距骨颈骨折的治疗策略

Surgical strategy for talar neck fractures

目的 探讨距骨颈骨折的治疗方法及疗效.方法 2003年1月至2008年1月共收治32例距骨颈骨折患者,男22例,女10例;年龄18～55岁,平均38.5岁.骨折根据改良的Hawkins方法分型：Ⅰ型6例,Ⅱ型19例,Ⅲ型7例.Ⅰ型骨折：2例采用保守治疗,非负重石膏固定6～8周;4例采用经皮螺钉固定.Ⅱ型和Ⅲ型骨折：21例采用切开复位螺钉内固定,5例粉碎性骨折采用钢板内固定. 结果 24例患者术后获平均20个月（12～48个月）随访,8例失访.伤口均Ⅰ期愈合,无感染发生.采用美国足踝外科协会踝与后足评分评定：术后评分平均为80.5分（60～96分）.术后评分70分以下者5例,其中距骨颈骨折不愈合1例,为Ⅱ型骨折,再次行切开复位植骨重建内固定术后愈合;距骨体缺血性坏死4例,为Ⅲ型骨折,其中2例采用保守治疗2个月后症状减轻,2例行距下关节融合术. 结论 距骨颈骨折应根据骨折的具体情况采用不同的治疗方案：Ⅰ型骨折建议采用保守治疗或经皮螺钉固定;Ⅱ型、Ⅲ型骨折建议采用切开复位螺钉内固定,若为粉碎性骨折,则采用钢板固定.

Objective To explore the operative methods of treating talar neck fractures.Methods From January 2003 to January 2008, 32 patients with talar neck fractures were treated in our department. They were 22 males and 10 females, with an average age of 38. 5 years （range, 18 to 55 years）.According to the modified Hawkins classification, there were 6 cases of type Ⅰ, 19 type Ⅱ, and 7 type Ⅲ.Two cases of the type Ⅰ were treated non-operatively with non-weight bearing cast for 6 to 8 weeks, and the other 4 with percutaneous screw fixation. All the patients of type Ⅱ and Ⅲ were treated operatively. Twenty-one cases were treated with open reduction and internal screw fixation, and 5 with plate fixation. Results Only 24 patients were followed up for an average of 20 months （range, 12 to 48 months） . No wound healing problems were observed. According to the Ankle and Hindfoot score system of American Orthopaedic Foot and Ankle Society （AOFAS）, the mean postoperative score was 80. 5 （ranging from 60 to 96） points.Nonunion occurred in one patient of type Ⅱ who eventually responded to open reduction, bone grafting and internal fixation. Avascular necrosis of the talus head occurred in 4 patients of type Ⅲ, but without collapse of the talar body. Of them, 2 underwent conservative treatment and 2 received subtalar arthrodesis. Conclusions Satisfactory clinical results can be achieved by suitable surgical treatment according to the type of the talar neck fracture. Fractures of type Ⅰ may be treated by conservative treatment or fixation with percutaneous screws,while fractures of types Ⅱ and Ⅲ may be treated by open reduction and screw fixation. If the fracture is comminuted, plate fixation should be performed.