Beltran Michael J, Mitchell Phillip M, Collinge Cory A
Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, San Antonio, TX, USA.
Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN, USA.
Foot Ankle Int. 2016 Oct;37(10):1130-1136. doi: 10.1177/1071100716655434. Epub 2016 Jun 23.
Screws placed from posterior to anterior have been shown to be biomechanically and anatomically superior in the fixation of talar neck and neck-body fractures, yet most surgeons continue to place screws from an anterior start point. The safety and efficacy of percutaneously applied posterior screws has not been clinically defined, and functional outcomes after their use is lacking.
After institutional review board approval, we performed a retrospective review of 24 consecutive talar neck fractures treated by a single surgeon that utilized posterior-to-anterior screw fixation. Clinical, radiographic, and functional outcomes were assessed at a minimum follow-up of 12 months. Functional outcomes including the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Olerud-Molander Scores, and the Short Form 36 (SF-36) measurement were collected and reviewed. Average patient follow-up was 44 months.
According to the classification system of Canale and Kelly, there were 4 type I fractures, 15 type II fractures, 4 type III fractures, and 1 type IV fracture. Four patients had open fractures. One superficial wound infection occurred, 1 patient reported FHL stiffness, and 6 complained of numbness or paresthesias in the distribution of the sural nerve (5 transient, 1 permanent). One reoperation was required to exchange a screw impinging on the talonavicular joint. Radiographically, 44% developed a positive Hawkins sign, and the specificity of this finding was 100% for talar dome viability. Avascular necrosis developed in 43% of patients, with 33% revascularizing and none going on to collapse. Subtalar arthrosis developed in 62% of patients.
Screws placed from posterior to anterior are a useful technique in the treatment of talar neck fractures. Functional outcomes following their use appear favorable compared with recent reports with minimal risk to local structures.
Level IV, retrospective case series.
从后向前置入螺钉已被证明在距骨颈及颈体骨折的固定中在生物力学和解剖学上更具优势，但大多数外科医生仍从前侧起始点置入螺钉。经皮应用后侧螺钉的安全性和有效性尚未在临床上得到明确界定，且缺乏使用后侧螺钉后的功能结局相关报道。
经机构审查委员会批准后，我们对一位外科医生连续治疗的24例距骨颈骨折病例进行了回顾性研究，这些病例均采用了从后向前的螺钉固定。在至少12个月的随访期内评估临床、影像学和功能结局。收集并分析了包括美国矫形足踝协会（AOFAS）后足评分、奥勒鲁德 - 莫兰德评分以及简明健康状况调查量表（SF - 36）测量结果在内的功能结局。患者平均随访时间为44个月。
根据卡纳尔和凯利的分类系统，有4例I型骨折、15例II型骨折、4例III型骨折和1例IV型骨折。4例患者为开放性骨折。发生1例表浅伤口感染，1例患者报告拇长屈肌僵硬，6例患者抱怨在腓肠神经分布区域有麻木或感觉异常（5例为短暂性，1例为永久性）。有1例需要再次手术以更换一枚撞击距舟关节的螺钉。影像学检查显示，44%出现了阳性霍金斯征，该发现对于距骨穹窿存活的特异性为100%。43%的患者发生了缺血性坏死，其中33%实现了再血管化，且无一例发生塌陷。62%的患者出现了距下关节骨关节炎。
从后向前置入螺钉是治疗距骨颈骨折的一种有用技术。与近期报道相比，使用后侧螺钉后的功能结局似乎较好，且对局部结构的风险最小。
IV级，回顾性病例系列。
