负重 X 线侧位片在踝关节骨折畸形愈合复位评估中的价值

 目的 探讨踝关节负重 X 线侧位片在踝关节骨折畸形愈合复位评估中的意义。方法 回顾性分析 2010 年3 月至 2012 年 10 月踝关节骨折畸形愈合接受重建手术治疗的 17 例患者资料,男 9 例,女 8 例;年龄 17～64 岁,平均 40.2岁。Takakura 踝关节炎退变分级:1 级 7 例,2 级 4 例,3 级 6 例。接受单纯切开复位内固定术 5 例,踝上胫骨截骨术 5 例,踝上腓骨截骨延长术 2 例,踝上胫腓骨截骨术 5 例。比较患者手术前、后负重 X 线正位片胫腓间隙,踝穴位 X 线片内踝间隙、胫腓间隙和胫腓重叠距离,X 线侧位片胫骨侧面角、胫骨轴线与距骨顶关节面中心的位移差（x 值）和胫距关节面圆心位移差（d 值）。应用美国足踝外科协会（American Orthopaedic Foot and Ankle Society,AOFAS）踝与后足评分对患者手术前、后踝关节功能进行评估。结果 17 例患者均获 9～32 个月随访,骨折均愈合,愈合时间 11～14 周;未见踝关节退变等级加重。手术前、后负重 X 线正位片上胫腓间隙、踝穴位 X 线片上内踝间隙、胫腓间隙和胫腓重叠距离比较无差异;胫骨侧面角[术前（76.9°±4.1°）与术后（80.9°±5.2°）]、x 值[术前（10.8±2.1）mm 与术后（2.0±0.5）mm]、d 值[术前（4.5±1.5）mm 与术后（2.2±1.0）mm]比较均有差异。术前 AOFAS 踝与后足评分为（45.7±15.9）分,末次随访时为（82.0±9.9）分。结论 负重 X 线侧位片可以辅助判断踝关节复位情况,即使负重正位及踝穴位 X 线片示测量数据均在正常范围内,X 线侧位片示相关指标仍可出现明显畸形;X 线侧位片示踝关节解剖复位的标准是胫骨轴线通过距骨顶关节面中心、胫距关节面平行。     

踝关节骨折的手术治疗

目的 探讨手术治疗踝关节骨折的疗效.方法 回顾性分析2000年1月至2008年4月手术治疗且有完整随访资料的92例踝父节骨折患者的疗效.评价指标包括美国足踝机会踝与后足功能评分(AOFAS评分)、骨折部位的疼痛评估(VAS评分)、患者满意度、踝关节活动度.并对踝关节健侧与患侧的关节活动度差异,以及不同AO分型之间、骨折累及不同部位(单踝、双踝、三踝骨折)之间、不同随访时限之间这二种情况下的踝关节屈伸活动度及AOFAS评分的差异进行统计学分析.结果 平均随访55个月,所有患者骨折均愈合;AOFAS评分平均为93.6分,优良率100%;VAS评分平均为0.17分,患者满意度评分平均为9.62分.健、患侧踝关节活动度差异有统计学意义(P<0.05),不同AO分型之间、骨折累及小同部位之问、不同随访时限之问的踝关节屈伸活动度和AOFAS评分差异无统计学意义(P>0.05).结论 手术治疗踝关节骨折可取得满意的临床疗效.     

踝关节骨折脱位的治疗

踝关节骨折脱位为临床常见损伤之一，若处理不当，易并发创伤性关节炎。现将我科1996年3月～2001年10月住院治疗的53例患者的治疗方法及疗效进行总结。     

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.     

容易忽视的踝关节骨折

<正>踝关节由胫腓骨远端、距骨及周围的韧带(三角韧带、外侧韧带及韧带联合)组成,由于其解剖结构较为复杂,踝关节骨折的诊治较为困难。近年来,踝关节骨折的发生率逐年提高,不规范的诊治及漏诊、误诊会导致极差的预后。本文拟从踝关节骨折的分型、特殊类型、合并软组织损伤及术后康复等容易忽视的问题进行阐述,以期为临床提供参考。     

踝关节骨折85例治疗体会

踝关节骨折是创伤骨科中最常见的骨折之一，它是一种关节内骨折，治疗需要精确的解剖复位和固定，以确保关节早期活动以及促进关节软骨的修复。如果踝关节骨折未能达到解剖复位，下胫腓联合不稳定，可导致早期退行性关节炎和迟发性踝关节不稳定。我院从1996—2002年共治疗踝关节骨折患者96例，其中手术治疗69例，对其中随访患者85例治疗方法和结果进行分析。     

波及踝穴的后踝骨折58例手术治疗的临床疗效分析

随着踝关节周围及本身所累及后踝踝穴关节面骨折的增多，其功能恢复的不尽人意，应使我们对其诊断和治疗作进一步探讨。本组总结2001年3月至2006年3月波及踝穴的后踝骨折58例CT扫描诊断和手术治疗方法，提出其适当的治疗技术方案和注意事项，并分析其临床意义。     

踝关节骨折治疗体会

目的探讨不同方法治疗踝关节骨折的效果。方法于2005年5月至2007年5月收治30例踝关节骨折病人,12例手法复位石膏外固定,18例手术治疗。结果随访6～24个月,非手木组10得到随访,其中优6例,良2例,可1例,差1例,优良率占80.0%.手木组16得到随访,其中优12例、良2例、差2例,优良率占87.5%。结论踝关节骨折只要掌握好适应症,保守治疗和手术治疗同样有效。     

踝关节骨折畸形愈合的重建手术

目的 总结踝关节骨折畸形愈合重建术的临床疗效.方法 2006年1月至2009年1O月,共收治23例踝关节陈旧性骨折畸形愈合患者.男14例,女9例;平均年龄45岁(21～69岁).初次受伤至最终重建术平均间隔18个月(12～36个月),其中11例患者曾接受切开复位内固定术.术前常规行X线及CT检查,对畸形进行个体化评估:所有患者均有不同程度的腓骨短缩或旋转,合并内、外翻畸形者4例,下胫腓联合间隙增宽者5例.对所有腓骨短缩或旋转的患者行腓骨延长截骨术,内外翻畸形则行开放或闭合楔形截骨,而下胫腓增宽者则须行下胫腓功能性融合.术后定期行影像学随访评估骨愈合情况,记录并发症发生情况,并采用美国骨科足踝外科协会(American Orthopedic Foot Ankle Society,AOFAS)踝关节与后足功能评分来评估治疗效果.结果 共21例患者获随访,平均随访36个月(12～58个月).所有随访患者均无感染、内固定失败、骨不连、畸形复发等发生.影像学随访显示于术后平均12周(10～14周)骨愈合,且力线恢复良好.AOFAS踝关节与后足功能评分从术前平均28分(15～39分)改善为术后1年平均82分(70～94分).2例患者因严重创伤性关节炎分别于术后18个月和术后2年行踝关节融合术.结论 对于踝关节骨折畸形愈合的患者,通过早期重建手术恢复腓骨长度和旋转及踝穴的匹配,踝关节功能可获得极大的改善,也可延缓创伤性关节炎的发展.

Abstract：

Objective To summarize the clinical outcomes of reconstruction of malunited ankle fractures.Methods From January 2006 to October 2009,23 malunited ankle fractures were treated in our department.All deformities were evaluated individually based on pre-operatively X-ray and CT scan.Varying degrees of fibular shortening or rotational deformity were found in all patients,with 4 cases of varus or valgus deformity,and 5 of a widen syndesmosis.Then different reconstructive techniques were chosen according to the type of malunion:a lengthening fibular osteotomy was performed in patients with fibular shortening or rotational deformity;an opening or closing wedge osteotomy was chosen correspondingly in patients with varus or valgus deformity;functional fusion of syndesmosis was performed in cases of widen syndesmosis.The postoperative follow-up included standard radiography to evaluate bone union;relative complications were also recorded and functional outcome were assessed with American Orthopedic Foot Ankle Society (AOFAS)ankle-hindfoot scores.Results Twenty-one patients were followed up with an average period of 36 months (12-58 months).There were no complications of infection,implant failure,nonunion or malunion.Solid union with a favorable alignment was obtained at an average of 12 weeks (10-14 weeks).The mean pre-operative AOFAS ankle-hindfoot score was 28 (15-39).While the score increased to 82 (70-94) one year after operations.But 2 patients underwent ankle arthrodesis correspondingly 18 months and 24 months post-operatively due to severely post-traumatic arthritis.Conclusion An early realignment reconstruction of the length and rotation of fibula and the congruity of ankle mortise may improve the ankle function and slow down the development of post-traumatic arthritis for patients who suffered from malunited ankle fractures.     

陈旧性踝关节骨折脱位的手术治疗

自1999年4月-2003年1月共收治陈旧性踝关节骨折脱位患者14例,疗效满意,现报告如下。1临床资料14例中男9例,女5例;年龄16~68岁,平均39·5岁。损伤至手术时间21d~9个月,平均52d。根据Lange-Hansen分类:旋前外展型Ⅲ度3例,Ⅳ度2例;旋前外旋型Ⅱ度2例,Ⅲ度3例,Ⅳ度1例;旋后外旋型Ⅲ     

踝部骨折的外科治疗及术后康复

1999年 1月 - 2 0 0 0年 12月 ,我院收治 6 0例踝部骨折脱位患者 ,依据骨折复位与否 ,分别给予石膏外固定和手术复位内固定 ,功能恢复良好 ,现报告如下。1　临床资料本组 6 0例中男 39例 ,女 2 1例 ;年龄 17～ 76岁 ,平均 34岁。手术治疗组 4 4例 ,非手术治疗组 (石膏外固定 ) 16例 ;依据Lange Hansen分型[1] ,旋前外旋型 2 4例 ,旋前外展型 16例 ,旋后外旋型 11型 ,旋后内收型 6例 ,垂直压缩型 3例。2　治疗方法2 1　手术方法　内踝骨折采用 2枚松质骨螺丝钉固定 ,并彻底清除关节内骨与软骨碎片。外踝骨折 ,若为旋后外旋型则用螺丝钉固定…     

记忆合金弓齿钉处理踝关节骨折中的下胫腓联合分离

目的:探讨踝关节骨折合并下胫腓联合分离的手术方法。方法:自2009年1月至2011年12月,对采用记忆合金弓齿钉固定治疗的24例下胫腓联合分离患者的临床资料进行回顾性分析,其中男10例,女14例;年龄19～71岁,平均43岁。所有患者结合病史、查体及影像学检查进行诊断,按Lauge-Hansen分型进行手术治疗。术后按照美国骨科足踝外科医师协会(AOFAS)评分标准进行功能评价。结果:24例均获得随访,时间6～28个月,平均16个月,所有骨折获愈合,愈合时间8～14周,平均9.2周。术后AOFAS评分为(87.50±13.16)分。1例并发创伤性关节炎,无断钉及内固定失效,临床疗效优16例,良5例,可2例,差1例。结论:记忆合金弓齿钉处理踝关节骨折并发的下胫腓联合分离,不仅能保留踝关节及下胫腓联合的生理活动,且负重前无须常规取出,是一种值得推广的治疗方法。     

开放性踝关节骨折内固定术后并发症的防治

自 1995 - 2 0 0 0年间我院 182例开放性踝关节骨折行不同方法内固定 ,发生多种并发症 35例报告如下。1　临床资料男 30例 ,女 5例 ;年龄 2 1～ 6 1岁 ,平均 4 3 5岁。发病原因 :车祸伤 12例、坠落伤 18例、挤压伤 5例。骨折类型 (Danis weber) :A型 3例、B型 8例、C型 2 4例。软组织损伤情况按朱通伯分度[1] :Ⅰ度开放 5例 ,Ⅱ度开放 2 1例 ,Ⅲ度开放 9例。其中伴内踝骨折18例 ,外踝骨折 30例 ,后踝骨折 8例。2　治疗方法伤口彻底清创 ,内踝 :1枚螺钉固定 10例 ,2枚螺钉固定 5例 ,张力钢丝固定 3例 ;后踝 :骨折 1枚螺钉固定 2例 ,2枚螺钉…     

Clinical audit of the management of stable ankle fractures

INTRODUCTION

Ankle fractures are common and ‘stable’ ankle fractures comprise 40–75% of this group. Studies show that these injuries can be managed successfully in a functional brace, with no need for further radiographs and minimal out-patient follow-up. We aimed to audit current practice and introduce change in order to improve treatment and produce financial savings.

PATIENTS AND METHODS

A retrospective 6-month audit was carried out to establish practice. Guidelines were then drawn up and widely distributed in the accident and emergency (A&E) and orthopaedic departments. These included criteria for diagnosis of stable ankle fractures, a management protocol for treatment of these injuries in a brace and also a follow-up algorithm in the out-patient clinic. A prospective 6-month audit was then carried out to assess the effectiveness of the guidelines.

RESULTS

Of patients presenting in the second 6-month period, 91% were managed in a functional brace. The mean number of out-patient follow-up appointments, weeks until discharge and repeat radiographs all decreased significantly (P < 0.05) after the implementation of the guidelines. The cost of treating a patient with a stable ankle fracture dropped from £310.75 to £129.80.

CONCLUSIONS

Previous studies have shown that stable ankle fractures are more effectively treated in a functional brace than a plaster cast, do not displace and, therefore, do not need repeat radiographs. A previous audit demonstrated that 60% of patients with stable fractures could be treated in a brace. We have shown that, with effective and persistent education of colleagues, the vast majority (91%) of patients can be managed in this way and this results in a significant cost saving. We have also shown that an evidence-based treatment protocol can produce significant improvements in management for patients and savings for healthcare organisations.     

Improvement in the treatment of stable ankle fractures: an audit based approach

Stable ankle fracture patients form a distinct, clinically benign group in which functional treatment can be used. An initial retrospective audit of the fracture clinic records of our institution for 1 calendar year demonstrated that recognition and functional treatment of stable ankle fractures was rarely followed. After the introduction of formal departmental evidence-based guidelines, subsequent audits have showed progressive improvements with significant reductions of time spent immobilised in plaster, time spent non-weight bearing and number of routine check radiographs, without compromising patient safety. This study illustrates the value of evidence-based guidelines in maintaining high standards of care over time.     

关节镜辅助下切开复位内固定治疗踝关节骨折的临床观察

目的：探讨Lauge-HansenⅣ度踝关节骨折关节镜辅助下手术治疗的临床效结果。方法：自2008年1月至2009年12月,对42例踝关节骨折采用关节镜辅助下切开复位内固定治疗。骨折按Lauge-Hansen分类法：旋后外旋型Ⅳ度26例,女11例,男15例,平均年龄（36.8±11.7）岁;旋前外旋型Ⅳ度16例,女6例,男10例,平均年龄（37.6±11.2）岁。所有患者在关节镜辅助下行骨折切开复位内固定,镜下观察韧带及软骨损伤情况,下胫腓联合分离患者行下胫腓联合螺钉固定,软骨损伤按Cheng-Ferkel分期进行治疗。临床疗效采用AOFAS评分系统进行评价。结果：42例均获随访,时间1年。术后AOFAS评分为（92.00±9.32）分,临床疗效优28例,良11例,可3例,其中31例存在不同程度的软骨损伤。无软骨损伤患者的AOFAS评分高于软骨损伤患者,C级以下软骨损伤患者的AOFAS评分高于C级以上软骨损伤患者,无软骨损伤患者的AOFAS评分高于C级以上软骨损伤患者。下胫腓联合固定患者AOFAS评分低于未固定组患者。结论：Lauge-HansenⅣ度踝关节骨折常合并有关节内软骨及周围韧带损伤,其中下胫腓联合损伤及C级以上的软骨损伤是导致踝关节功能恢复欠佳的重要因素,关节镜辅助下切开复位内固定治疗不仅利于关节面的解剖复位,同时可以对合并的软骨和韧带损伤进行更好的诊治,从而提高手术的临床效果。     

Early versus late weight bearing & ankle mobilization in the postoperative management of ankle fractures: A systematic review and meta-analysis of randomized controlled trials

BackgroundWhile open reduction and internal fixation is currently considered the optimum treatment option for displaced ankle fractures, the most optimal post-operative rehabilitation strategy in this setting remains unclear. The objective of this investigation was to compare the effect of early vs. late weight bearing and ankle mobilization in the post-operative management of ankle fractures.MethodsMedline, Embase, CENTRAL, Scopus, CINHAL, and Web of Science were searched to identify randomized controlled trials (RCTs) and quasi-RCTs. Two review authors screened articles, abstracted data, and evaluated risk of bias in duplicate. Outcomes of interest included post-operative ankle function and overall time to return to work. Studies on weight bearing and ankle mobilization were analysed separately and all data were pooled using random-effects models.ResultsEighteen trials were included in the review of which 14 were included in the meta-analysis of at least one outcome of interest. Majority of the studies presented a high overall risk of bias. Early weight bearing demonstrated significantly better short-term postoperative functional scores at 6–9 weeks postoperatively (SMD: 0.39, 95% CI: 0.19, 0.58; p < 0.0001; I² = 0%). However, the functional effect of early weight bearing compared to late weight bearing gradually became equivalent by the 6 month postoperative time-period. Early weight bearing also demonstrated a significant reduction in the time to return to work/daily activities (MD: ?12.29, 95% CI: ?17.39, ?7.19; p < 0.0001; I² = 0%). In comparison, no significant differences were found between early ankle mobilization/exercises and immobilization.ConclusionOur findings suggest a potential role of EWB in improving post-operative ankle-function in the short-term and reducing the overall time to return to work/daily activities, but no clinical benefit associated with early ankle mobilization post-surgery.     

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。     

关节镜下踝关节骨折的手术治疗

踝关节是个高度适配的鞍状负重关节，骨折时还可同时伴有软骨、韧带和肌腱的损伤，创伤性关节炎发生率高。作为常见的关节内骨折，踝关节稳定性重建非常重要，但临床上仍发现部分患者虽然影像学资料显示复位固定满意，但并发后期关节炎，影响生活质量。同时部分患者骨折部皮肤条件差，切开手术感染概率高，为此，我们利用关节镜技术，进行微创手术治疗踝部骨折，     

陈旧性踝关节骨折手术治疗的远期疗效分析

目的：对陈旧性踝关节骨折手术治疗的远期疗效进行分析，确定恰当的治疗方案。方法：对46例陈旧性踝关节骨折患施行手术治疗，37例行切开复位内固定，9例行踝关节融合术，应用AOFAS评分系统进行评分。结果：随访26－121个月，平均87个月。远期疗效良好，骨折全部愈合，无痛可负重，但延迟1－3个月手术AOFAS评分术后较术前明显提高，延迟三个月以上术后较术前无明显提高。结论：延迟1－3个月手术的踝关节骨折如踝穴恢复完整并获得解剖复位或接近解剖复位宜行关节切开复位内固定术；否则宜行关节融合术。延迟三个月以上手术的骨折，由于软骨和软组织发生退变，难以获得解剖复位，宜行关节融合术。