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JBJS:单纯胫腓螺钉固定旋前外旋踝关节骨折长期疗效良好

2013-09-25 佚名 丁香园

早在1840年,法国医生Maisonneuve描述了一种踝关节骨折,腓骨骨折位于近端,下胫腓联合韧带断裂,三角韧带撕裂。这类踝关节骨折并不少见,虽然相关的文献报道不多。1976年,Pankovich首先报道了一组Maisonneuve踝关节骨折病例的研究结果。 从最近的文献报道来看,大多数学者都主张Maisonneuve骨折应该进行手术治疗。大多数术者都认为腓骨近端的

早在1840年,法国医生Maisonneuve描述了一种踝关节骨折,腓骨骨折位于近端,下胫腓联合韧带断裂,三角韧带撕裂。这类踝关节骨折并不少见,虽然相关的文献报道不多。1976年,Pankovich首先报道了一组Maisonneuve踝关节骨折病例的研究结果。

从最近的文献报道来看,大多数学者都主张Maisonneuve骨折应该进行手术治疗。大多数术者都认为腓骨近端的骨折不需要进行切开复位内固定。但这一点并没有1级证据支持。此外,除非后踝骨折固定以后下胫腓联合稳定性良好,否则都应该用1或2枚螺钉固定下胫腓联合。

然后,目前并没有研究报道Maisonneuve骨折的长期随访结果。为此,荷兰阿姆斯特丹大学医学中心Lambers教授等进行了一项长期随访研究,评价单纯下胫腓联合螺钉固定Maisonneuve踝关节骨折的功能以及影像学结果,并通过双变量和多变量回归分析确定相关的预测因子,该研究结果发表在2013年9月4日出版的JBJS杂志上。【原文下载】

从1974年至2002年,在作者所在的1级创伤中心共有117例旋前外旋型踝关节骨折单纯应用1枚或2枚下胫腓联合螺钉进行固定。其中16例患者死亡,1例患有精神疾病,1例由于其他原因进行了截肢。剩下99例可以进行长期随访,但14例由于移民等原因失去联系,35例由于拒绝或其他原因不同意常见研究。最终作者对50例(50%)患者进行了前瞻性研究。

平均随访21年(9-35年),评价的指标包括:(1)足踝功能评分(Foot and Ankle Ability Measure, FAAM);(2)美国骨科足踝外科协会(AOFAS)踝-后足评分;(3)流行病调查中心抑郁量表(Center for Epidemiologic Studies-Depression, CES-D)。另外,在标准的双侧踝关节正侧位片上,用van Dijk骨关节炎评分和改良Takakura评分评价其骨关节炎的严重程度。

术后平均8周在局麻下取出下胫腓联合螺钉。

结果发现,48例患者中44例(92%)AOFAS评分结果优良;49例患者中44例(90%)FAAM评分结果优良。2例患者由于严重的骨关节炎进行了融合手术。49例患者中有24例(49%)在影像学图片上有明显的骨关节炎。

多变量分析显示,疼痛是踝关节长期功能(AOFAS评分和FAAM评分)最主要的独立的预测因子,能够分别解释评分结果中91%和53%的变异。在双变量分析中,将疼痛作为因变量进行分析时显示,抑郁、踝关节活动度以及后续的手术等都与较高的疼痛评分明显相关。

作者的结论认为,旋前外旋型踝关节骨折单纯采用1或2枚下胫腓联合螺钉进行固定,大多数患者平均21年时的长期功能结果为优良,虽然半数的患者在影像学上有骨关节炎的征象。对于长期功能结果而言,患者主观的疼痛是最重要的预测因子,而不是客观的功能评分或创伤后骨关节炎。此外,影像学上的创伤性关节炎与疼痛没有明显的相关性。


原文下载

Lambers KT, van den Bekerom MP, Doornberg JN, Stufkens SA, van Dijk CN, Kloen P.Long-term outcome of pronation-external rotation ankle fractures treated with syndesmotic screws only.J Bone Joint Surg Am 2013 Sep .


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    2013-09-27 qilu_qi
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    2013-09-27 qingrejiedu
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