内、外侧双切口结合Herbert螺钉内固定治疗合并同侧踝关节骨折的Hawkins Ⅲ型距骨颈骨折

Surgery of ipsilateral Hawkins Ⅲ talus neck and ankle joint fractures via internal and lateral approaches with Herbert screws

目的探讨内、外侧双切口结合Herbert螺钉内固定治疗合并同侧踝关节骨折的HawkinsⅢ型距骨颈骨折的手术方法及手术操作及疗效。方法回顾性分析2009年1月至2014年12月福建中医药大学附属福鼎医院骨科11例及苏州科技城医院骨科2例有完整随访资料的采用内、外侧双切口结合Herbert螺钉内固定治疗合并同侧踝关节骨折的Hawkinsm型距骨颈骨折的患者，男10例，女3例；平均年龄31．5（20～60）岁；右侧9例，左侧4例；单纯合并内踝骨折3例，同时合并内、外踝骨折10例。术前11例行跟骨骨牵引，所有患者均行足及踝关节CT平扫及三维重建。2例急诊手术，11例择期手术，受伤至手术时间5h～10d。末次随访时根据美国足与踝关节外科协会（AOFAS）制定的踝与后足功能评分系统评定术后功能。结果13例患者术后平均随访22．6（14—65）个月。1例出现切口皮缘坏死，未发生感染、复位丢失及骨折不愈合等并发症。末次随访时AOFAS踝与后足功能评分为42～93（75．2±7．8）分，高于术前的23～60（39．2±2．3）分，P=0．023；优4例、良5例、可3例、差l例，优良率69．2％。3例发生不同程度距骨缺血性坏死，发生率为23．1％（3／13）。5例出现创伤性关节炎，发生率为38．5％（5／13），累及胫距关节者2例，累及距下关节者1例，同时累及胫距关节、距下关节者2例。结论采用内、外侧双切口显露、复位骨折，结合Herbert螺钉内固定治疗合并踝关节骨折的HawkinsⅢ型距骨颈骨折可取得满意疗效。正确的手术入路、术中注意保护残存血运及牢固的解剖复位固定是提高疗效的关键。

Objective To explore the manual operation skills of operative treatment of ipsilateral Hawkins Ⅲ talus neck and ankle joint fractures via internal and lateral approaches with Herbert screws, and to study the clinical results. Method From Jan 2009 to Dec 2014, the clinical data of 13 patients with ipsilateral Hawkins m talus neck and ankle joint fraetres via internal and lateral approaches with Herbert screws were retrospectively analyzed in our department. There were l0 males and 3 female, ranging in age from 20 to 60 years with an average age of 31.5 years. The fractures occurred on the right side in 9 patients and on the left side in 4 patients. Three cases had .the complication of medial malleolar fracture. Ten cases had the complication of medial and lateral malleolar fracture. Totally 11 cases were made calcaneal skeletal traction, and all the were made CT with three-dimensional image reconstruction. Two cases were treated with emergency operation. Eleven cases were treated with selective operation. The operation time was 5 hours - 10 days after injury. The functional results were evaluated by American Orthopaedic Foot and Ankle Society （AOFAS）. Result The average duration of follow-up was 22. 6 months （ range, 14 - 65 months）. There was skin necrosis in one cases, no incision infection, malunion and nonunion of the fractures and loss of reduction. At final follow-up, AOFAS ankle score was 75.2 （ range, 42 to 93 ）, higher than preoperative 39. 2 （range, 23 to 60）, the difference was statistically significant （P = 0. 023）. The result was excellent in 4 cases, good in 5 cases, fair in 3 cases and 1 cases in poor, and the overall excellent or good rate was 69. 2%. Avascular necrosis occurred in 3 cases （23.1% , 3/13 ）. Traumatic arthritis was found in 5 cases （38.5%, 5/13）, involved tibial astragaloid joint in 2 cases, involved subtalar joint in 1 case, involved tibial astragaloid joint and subtalar joint in 2 cases. Conclusion The effect of surgical treatment for ipsilateral Hawkins m talus neck and ankle joint fractures via internal and lateral approaches with Herbert screws is satisfactory. Correct operative approach and pay more attention to protect blood circulation of intraoperative, anatomical precision and strong reduction and fixation are the key to achieve and gain better long-term results for the surgical treatment of ipsilateral Hawkins Ⅲtalus neck and ankle joint fractures.