Swart Eric F, Vosseller J Turner
Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Columbia University Medical Center, 622 West 168th Street, PH-11, New York, NY, 10032, USA.
Arch Orthop Trauma Surg. 2014 Sep;134(9):1287-92. doi: 10.1007/s00402-014-2031-7. Epub 2014 Jun 14.
Ankle fractures treated with open reduction internal fixation are fixed in an effort to reestablish anatomic bony alignment and avoid a malunion, thereby diminishing the risk of post-traumatic arthritis. For a medial malleolar fracture, an articular step-off is likely more related to the risk of post-traumatic arthritis than is a cortical step-off. However, the external cortical alignment is often used to judge the adequacy of reduction, as the articular component of the fracture is not as readily visualized. Arthroscopy has been used in various articular fractures as an aid to diagnosis and treatment. The current study prospectively assessed both the quality of medial malleolar reduction on the articular side using arthroscopy and the adequacy of using cortical cues to guide the articular reduction.
Twelve consecutive patients were enrolled in this prospective diagnostic study. All patients had medial malleolar fractures that required fixation. The outcome variables of interest were extra-articular fracture displacement and articular surface displacement.
After reduction and provisional fixation, 10 of the 12 patients had an anatomic reduction based on cortical cues. On arthroscopy 7 of the 12 patients had an anatomic reduction. Four of the patients had a slight gap (<1 mm) at the anterior edge of the fracture. The last patient had an anterior gap just under 2 mm. Two patients had impaction of the medial malleolus that made reduction difficult and was recognized during arthroscopy after obtaining a reduction based on cortical cues.
The cortical reduction of the medial malleolus often matched up with the articular reduction. However, in some patients, impaction of the medial malleolus made it so that the two did not match up. There are some cases in which extra-articular cues are insufficient to evaluate for intra-articular reduction.
采用切开复位内固定治疗踝关节骨折，目的是重建解剖学骨对线并避免畸形愈合，从而降低创伤后关节炎的风险。对于内踝骨折，关节面台阶移位可能比皮质骨台阶移位更易导致创伤后关节炎。然而，由于骨折的关节部分不易可视化，外部皮质骨对线常被用于判断复位的充分性。关节镜已被用于各种关节骨折的诊断和治疗辅助。本研究前瞻性地评估了使用关节镜观察内踝关节侧复位质量以及利用皮质骨线索指导关节复位的充分性。
12例连续患者纳入本前瞻性诊断研究。所有患者均有需要固定的内踝骨折。感兴趣的结局变量为关节外骨折移位和关节面移位。
复位并临时固定后，12例患者中有10例根据皮质骨线索实现了解剖复位。关节镜检查显示，12例患者中有7例实现了解剖复位。4例患者在骨折前缘有轻微间隙（<1mm）。最后1例患者前缘间隙略小于2mm。2例患者内踝有嵌插，导致复位困难，在根据皮质骨线索复位后关节镜检查时被发现。
内踝的皮质骨复位通常与关节复位相符。然而，在一些患者中，内踝嵌插导致两者不相符。在某些情况下，关节外线索不足以评估关节内复位情况。
