踝部的骨折与损伤

What's New in Foot and Ankle Surgery Introduction This update summarizes recent research pertaining to foot and ankle surgery that was published or presented between August 2008 and July 2009. The sources of these studies include The Journal of Bone and Joint Surgery (American and British Volumes); Foot and Ankle International; the proceedings of Specialty Day at the Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), held on February 28, 2009, in Las Vegas, Nevada; and the summer meeting of the American Orthopaedic Foot and Ankle Society (AOFAS), held on July 15 through 18, 2008, in Vancouver, British Columbia, Canada. 引言 这些有关足踝外科更新文献来自于2008年8月到2009年7月其间发的或公开的，来源包括JBJS杂志（美国版和英国版）、国际足踝杂志、2009年2月28日在Nevada Las Vegas的美国矫形外科医师学会上的记录、2008年7月15号到18号华美国矫形外科足踝协会（AOFAS)在加拿大的不列颠哥仑比亚省的温哥华举行的夏季年会。 Ankle Fractures and Trauma 踝部的骨折与损伤 Since its inception, the Lauge-Hansen ankle fracture classification system has commonly been utilized by the orthopaedic community to correlate the mechanism of injury with the radiographic fracture pattern. Despite its enduring clinical use, the Lauge-Hansen classification system is often confusing and cumbersome and has lacked experimental reproducibility. Numerous investigators have been unable to specifically recreate the stage-4 supination-external rotation fracture pattern in an experimental setting. The lack of reproducibility has caused investigators to challenge the dogma that an external rotation force produces a fibular fracture pattern oriented from anteroinferior to posterosuperior only with the foot in a supinated position. Haraguchi and Armiger used a biomechanical cadaver model to prove their hypothesis that a pronated foot could produce fracture patterns traditionally ascribed to a supination-external rotation mechanism1. According to the authors, the pattern of fibular fracture would largely be determined by the amount of laterally directed force (an abduction moment) applied to the foot in pronation. Fifteen cadaver specimens were mounted onto a load frame in a position of pronation-external rotation and were subjected to a large axial force with internal tibial rotation, and another eight specimens received a simultaneous laterally directed force to increase the abduction moment acting on the ankle joint. Eight of the fifteen specimens in the axial load group sustained oblique distal fibular fractures consistent with a traditional Lauge-Hansen supination-external rotation fracture pattern. Three of the eight specimens receiving the combined axial load with an abduction moment sustained a high fibular fracture pattern consistent with a traditional Lauge-Hansen pronation-external rotation mechanism. These results suggest that the pronation-external rotation ankle injury could account for fracture patterns originally attributed to a supination-external rotation mechanism. This may be of clinical value when attempting to "reverse the mechanism of injury" to reduce a displaced ankle fracture. The variable determining the type of fibular fracture pattern may be the magnitude of the abduction moment acting on the pronated foot. Additional testing is necessary to create a more straightforward system for the classification of ankle fractures based on applied loads. 自从出现lauge - hansen踝部骨折分型，它就成为整个矫形外科界使用放射学解释受伤机制的常用骨折分型。尽管它在临床上的使用广泛，但是它常常是非常繁琐的，并缺乏试验的再现性。许多的研究者明确的认为旋后外旋型损伤类型在试验上不可能得到重现。缺乏再现性使研究者对这一分型提出质疑，外旋力使腓骨发生从前下到后上的骨折类型难道仅仅会出现在足旋后位置的旋前型。Haraguchi和Armiger使用尸体生物力学模型证明了他们的假说：旋前位产生的骨折类型，应该是旋后外旋的机制。按照作者的这个理论，腓骨的骨折类型很大程度上取决于在足旋前的位置，外侧受到直接力量的大小（外展的力矩）。十五个尸体样品设置旋前-外旋位时受到大的轴向力并伴有胫骨的转动，另外八个样品承受在侧面直接的力量，并不断增加外展力矩作用于踝关节。十五个样品的八个在轴向负荷分组获得了腓骨远端的倾斜的骨折，符合传统的lauge - hansen旋后-外旋骨折类型。八个中的三个在承受轴向负载联合外展力矩的情况，获得了高位的腓骨的骨折类型，与传统的lauge - hansen旋前-外旋机制一致。这些结果表明旋前-外旋的踝关节伤害是最初由于旋后-外旋的机制。这些可能是在临床上有价值的，可以使避免受伤机制来减少移位骨折。决定腓骨的骨折类型的变量可能是巨大外展力矩作用于旋前位的足。更多的对踝关节施加负荷模型对于踝关节骨折的分型建立是非常必要的。 Magnetic resonance imaging and ankle arthroscopy have recently drawn attention to the frequency of intra-articular injuries associated with acute ankle fractures. The frequency or degree of chondral injury, however, has not been correlated with the severity of the ankle fracture as classified according to the Lauge-Hansen criteria. Leontaritis et al. retrospectively reviewed their experience in the treatment of acute ankle fractures with use of open reduction and internal fixation as well as routine ankle arthroscopy2. The authors correlated arthroscopic findings of intra-articular chondral injury with the severity of the ankle fracture pattern as staged with the Lauge-Hansen classification system. Among the eighty-four patients who met the inclusion criteria, the prevalence of associated chondral injury was 73% (sixty-one of eighty-four). Overall, fifty-one ankles (61%) sustained a chondral injury to the talar dome, five (6%) had lesions involving the tibial plafond, and ten (12%) sustained an injury to the medial and/or lateral malleolus. Fracture severity as determined by higher staging with the Lauge-Hansen classification also correlated with increased intra-articular injury. Type-IV supination-external rotation and pronation-external rotation fractures were found to be associated with a higher frequency of loose bodies and chondral lesions of the talar dome. Additionally, the type-IV fractures were 8.1 and 9.7 times more likely to be associated with two or more chondral lesions than their type-I and type-II fracture counterparts, respectively. These results demonstrate that articular cartilage injury of the ankle commonly occurs during acute ankle fractures, and the treating physician should anticipate more severe chondral damage with higher stages of ankle fracture as classified with the Lauge-Hansen system. 最近比较热门的踝关节内骨折的损伤使用核磁共振和踝关节镜进行检查。然而，软骨损伤的程度和发生率与lauge - hansen分类中的踝关节损伤严重性并不完全一致。Leontaritis等对急性踝关节骨折的病例进行了回顾性研究，他们在切开复位内固定治疗前，常规使用踝关节镜进行检查。作者对各种lauge - hansen骨折类型的病例进行了相关关节镜的关节内软骨检查。在符合分类标准的84个病人中，常见相关的软骨损害是73% (84个中的61个）。总的说来，51个( 61%)病人踝关节的软骨损害在距骨的顶部，5个( 6%)个损害涉及胫骨的全面的，10个( 12%)伤及内踝和（或）外踝。骨折严重性既取决于lauge - hansen分类级别较高的类型也跟关节内伤害的程度有关。旋后-外旋IV和旋前-外旋骨折的被证实与距骨顶部的骨质和软骨高度相关。另外，类型- IV的骨折发生两个或更多软骨的损害的相关性与Ｉ和II型相比分别是8.1和9.7。这些结果论证了严重踝关节骨折通常发生踝关节软骨损伤，医生在对待lauge - hansen分类中的较高损伤程度的踝关节骨折时，应当预料有更严重的软骨损害。 Open reduction and internal fixation of ankle fractures is associated with inherent surgical risks. Until now, the rate of complications and the risk factors associated with operative fixation of ankle fractures have not been investigated in a large population-based study. Using California's discharge database, SooHoo et al. identified 57,183 patients who underwent open reduction and internal fixation of an ankle fracture during an eleven-year period3. Pooling of the data during this time period allowed for an analysis of relevant demographic characteristics and hospital characteristics as well as short and intermediate-term complications. The overall complication rate was reported to be low in both the short term and the intermediate term. The exception was noted in patients with complicated diabetes and peripheral vascular disease, which were associated with significantly higher risks of infection and amputation in the short term and a higher risk of reoperation in the intermediate term. Strong predictors of intermediate-term conversion to ankle fusion or replacement were associated with open injuries and the severity of the ankle fracture. Severe ankle fractures, such as trimalleolar fractures, were associated with higher rates of revision when compared with isolated medial or lateral malleolar fractures. Hospital characteristics such as procedure volume, teaching status, and rural location had no significant effect on the complication rates. Interestingly, the overall rate of pulmonary embolism requiring readmission within ninety days following discharge was also very low (0.34%). 踝部骨折切开复位内固定存在固有的手术风险。直到现在，手术的固定踝关节骨折的并发症发生率和风险系数的有关大的研究尚未建立。利用加利福尼亚的出院病人数据库，soohoo等人识别11年中的期间57,183个经历踝关节骨折切开复位内固定的病人，分析这一资料的相关人口特征和医院特征出现的短期及中期并发症。短期和中期报道并发症比率比较低。例外的情况是病人患有糖尿病和周围性血管疾病，这种病人短期有较高的感染和截肢的风险，中期有较高的再次手术风险。对开放损伤和严重的踝关节骨折，中期并发症为踝关节融合或置换的几率较大。严重的踝关节骨折例如三踝骨折,与单纯的内或外踝骨折相比，翻修的比率较高。医院的差异如手术程序、知识状况及地区分布对并发症发生率没有重要的影响。有趣的是，出院后在九十天内由于肺栓塞要求再入院的比率也是非常低。 Early joint mobilization has become a commonly utilized postoperative modality following the stabilization of shoulder and elbow injuries. Despite its common application in the upper extremity, the value of early joint motion following operative fixation of ankle fractures is unclear. Thomas et al. performed a systematic review of the literature seeking evidence to support either early ankle motion or cast immobilization as the preferred postoperative treatment following open reduction and internal fixation of an ankle fracture4. Their meta-analysis included nine randomized controlled trials comparing postoperative treatment in a nonremovable cast with early motion of the ankle joint. Outcomes according to the Olerud and Molander score were significantly improved in the early motion group at six weeks; however, no significant benefit remained at one year. Early motion was associated with a quicker return to work on the average and with a trend toward a lower risk of deep venous thrombosis but was also associated with an increased risk of wound infection. The results of that meta-analysis suggest that early motion may improve short-term function and allow earlier return to work at the cost of increasing the risk of wound infection. The postoperative regimen that is implemented remains a clinical decision that the surgeon must make on the basis of patient-related factors. 如果合并肩膀和肘损伤是稳定的，早期关节活动已经成为手术后的的常规。尽管活动的部位在上肢，遵循手术的固定后的早期关节运动的价值是不清楚的。Thomas等人对文献进行了回顾，试图找到踝关节骨折切开复位内固定术后支持早期活动或石膏固定的证据。他们的meta分析包括九个随机化的控制试验进行比较踝关节早期活动和石膏固定的治疗结果。结果按照Olerud和Molander得分评价，早期运动组在六星期效果明显；然而，一年时没有重要的差异。早期运动可以较快的恢复工作和降低深静脉血栓形成，但是增加创伤感染风险。meta分析结果建议早期运动可以改善短期的功能和允许较早地恢复工作，但是要以增加创伤感染风险为代价。手术后的治疗应根据临床的决定执行，必须是有利于病人的相关因素。 Calcaneal Fractures 跟骨骨折 Delayed subtalar arthrodesis frequently is required for salvage treatment in cases of symptomatic subtalar arthritis and foot deformity resulting from displaced intra-articular calcaneal fractures, irrespective of the manner in which the calcaneal fracture was initially treated. Radnay et al. investigated whether outcomes following subtalar arthrodesis were influenced by initial treatment of the calcaneal fracture with either open reduction and internal fixation or nonoperative treatment5. Seventy-five fractures with symptomatic posttraumatic subtalar arthritis were retrospectively reviewed. Thirty-six fractures that were initially treated with operative fixation at their institution were compared with thirty-nine fracture malunions that initially were treated nonoperatively at an outside institution. In the subgroup initially treated with fracture fixation, the subtalar arthrodesis procedure was performed through an extensile lateral approach with removal of hardware, débridement of joint cartilage, and in situ fusion with allograft cancellous bone chips and 8.0-mm cannulated cancellous lag screws. In the malunion subgroup, subtalar arthrodesis was approached in a similar fashion, with the addition of a lateral wall exostectomy with or without a Dwyer-type calcaneal osteotomy for the correction of deformity. Better functional outcomes and fewer wound complications were found in the subgroup receiving subtalar fusion after initial open reduction and internal fixation of the displaced intra-articular calcaneal fracture. The authors concluded that initial open reduction and internal fixation of the fracture restores calcaneal shape, alignment, and height, which improves outcomes and facilitates future subtalar arthrodesis procedures that may be required to treat subtalar arthritis. 不管跟骨关节内骨折的初始治疗是何种选择，一旦有症状的距下关节炎和足畸形，经常地需要的进行二期的距下关节固定术。Radnay等人研究研究跟骨骨折初期治疗是切开复位内固定还是非手术的治疗对二期距下关节固定术的结果是否有影响。回顾性研究75例创伤后的距下关节炎症状的跟骨骨折。三十六个骨折最初治疗使用手术固定在本单位，而三十九最初治疗使用非手术治疗骨折畸形愈合在其它单位。最初治疗使用手术的一组，距下关节固定术程序是施行扩大外侧入路，清理关节软骨,原位使用同种异体移植松质骨碎片融合，并拧入松质骨方头螺钉。在这骨折畸形愈合一组，距下关节固定术入路是类似的，外加一外侧壁切除术有或者没有Dwyer类型畸形矫正术的跟骨截骨。跟骨关节内移位骨折初始的切开复位内固定组距骨下的融合后功能更好，并发症发生更少。作者作结论初始的切开复位内固定修复了跟骨形状、力线和高度，对二期距下关节固定术结果更优良。 Percutaneous screw fixation of calcaneal fractures has gained momentum as a means to mitigate the potential wound complications associated with lateral plating through an extensile surgical approach. In a biomechanical cadaver model, Smerek et al. created Sanders type-2B calcaneal fractures in ten pairs of specimens6. Ten fractures were stabilized with a titanium perimeter plate (DePuy, Warsaw, Indiana) that was contoured to the lateral calcaneal cortex and secured with eight 3.5-mm titanium cortex screws. The other ten specimens were stabilized with a standardized percutaneous screw configuration consisting of two 4.0-mm titanium partially threaded screws fixing the posterior facet, two 6.5-mm titanium cannulated partially threaded screws securing the posterior tuberosity to the anterior process, and one 4.0-mm titanium cannulated fully threaded "rafting" screw inserted from the plantar-lateral aspect of the posterior tuberosity to the subchondral surface of the posterior facet fragment. Biomechanical testing demonstrated that the mean load to failure and construct stiffness did not differ significantly between the two fixation groups. The specimens in the plate fixation group most commonly failed by means of pullout of screws from the constant fragment, whereas the specimens in the percutaneous fixation group most commonly failed by means of pullout of the two 6.5-mm cannulated screws from the anterior process fragment. These results suggest that percutaneous screw fixation of Sanders type-2B fractures has comparable strength in comparison with standard perimeter plating. Percutaneous techniques hold promise for being a reliable alternative to the extensile lateral surgical approach and may aid in reducing the rate of wound complications associated with open surgical treatment of these fractures. 经皮固定跟骨骨折明显可以减少经外侧入路放置外侧钢板所带来的并发症。smerek等人在10具尸体的生物力学模型上，制造了Sanders 2B类型跟骨骨折。其中10例骨折使用钛合金钢板（DePuy华沙印地安那州）放于跟骨的外侧，使用8枚螺钉进行恰当的固定。另10个跟骨折标本使用标准化经皮螺钉固定，包括2枚4.0部分螺纹钛合金螺丝钉固定后关节面，2枚6.5 - mm部分螺纹钛合金空心螺钉经后部结节固定前部的突起，一枚4.0 - mm钛合金全螺纹空心螺钉从足底后部结节的外侧面到软骨表面下的后侧骨碎片。生物力学试验论证固定失败的平均负荷与牢固性两组没有差别。钢板固定组通常是由于骨碎片的拔钉导致固定失败，而经皮组失败的原因是2枚6.5 mm空心螺钉从前部的突起的骨碎片拔钉。这些结果表明经皮螺钉固定Sanders 2B类型骨折与标准环形钢板固定相差无几。为了减少外侧手术入路钢板固定所带来的伤口的并发症，经皮固定是一个不错的选择。 Weber et al., in a retrospective review of their experience with the treatment of Sanders type-2 and type-3 calcaneal fractures, compared outcomes following lateral plating through an extensile approach with those following the use of a limited-incision technique with percutaneous fixation7. The limited-incision technique involved a short lateral subtalar incision with percutaneous manipulation of the posterior tuberosity with use of a Schanz pin and manual disimpaction of the fracture fragments. The fracture fragments were fixed with transverse screws across the posterior facet and percutaneous screws directed from the posterior tuberosity into the anterior process and the subchondral bone of the posterior facet. Compared with lateral plating through the standard extensile lateral incision, the limited-incision technique resulted in a significant reduction in operating time, saving an average of fifty-two minutes per operation, while producing equivalent fracture alignment and joint reduction as judged clinically and radiographically. The extended approach and lateral plating resulted in more wound-healing complications and more cases of postoperative complex regional pain syndrome. Interestingly, the limited open approach required a higher number of subsequent minor procedures to remove symptomatic hardware. These results lend further support to fixation of calcaneal fractures through limited or percutaneous means in order to minimize potential wound complications and to reduce the prolonged surgical time associated with lateral plating through an extensile lateral approach. 韦伯等人对他们治疗的sander２型和３型的病人进行了回顾性研究，把可延长的外侧入路钢板治疗与有限切口经皮固定的方法进行了比较。有限切开的方法是通过距下关节外侧的短切口，经皮Schanz钉操作后部结节，直视下处理骨折。骨折碎片使用横向螺丝钉交叉固定后部关节面，经皮螺钉通过后部结节进入前部的突起和后部关节面的软骨下。与标准外侧扩大切口的钢板固定相比，有限切开方法明显减少操作时间，平均每一手术节约五十二分钟，而通过临床上和影像学的判断骨折的固定复位并没有不同。外侧钢板的扩大入路会导致更多伤口愈合并发症及手术后的局部疼痛综合症。有趣地是，很多有限切口的病人不是由于产生症状要求取出内固定。这些结果更多的支持经皮固定跟骨骨折，不仅使伤口并发症最小化，而且减少扩大外侧入路外侧钢板固定术的时间。 Lisfranc Joint Injury跗跖关节的损伤 Investigational attempts to develop a cadaver model recreating Lisfranc joint injuries have concentrated on tarsometatarsal fracture dislocations and severe Lisfranc variants. In two related experiments, Panchbhavi et al. sought to develop a reliable cadaver model to produce diastasis characteristic of ligamentous Lisfranc injuries in order to subsequently test different fixation techniques8,9. In the first experiment, a digitizer was used to record the three-dimensional position of screws placed into both the medial cuneiform and the base of the second metatarsal. The cadaver specimens were then loaded through the metatarsals with a force equal to half body weight with the ankle in 30° of plantar flexion before and after transection of the Lisfranc ligament. With this experimental setup, the authors were able to reliably create detectable displacement similar to the diastasis that is clinically observed in association with ligamentous Lisfranc injuries. In a second well-designed experiment, simulated cadaver Lisfranc injuries were stabilized either with a 3.5-mm-diameter cannulated screw or with a suture button (TightRope repair kit; Arthrex, Naples, Florida). Biomechanical testing demonstrated no significant difference in Lisfranc ligament displacement between the two fixation techniques. With equivalent fixation strength, the suture button may offer a more physiologic and nonrigid stabilization technique that may eliminate the need for subsequent hardware removal. These advantages of the suture button, however, may be offset by its significantly higher price in comparison with cannulated screws as well as by the paucity of evidence demonstrating its clinical efficacy. 调查研究利用尸体模型再造跖跗关节损伤，集中于跗跖的骨折脱位和严重的跖跗骨的变形。在两个有关实验中，Panchbhavi等人制造了一个可靠的尸体模型，其特点是合并韧带断裂的跖跗骨损伤，为了测试不同固定方法的效果。第一个实验中，使用数字转换器记录内侧楔骨和第二跖骨螺钉的立体的位置。尸体样品在跖跗关节韧带横切后踝关节跖屈30°，使用等同于身体一半的重量作用于跖骨。分离使用这个实验设备，作者能可靠地创造可检测的位移，类似于临床上相联系的跖跗骨损伤伴有韧带的损伤。在第二个得很好的实验中，模拟尸体跖跗关节损伤是稳定的，使用3.5 mm空心螺钉或者缝合钮扣。生物力学的测试论证了两个固定方法之间没有显著差异。用相等的固定力量，缝合钮扣可以提供更好的生理稳定性，还可以不用除去内固定。然而，缝合钮扣的这些优势与空心螺钉比较，它较高的价格和缺乏临床上的疗效证据可能会使应用大打折扣。 Detecting midfoot instability following subtle Lisfranc injury historically has presented a diagnostic challenge. Weight-bearing radiographs producing a diastasis of 2 mm between the second metatarsal base and the medial cuneiform previously has been advanced as the imaging definition of instability; however, the examination is often limited by pain. Manual stress radiographic evaluation with the patient under anesthesia has therefore become the more accurate determinant of midfoot instability. Raikin et al. performed a retrospective investigation demonstrating the accuracy of magnetic resonance imaging for the detection of traumatic injury of the Lisfranc ligament and for the prediction of Lisfranc joint complex instability10. Twenty-one Lisfranc injuries were evaluated with magnetic resonance imaging, and instability was confirmed through manual stress radiography with the patient under anesthesia. Magnetic resonance imaging correctly diagnosed 94% of the injuries as being either stable or unstable on the basis of the integrity of the plantar Lisfranc ligament, corresponding with a sensitivity of 94% and a specificity of 75%. All evaluations with weight-bearing radiographs were limited by pain and failed to produce a diastasis of 2 mm between the medial cuneiform and the second metatarsal base. These results suggest that magnetic resonance imaging is both an accurate modality to diagnose traumatic Lisfranc ligament injury and an accurate predictor of the resultant midfoot instability. 细微跖跗关节损伤导致中足不稳定