后外侧入路与联合入路治疗Mason 2B型后踝骨折疗效比较

Comparison of posterolateral approach and combined approach in treatment of Mason type 2B posterior malleolar fracture

目的探讨并比较后外侧入路与后外侧联合后内侧入路治疗踝关节骨折中合并Mason 2B型后踝骨折的临床疗效。方法回顾分析2015年1月—2022年1月收治且符合选择标准的79例后踝骨折患者临床资料。其中Mason 2B Pilon亚型62例、撕脱亚型17例。Mason 2B Pilon亚型患者中,35例采用后外侧入路(A组),27例采用联合入路(B组),两组患者性别、年龄、受伤侧别、致伤原因、受伤至手术时间、术前住院时间、术前疼痛视觉模拟评分(VAS)及术中内固定方式等基线资料比较差异均无统计学意义(P>0.05)。Mason2B撕脱亚型患者均采用后外侧入路,其中男7例,女10例;年龄25~68岁,平均46.1岁。记录手术时间、术中出血量、术后住院时间及并发症发生情况;采用Ovadia deals放射学评分评估复位质量,VAS评分、美国矫形足踝协会(AOFAS)评分及踝关节活动度进行功能评价。结果Mason 2B Pilon亚型:两组手术时间、术中出血量、术后住院时间及随访时间比较差异均无统计学意义(P>0.05)。术后1周内影像学复查示,A组Ovadia deals放射学评分差于B组(P<0.05)。术后各时间点两组VAS评分均较术前显著改善,术后随时间延长VAS评分和AOFAS评分均进一步改善,差异有统计学意义(P<0.05)。除末次随访时A组AOFAS评分小于B组(P<0.05)外,两组间其余时间点VAS评分和AOFAS评分比较差异均无统计学意义(P>0.05)。末次随访时,A组踝关节活动度小于B组(P<0.05)。在并发症方面,两组腓肠神经损伤、深部组织感染、踇趾活动受限及创伤性踝关节炎发生率比较差异均无统计学意义(P>0.05)。Mason 2B撕脱亚型:手术时间(119.47±20.61)min,术中出血量50(35,55)mL。17例患者均获随访,随访时间13~25个月,平均18个月。术后1周测量Ovadia deals放射学评分获优10例、良6例、差1例,优良率94.1%。所有骨折均获骨性愈合,愈合时间8~18周,平均12.35周。术后发生腓肠神经损伤1例,创伤性踝关节炎3例,无深部组织感染、踇趾活动受限发生。随时间延长,VAS评分显著下降,AOFAS评分显著增加,手术前后各时间点间差异均有统计学意义(P<0.05)。末次随访时踝关节活动度为(56.71±2.47)°。结论与后外侧入路相比,联合入路对骨折复位质量更优,远期随访功能更佳,是治疗Mason 2B Pilon亚型的较好选择;对于Mason 2B撕脱亚型,若后内侧骨块不影响内踝复位,仅后外侧入路即可获得较好的临床疗效。

Objective To compare the effectiveness between the posterolateral approach and the posterolateral combined posteromedial approaches in the treatment of Mason type 2B posterior malleolar fracture.Methods A retrospective analysis was performed on the clinical data of 79 patients with posterior ankle fracture who met the selection criteria between January 2015 and January 2022.There were 62 cases of Mason 2B Pilon subtype and 17 cases of avulsion subtype.Among Mason 2B Pilon subtype patients,35 were treated with posterolateral approach(group A),27 patients were treated with combined approach(group B).There was no significant difference in gender,age,injured side,cause of injury,time from injury to operation,preoperative hospital stay,preoperative visualanalogue scale(VAS)score,and intraoperative internal fixation between the two groups(P>0.05).All patients with Mason 2B avulsion subtype were treated by posterolateral approach,including 7 males and 10 females,aged from 25 to 68 years,with an average of 46.1 years.The operation time,intraoperative blood loss,postoperative hospital stay,and complications were recorded.The reduction quality was evaluated by Ovadia deals radiographic score,and the ankle function and pain were evaluated by VAS score,American Orthopaedic Foot and Ankle Society(AOFAS)score,and ankle range of motion.Results Mason 2B Pilon subtype:There was no significant difference in operation time,intraoperative blood loss,postoperative hospital stay,and follow-up time between the two groups(P>0.05).The radiological evaluation of Ovadia deals in group A was significantly worse than that in group B(P<0.05).The VAS score in the two groups significantly improved at each time point after operation,and the VAS score and AOFAS score further improved with the extension of time after operation,and the differences were significant(P<0.05).Except that the AOFAS score of group A was significantly lower than that of group B at last follow-up(P<0.05),there was no significant difference in VAS score and AOFAS score between the two groups at other time points(P>0.05).At last follow-up,the ankle range of motion in group A was significantly less than that in group B(P<0.05).There was no significant difference in the incidence of sural nerve injury,deep tissue infection,limitation of toe movement,and traumatic ankle arthritis between the two groups(P>0.05).Mason 2B avulsion subtype:The operation time was(119.47±20.61)minutes and the intraoperative blood loss was 50(35,55)mL.Seventeen patients were followed up 13-25 months,with an average of 18 months.The Ovadia deals score was excellent in 10 cases,good in 6 cases,and poor in 1 case at 1 week after operation,and the excellent and good rate was 94.1%.All fractures healed in 8-18 weeks with an average of 12.35 weeks.There were 1 case of sural nerve injury and 3 cases of traumatic ankle arthritis after operation.No deep tissue infection or limitation of toe movement occurred.The VAS score decreased significantly and AOFAS score increased significantly with time,and the differences were significant between different time points before and after operation(P<0.05).The ankle range of motion at last follow-up was(56.71±2.47)°.Conclusion Compared with the posterolateral approach,the combined approach is a better choice for the treatment of Mason 2B Pilon subtype.If the posteromedial bone block does not affect the reduction of the medial malleolus,the posterolateral approach can achieve good effectiveness for Mason 2B avulsion subtype.