不同大小后踝骨折块的手术选择及疗效分析

Influence of fragment size on operative choice and effect analysis in posterior malleolar fractures

背景:后踝骨折的手术指征目前存在争议。目的:通过比较后踝骨块大小及固定与否对三踝骨折预后的影响,探讨后踝骨折的手术指征。方法:回顾性分析2013年1月至2017年12月手术治疗的63例三踝骨折患者的病例资料,其中男23例,女40例;年龄17~69岁,平均(41.4±11.6)岁。根据后踝骨块占胫骨远端关节面面积大小分为<10%(A组)、10%~25%(B组)、>25%(C组)三组。采用美国足踝外科协会(AOFAS)踝与后足评分和视觉模拟评分(VAS)作为功能评价指标,术后X线片显示的关节平整度和关节退变程度作为影像学评价标准,比较3组后踝固定患者的预后,进一步比较A、B两组后踝固定与否对预后的影响。结果:患者随访时间9~27个月,平均(16.9±5.2)个月,均获得骨性愈合,3例出现关节平整度欠佳,2例出现轻度关节退变。各组比较VAS评分差异无统计学意义(P>0.05)。C组后踝固定患者AOFAS评分低于A、B两组后踝固定患者[(84.0±3.5)vs.(89.1±4.0)、(89.1±4.0),P<0.05]。A组后踝固定患者与未固定患者AOFAS评分差异无统计学意义(P>0.05),B组后踝固定患者与未固定患者AOFAS评分差异有统计学意义(P<0.05)。结论:后踝骨块大小影响三踝骨折预后,当后踝骨块>25%时预后较差。当后踝骨块≥10%时应行内固定,当<10%时可采取保守治疗。

Background:There are still controversies on the surgical indications of posterior malleolar fractures.Objective:To investigate the surgical indications of posterior malleolar fractures by comparing the effect of fragment size and internal fixation of posterior malleolar fractures on the prognosis of trimalleolar fractures.Methods:The clinical data of 63 patients with trimalleolar fractures who underwent surgical treatment from January 2013 to December 2017 were retrospectively analyzed including 23 males and 40 females with the mean age of(41.4±11.6)years(range,17-69 years).According to the fragment size of posterior malleolar fractures in distal tibial articular surface,the patients were divided into three groups as<10%(A),10%-25%(B),>25%(C).AOFAS and VAS scores were used as functional evaluation indexes.Articular smoothness and degeneration in the X-ray films were considered as image evaluation criteria.The prognosis of patients with fixation of posterior malleolar fractures were compared between the three groups,and further comparison of the prognosis was made between patients with fixation and non-fixation of posterior malleolar fractures in the groups of A and B.Results:All patients were followed up for 9 to 27 months with an average follow-up period of(16.9±5.2)months and all of them received bone healing.Irregular articular surface was observed in 3 patients and mild degeneration was observed in 2 patients during the follow-up period.There was no significant difference in VAS score among all groups(P>0.05).AOFAS score of patients with fixation of posterior malleolar fractures in group C was lower than that of group A and group B(P<0.05).AOFAS score did not differ significantly between patients with fixation and non-fixation of posterior malleolar fractures in group A(P>0.05),however,there was significant difference in AOFAS score between patients with fixation and non-fixation of posterior malleolar fractures in group B(P<0.05).Conclusions:The fragment size of posterior malleolar fractures has an influence on the prognosis of trimalleolar fractures.When the fragment is more than 25%,the prognosis is relatively poorer.When the fragment is no less than 10%,internal fixation should be considered.When the fragment is less than 10%,conservative treatment may be a better choice.