三柱理论对中足复杂骨折脱位手术治疗的指导意义

Guiding signi?cance of three column theory for surgical treatment of complex fracture and dislocation of midfoot

目的探讨三柱理论对中足复杂骨折脱位临床诊疗的指导作用。方法 2013年1月-2017年9月成都市第一人民医院骨科共收治24例中足复杂损伤患者,女8例,男16例;年龄18～57岁,平均41岁;按解剖三柱分类:内侧柱6例,内侧柱合并中间柱6例,累及三柱12例。采用跨关节长钢板坚强固定内侧柱及中间柱,克氏针弹性固定外侧柱,术中根据固定需要配合使用螺钉。骨折后伴有内侧柱足舟骨或外侧柱骰骨短缩者,需要撑开复位,跨关节钢板固定,必要时植骨,重建各柱的长度,维系足弓正常结构与功能。术后通过影像学及临床检查随访,采用X线片评估中足对位对线及骨折愈合情况。依据Mariland足部评分量表评估疗效,采用VAS疼痛评分量表评估损伤部位疼痛程度。结果治疗后随访12个月。24例中1例内侧柱因足舟骨粉碎骨折长度未充分恢复,术后出现跛行,内固定取出后步态恢复正常;其他23例均取得满意疗效,足弓正常负重,行走功能正常,未见钢板螺钉失效、感染等情况发生。末次随访患者足部X线复查示中足骨折均骨性愈合,中足结构正常、稳定,对位对线正常;Mariland足部评分平均94(70～98)分:优19例,良2例,可3例;平均VAS评分为1.2(0～2)分。结论在三柱损伤理论的指导下及时手术治疗中足复杂骨折,术中精准解剖复位,根据不同的固定强度选择不同的方式固定内侧柱、中间柱及外侧柱,恢复足弓正常解剖结构及功能,术后早期功能锻炼,可获得满意的临床效果。

Objective To explore the guiding role of three column theory in the diagnosis and treatment of complex fracture and dislocation of middle foot. Methods From January 2013 to September 2017, 24 cases with complicated foot injuries in Chengdu First People’s Hospital were treated, including 8 females and 16 males, aged 18-57 years with an average of 41 years. According to the functional anatomy of three columns theory, 6 cases were injured in medial column, 6 cases in intermediate column combined with medial column, and 12 cases in three columns. Inter-articular long plate was used to rigidly ?x the medial column and the intermediate column, and Kirschner wire was used to ?x the lateral column elastically. According to the need of ?xation, screws were used during the operation. If the fracture was accompanied by shortening of scaphoid or cuboid bone of medial column foot or lateral column, open and reposition was needed, then cross-articular plate was ?xed. Bone graft would be implanted if necessary,so as to reconstruct the length of each column and maintain the normal structure and function of the arch of the foot. Postoperative imaging and clinical follow-up were performed to evaluate the alignment of midfoot and fracture healing, and the curative effect was evaluated by Mariland Foot Score Scale. The VAS pain scale was used to assess the pain level at the site of injury. Results After12-month follow-up, one patient had limp because of poor recovery of scaphoid comminuted fracture in the medial column, and the gait was restored to normal after removal of internal fixation. The other 23 patients achieved satisfactory results. The foot arch was normal in weight bearing, with normal walking function. No plate screw failure, infection and other complications occurred. The?nal follow-up showed that all fractures of the midfoot healed with normal and stable structure and normal alignment. The average Mariland’s foot score was 94(70-98) in 19 cases achieved excellent, 2 cases were good, and 3 cases were fair. The average VAS score was 1.2(0-2). Conclusion Under the guidance of three-column theory, timely operation, accurate anatomical reduction during operation, different ways to fix the medial column, intermediate column and lateral column according to different fixed strength,restore the normal anatomical structure and function of the arch and early functional exercise after operation, are all helpful to obtain satisfactory clinical outcomes for complex fracture and dislocation of midfoot.