Guo Jialiang, Liu Lei, Yang Zongyou, Hou Zhiyong, Chen Wei, Zhang Yingze
Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, People's Republic of China.
Key Laboratory of Orthopaedic Biomechanics of Hebei Province, Shijiazhuang, 050051, People's Republic of China.
Int Orthop. 2017 Sep;41(9):1935-1943. doi: 10.1007/s00264-016-3388-8. Epub 2017 Jan 10.
The posterior malleolar fracture (PMF) in tibial spiral fractures are a common type of complication that occurs in tibial fractures. However, the indication of fixation for posterior fractures is still under debate and varies between different surgeons'. It is not unusual to find the smaller PMF (<25%), which could be treated conservatively within guidelines, treated with internal fixation in clinic. The aim of this study is to evaluate the clinical outcomes of tibial spiral fractures with PMF and provide proper guidance for the treatment of this special fracture.
A total of 284 cases of spiral fractures combined with PMF were collected and analyzed. Demographic data, fragment size (classified by 25% involvement of ankle joint), time to weight-bearing and functional scores post-operatively were recorded. The ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society (AOFAS), a visual analogue scale (VAS) pain score, assessment of dorsiflexion restriction and arthritis scale were used as the main evaluations.
Forty patients with a larger PMF (≥25%) and 72 with smaller ones (<25%) were fixed and categorized as the fixation group (FG). In the nonfixation group (NG), the corresponding numbers were four and 168 patients respectively. A total of 279 PMF were classified as large posterolateral triangular fragment carrying the posterior half of the fibular notch and intra-incisural posterolateral fragment involving one-fourth to one-third of the fibular notch. However, no obvious differences were observed in terms of the clinical outcomes in PMF involving one-fourth to one-third of the fibular notch. In the treatment of smaller PMF (<25%) of this type, there were no obvious differences in the functional outcomes between fixed (SF) and nonfixed PMF (SN).
Many patients with smaller PMFs were fixated, but functional outcomes of SF were not better than those of SN. There is no need to emphasize other factors guiding the treatment of PMF involving one-fourth to one-third of the fibular notch in spiral fractures. The traditional size of PMF may be only enough to guide the treatment of spiral fracture with PMF. But other types of PMF should still be treated considering morphology and fragment simultaneously.
胫骨螺旋骨折中的后踝骨折（PMF）是胫骨骨折常见的并发症类型。然而，后踝骨折的固定指征仍存在争议，不同外科医生的观点各异。临床中常发现较小的PMF（<25%），按指南本可保守治疗，却进行了内固定。本研究旨在评估合并PMF的胫骨螺旋骨折的临床疗效，并为这种特殊骨折的治疗提供恰当指导。
共收集并分析284例螺旋骨折合并PMF的病例。记录人口统计学数据、骨折块大小（按踝关节受累25%分类）、负重时间及术后功能评分。主要评估采用美国矫形足踝协会（AOFAS）的踝-后足评分、视觉模拟量表（VAS）疼痛评分、背屈受限评估及关节炎评分。
40例较大PMF（≥25%）和72例较小PMF（<25%）患者接受固定，归入固定组（FG）。非固定组（NG）中，相应病例数分别为4例和168例。共有279例PMF被分类为携带腓骨切迹后半部分的大后外侧三角形骨折块和累及腓骨切迹四分之一至三分之一的切迹内后外侧骨折块。然而，在累及腓骨切迹四分之一至三分之一的PMF的临床疗效方面未观察到明显差异。在治疗此类较小PMF（<25%）时，固定PMF（SF）和非固定PMF（SN）的功能结局无明显差异。
许多较小PMF患者接受了固定，但SF的功能结局并不优于SN。对于螺旋骨折中累及腓骨切迹四分之一至三分之一的PMF，无需强调其他指导治疗的因素。传统的PMF大小可能仅足以指导合并PMF的螺旋骨折的治疗。但其他类型的PMF仍应同时考虑形态和骨折块情况进行治疗。
