Lisfranc骨折脱位两种术中判断解剖复位标准比较（开放获取）

Comparison of two anatomic reduction criteria for open reduction and internal fixation of Lisfranc fracture and dislocation

摘要:

[目的]探讨Lisfranc损伤手术治疗过程中判断第一跖楔关节是否解剖复位的方法。[方法]回顾性研究2011年1月 —2019 年12月本院手术治疗的闭合性Lisfranc骨折脱位的74例患者临床资料。早期的35例患者采用单一标准，以第1跖楔关节相邻的背侧皮质与内侧皮质为解剖复位的标志；后期的39例采用复合标准，在原有标准基础上，再加上术中透视以胫侧籽骨为标志，避免第一跖骨的旋转。比较两组围手术期、随访和影像资料。[结果]两组患者均顺利手术，术中无严重并发症。两组患者在手术时间、切口总长度、术中失血量、术中透视次数、下地行走时间、切口愈合和住院时间的差异均无统计学意义（P＞0.05）。术后随访终点为内固定取出之前，为术后10~14个月。复合标准组恢复完全负重活动时间显著早于单一标准组[(61.6±9.0) d vs (69.2±7.2) d, P＜0.001]。与术前相比，末次随访时两组患者的休息VAS 评分和行走VAS评分均显著减少（P＜ 0.05），而 AOFAS 中足评分显著增加（P＜0.05）。末次随访时，复合标准组行走时VAS评分[(1.4±1.0)vs(2.7±1.5),P＜0.001] 和 AOFAS 评分[(98.2±3.9) vs (95.5±6.0), P=0.025] 显著优于单一标准组。影像方面，与术前相比，末次随访时两组患者的SOS、 C1-M2 间隙、M1-M2间隙、C1-C2间隙、Méary-Tomeno 角和籽骨Hardy评分均显著减小（P＜0.05）。末次随访时复合标准组患者的Hardy-Clapham 籽骨分度显著小于单一标准组[(2.6±0.5)vs(4.7±0.9), P＜0.001]。[结论]解剖复位是 Lisfranc 手术治疗的关键。以第一跖趾关节关节面的背侧与内侧皮质，结合远端胫侧籽骨位置为标志，可以确保第一跖楔关节的矢状位、冠状位与旋转解剖复位。

Abstract:

[Objective] To search the method of determining the anatomic reduction of the first metatarsal cuneiform joint during open reduction and internal fixation (ORIF) of Lisfranc injury. [Methods] A retrospective study was conducted on 74 patients who received ORIF for closed Lisfranc fracture and dislocation in our hospital from January 2011 to December 2019. Of them, 35 patients in the earlier stage had a single criterion (SC) used in ORIF, which was anatomic restoration of the dorsal and medial cortices alignment, while 39 patients in the later stage had combined criteria (CC) used, in which hallux tibial sesamoid position on the anteroposterior fluoroscopy was added based on abovesaid standard to avoid the rotation of the first metatarsal. The perioperative, follow-up and imaging data of the two groups were compared. [Results] All patients in both groups had operation performed successfully without serious complications. There were no significant differences in operation time, total incision length, intraoperative blood loss, intraoperative fluoroscopy times, walking time, incision healing and hospital stay between the two groups (P＞0.05). The end point of postoperative follow-up was of 10~14 months postoperatively, before removal of internal fixation. The CC group regained full weight-bearing activity significantly earlier than the SC group [(61.6±9.0) days vs (69.2±7.2) days, P＜0.001]. At the last follow-up, the rest VAS score and walking VAS score significantly decreased (P＜0.05), while the AOFAS middle foot score was significantly increased in both groups (P＜0.05). At the last follow-up, the CC group proved significantly superior to the SC group in terms of VAS score [(1.4±1.0) vs (2.7±1.5), P＜0.001] and AOFAS score [(98.2±3.9) vs (95.5±6.0), P=0.025]. As for imaging, the step-off sign (SOS), C1-M2 space, M1-M2 space, C1-C2 space, Meary Tomeno angle and Hardy-Clapham sesamoid scale in both groups significantly reduced at the last follow-up compared with those preoperatively (P＜0.05). At the last follow-up, the CC group got significantly less Hardy-Clapham sesamoid scale than the SC group [(2.6±0.5) vs (4.7±0.9), P＜0.001]. [Conclusion] Anatomical reduction is the key to Lisfranc surgical treatment. The alignment of dorsal and medial cortices of the first metatarsal cuneiform joint, combined with the position of the hallux tibial sesamoid, can ensure the sagittal, coronal and rotational anatomical reduction of the first metatarsal cuneiform joint.