踝部骨折是否下胫腓固定的术中判断

Intraoperative determination of tibiofibular fixation in open reduction and internal fixation for ankle fractures

摘要:

［目的］ 探讨踝关节骨折术中何时行下胫腓固定。［方法］ 回顾性分析 2016 年 2 月—2020 年 6 月手术治疗的 26 例踝关节骨折患者的临床资料，男 15 例，女 11 例，年龄 20~67 岁，平均（47.26±16.03）岁。术中行外旋试验或透视观察内侧关节间隙是否异常增宽，若结果为阴性，不给予下胫腓螺钉固定；若显示阳性，固定下胫腓。［结果］ 26 例患者均顺利完成手术，无明显严重并发症。根据术中判断，12 例行下胫腓固定，14 例未行下胫腓固定。固定组手术时间、术中透视次数显著大于非固定组 （P<0.05），两组切口总长度、术中失血量、切口愈合等级等方面的差异无统计学意义 （P>0.05）。26 例患者随访 13~50 个月，平均 （33.30±11.65） 个月，固定组恢复行走时间和完全负重时间显著晚于非固定组 （P<0.05）。随术后时间推移，两组患者 AOFAS 评分和 ROM 均显著增加（P<0.05），相应术后时间点，两组间 AOFAS 评分和 ROM 的差异无统计学意义 （P>0.05）。影像方面，与术前相比，末次随访时两组 TFOL 显著增加 （P<0.05），而 TFCS 显著减少 （P<0.05）。相应时间点， 两组间上述指标的差异无统计学意义（P>0.05）。［结论］术中行外旋试验或透视观察内侧关节间隙是否异常增宽可有效判断并决定踝部骨折术中是否固定下胫腓。

Abstract:

[Objective] To explore how to determine whether or not to fix the inferior tibiofibular syndesmosis during open reduction and internal fixation of ankle fractures. [Methods] A total of 26 patients, including 15 males and 11 females, aged 20~67 years with a mean of (47.26±16.03) years, underwent surgical treatment for ankle fractures from February 2016 to June 2020. Intraoperative external rotation test, or fluoroscopic assessment to observe whether the medial joint space was abnormally widened were conducted. If the result was nega- tive, the inferior tibiofibular syndesmosis was not fixed with screws, whereas if positive, the inferior tibiofibular syndesmosis was fixed with screws. [Results] All the 26 patients were successfully operated on without serious complications. According to the consequences of intraop- erative judgment, 12 patients underwent tibiofibular fixation, while the remaining 14 cases did not. The fixed group had significantly greater operative time and intraoperative fluoroscopy times than the non-fixed group (P<0.05) , but there were no significant differences in incision length, intraoperative blood loss and incision healing between the two groups (P>0.05) . All the 26 patients were followed up for more than 12 months. The fixed group resumed walking and full weight-bearing activity significantly later than that of the non-fixed group (P<0.05) . The AOFAS score and dorsal extension-plantar flexion range of motion (ROM) increased significantly in both groups over time postopera- tively (P<0.05) , however there were no significant differences in AOFAS score and ROM between the two groups at corresponding postoper- ative time points (P>0.05) . In terms of radiographic evaluation, the tibiofibular overlap (TFOL) significantly increased, while the tibiofibu- lar clear space (TFCS) significantly decreased postoperatively compared with those preoperatively in both groups (P<0.05) . At the matching time points, there was no significant difference in the above indexes between the two groups (P>0.05) . [Conclusion] Intraoperative external rotation test or fluoroscopic observation of abnormal widening of medial joint space do effectively determine whether to fix the inferior tibio- fibular syndesmosis during open reduction and internal fixation of ankle fractures.