Comparison of Two Surgical Managements for the Delayed Ankles Fracture Combined with Distal Tibiofibular Syndesmosis Injuries
-
摘要:
目的 探讨陈旧性踝关节骨折合并下胫腓联合韧带损伤(ankles fracture combined with distal tibiofibular syndesmosis injuries,AFTSI)的手术治疗效果。 方法 回顾性分析38例陈旧性AFTSI手术疗效,患者受伤至手术时间28~196 d,平均53 d。其中切开复位内固定 + 下胫腓联合Tighttrope袢钢板弹性固定18例(A组,n = 18),切开复位内固定 + 下胫腓联合螺钉固定20例(B组,n = 20),术后美国足踝外科学会评分、手术前后下胫腓间隙及下胫腓重叠阴影差值,平均住院时间,手术时间,术中失血量,术后开始完全负重时间用于评价疗效。所有患者均接受平均18个月随访,下胫腓联合螺钉于术后2~3月取出。 结果 所有患者均未出现切口感染、骨性关节炎、内固定断裂及踝穴增宽情况;术后AOFAS评分A组高于B组,术后开始完全负重时间A组早于B组(P < 0. 05);平均手术时间,术中失血量,平均住院时间,手术前后下胫腓重叠阴影差值及下胫腓间隙差值2组差异无统计学意义(P > 0. 05)。 结论 陈旧性AFTSI使用Tightrope袢钢板弹性固定患者可以早期负重,较传统的螺钉内固定具有更好的疗效。 Abstract:Objective To investigate the effect of surgical treatments for delayed ankles fracture combined with distal tibiofibular syndesmosis injuries (AFTSI). Methods A retrospective study the operative effects of 38 cases of delayed AFTSI treated with open reduction and internal fixation (ORIF) + Tightrope fixation (group A, n = 18) or ORIF + screw fixation (group B, n = 20) for syndesmosis injuries. AOFAS (Ankle-Hindfoot Score system), hospital stay, operative time, introperative blood loss, full weightbearing time, difference value between preoperative and postoperative tibiofibular clear space (TFCS) and tibiofibular overlap (TFO) were used to evaluate the postoperative curative effect. All patients were received a follow-up with an average of 18 months, and the syndesmosis screws were removed 2-3 months after operations. Results AOFAS score was higher in group A than in group B, postoperative onset time of full weightbearing was earlier in group A than in group B statistically (P < 0. 05), while no statistics difference were found between 2 groups in the factors of hospital stay, operative time, introperative blood loss, and the difference value between preoperative and postoperative time on TFCS together with TFO. Conclusion Tightrope syndesmosis fixation is a better options to enable early weight bearing for the delayed AFTSI compared with the traditional screws fixation. -
Key words:
- Delayed ankle fracture /
- Syndesmosis injury /
- Surgical management /
- Dynamic stabilization
-
踝关节骨折合并下胫腓联合损伤(ankles fracture combined with distal tibiofibular syndesmosis injuries,AFTSI)时间超过3周即演变为陈旧性损伤,往往合并腓骨短缩畸形、距骨外移(talus shift)、踝穴增宽(mortise widening)等后遗症可导致踝关节创伤性骨关节炎,手术治疗仍然是目前较好的选择[1-3]。下胫腓联合(distal tibiofibular syndesmosis,DTFS)解剖复位是其治疗要点[4-5],传统的下胫腓联合螺钉固定为非弹性固定,将限制踝关节活动,减少其顺应性,引起螺钉松动断裂、关节僵硬及负重时间的延迟[6-7]。弹性固定(Dynamic stabilization)如Tighttrope袢钢板重建下胫腓联合是目前广泛接受的观点,有助于踝关节获得更好的功能恢复,但在陈旧性踝关节损伤中应用报道不多[8-9]。本文回顾研究了自2016年1月至2021年4月昆明医科大学第二附属医院骨科收治及外院转入38例DAFTSI患者使用螺钉及Tighttrope袢钢板固定的疗效,现报道如下。
1. 资料与方法
1.1 一般资料
选取2016年1月至2021年4月收治及外院转入的陈旧性AFTSI患者(损伤至手术时间 > 3周)38例,均经影像学确诊,根据切开复位不同的下胫腓固定方式分别纳入A组,B组,性别、年龄、损伤机制分型等指标无统计学差异,具有可比性,见表1。
表 1 患者一般资料($\bar x \pm s $ )Table 1. General information of patients ($\bar x \pm s $ )组别 A组(下胫腓弹性固定,n = 18) B组(下胫腓螺钉固定,n = 20) P 病例数(n) 18 20 - 性别(男/女,n) 14/4 16/4 0.867 年龄(岁) 41.78 ± 13.65 39.5 ± 12.04 0.588 损伤至手术时间(d) 48.56 ± 33.78 57.1 ± 38.49 0.474 受伤机制(高坠/车祸/扭伤)(n) 6/5/7 7/4/9 0.846 Lauge-Hansen分型[10](旋后外旋/旋后内收型/
旋前外旋型/旋前外展型/垂直跖屈型)(n)7/4/4/2/1 9/5/3/2/1 0.982 骨折解剖分型(双踝/三踝)(n) 10/8 14/6 0.357 一般资料中年龄及损伤至手术时间2组比较采用独立样本t检验,其余指标卡方检验,显著水平设定成0.05。 下胫腓损伤影像学诊断标准如下:术前X线及CT检查下胫腓间隙(tibiofibular clear space,TFCS)> 6 mm,下胫腓重叠阴影(tibiofibular overlap,TFO)< 6 mm,提示下胫腓分离损伤(图1);术中C臂透视下行外翻应力试验及拉钩试验进一步判断明确下胫腓损伤情况。
X线平片(AP View)下于胫距关节间隙近端1 cm处平行于胫距关节面划线测量,见图1。A:下胫腓重叠阴影(tibiofibular overlap,TFO)< 6 mm提示下胫腓损伤;B:下胫腓间隙(tibiofibular clear space,TFCS):胫骨腓切迹后部最深点与临近腓骨皮质之间的距离,> 6 mm提示下胫腓损伤[11]。
1.2 手术方法
腰麻或硬膜外麻醉下,采用踝关节前内侧和后外侧入路,显露后清除骨折端骨痂及瘢痕组织,使距骨复位不受阻碍。双踝骨折先固定外踝,后固定内踝;三踝骨折,先暴露内踝,清除嵌入物,后外侧切口显露外踝及后踝,如果后外侧切口显露后踝不够完整,借助内踝切口进一步显露清除周围粘连组织和距骨与后踝骨块间的瘢痕,待后踝、外踝固定后再固定内踝。畸形愈合者沿原始骨折线透视下克氏针定位截骨,截骨后彻底清除骨折周围骨痂,使其成为新鲜骨折,再逐一清理内踝与距骨、距骨与胫骨下关节面及下胫腓联合肉芽疤痕组织,显露胫骨之腓骨切迹,恢复踝穴以便复位踝关节。直视下复位骨折,外踝及腓骨选用钢板固定,内踝骨块较大时用全螺纹空心螺钉固定,骨折块较小时选用张力带钢丝固定。最后分别选用Tightrope袢钢板或螺钉固定DTFS。在距离胫距关节上方约2~3 cm处平行胫距关节面由后外侧至前内侧倾斜25° ~30° 建立骨隧道,穿入Tighttrope袢钢板重建下胫腓(图2)。在距离胫距关节上方约5~7 cm处建立骨隧道重建骨间韧带。畸形愈合者截骨复位,选用2~3枚拉力螺钉从前向后固定(图2,图3)。若有胫距关节脱位,在距骨复位后,斯氏针于跟骨、距骨、胫骨远端固定踝关节于中立位,再分别行骨折端及DTFS固定。术后放置负压引流于24~48 h内拔出,抗生素使用3 d。观察术口无感染,复查血常规正常后出院。术后3 d后行踝关节主动功能锻炼,7周后部分负重,8~9周后根据复查情况确定是否完全负重。DTFS螺钉于术后2~3月取出。
1.3 疗效判定标准
患者13~25个月随访,平均18个月,美国足踝外科学会AOFAS踝-后足评分(0~100)评价术后疗效。X平片下手术前后下胫腓间隙及下胫腓重叠阴影差值,平均住院时间,平均手术时间,术中失血量,术后开始完全负重时间同时用于评价疗效。
1.4 统计学处理
资料采用SPSS20.0软件进行统计学处理,独立样本t检验统计分析。
2. 结果
所有患者均未出现切口感染、骨性关节炎、内固定断裂及踝穴增宽情况;AOFAS术后评分A组高于B组,术后开始完全负重时间A组早于B组(P < 0. 05);平均手术时间,术中失血量,平均住院时间,手术前后下胫腓重叠阴影差值及下胫腓间隙差值2组无统计学差异(P > 0. 05);患者随访期内2例患者出现内踝骨折不愈合现象,2组各1例,并发症发生率为5.26%,见表2。
表 2 AOFAS评分,术后完全负重、平均手术、住院时间,术中失血量,手术前后下胫腓-重叠阴影差值及间隙差值比较Table 2. Comparison of AOFAS score,complete weight-bearing and average operative time,intraoperative blood loss,hospital stay,difference of pre- and post-operative tibiofibular clear space and overlap项目 A组 B组 P F 例数 18 20 术后AOFAS评分 81.11 ± 8.49# 73.65 ± 12.68 < 0.05 3.52 开始完全负重时间(周) 8.44 ± 2.15# 11 ± 1.5 < 0.05 0.16 平均手术时间(h) 3.06 ± 0.75 3.23 ± 0.62 > 0.05 0.84 术中失血量(mL) 323.17 ± 49.62 347.7 ± 62.59 > 0.05 3.91 平均住院时间(d) 15.61 ± 2.43 16.55 ± 3.55 > 0.05 1.15 手术前后下胫腓重叠阴影差值(mm) 2.6 ± 0.49 2.49 ± 0.68 > 0.05 1.73 手术前后下胫腓间隙差值(mm) 2.84 ± 0.582 3.01 ± 0.74 > 0.05 2.17 与B组比较,#P < 0.05。 3. 讨论
陈旧性AFTSI伴随腓骨短缩畸形和旋转畸形及踝穴不稳,腓骨及DTFS解剖复位是手术治疗的关键步骤[12-13]。本组18例陈旧性踝关节骨折患者均采取手术治疗,术后平均18个月随访,效果良好。陈旧性AFTSI要求多个入路才能清楚显示复位固定,容易合并较重的深部软组织损伤,如何在保护避免软组织的二次损伤的同时又能充分显露踝穴、内外踝及下胫腓联合仍然是一个难题,具体采用什么手术入路因根据患者情况决定[14-15]。首先充分显露踝穴,清除瘢痕组织、骨赘松解踝关节,再复位固定骨折,然后再固定外踝于腓骨切迹内,接下来固定内踝,最后重建DTFS。对畸形愈合者行截骨复位螺钉从前向后固定。笔者认为解剖复位踝穴、腓骨长度及下胫腓联合有助于恢复踝穴,是其治疗的要点[16-17]。
传统的DTFS螺钉固定目前被认为弊端较大,其坚强固定将限制腓骨相对于胫骨干的位移和旋转,从而影响踝穴对距骨运动的顺应性调节,限制患者早期负重,而且螺丝钉随腓骨一起上下移动,可引起螺钉断裂[18-19]。Sanders等(2019)对103例OTA/ao44-C型复杂AFTSI进行了一项随访12个月的前瞻性随机对照多中心试验,使用2枚3.5 mm皮质骨螺钉或无节TightRope线缆固定DTFS,以移位2 mm或旋转10度提示复位不良,结果螺钉固定的复位不良率为39%,再手术率30%,TightRope线缆复位不良率为15%,再手术率4%,笔者认为TightRope线缆比两枚3.5 mm皮质螺钉固定更有效[20]。Ba等(2019)对6项有关AFTSI临床研究(2项随机对照试验,2项前瞻性和2项回顾性队列研究,共275例患者)进行了系统回顾,结果表明,与下胫腓螺钉固定相比较,缝合扣固定以及线缆固定显示出明显更低的再手术和畸形复位率,以及更好的美国矫形外科足踝评分[21]。
本研究也表明陈旧性AFTSI下胫腓使用Tighttrope袢钢板固定组术后AOFAS评分高于下胫腓螺钉固定组,术后开始完全负重时间也早于螺钉固定组。提示Tighttrope袢钢板弹性固定对陈旧AFTSI也是一种较好的选择。
综上所述,陈旧性AFTSI患者骨折畸形愈合严重合并下胫腓损伤,手术入路应充分显露骨折畸畸形愈合区域、DTFS,以踝穴为中心清除瘢痕骨赘松解踝关节,之后解剖复位骨折,最后解剖复位固定DTFS[24]。至于使用传统螺钉固定,还是Tighttrope袢钢板等弹性固定下胫腓联合,由于面临内置物松动断裂、内置物取出、不能早期负重及术中过度加压导致踝关节不稳等问题,尽管仍有争议,考虑到弹性固定不必担心内固定断裂,不必取出内固定,可早期负重康复,而这对陈旧损伤患者尤其重要,因此弹性固定是较好的选择。
-
表 1 患者一般资料(
$\bar x \pm s $ )Table 1. General information of patients (
$\bar x \pm s $ )组别 A组(下胫腓弹性固定,n = 18) B组(下胫腓螺钉固定,n = 20) P 病例数(n) 18 20 - 性别(男/女,n) 14/4 16/4 0.867 年龄(岁) 41.78 ± 13.65 39.5 ± 12.04 0.588 损伤至手术时间(d) 48.56 ± 33.78 57.1 ± 38.49 0.474 受伤机制(高坠/车祸/扭伤)(n) 6/5/7 7/4/9 0.846 Lauge-Hansen分型[10](旋后外旋/旋后内收型/
旋前外旋型/旋前外展型/垂直跖屈型)(n)7/4/4/2/1 9/5/3/2/1 0.982 骨折解剖分型(双踝/三踝)(n) 10/8 14/6 0.357 一般资料中年龄及损伤至手术时间2组比较采用独立样本t检验,其余指标卡方检验,显著水平设定成0.05。 表 2 AOFAS评分,术后完全负重、平均手术、住院时间,术中失血量,手术前后下胫腓-重叠阴影差值及间隙差值比较
Table 2. Comparison of AOFAS score,complete weight-bearing and average operative time,intraoperative blood loss,hospital stay,difference of pre- and post-operative tibiofibular clear space and overlap
项目 A组 B组 P F 例数 18 20 术后AOFAS评分 81.11 ± 8.49# 73.65 ± 12.68 < 0.05 3.52 开始完全负重时间(周) 8.44 ± 2.15# 11 ± 1.5 < 0.05 0.16 平均手术时间(h) 3.06 ± 0.75 3.23 ± 0.62 > 0.05 0.84 术中失血量(mL) 323.17 ± 49.62 347.7 ± 62.59 > 0.05 3.91 平均住院时间(d) 15.61 ± 2.43 16.55 ± 3.55 > 0.05 1.15 手术前后下胫腓重叠阴影差值(mm) 2.6 ± 0.49 2.49 ± 0.68 > 0.05 1.73 手术前后下胫腓间隙差值(mm) 2.84 ± 0.582 3.01 ± 0.74 > 0.05 2.17 与B组比较,#P < 0.05。 -
[1] Han S M,Wu T H,Wen J X,et al. Radiographic analysis of adult ankle fractures using combined danis-weber and lauge-hansen classification systems[J]. Scientific Reports,2020,10(1):7655. doi: 10.1038/s41598-020-64479-2 [2] Baumbach S F,Braunstein M,Herterich V,et al. Arthroscopic repair of chronic lateral ankle instability[J]. Operative Orthopadie und Traumatologie,2019,31(3):201-210. doi: 10.1007/s00064-019-0595-7 [3] Cammas C,Ancion A,Detrembleur C,et al. Frequency and risk factors of complications after surgical treatment of ankle fractures:a retrospective study of 433 patients[J]. Acta Orthopaedica Belgica,2020,86(3):563-574. [4] Hamam A W,Chohan M B Y,Tieszer C,et al. Anatomic repair vs closed reduction of the syndesmosis[J]. Foot & Ankle International,2021,107(11):72. [5] Mandel J,Behery O,Narayanan R,et al. Single- vs 2-screw lag fixation of the medial malleolus in unstable ankle fractures[J]. Foot & Ankle International,2019,40(7):790-796. [6] Wu K,Lin J,Huang J,et al. Evaluation of transsyndesmotic fixation and primary deltoid ligament repair in ankle fractures with suspected combined deltoid ligament injury[J]. Journal of Foot & Ankle Surgery,2018,57(4):694-700. [7] Lee D O,Yoo J H,Choi W Y. Optimal screw fixation of syndesmosis using a targeting drill guide:a technical note[J]. The Journal of Foot and Ankle Surgery,2020,59(1):206-209. doi: 10.1053/j.jfas.2019.05.005 [8] Song L,Liao Z,Kuang Z,et al. Comparison of tendon suture fixation and cortical screw fixation for treatment of distal tibiofibular syndesmosis injury:A case-control study[J]. Medicine,2020,99(34):e21573. doi: 10.1097/MD.0000000000021573 [9] Rder B W,Figved W,Madsen J E,et al. Better outcome for suture button compared with single syndesmotic screw for syndesmosis injury:five-year results of a randomized controlled trial[J]. Bone and Joint Journal,2020,102-B(2):212-219. doi: 10.1302/0301-620X.102B2.BJJ-2019-0692.R2 [10] Shariff S S,Nathwani D K. Lauge-hansen classification-A literature review[J]. Injury-international Journal of the Care of the Injured,2006,37(9):888-890. doi: 10.1016/j.injury.2006.05.013 [11] Hermans J J,Wentink N,Beumer A,et al. Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI[J]. Skeletal Radiology,2012,41(7):787-801. doi: 10.1007/s00256-011-1284-2 [12] 苏琰,李振东,薛剑锋,等. 经腓骨截骨复位内固定治疗中老年累及后踝陈旧性踝关节骨折[J]. 中华创伤杂志,2020,36(4):315-320. [13] Blom R P,Meijer D T,de Muinck Keizer R J O,et al. Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures[J]. Injury,2019,50(7):1392-1397. doi: 10.1016/j.injury.2019.06.003 [14] Grambart S T,Prusa R D,Ternent K M. Revision of the Chronic Syndesmotic Injury[J]. Clinics in Podiatric Medicine and Surgery,2020,37(3):577-592. doi: 10.1016/j.cpm.2020.03.011 [15] Ju D G,Debbi E M,Neustein A Z,et al. Fibular lengthening osteotomy with revision syndesmotic repair for ankle fracture malunion[J]. Journal of orthopaedic trauma,2019,33(Suppl1):S38-S39. [16] Lemmers D H L,Lubberts B,Stavenuiter R,et al. Factors associated with adverse events after distal tibiofibular syndesmosis fixation[J]. Injury,2020,51(2):542-547. doi: 10.1016/j.injury.2019.12.011 [17] Mosca M,Buda R,Ceccarelli F,et al. ,Vocale E,Massimi S,Benedetti MG,Grassi A,Caravelli S,Zaffagnini S. Ankle joint re-balancing in the management of ankle fracture malunion using fibular lengthening:prospective clinical-radiological results at mid-term follow-up[J]. International Orthopaedics,2021,45(2):411-417. doi: 10.1007/s00264-020-04690-y [18] Burton C A,Arthur R J,Rivera M J,et al. The Examination of Repeated Self-Mobilizations With Movement and Joint Mobilizations on Individuals With Chronic Ankle Instability[J]. Journal of Sport Rehabilitation,2020,30(3):458-466. [19] Kapadia B H,Sabarese M J,Chatterjee D,et al. Evaluating success rate and comparing complications of operative techniques used to treat chronic syndesmosis injuries[J]. Journal of Orthopaedics,2020,22:225-230. doi: 10.1016/j.jor.2020.04.011 [20] Sanders D,Schneider P,Taylor M,et al. Improved reduction of the tibio-fibular syndesmosis with tightrope compared to screw fixation:results of a randomized controlled study[J]. Journal of Orthopaedic Trauma,2019,33(11):531-537. doi: 10.1097/BOT.0000000000001559 [21] McKenzie A C,Hesselholt K E,Larsen M S,et al. A systematic review and meta-analysis on treatment of ankle fractures with syndesmotic rupture:suture-button fixation versus cortical screw fixation[J]. The Journal of Foot and Ankle Surgery,2019,58(5):946-953. doi: 10.1053/j.jfas.2018.12.006 期刊类型引用(4)
1. 张艳. 改良悬雍垂腭咽成形术联合鼻中隔成形术同期治疗阻塞性睡眠呼吸暂停低通气综合征的可行性研究. 数理医药学杂志. 2021(01): 19-21 . 百度学术
2. 符牧,杨中川,赵迎彬,陈扬. 改良悬雍垂腭咽成形术治疗重度阻塞性睡眠呼吸暂停低通气综合征对患者生活质量的改善评估. 检验医学与临床. 2018(12): 1701-1703+1706 . 百度学术
3. 史征. 改良悬雍垂腭咽成形术治疗鼾症的应用意义分析. 中国处方药. 2018(10): 118-119 . 百度学术
4. 唐成忠,吴跃军,余成清,孙晓强. H-UPPP治疗重度OSAHS手术疗效分析. 中国中西医结合耳鼻咽喉科杂志. 2018(06): 451-453+474 . 百度学术
其他类型引用(1)
-