小切口联合全修复策略治疗Lauge-Hansen旋前-外旋型Ⅳ度踝关节闭合骨折

Clinical analysis of full-repair strategy under small incision for closed Lauge-Hansen pronation-external rotation typeⅣankle fracture

目的探讨小切口联合全修复策略治疗Lauge-Hansen旋前-外旋型Ⅳ度踝关节闭合骨折的安全性、可行性及临床疗效。方法回顾分析2012年1月-2017年1月采用小切口联合骨折、韧带及骨软骨全修复策略治疗的57例Lauge-Hansen旋前-外旋型Ⅳ度踝关节闭合骨折患者临床资料。男31例,女26例;年龄21~65岁,平均41.1岁。致伤原因:交通事故伤33例,摔伤24例。其中内踝骨折20例,内踝完整但三角韧带深浅层断裂37例。受伤至入院时间3~34 h,平均9.6 h。术后评估胫骨远端关节面复位质量(采用Ketz-Sanders标准)、下胫腓联合复位情况(踝关节线上10 mm CT断层测量下胫腓联合前、后间距和外踝扭转角)及骨折愈合情况。于踝穴位X线片上测量内踝间隙(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)。手术前后采用疼痛视觉模拟评分(VAS)及美国矫形足踝协会(AOFAS)评分评价踝关节疼痛及功能改善情况,并测量踝关节背伸、跖屈活动度。结果术中发现3例距骨骨软骨损伤,均采用微骨折技术处理。术后麻醉清醒后有2例发生止血带麻痹;患者手术切口均Ⅰ期愈合。57例患者均获随访,随访时间24~84个月,平均38.6个月。术后12个月骨折均达骨性愈合,无骨不愈合及畸形愈合发生。术后3个月胫骨远端关节面复位质量达优56例、良1例,优良率为100%。术后12个月患侧与健侧比较踝关节MCS、TFCS、DFTL、下胫腓联合前间距、下胫腓联合后间距及外踝扭转角,差异均无统计学意义(P>0.05)。末次随访时,患侧VAS评分、AOFAS评分、踝关节背伸和跖屈活动度均较术前显著改善(P<0.05)。同时,与健侧比较,踝关节背伸和跖屈活动度差异均无统计学意义(P>0.05)。结论小切口联合全修复策略治疗Lauge-Hansen旋前-外旋型Ⅳ度踝关节闭合骨折是有效且安全的,不仅能降低切口并发症发生风险,还能提高踝关节及下胫腓联合复位质量,骨折、韧带及骨软骨的全修复能提高踝关节的内固定强度和关节稳定性。

Objective To investigate the safety,feasibility,and efficacy of full repair strategy under small incision in the treatment of closed Lauge-Hansen pronation-external rotation typeⅣankle fracture.Methods The clinical data of 57 patients with closed Lauge-Hansen pronation-external rotation typeⅣankle fracture treated by full repair strategy(fracture,ligament,and cartilage repair)under small incision between January 2012 and January 2017 were retrospectively analyzed.There were 31 males and 26 females,with an average age of 41.1 years(range,21-65 years).The causes of injury included traffic accident injury in 33 cases and falling injury in 24 cases.All of them were closed fractures,including 20 cases of medial malleolus fracture,37 cases of complete medial malleolus but deep and shallow rupture of deltoid ligament.The average time from injury to admission was 9.6 hours(range,3-34 hours).The quality of reduction of distal tibial articular surface(based on Ketz-Sanders standard),the reduction of tibiofibular syndesmosis(the anterior and posterior distances of distal tibiofibular syndesmosis and the lateral ankle twist angle measured by CT scan at 10 mm above the ankle joint line),and the fracture healing were evaluated.The medial clear space(MCS),tibiofibular clear space(TFCS),and distal fibular tip to lateral process of talus(DFTL)were measured on the X-ray films of ankle points.Before and after operation,the pain and functional improvement of ankle joint were evaluated by visual analogue scale(VAS)score and American Orthopedic Foot and Ankle Association(AOFAS)score,and the activities of ankle dorsiflexion and plantar flexion were measured.Results Three cases with osteochondral lesions of the talus were found during operation and all were treated with microfracture techniques.Tournament paralysis occurred in 2 cases after anesthesia.The surgical incisions healed by first intention in all patients.All the 57 patients were followed up 24-84 months,with an average of 38.6 months.All patients achieved bone healing without bone nonunion and malunion at 12 months after operation.The reduction quality of distal tibial articular surface was excellent in 56 cases and good in 1 case at 3 months after operation,the excellent and good rate was 100%.There was no significant difference in the MCS,TFCS,DFTL,anterior distance of distal tibiofibular syndesmosis,posterior distance of distal tibiofibular syndesmosis,and lateral ankle twist angle between the affected and healthy sides at 12 months after operation(P>0.05).At last follow-up,the VAS score,AOFAS score,ankle dorsiflexion and plantar flexion activities of the affected side were significantly improved when compared with preoperative ones(P<0.05).Compared with the healthy side,there was no significant difference in ankle dorsiflexion and plantar flexion activities(P>0.05).Conclusion Full-repair strategy under small incisions for the treatment of Lauge-Hansen pronation-external rotation typeⅣankle fracture is effective and safe.It can not only reduce wound complications,but also improve the quality of joint reduction of the ankle joint and distal tibiofibular syndesmosis.Full repair of ligaments and cartilage can improve the internal fixation strength and joint stability of the ankle joint.