times.     

Postoperative Radiographic and Clinical Assessment of the Treatment of Posterior Tibial Plafond Fractures Using a Posterior Lateral Incisional Approach

The purpose of the present study was to evaluate the postoperative radiographic and functional outcomes of reduction and fixation of a posterior plafond fracture using a posterolateral approach. We included 38 patients with a tibial plafond fracture. Fixation was most commonly performed using screws, T plates, or meta plates. The average follow-up period was 38 (range 25 to 72) months. The clinical outcomes of these patients were evaluated using the American Orthopaedic Foot Ankle Society score. The radiographs of the included patients were evaluated twice within 2 months by 3 experienced orthopedic trauma surgeons, who performed the retrospective radiographic review. Articular step off measures included the radiographic appearance of the reduction using picture archiving and communication system measurement tools. All 32 patients showed radiologic evidence of bony union at the follow-up visit; 6 patients were lost to follow-up. The American Orthopaedic Foot Ankle Society average score was 92 points; 21 patients (93.7%) had excellent scores (90 to 100 points), 9 patients (28.1%) had good scores (80 to 89 points), and 2 patients (6.2%) had fair scores (<80 points). Excellent to good outcomes were noted in 93.7% of the patients. One patient developed a superficial infection. Another patient experienced a sural cutaneous nerve injury. The radiographic articular step off was measured as 1 mm or less in 29 patients (90.6%) and 1 to 2 mm in 3 patients (9.4%). One patient (3.1%) developed symptomatic post-traumatic arthritis. The posterolateral approach allowed for good exposure and buttress fixation of the posterior plafond fractures with few local complications. The anatomic repositioning and stable fixation resulted in good functional and subjective outcomes.     

动力型外固定架结合有限内固定治疗Pilon骨折

目的探讨Orthofix动力型外固定支架结合有限内固定在治疗高能量Pilon骨折中的价值。方法2002年4月至2004年3月对11例高能量Pilon骨折采用Orthofix公司第四代跨关节外固定结合克氏针或螺钉有限内固定治疗,远端外固定螺钉固定于跟骨和距骨颈,外固定活动轴和踝关节运动的轴心位置保持一致。术后3周开始踝关节功能锻炼,2~5个月后去除外固定。结果11例均得到随访,随访6~18个月(平均13个月),骨折全部达骨性愈合,无切口感染、内植物外露等并发症。踝关节症状与功能评分按Mazur标准进行,临床评分68~97分(平均82分),其中优6例,良4例,可1例。结论Orthofix跨关节动力型外固定支架结合有限内固定治疗高能量Pilon骨折能促进骨折愈合,有利于踝关节早期活动,最大程度恢复踝关节功能,是治疗高能量Pilon骨折的一种理想方法。     

Measuring Recovery After Ankle Fractures: A Systematic Review of the Psychometric Properties of Scoring Systems

Recovery after ankle fractures places a considerable burden on patients both short and long term. Numerous tools called patient-reported outcome measures (PROMs) have been developed to measure the outcome of ankle fractures. They can assist clinicians to measure the effect, guide intervention, and assess the rate of recovery. We identified and evaluated the psychometric properties of PROMs used in the assessment of ankle fractures. In a systematic search, we examined 4 databases from inception to December 4, 2016. Search terms included ankle fracture, ankle pain, disability, gait, questionnaire, and PROMs. Reference lists were also examined. The inclusion criteria were English studies and adult populations. The psychometric properties of the identified PROMs were examined, including internal consistency, test–retest reliability, validity, floor–ceiling effects, and minimally important clinical differences. We identified 22 PROMs relating to ankle pain and disability. Only 5 were specifically used for ankle fractures. The 36-item short-form health survey and short musculoskeletal functional assessment reported floor–ceiling effects, and the lower extremity functional scale reported good responsiveness and content validity, although these are not tools specifically related to ankle fractures. The ankle-fracture outcome of rehabilitation measure (A-FORM) and the Olerud and Molander questionnaire were ankle fracture specific and assessed for internal consistency and validity. Clinicians should use the most appropriate PROM to evaluate patients' recovery from ankle fractures. The A-FORM currently has the most appropriate evidence supporting its use as a PROM for ankle fracture management and rehabilitation.     

Pilon骨折的诊断及治疗

目的探讨Pilon骨折的诊断与治疗方法。方法对我院2002年5月至2006年5月收治的20例Pilon骨折，根据骨折类型，分别采用不同手术方法治疗。结果20例患者均获得随访，随访时间1～3年，平均2年1个月。20例患者中13例行切开复位钢板内固定术，5例行外固定架固定术，2例行踝关节融合术，根据AOFAS踝关节功能评定标准评分，优16例，良2例，可2例，优良率90％。Ⅰ型6例评分（92±2．6）分；Ⅱ型10例，9例评分（93±1．7）分，1例评分（70±2．6）分；Ⅲ型4例，3例评分（90±2．1）分，1例评分（70±2．0）分。结论Pilon骨折需早期及正确诊断，根据骨折类型、损伤程度及时有效地采取恰当的手术治疗，可以获得关节解剖复位，恢复下肢力学轴线，保持关节稳定，达到骨折愈合和重获一个有功能、无疼痛、能负重、可运动的关节，避免感染和创伤并发症的发生。     

Early Operative Intervention Is Associated With Better Patient Survival in Patients With Intracapsular Femur Fractures But Not Extracapsular Fractures

The purpose of this study was to determine patients' survival after undergoing an early or delayed operation. We retrospectively assessed 1849 files of patients operated for proximal femoral fracture, divided into two diagnostic groups: intracapsular (n = 640) and extracapsular (n = 1209). 1163 (63%) were treated within 48 h from hospital admission and 686 (37%) were treated > 48 h afterwards. Delayed operation in patients with intracapsular fractures was associated with a 1.8-fold excess risk for 1-year mortality (HR = 1.83, P = 0.008), while no effect was observed for patients with extracapsular fractures. Males had a higher HR for mortality in both diagnostic groups. Early surgical intervention is beneficial for intra-capsular femoral fractures; male gender and a high ASA score are associated with an increased mortality hazard risk.