Lisfranc损伤足底入路的解剖学研究及初步疗效分析

Plantar approach for Lisfranc injury: an anatomical study and preliminary clinical application

目的探讨采用单一足底入路或联合足背入路治疗足背软组织条件差、跖侧撕脱性骨折或多柱复杂的Lisfranc损伤的安全性、有效性及初步应用疗效。方法①收集新鲜成人足部标本6支,采用足底入路解剖标本,以明确足底入路的皮肤切口和放置钢板螺钉内固定的安全区域,并完成相应钢板、螺钉固定。②足底入路解剖研究明确后,对2020年9月至2021年11月南方医科大学第三附属医院足踝外科收治的3例足背皮肤挫伤严重坏死或跖骨基底撕脱性移位骨折的Lisfranc损伤患者采用足底入路治疗,其中男2例,女1例;年龄平均为51岁(34~68岁)。通过分析患者的复位效果、末次随访时的疼痛视觉模拟评分(VAS)、美国足踝外科协会(AOFAS)的中足评分、Maryland评分、Kofoed评分、骨折愈合情况、术后并发症以评估初步疗效。结果①解剖显露范围:内侧可显露内侧柱(内至第1跖楔关节跖侧),外侧可显露中间柱(外至第3跖楔关节跖侧);可探查腓骨长肌肌腱、Lisfranc足底韧带及骨间韧带;模拟手术后X线片示钢板位置满意。②临床结果:所有患者均获随访,时间6~14个月(平均11个月)。末次随访时VAS评分为0~1分(平均0.5分),AOFAS评分为85~92分(平均89分),Maryland评分为93~96分(平均95分),Kofoed评分为92~95分(平均94分)。所有患者骨折均愈合,均未发生并发症。结论在明确解剖研究后,采用单一足底入路或联合足背入路治疗足背软组织条件差、跖侧撕脱性骨折或合并多柱复杂Lisfranc损伤安全、有效,初步疗效满意。

Objective To explore the safety,efficacy and preliminary clinical application of the single plantar approach or in combination with the dorsalis pedis approach in the treatment of Lisfranc injury with poor dorsalis pedis soft tissue,metatarsal avulsion fracture or complicated multi-column lesions.Methods(1)Six fresh cadaveric specimens of adult foot were collected and dissected through the plantar approach in order to determine the skin incision of the plantar approach and the safe area for plate-screw internal fixation,including start-stop points and courses of plantar nerves,blood vessels,tendons and ligaments,followed by plate-screw fixation on the specimens.(2)After feasibility of the plantar approach was confirmed by our anatomical study,it was used to treat the 3 patients who were admitted to Department of Orthopedics,The Third Hospital Affiliated to Southern Medical University between September 2020 and November 2021 for Lisfranc injury with severe necrosis due to dorsalis pedis skin contusion or metatarsal base avulsion fracture.They were 2 males and one female,with an average age of 51 years(from 34 to 68 years).The preliminary clinical efficacy was evaluated in terms of visual analogue scale(VAS),midfoot score of American Orthopaedic Foot and Ankle Surgeons(AOFAS),Maryland score,Kofoed score,fracture healing at the last follow-up and postoperative complications.Results(1)Regarding the anatomical exposure range,the metatarsal side of the first metatarsal wedge joint was exposed medially and the metatarsal side of the third metatarsal wedge joint was exposed laterally;the peroneus longus tendon,Lisfranc plantar ligament and interosseous ligament were explored.X-ray films after the simulated operation showed satisfactory plate positions.(2)As for the preliminary clinical application,all patients were followed up for 6 to 14 months(mean,11 months).At the last follow-up,the VAS score ranged from 0 to 1(mean,0.5),AOFAS score from 85 to 92(mean,89),Maryland score from 93 to 96(mean,95),and Kofoed score from 92 to 95(mean,94).There were no early complications such as fascial compartment syndrome,skin necrosis or infection.All fractures got united,with no complications like traumatic arthritis,muscle atrophy or screw loosening.Conclusion Testified by the anatomical study,the plantar approach can be used to treat Lisfranc injury with poor dorsalis pedis soft tissue,metatarsal avulsion fracture or complicated multi-column lesions,leading to safe,effective and satisfactory clinical outcomes.