无头加压空心螺钉治疗Lisfranc损伤的临床及影像学疗效评估

CLINICAL AND RADIOGRAPHIC EVALUATION OF OPEN REDUCTION AND INTERNAL FIXATION WITH HEADLESS COMPRESSION SCREWS IN TREATMENT OF Lisfranc JOINT INJURIES

目的探讨无头加压空心螺钉内固定治疗Lisfranc损伤的临床及影像学疗效及其影响因素。 方法回顾性分析2006年1月－2012年1月，采用无头加压空心螺钉治疗并获随访1年以上的34例36足Lisfranc损伤患者临床资料。男22例24足，女12例12足；年龄21～73岁，平均38.9岁。致伤原因：交通事故伤16例17足，高处坠落伤11例12足，碾压伤5例5足，运动损伤2例2足。19例20足为闭合性损伤，15例16足为开放性损伤。单纯Lisfranc关节脱位及韧带性损伤（pure dislocations of tarsometatarsal joints and ligamentous Lisfranc injuries，LD）7 例8足，Lisfranc关节骨折脱位（Lisfranc joint fracture dislocations，LFD）22例23足，合并Chopart关节损伤的LFD（combined Chopart-LFD，CLFD）5例5足。根据Myerson等分类系统：A型5例5足，B1型7例8足，B2型14例15足，C1型5 例5足，C2型3例3足。合并跖骨干骨折12例13足，骰骨骨折4例4足，舟骨骨折4例4足，楔骨骨折/脱位6例7足，同侧下肢多处骨折8例10足，对侧下肢多处骨折4例4足。临床疗效采用美国矫形足踝协会（AOFAS）评分标准，足部疼痛评价采用疼痛视觉模拟评分（VAS）评价。根据双足正、侧位及45°斜位X线片，观察Lisfranc关节解剖复位，螺钉断裂、创伤性关节炎以及足弓恢复等情况。 结果患者均获随访，随访时间1年～5年2个月，平均3.5年。X线片示，31例33足（91.7%）获解剖复位。末次随访时，VAS评分为0～6分，平均2.3分；AOFAS评分为60～100分，平均80.6分，其中解剖复位患者评分显著高于非解剖复位患者，LD、LFD患者评分显著高于CLFD患者，合并楔骨骨折/脱位患者评分显著低于未合并楔骨骨折/脱位患者，比较差异均有统计学意义（P 〈 0.05）。末次随访时患侧距骨-第1跖骨角、第1、2跖骨基部间距、足弓高度与健侧比较，差异均无统计学意义（P 〉 0.05）。1例1足因过早负重导致复位丢失；9例10足并发创伤性关节炎。创伤性关节炎及非创伤性关节炎患者中解剖复位、合并楔骨骨折/脱位、严重关节内粉碎性骨折、损伤模式构成差异均有统计学意义（P 〈 0.05）。 结论采用无头加压空心螺钉治疗Lisfranc损伤患者可获得良好疗效。但应注意术中解剖复位，稳定固定，尤其对于合并Chopart关节损伤、楔骨骨折/脱位、严重关节内粉碎性骨折患者，应尽量避免继发性创伤性关节炎的发生。

ObjectiveTo evaluate the clinical and radiographic outcomes of headless compression screws for Lisfranc joint injuries. Methods A retrospective analysis was made on clinical data of 34 patients （36 feet） with Lisfranc joint injuries who underwent open reduction and internal fixation with headless compression screws between January 2006 and January 2012. There were 22 males （24 feet） and 12 females （12 feet）, aged 21-73 years （mean, 38.9 years）. The causes of injury included traffic accident in 16 cases （17 feet）, falling from height in 11 cases （12 feet）, crushing in 5 cases （5 feet）, and sports in 2 cases （2 feet）. Of them, there were 19 cases （20 feet） of closed injury and 15 cases （16 feet） of open injury; there were 7 cases （8 feet） of pure dislocations of tarsometatarsal joints and ligamentous Lisfranc injuries （LD）, 22 cases （23 feet） of Lisfranc joint fracture dislocations （LFD）, 5 cases （5 feet） of combined Chopart-LFD （CLFD）. According to Myerson classification, 5 cases （5 feet） were rated as type A, 7 cases （8 feet） as type B1, 14 cases （15 feet） as type B2, 5 cases （5 feet） as type C1, and 3 cases （3 feet） as type C2. Associated fractures included 12 cases （13 feet） of metatarsal shaft fracture, 4 cases （4 feet） of cuboid fracture, 4 cases （4 feet） of navicular bone fracture, 6 cases （7 feet） of coneiform bone fracture/dislocation, 8 cases （10 feet） of ipsilateral lower limb multiple fracture, and 4 cases （4 feet） of contralateral lower limb multiple fracture. The clinical outcomes were evaluated according to American Orthopaedic Foot and Ankle Society （AOFAS） score and visual analogue scale （VAS） score. Postoperative X-ray films were taken to assess the reduction, internal fixation, and the foot arch height. ResultsAll patients were followed up 1 year to 5 years and 2 months （mean, 3.5 years）. X-ray films showed anatomical reduction in 31 cases （33 feet, 91.7%）. At last follow-up, AOFAS score and VAS score averaged 80.6 （range, 60-100） and 2.3 （range, 0-6）, respectively; the AOFAS score was significantly higher in patients having anatomical reduction than the patients having no anatomical reduction, in patients with LD and LFD than in patients with CLFD, and in patients without cuneiform bone fracture/dislocation than in patients with cuneiform bone fracture/dislocation （P 〈 0.05）. There was no significant difference in the talus-first metatarsal angle, the distance between the lateral edge of the base of the first metatarsal bone and the medial edge of the base of the second metatarsal bone, and the arch height between the injured foot and normal foot （P 〉 0.05）. Reduction loss was observed in 1 case （1 foot） because of early weight bearing; post-traumatic arthritis developed in 9 patients （10 feet）. The incidence of post-traumatic osteoarthritis was higher in the patients with non-anatomic reduction, coneiform bone fracture/dislocation, comminuted intra-articular fractures of Lisfranc joints, the injury types （P 〈 0.05）. ConclusionHeadless compression screws for fixation of Lisfranc joint injuries can provide satisfactory short- and mid-term clinical and radiographic outcomes. During surgery, the precise anatomic reduction and stable fixation should be paid attention to, especially in patients with CLFD, coneiform bone fracture/dislocation, and comminuted intra-articular fractures of Lisfranc joints so as to control the incidence of the post-traumatic osteoarthritis.