采用直接修复三角韧带和后踝固定治疗下胫腓联合分离的开放踝关节骨折脱位

Combination of deltoid ligament augment and posterior malleolus fixation for open ankle fracture and dislocation with inferior syndesmosis diastasis

目的 探讨采用对损伤结构进行直接加强和修复代替下胫腓螺钉固定治疗三角韧带断裂、后踝骨折伴下胫腓联合分离的开放踝关节骨折脱位的临床效果。方法 对2018年1月至2019年6月北京积水潭医院创伤骨科急诊行三角韧带缝合锚加强与后踝空心螺钉固定治疗的三角韧带损伤、后踝骨折伴下胫腓联合分离的开放踝关节骨折患者6例的临床资料进行回顾性分析。其中男4例,女2例;年龄(44.8±10.8)(25~57)岁;Gustillo开放骨折分型为Ⅰ型3例,Ⅱ型3例;踝关节骨折Laugh-Hansen分型为旋前外旋3例,旋前外展1例,另2例为经下胫腓联合骨折脱位的特殊形态骨折;踝关节骨折Weber分型为C型6例。受伤至就诊时间为(3.7±1.5)(2~6)h。采用术后影像学表现、疼痛视觉模拟评分(VAS)、美国足踝外科学会(AOFAS)后足功能评分、患侧与健侧踝关节活动范围差异、骨折愈合情况和感染率等指标对临床效果进行评价。结果 随访时间为(2.8±0.7)(2.0~3.5)年。手术时间为(152±12)(135~167)min。骨折愈合时间为(4.2±1.8)(3~7)个月。术后未见固定失效发生。VAS评分为0分4例、1分2例。踝关节最大背伸较健侧差为(10.0°±4.5°)(5°~15°)。AOFAS评分为(94±6)(86~100)分,优良(AOFAS评分≥80分)率为100%。未见急、慢性感染及创伤性关节炎发生。结论 采用三角韧带加强和后踝固定代替下胫腓螺钉固定治疗三角韧带断裂及伴后踝骨折和下胫腓联合分离的开放踝关节骨折,可获得良好的治疗效果。

Objective To investigate the effect of direct augment or fixation of the damaged structure instead of inferior tibiofibular screw fixation in treatment of open ankle fracture with deltoid ligament rupture,posterior malleolus fracture and inferior tibiofibular syndesmosis diastasis.Methods Clinical data of 6 patients with open ankle fracture and primarily treated with deltoid ligament augment,posterior malleolus fixation following open wound debridement in emergency theatre of Department of Orthopedic Traumatology,Beijing Jishuitan Hospital between January 2018 and June 2019 were analyzed retrospectively.There were 4 males and 2 females,with an age of(44.8±10.8)(range:25-57)years.According to Gustillo open fracture classification,3 cases were typeⅠand 3 cases were typeⅡ.According to the Laugh-Hansen classification,3 cases were pronation-external rotation,one case was pronation-abduction and the other 2 cases of special fracture pattern were transsyndesmotic ankle fracture and dislocation.All 6 patients were classified as type C according to Weber classification scheme.The main outcome measures included post-operative radiographic presentation,visual analogue score(VAS),American Orthopedic Foot and Ankle Society(AOFAS)score,the difference of range of motion(ROM)between bilateral ankle joints,fracture healing and incidence of infection.Results The follow-up duration of the 6 patients was(2.8±0.7)(range:2.0-3.5)years.The time from injury to admission was(3.7±1.5)(range:2-6)h.The operation time was(152±12)(range:135-167)min.The healing time was(4.2±1.8)(range:3-7)months.No case of fixation failure was found in post-operative radiographs during the whole follow-up period.VAS score was 0 in 4 patients and one in 2 patients.The difference between the maximum dorsiflexion of the ankle and the contralateral side was 10.0°±4.5°(range:5°-15°).AOFAS scores was 94±6(range:86-100),and the excellent and good(AOFAS score≥80)rate was 100%.No acute or chronic infection or traumatic arthritis occurred.Conclusion Application of deltoid ligament augment and posterior malleolus fixation instead of the inferior tibiofibular screw fixation in treatment of open ankle fracture with deltoid ligament rupture and inferior syndesmosis diastasis with posterior malleolus fracture may obtain satisfactory outcome.