后踝骨折手术入路选择探讨

Selection of surgical approach for posterior malleolar fracture

目的探讨后踝骨折临床特点以及如何进行手术入路选择。方法对2013年1月—2015年9月在我院接受手术治疗的后踝骨折病例资料进行回顾性分析,共83例。根据踝关节三维CT进行Haraguchi分型,其中HaraguchiⅠ型54例、HaraguchiⅡ型16例、HaraguchiⅢ型13例。根据不同骨折分型选择相应手术入路进行切开复位内固定术。HaraguchiⅠ型、HaraguchiⅢ型采用后外侧入路;HaraguchiⅡ型后踝骨折根据是否合并内踝骨折分别采用后内侧入路和跟腱旁后内侧入路。术后2周、4周、12周、6个月、12个月拍摄踝关节正侧位像。通过X线及临床检查判断骨折愈合时间,记录并发症及相应转归。末次随访时根据美国矫形足踝协会(AOFAS)踝与后足评分标准和SF-36分别评价术后踝关节功能和术后患者生活质量。结果 83位患者获得6~24个月随访,平均(15.4±6.2)个月,骨折全部愈合,X线愈合时间12~24周,平均(18.6±4.2)周。AOFAS踝与后足评分为71~100分,平均(88.4±8.4)分;获优67例、良14例、中2例,优良率为97.59%。SF-36生理评分31.6~69.2分,平均(48.4±4.8)分,SF-36心理评分28.6~64.5分,平均(45.8±3.5)分。术后踝关节慢性疼痛1例,诊断为创伤性关节炎,经口服非甾体类药物治疗,踝关节疼痛可缓解。术后发生浅表软组织感染1例,经伤口换药后延迟愈合。所有病例未发生钢板螺钉松动、断裂等内固定失败并发症。结论根据后踝骨折Haraguchi分型及骨折解剖特点有针对性地选择后外、后内、跟腱旁后内侧入路进行切开复位内固定手术,可获得满意手术效果。

Objective To investigate the clinical characteristics of posterior malleolar ankle fracture,and the selectionof the surgical approach.Methods From January2013to September2015,83cases of posterior malleolar fractures wereretrospectively analyzed.Haraguchi typing was performed based on the three-dimensional CT.There were54cases withHaraguchiⅠtype,16cases with HaraguchiⅡtype,and13cases with HaraguchiⅢtype.The patients who were HaraguchiⅠand HaraguchiⅢtypes accepted the operation with posterolateral approach.The patients who were HaraguchiⅡtype andcombined medial malleolus fracture accepted the operation with medial approach.The HaraguchiⅡpatients who were notcombined medial malleolus fracture were used the medial paraachilles approach.Images of the ankle joint were filmed2weeks,4weeks,12weeks,6months and12months after the surgery.The healing time,complications and correspondingrecord outcome were determined by X-ray and clinical examination.At the last follow-up,ankle function and quality of lifeof patients were evaluated according to the American Orthopaedic Foot and Ankle Society(AOFAS)ankle and hindfoot scoreand SF-36.Results Eighty-three patients were follow-up for6-24(mean15.4±6.2)months.The fractures healed on Xray.The average X-ray healing time was from12to24(mean18.6±4.2)weeks.AOFAS score was71to100(mean88.4±8.4)points.Sixty-seven cases were excellent,14cases were good,2cases were moderate,and good rate was97.59%.SF-36physiological score was31.6-69.2points(mean48.4±4.8points);SF-36psychological score28.6-64.5points(mean45.8±3.5points).Chronic ankle pain was complained by one patient.He was diagnosed traumatic arthritis,oral non-steroidaldrugs was used to relief his ankle pain.One patient wound infected,and healed after treatment.No instrument failure and fracture displacement were found.Conclusion According to fracture morphology and clinical features after posteriormalleolar ankle fracture,different surgical approaches are selected,which will be satisfied with the outcome.