解剖路径骨-韧带修复技术在旋前型踝关节骨折中的临床应用研究

Application of anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures

目的探讨采用解剖路径骨-韧带修复技术治疗旋前型踝关节骨折的安全性和疗效。方法回顾分析2015年4月—2016年10月收治并符合选择标准的53例旋前型踝关节骨折患者临床资料,均采用解剖路径骨-韧带修复技术行切开复位内固定。男35例,女18例;年龄18~60岁,平均33.1岁。致伤原因:交通事故伤27例,摔伤5例,高处坠落伤4例,扭伤6例,运动伤4例,砸伤7例。Lauge-Hansen分型:旋前外旋型Ⅳ度44例,旋前外展型Ⅲ度9例。受伤至手术时间为4~10 d,平均7 d。术后参照美国矫形足踝协会(AOFAS)踝-后足评分评价踝关节功能,疼痛视觉模拟评分(VAS)评价踝关节疼痛程度。摄双侧踝关节X线片和CT,测量内踝间隙(medial clear space,MCS)、下胫腓联合间隙(tibiofibular clear space,TFCS)、外踝尖至距骨外侧突距离(distal fibular tip to lateral process of talus,DFTL)以及下胫腓联合前间距、后间距和外踝扭转角,并进行比较。结果术中止血带应用时间为55~90 min,平均72.5 min;透视次数5~13次,平均8.9次。术后切口均Ⅰ期愈合,无感染、下肢深静脉血栓形成等并发症发生。53例患者均获随访,随访时间28~48个月,平均36个月。术后健、患侧MCS、TFCS、DFTL、下胫腓联合前间距及后间距、外踝扭转角比较,差异均无统计学意义(P>0.05)。末次随访时,无踝关节失稳发生,5例踝关节出现退变(Kellgren-LawrenceⅡ级)。AOFAS评分为85~95分,平均90.84分。踝关节活动度背伸15~25°,平均20.24°;跖屈30~50°,平均42.56°。疼痛VAS评分0~5分,平均1.23分。结论解剖路径骨-韧带修复技术治疗旋前型踝关节骨折能充分显露胫距关节和下胫腓联合、修复踝关节周围骨-韧带损伤,有助于下胫腓联合和胫距关节解剖复位,降低术后踝关节退变发生率。

Objective To investigate the safety and effectiveness of anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures.Methods The clinical data of 53 patients with pronation ankle fractures between April 2015 and October 2016,who were treated with anatomical approach osteoligaments repair technique applied for fracture reduction and internal fixation,were analysed retrospectively.There were 35 males and 18 females with an average age of 33.1 years(range,18-60 years).The cause of injury included traffic accidents in 27 cases,tumbling in 5 cases,fall from height in 4 cases,twisted injury in 6 cases,sports injuries in 4 cases,and bruises in 7 cases.According to Lauge-Hansen classification,there were 44 cases of pronation external rotation stageⅣand 9 cases of pronation abduction stageⅢ.The interval between injury and operation was 4-10 days(mean,7 days).Postoperative pain and function of ankles were assessed by American Orthopedic Foot and Ankle Score(AOFAS)and visual analogue pain scale(VAS)score.The medial clear space(MCS),tibiofibular clear space(TFCS),distal fibular tip to lateral process of talus(DFTL),the anterior and posterior tibiofibular syndesmosis distance,and the lateral malleolus twist angle were measured by X-ray films and CT of bilateral ankle joints.Results The tourniquet application time was 55-90 minutes(mean,72.5 minutes);the frequency of fluoroscopy was 5-13 times(mean,8.9 times).All incisions healed by first intention and no infection,deep vein thrombosis occurred after operation.All patients were followed up 28-48 months(mean,36 months).There was no significant difference in postoperative MCS,TFCS,DFTL,the anterior and posterior tibiofibular syndesmosis distance,and the lateral malleolus twist angle between bilateral ankle joints(P>0.05).At last follow-up,no ankle instability occurred and the degenerative changes of ankle joints(Kellgren-Lawrence gradingⅡ)occurred in 5 cases.The average AOFAS score of the ankle joint was 90.84(range,85-95);mean VAS score was 1.23(range,0-5).The average dorsiflexion and plantar flexion of ankle joints was 20.24°(range,15-25°)and 42.56°(range,30-50°),respectively.Conclusion Anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures can expose the talocrural joint and lower tibiofibular syndesmosis clearly,repair the osteoligaments injury directly,and assist the syndesmosis and talocrural joint reduction,and decline the incidence of ankle degeneration.