螺钉内固定与保守治疗后踝骨折:踝关节功能和足底压力的差异

Screw internal fixation and conservative treatment of posterior ankle fractures:differences in ankle joint function and plantar pressure

背景:对于后踝骨折累及关节面面积小于25%时,采用积极内固定治疗还是保守治疗,一直存在争议。目的:评价后踝骨折累及胫骨远端关节面面积10%-25%时采用螺钉固定与保守治疗对于踝关节功能和足底压力的影响。方法:纳入2017年3月至2020年5月广州医科大学附属第五医院收治的三踝骨折患者,CT测量后踝骨折累及胫骨远端关节面面积10%-25%,随机分组,其中后踝螺钉内固定组62例使用螺钉固定后踝骨折,后踝非内固定组53例后踝处骨块于C型臂X射线机透视辅助下行手法复位。采用X射线平片评估后踝骨折愈合情况,临床采用目测类比评分、美国矫形外科足踝协会踝-后足评分及足底压力评估结果。结果与结论:①术后3个月两组患者的目测类比评分相比差异无显著性意义(P>0.05);术后6,12个月,后踝螺钉内固定组的目测类比评分低于后踝非内固定组(P<0.05);术后3,6,12个月,两组患者的目测类比评分均呈降低趋势,组内对比差异有显著性意义(P<0.05);②术后3个月两组患者的美国矫形外科足踝协会踝-后足评分相比差异无显著性意义(P>0.05);术后6,12个月,后踝螺钉内固定组的美国矫形外科足踝协会踝-后足评分高于后踝非内固定组(P<0.05);术后3,6,12个月,两组患者美国矫形外科足踝协会踝-后足评分均呈升高趋势,组内对比差异有显著性意义(P<0.05);③术后3个月,两组患者患侧足足底压力(全足、后足、中足、前足)显著低于健侧足(P<0.05);术后6个月时,后踝螺钉内固定组患者患侧足的全足、前足的足底压力低于健侧足(P<0.05),后足、中足的足底压力与健侧相比差异无显著性意义(P>0.05);后踝非内固定组患者患侧足足底压力(全足、后足、中足、前足)显著低于健侧足(P<0.05);术后12个月,两组患者患侧足足底压力(全足、后足、中足、前足)与健侧足相比差异无显著性意义(P>0.05);④提示在累及胫骨远端关节面10%-25%的后踝骨折中,螺钉内固定对骨折愈合和维持踝关节对位有较好的效果,并可改善早期临床结果;建议对于累及胫骨远端关节面10%-25%的后踝骨折可以积极进行螺钉内固定治疗。

BACKGROUND:When the posterior malleolus fracture involves less than 25%of the articular surface area,whether it should be actively treated with internal fixation or conservative treatment has been controversial.OBJECTIVE:To evaluate the impact of screw fixation and conservative treatment on the ankle joint function and plantar pressure of posterior malleolus fractures involving 10%-25%of the articular surface area of the distal tibia.METHODS:From March 2017 to May 2020,patients with three ankle fractures treated in The Fifth Affiliated Hospital of Guangzhou Medical University received computed tomography to measure the area of the posterior malleolus fracture involving 10%-25%of the distal tibia articular surface area.The patients were randomized into two groups.The 62 cases in the internal fixation group were treated with screws and 53 cases in the non-internal fixation group were treated with C-arm X-ray machine fluoroscopy assisted downward manual reduction.Plain radiographs were used to evaluate the healing of posterior ankle fractures,and the visual analogue scale score,the American Orthopaedic Association ankle-hindfoot scale score and plantar pressure evaluation results were used clinically.RESULTS AND CONCLUSION:(1)There was no significant difference in the visual analogue scale scores of the two groups at 3 months after surgery(P>0.05).The visual analogue scale scores of the internal fixation group were significantly lower than those in the non-internal fixation group at 6 and 12 months after the operation(P<0.05).The visual analogue scale scores of the two groups were significantly reduced at 3,6 and 12 months after surgery(P<0.05).(2)There was no significant difference in the American Orthopaedic Association ankle-hindfoot function score between the two groups at 3 months after operation(P>0.05).American Orthopaedic Association ankle-hindfoot function score of the internal fixation group was better than those in the non-internal fixation group at 6 and 12 months after the operation(P<0.05).The American Orthopaedic Association ankle-hindfoot function scores were significantly improved in the two groups at 3,6 and 12 months after surgery(P<0.05).(3)Three months after the operation,the plantar pressure of the affected side of the two groups(full foot,hind foot,midfoot,and forefoot)was significantly lower than that in the contralateral foot(P<0.05).At 6 months postoperatively,the plantar pressure of the whole foot and forefoot of the affected foot in the internal fixation group was lower than that of the contralateral foot(P<0.05).There was no significant difference in the plantar pressure of the affected side(hind foot and midfoot)and the contralateral foot(P>0.05).The plantar pressure of the affected side of the non-internal fixation group(full foot,hind foot,midfoot,and forefoot)was significantly lower than that of the uninvolved foot(P<0.05).At 12 months after operation,there was no significant difference between the plantar pressure of the affected side(full foot,hind foot,midfoot,and forefoot)and the plantar pressure of the unaffected side between the two groups(P>0.05).(4)It is indicated that in posterior malleolus fractures involving 10%-25%of the distal articular surface of the tibia,screw internal fixation has a better effect on fracture healing and maintenance of ankle alignment,and improves early clinical results.It is recommended that posterior malleolus fractures involving 10%-25%of the distal tibial articular surface can be actively treated with screw internal fixation.