全踝关节镜下骨折复位空心螺钉固定术治疗伴距骨脱位距骨颈骨折的疗效观察

目的 探讨全踝关节镜下骨折复位空心螺钉固定术治疗伴距骨脱位距骨颈骨折的临床效果。方法 回顾性研究。纳入2019年1月—2020年12月徐州市中心医院手足显微外科伴距骨脱位的距骨颈骨折患者23例23足,其中男15例、女8例,年龄18~56（29.4±10.2）岁;改良Hawkins分型Ⅱ型17例、Ⅲ型6例,左侧10例、右侧13例;受伤到手术时间2~9（4.1±2.6）d。所有患者在全踝关节镜下行骨折复位、经皮空心螺钉内固定术治疗。术后定期复查X线片,观察患者骨折复位、内固定情况,骨折愈合情况,距骨骨不连、畸形愈合、缺血性坏死以及创伤性关节炎等并发症。随访期间观察患者踝关节活动度、足部外观满意度、行走步态;对比术前与末次随访时患者踝关节疼痛视觉模拟评分法（VAS）评分及美国足踝外科协会（AOFAS）踝与后足评分系统评分,并采用末次随访时AOFAS评分评价患者踝关节功能。结果 本组23例患者手术均获成功,手术时间50~100（73.21±18.32）min、术中出血量5~10（7.10±1.31）mL、住院时间6~14（8.41±2.03）d,所有患者手术切口一期愈合,未出现血管、神经及肌腱损伤等并发症。本组23例患者均获得随访,随访时间12~20（15.71±4.63）个月。术后X线显示所有患者距骨得到解剖复位,未发现距骨骨不连、畸形愈合、缺血性坏死以及创伤性关节炎等并发症,骨折均于术后10~14（11.63±2.10）周愈合。末次随访时,除1例患者踝关节活动范围减小（背伸约5°、跖屈约30°）,其余患者踝关节活动良好、外观满意、行走步态无异常、切口局部皮肤无感觉过敏及瘢痕触痛。末次随访时,患者踝关节疼痛VAS评分为0~2（0.65±0.71）分、低于术前的3~9（6.08±1.47）分,AOFAS评分为88~99（94.34±2.53）分、高于术前的59~81（71.30±6.73）分,差异均有统计学意义（t=15.32、-16.72,P值均<0.05）。依据AOFAS评分,本组患者术后踝关节功能优20例、良3例,优良率100%。结论 全踝关节镜下骨折复位空心螺钉固定术治疗伴距骨脱位的距骨颈骨折效果较好,具有直视下精准复位、创伤小、对血供破坏小等优点,且避免了传统手术切口并发症的发生。

Treatment of talus neck fracture with talus dislocation by using all ankle arthroscopic fracture reduction and hollow screw fixation

Objective This study aimed to investigate the clinical effect of total ankle arthroscopic fracture reduction and cannulated screw fixation in the treatment of talus neck fracture with talus dislocation. Methods A retrospective study was conducted. From January 2019 to December 2020, 23 patients of talus neck fracture with talus dislocation in the Hand and Foot Microsurgery Department of Xuzhou Central Hospital were included in this study, including 15 males and 8 females aged 18-56 (29.4±10.2) years. On the basis of modified Hawkins classification, 17 and six cases were identified as types Ⅱ and Ⅲ, respectively. In addition, 10 and 13 cases were on the left and right sides, respectively, and the time from injury to operation was 2-9 (4.1±2.6) days. All patients underwent fracture reduction under ankle arthroscopy and percutaneous cannulated screw internal fixation. X-ray films were regularly reviewed after the operation to observe the fracture reduction, internal fixation, fracture healing, and complications, such as nonunion, malunion, avascular necrosis, and traumatic arthritis. The ankle range of motion was observed during the follow-up period, along with foot appearance satisfaction and walking gait. The visual analog scale (VAS) score of the patients' ankle joint pain and the American Foot and Ankle Surgeon Association Ankle and Hindfoot Scoring System (AOFAS) score were compared between pre-operation and final follow-up. The AOFAS score was used to evaluate the ankle function of the patients during follow-up. Results The operation success rate was 95.6%, the operation time was 50-100 (73.21±18.32) min, the intraoperative blood loss was 5-10 (7.10±1.31) mL, the hospitalization time was 6-14 (8.41±2.03) days, and the surgical incision of all patients was one stage. All fractures healed without complications, such as vascular, nerve, and tendon injuries. All the 23 patients were followed up for 12-20 (15.71±4.63) months. Postoperative X-rays showed that all patients had anatomical reduction of the talus, and no complications, such as talus nonunion, malunion, avascular necrosis, and traumatic arthritis, were found. All fractures healed for 10-14 (11.63±2.10) weeks. At the last follow-up, except for one patient with reduced ankle range of motion (approximately 5° of dorsiflexion and approximately 30° of plantar flexion), the patients had good ankle motion, satisfactory appearance, no abnormal walking gait, and no hyperesthesia in the local skin of the incision and scar tenderness. At the last follow-up, the VAS score of the patients' ankle pain was 0-2 (0.65±0.71), which was lower than the preoperative score of 3-9 (6.08±1.47). The AOFAS score was 88-99 (94.34±2.53), which was higher than the preoperative score of 59-81 (71.30±6.73). The differences were statistically significant (t=15.32,-16.72; all P values <0.05). The AOFAS score indicated 20 and two cases of excellent and good ankle joint functions after the operation, respectively, and the excellent and good rates were 100%. Conclusion Total ankle arthroscopic fracture reduction with cannulated screw fixation is a minimally invasive technique that has the advantages of precise reduction under direct vision, less trauma, less blood supply damage, and avoidance of the occurrence of complications of traditional surgical incisions. It is an effective treatment method for talus neck fracture with talus dislocation.