Maisonneuve骨折的临床特点及疗效分析

The clinical characteristics and outcomes of Maisonneuve fractures

目的探讨Maisonneuve骨折的临床特点及手术治疗效果。方法回顾性分析2015年2月至2017年12月治疗21例Maisonneuve骨折患者资料,男16例,女5例;年龄21~61岁,平均38.8岁;左侧11例,右侧10例;车祸伤4例,扭伤9例,摔伤8例。21例患者中,内踝骨折16例,三角韧带完全断裂4例,部分断裂1例;后踝骨折17例,根据Bartonícek分型,Ⅰ型5例,Ⅱ型8例,Ⅲ型4例,无后踝骨折者4例,其中下胫腓后韧带完全断裂者1例;初次诊断时4例腓骨近端骨折被漏诊。受伤至手术时间2~12 d,平均4.9 d。结果21例患者中腓骨钢板固定3例。内踝骨折16例,其中空芯钉固定13例,抗滑钢板固定3例。三角韧带完全断裂者4例,均行锚钉缝合修复;三角韧带部分断裂者1例,未予处理。后踝骨折17例,其中手术治疗12例,包括空芯钉固定9例、抗滑钢板固定3例。下胫腓联合损伤21例,其中钢板固定1例;内踝及后踝固定结合下胫腓前韧带锚钉缝合后,下胫腓稳定未应用螺钉者1例;其余19例应用下胫腓螺钉固定(2枚螺钉固定11例,1枚螺钉固定8例)。21例患者均获得随访,随访时间13~48个月,平均25.6个月。腓骨及踝部骨折均愈合,愈合时间3~6个月,平均4.9个月。踝关节均获得解剖复位,活动范围与健侧相比无明显减少,无一例发生切口感染、骨折复位丢失、下胫腓螺钉断裂及创伤性关节炎等并发症。13例在术后13~25周(平均15.38周)取出下胫腓螺钉。末次随访时,美国足踝外科协会(American orthopaedic foot and ankle society,AOFAS)踝与后足功能评分为84~100分,其中优13例、良8例,优良率为100%(21/21);Baird?Jackson功能评分为83~100分,其中优11例、良8例、可2例,优良率为90.48%(19/21)。结论Maisonneuve骨折中腓骨近端损伤易被漏诊,对于完全断裂的三角韧带和明显移位的后踝骨折,建议行切开复位内固定治疗,术中注意恢复腓骨长度,解剖复位并固定下胫腓联合,术后疗效满意。

Objective To investigate the clinical characteristics and outcomes of Maisonneuve fractures.Methodse Data of 21 cases of Maisonneuve fractures from February 2015 to December 2017 were retrospectively analyzed.There were 16 males and 5 females with an average age of 38.8 years(range,21 to 61 years).The fractures occurred on the left side in 11 patients and on the right side in 10 patients.The causes of injuries were traffic accident in 4 patients,sprain injury in 9 patients and falling injury from height in 8 patients.There were 16 cases of medial malleolar fractures and 5 cases of ruptures of deltoid ligament(4 entirely and 1 partial).There were 17 cases of fractures of the posterior malleolus,among which there were 5 of typeⅠ,8 of typeⅡand 4 of typeⅢaccording to the Bartonícek classification of posterior malleolus.There were 4 cases without fracture of posterior malleolus including 1 complete disruption of posterior inferior tibiofibular ligament.Four cases were overlooked of Maisonneuve fracture at the first time.The interval between injury and operation was 2-12 days(mean,4.9 days).Results Stabilization of proximal fibular fractures were achieved with plate in 3 cases.There were 16 cases of medial malleolar fractures,and the fixation were achieved with cannulated screws in 13 cases and with anti-glide plates in 3 cases.The entirely rupture of deltoid ligament was repaired in 4 cases with suture anchors,the partial rupture of deltoid ligament was not repaired.There were 17 cases of posterior malleolar fractures,12 cases treated with open reduction and internal fixation including cannulated screws in 9 cases and anti-glide plates in 3 cases.Stabilization of syndesmosis was achieved with syndesmotic plate in 1 case;the medial and posterior malleolar fractures were stabilized and anterior inferior tibiofibular ligament was repaired with suture anchor in 1 case;the other 19 cases were stabilized with syndesmotic screws,2 screws in 11 cases and 1 screw in 8.Twenty-one patients were followed up for 13-48 months with an average of 25.6 months.The time of bony union was from 3 to 6 months with an average time of 4.9 months after operation.All patients received anatomical reduction without postoperative complications such as incision infection,reduction lose,breakage of screw and posttraumatic arthritis.In 13 cases,the syndesmotic screw was removed at the mean time of 15.38 weeks postoperative(range,13-25 weeks).At the latest follow up,AOFAS score was from 84 to 100,with excellent in 13 cases,good in 8 cases,and the excellent and good rate was 100%(21/21).Baird-Jackson score was from 83 to 100,with excellent in 11 cases,good in 8 and fair in 2,and the excellent and good rate was 90.48%(19/21).Conclusion The diagnosis of proximal fibular fracture of Maisonneuve fracture is easily missed.The complete rupture of deep deltoid ligament and displaced obviously of posterior malleolar fracture should be reduction and stabilization.The accuracy of reduction of the syndesmosis is of great concern.The outcome of operation is satisfied.