Lauge-Hansen旋后-内收型Ⅱ度踝关节骨折的CT影像解剖学特点及手术治疗

Imaging anatomy characters and surgery treatment of gradeⅡsupination-adduction ankle joint fractures

目的总结Lauge-Hansen旋后-内收型Ⅱ度踝关节骨折的CT影像解剖学特点,为临床手术治疗方法的选择提供参考。方法回顾性分析中国科技大学附属第一医院(安徽省立医院)骨科2014年6月—2017年12月收治的36例Lauge-Hansen旋后-内收型Ⅱ度踝关节骨折患者的临床资料,其中男24例、女12例,年龄19~56岁;左踝21例,右踝15例。所有患者行切开复位支撑钢板内固定术,8例合并骨缺损者予一期植骨。应用人体三维可视化手术规划与仿真系统软件(V1.0.0)对患者术前骨折CT影像学资料进行处理,测量以下指标:内踝骨折面与胫骨纵轴的夹角(α)、胫骨远端关节面塌陷的最大深度(d)、塌陷面积(S)、塌陷体积(V)和腓骨骨折线与胫骨远端关节面穹隆顶点的距离(L),分析d、V与α的相关性,总结Lauge-Hansen旋后-内收型踝关节骨折的影像解剖学特征。采用美国骨科足踝协会(AOFAS)踝关节-后足评分标准和术后疼痛视觉模拟评分(VAS)评价治疗效果。结果术前CT影像测量结果显示,本组36例患者α为4.5°~15.5°(9.85°±4.05°),其中20例胫骨远端关节面塌陷患者α为5.04°±1.49°,明显小于16例未塌陷患者α(12.83°±2.87°),两组差异有统计学意义(t=-9.847, P<0.05);20例胫骨远端关节面塌陷患者d、S、V分别为(8.86±3.69)mm,(47.69±13.95)mm^2和(680±620)mm^3,关节面塌陷集中在前内侧,且d、V与α角无明显相关性(rs=0.309、0.389, P值均>0.05)。36例患者腓骨骨折线主要发生在胫骨穹隆最高点以上,L为1.27~12.55(5.50±5.54)mm。所有术后随访时间10(6~15)个月,骨折均解剖复位并完全愈合,愈合时间10.5(9~16)周,术后AOFAS评分和VAS分别为(85±8)分和(2.1±0.9)分。结论Lauge-Hansen旋后-内收型Ⅱ度踝关节骨折患者的内踝骨折线与胫骨的夹角较小,骨折线与胫骨纵轴越接近平行,提示合并胫骨远端内侧关节面塌陷的可能性越大;该型骨折剪切力较大,手术治疗以切开复位支撑钢板内固定为主,缺损较大处常规行一期植骨以恢复关节面高度和力学支撑功能;腓骨骨折块较大或合并关节面塌陷时,建议采用钢板牢固固定,对维持踝关节稳定性起重要作用,可获得较好的手术治疗效果。

Objective To define the imaging characters and effective surgery treatment of stageⅡsupination-adduction type ankle fractures. Methods From June 2014 to December 2017 in the First Affiliated Hospital of University of Science and Technology of China(Anhui Provincial Hospital), 36 patients (24 males and 12 females) with stageⅡsupination-adduction type ankle fractures (21 left ankles and 15 right ankles) ranged from 19 to 56 years old. All patients accepted the treatment of open reduction and internal fixation with buttres plate, and eight patients who also suffered bone defect were treated with bone transplantation. Before operation, all imaging data, including X-ray and computerized tomography(CT) examination, were analyzed the angle (α) between fracture surface and tibia longitudinal axis, the distance (d) from fracture zone to arched roof of tibia distal end joint surface, and area (S) and volume (V) of collapse joint surface, and the relationship between them with three dimension (3D) visualization operation and simulation software system (V1.0.0). The distance (L) between fracture line of fibula and arched roof of tibia distal end joint surface was also measured. The correlation analysis between d, V and α were performed. And then all data were used to analyzed the imaging characters of stageⅡsupination-adduction type ankle fractures. After operations, the results were evaluated with AOFAS and VAS. Results From the pre-operation results of CT imaging of 36 patients,α angle was 4.5°-15.5°(9.85°±4.05°). And α angle of 20 other patients with collapse of tibia distal end joint surface was 9.85°±4.05°, which was significant smaller than that of the other 16 patients without collapse (12.83°±2.87°)(t=-9.847, P<0.05). The d, S and V of 20 patients with collapse of tibia distal end joint surface were (8.86±3.69) mm,(47.69±13.95) mm^2, and (680±620) mm^3 respectively, and the collapse position concentrated on anteromedial ankle joint.Neither d nor V had significant correction to α(rs=0.309, 0.389, all P valus>0.05), the fracture line of fibula mainly lied in the top point of tibia dome, and the L was 1.27-12.22(5.50±5.54) mm. All patients achieved anatomic reduction and were followed up 10(6-15) months without infection or bone absorption or transposition. Healing time were 10.5 (9-16) weeks. AOFAS and VAS improved to(85±8)and(2.1±0.9). Conclusions The fracture line of stageⅡsupination-adduction type ankle fractures is close to vertical line. Open reduction and internal fixation with buttress plate for tibia fracture fragment is commendable option because of great shear force, larger defect should restore joint surface height by bone grafting, and plate is a good choice to treat fibular fractures.