后踝骨折的手术入路选择

Approaches for surgical treatment of posterior malleolar fracture

目的 通过观察固定后踝骨折块所选择的手术入路对于累及后踝的踝关节骨折预后的影响,探讨后踝骨折块手术入路的选择.方法 回顾性分析2000年7月至2013年6月手术治疗的69例累及后踝的踝关节骨折患者资料,男24例,女45例;年龄14 ～ 80岁,平均46.2岁.骨折按照AO分型：44A型8例,44B型49例,44C型12例.比较后踝骨折块≥25％的从前向后固定患者（27例）和从后向前固定患者（15例）的美国骨科足踝外科协会（AOFAS）踝-后足评分和视觉模拟评分（VAS）,以及后踝骨折块＜25％的从前向后固定患者（15例）和从后向前固定患者（12例）的AOFAS踝-后足评分和VAS评分.结果 所有患者术后获12 ～ 126个月（平均52.0个月）的随访.当后踝骨折块≥25％时,从前向后固定患者的AOFAS踝-后足评分[（94.4±5.0）分]和VAS评分[（0.2±0.4）分]分别与从后向前固定患者[（94.1±7.0）分和（0.4±0.8）分]比较,差异均无统计学意义（P＞0.05）.当后踝骨折块＜25％时,从前向后固定患者的AOFAS踝-后足评分[（93.2±5.4）分]小于从后前向固定患者[（98.3±3.9）分],差异有统计学意义（P=0.009）;但两种入路患者的VAS评分[（0.1±0.4）分和0分]比较差异无统计学意义（P =0.058）.结论 对于累及后踝的踝关节骨折,当后踝骨折块≥25％时,固定后踝的手术入路对预后无明显影响,可优先选择具有操作简单、切口小等优点的从前向后固定的方式;当后踝骨折块＜25％时,则选择从后向前固定的方式.

Objective To compare the approaches for surgical treatment of posterior malleolar fracture in terms of their effect on the fracture prognosis.Methods We analyzed retrospectively the 69 patients with posterior malleolar fracture who had been treated by surgery from July 2000 to June 2013.They were 24 males and 45 females,14 to 80 years of age （average,46.2 years）.By AO classification,there were 8 cases of type 44A,49 cases of type 44B and 12 cases of type 44C.American Orthopaedic Foot and Ankle Society （AOFAS） and visual analogue scale （VAS） scores were compared between the 27 patients with ≥25% fragments which were fixated from the anterior to the posterior and the 15 ones with ≥25% fragments which were fixated from the posterior to the anterior,as well as between the 15 patients with 〈 25% fragments which were fixated from the anterior to the posterior and the 12 ones with 〈 25% fragments which were fixated from the posterior to the anterior.Results This cohort obtained follow-up from 12 to 126 months （average,52.0 months）.When the fragments ≥25%,there was no significant difference in AOFAS or VAS score between those fixated from the anterior to the posterior （94.4 ± 5.0 and 0.2 ± 0.4 respectively） and those fixated from the posterior to the anterior （94.1 ±7.0 and 0.4 ±0.8 respectively） （P 〉 0.05）.When the fragments 〈 25%,those fixated from the anterior to the posterior had a significantly lower AOFAS score （93.2 ± 5.4） than those fixated from the posterior to the anterior （98.3 ± 3.9） （P =0.009）,but there was no significant difference in VAS score between the 2 groups （0.1 ± 0.4 versus 0） （P =0.058）.Conclusions In the treatment of posterior malleolar fracture with a ≥ 25% fragment,as the operative approaches may exert little impact on the fracture prognosis,the approach from anterior to posterior may be a priority choice due to its simplicity and smaller incision.When a posterior malleolar fragment is less than 25%,it may be better to choose the approach from posterior to anterior.