腓骨截骨下胫腓联合融合治疗外翻型陈旧性Pilon骨折畸形愈合

Fibular osteotomy and distal tibiofibular joint fusion for treatment of chronic valgus Pilon fracture malunion

目的:探讨采用腓骨截骨下胫腓联合融合治疗外翻型陈旧性Pilon骨折畸形愈合的临床疗效。方法 :自2014年1月至2017年1月收治8例陈旧性Pilon骨折畸形愈合患者,其中男7例,女1例;年龄20~47岁;左侧2例,右侧6例;骨折根据Rüedi-Allg?wer分型,Ⅰ型1例,Ⅱ型3例,Ⅲ型4例;受伤至入院时间7~21个月。术前常规行负重下X线及三维重建CT检查对畸形进行评估,并通过3D打印模型设计实施模拟手术。其中5例存在距骨相对胫骨向后上方半脱位,5例受伤时合并腓骨骨折(2例腓骨骨折畸形愈合)。所有患者采用腓骨截骨下胫腓联合融合方式恢复关节面平整,纠正下肢力线。记录患者术后并发症、骨愈合时间及复位情况,术后1年采用美国足踝外科协会(American Orthopedic Foot and Ankle Society,AOFAS)踝与后足功能评分进行临床疗效评价。结果:8例患者均获随访,时间12~30个月。术后切口均Ⅰ期愈合,无感染、血管神经损伤、内固定失效、复位丢失等发生。骨折愈合时间13~19周,且力线恢复良好。术后1年AOFAS评分63~90分;其中优1例,良4例,可3例。7例患者术后6~14个月重返原工作岗位。结论:对于外翻型陈旧性Pilon骨折畸形愈合,采用腓骨截骨、下胫腓联合融合手术可以有效恢复关节面平整,纠正下肢力线,改善踝关节功能,并发症少,短期疗效满意。

Objective:To explore clinical effects of fibular osteotomy and distal tibiofibular joint fusion for chronic valgus Pilon fracture malunion.Methods:From January 2014 to January 2017,8 patients with chronic valgus Pilon fracture malunion were treated,including 7 males and 1 female,aged from 20 to 47 years old,6 patients on the left side and 2 patients on the right side;according to Ruedi-Allgower classification,1 case was type Ⅰ,3 cases were type Ⅱ and 4 cases were type Ⅲ;the time from injury to admission ranged from 7 to 21 months.All deformities were evaluated individually based on pre-operatively weight-bearing X-ray and 3 D CT scan,and 3 D printing model was also used for preliminary surgery.Weight-bearing X-ray showed posterior subluxation of ankle joint in 5 cases.There were 5 cases of fibular fracture at primary injury,and 2 cases of fibular fracture malunion.Fibular osteotomy and distal tibiofibular syndesmosis fusion strategy was performed to reduce articular surface congruency and correct lower limb alignment.Postoperative complication,fracture healing time and reduction were regularly recorded.Clinical function was evaluated according to American Orthopedic Foot and Ankle Society(AOFAS) at 1 year after operation.Results:All patients were followed up from 12 to 30 months.All incisions were primarily healed.No infection,neurovascular injuries or implant failure,lost of reduction occurred.Fracture healing time ranged from 13 to 19 weeks with good lower limb alignment.AOFAS score at 1 year after operation was 63 to 90 points,1 patient got excellent result,4 good and 3 fair.Seven patients returned to work at 6 to 14 months after opertaion.Conclusion:For chronic valgus Pilon fractures malunion,fibular osteotomy and distal tibiofibular syndesmosis fusion could effectively restore congruency and alignment,correct lower limb alignment,improve ankle joint function,reduce occurrence of complication,and receive short term clinical effects.