后pilon骨折Die-punch骨块的及应用CT分型

Treatment of posterior pilon fractures according to classification of die-punch fragments by CT scanning

目的提出后pilon骨折的Die-punch骨块CT分型，观察其指导手术治疗的意义。方法根据后pilon骨折术前CT结果中Die—punch的大小和位置将Die—punch骨块分为5型。回顾性分析2013年1月至2015年12月复旦大学附属华山医院骨科收治的48例后pilon骨折患者资料，男16例，女32例；年龄20～87岁，平均46．5岁；根据Die—punch骨块CT分型：Ⅰ型16例（33．3％），Ⅱ型2例（4．2％），Ⅲ型18例（37．5％），Ⅳ型10例（20．8％），Ⅴ型2例（4．2％）；根据分型结果指导手术入路并进行Die—punch骨块的复位内固定或骨折块的取出。术后通过美国足踝外科协会（AOFAS）的踝-后足评分与疼痛视觉模拟评分（VAS）评估踝关节功能。结果所有患者术后随访11～21个月，平均13．7个月。末次随访时AOFAS的踝-后足评分77～92分，平均84．3分；VAS评分0～1分，平均0．2分。各分型患者间术后AOFAS的踝-后足评分和VAS评分比较差异均无统计学意义（P〉0．05）。术后并发症包括：踝关节后内侧伤口浅表感染2例，跗管综合征2例，腓肠神经刺激症状2例。未见其他并发症发生。结论根据后pilon骨折术前CT结果中Die—punch骨块的位置和大小进行分型，并指导后pilon骨折手术切口的选择与骨折块的处理，有较好的临床可行性和良好的临床效果。

Objective To propose a CT classification of die-punch fragments in posterior pilon fracture and to explore its significance in helping the surgery. Methods ACT scan classification of die-punch fragments in posterior pilon fracture into 5 types was proposed according to their size and location. A retrospective study was conducted of the 48 posterior pilon fractures which had been treated at Department of Orthopaedics, Huashan Hospital from January 2013 to December 2015. They involved 16 men and 32 women, aged from 20 to 87 years （average, 46.5 years） . According to the preoperative CT scan classification of die-punch fragments, 16 cases （33.3%） belonged to type Ⅰ, 2 （4. 2% ） to type Ⅱ, 18 （37.5%） to type Ⅲ, 10 （20.8%） to type Ⅳand 2 （4.2%） to type Ⅴ. Choice of operative approach, reduction and internal fixation and removal of the fragments were guided by the CT classification of die-punch fragments. Their postoperative ankle functions were evaluated with American Orthopaedic Foot and Ankle Society （AOFAS） and visual analog scale （VAS） scoring systems. Results All the 48 cases were followed up for 11 to 21 months （average, 13.7 months）. Their AOFAS scores for ankle-hindfoot at the final follow-up ranged from 77 to 92 points, averaging 84. 3 points; their VAS scores ranged from 0 to 1 point, averaging 0.2 point. There were no significant differences in their postoperative AOFAS scores for ankle-hindfoot or in their postoperative VAS scores between the types of die-punch fragments （ P 〉 0.05） . No complications were recorded except superficial infection at the posteromedial wound of the ankle in 2 cases, tarsal tunnel syndrome in 2 cases, and sural nerve irritation in 2 cases. Conclusion It is feasible and effective to classify the die-punch fragments in posterior pilon fracture according to their size and location on the CT scan, because the classification can help choose an appropriate operative approach and manage the die-punch fragment, leading to fine clinical outcomes.