Warner Stephen J, Garner Matthew R, Schottel Patrick C, Hinds Richard M, Loftus Michael L, Lorich Dean G
Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA
Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA.
Foot Ankle Int. 2015 Apr;36(4):377-82. doi: 10.1177/1071100714558845. Epub 2014 Nov 3.
Reduction and stabilization of the syndesmosis in unstable ankle fractures is important for ankle mortise congruity and restoration of normal tibiotalar contact forces. Of the syndesmotic ligaments, the posterior inferior tibiofibular ligament (PITFL) provides the most strength for maintaining syndesmotic stability, and previous work has demonstrated the significance of restoring PITFL function when it remains attached to a posterior malleolus fracture fragment. However, little is known regarding the nature of a PITFL injury in the absence of a posterior malleolus fracture. The goal of this study was to describe the PITFL injury pattern based on magnetic resonance imaging (MRI) and intraoperative observation.
A prospective database of all operatively treated ankle fractures by a single surgeon was used to identify all supination-external rotation (SER) types III and IV ankle fracture patients with complete preoperative orthogonal ankle radiographs and MRI. All patients with a posterior malleolus fracture were excluded. Using a combination of preoperative imaging and intraoperative findings, we analyzed the nature of injuries to the PITFL. In total, 185 SER III and IV operatively treated ankle fractures with complete imaging were initially identified.
Analysis of the preoperative imaging and operative reports revealed 34% (63/185) had a posterior malleolus fracture and were excluded. From the remaining 122 ankle fractures, the PITFL was delaminated from the posterior malleolus in 97% (119/122) of cases. A smaller proportion (3%; 3/122) had an intrasubstance PITFL rupture.
Accurate and stable syndesmotic reduction is a significant component of restoring the ankle mortise after unstable ankle fractures. In our large cohort of rotationally unstable ankle fractures without posterior malleolus fractures, we found that most PITFL injuries occur as a delamination off the posterior malleolus. This predictable PITFL injury pattern may be used to guide new methods for stabilizing the syndesmosis in these patients.
Level IV, case series.
不稳定踝关节骨折中联合韧带的复位和稳定对于踝关节 mortise 的一致性及恢复正常胫距接触力很重要。在联合韧带中，胫腓后下韧带（PITFL）为维持联合稳定提供了最大的力量，并且先前的研究表明，当 PITFL 仍附着于后踝骨折块时，恢复其功能的重要性。然而，对于无后踝骨折时 PITFL 损伤的性质知之甚少。本研究的目的是基于磁共振成像（MRI）和术中观察描述 PITFL 损伤模式。
使用由单一外科医生手术治疗的所有踝关节骨折的前瞻性数据库，以识别所有具有完整术前踝关节正位 X 线片和 MRI 的旋后-外旋（SER）III 型和 IV 型踝关节骨折患者。排除所有有后踝骨折的患者。结合术前影像学和术中发现，我们分析了 PITFL 的损伤性质。最初共识别出 185 例接受手术治疗且有完整影像学资料的 SER III 型和 IV 型踝关节骨折。
对术前影像学和手术报告的分析显示，34%（63/185）有后踝骨折并被排除。在其余 122 例踝关节骨折中，97%（119/122）的病例中 PITFL 从后踝分层。较小比例（3%；3/122）有 PITFL 实质内破裂。
准确和稳定的联合复位是不稳定踝关节骨折后恢复踝关节 mortise 的重要组成部分。在我们大量无后踝骨折的旋转不稳定踝关节骨折队列中，我们发现大多数 PITFL 损伤表现为从后踝分层。这种可预测的 PITFL 损伤模式可用于指导这些患者联合稳定的新方法。
IV 级，病例系列。
