Zhong Sheng, Shen Lin, Zhao Jia-Guo, Chen Jie, Xie Jin-Feng, Shi Qi, Wu Ying-Hua, Zeng Xian-Tie
Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
Department of Foot and Ankle Surgery, Tianjin Hospital, Tianjin, China.
Orthop Surg. 2017 Feb;9(1):69-76. doi: 10.1111/os.12308.
To compare clinical and radiographic outcomes of posterior malleolar fractures (PMF) treated with lag screws from anterior to posterior versus posterior to anterior approach.
We retrospectively analyzed 48 patients with trimalleolar fractures who underwent open reduction and internal fixation (ORIF) with either posteromedial (PM) or posterolateral (PL) approaches between January 2012 and December 2014. Fixation of the posterior malleolus was made with anteroposterior screws in 20 patients using the PM approach and posteroanterior screws in 28 patients using the PL approach. The American Orthopedic Foot and Ankle Society (AOFAS) scores and range of motion (ROM) of the ankle were used as the main outcome measurements, and results were evaluated at the 6-month, 12-month and final follow-up. Postoperative radiographs and computed tomography scans were used to evaluate the residual gap/step-off. The degree of arthritis was evaluated on final follow-up using Bargon criteria. Other complications were also recorded to compare the clinical outcomes of the two approaches.
The mean duration of follow-up regardless of the approaches was 21.1 months (range, 15-54 months). None of the patients developed delayed union or nonunion. Functional bone healing was obtained in all patients at 10.7 weeks (range, 8-16 weeks). The mean AOFAS scores of the PM group at the postoperative 6-mouth, 12-month, and final follow-up were 91.4 (range, 82-100), 92.5 (range, 84-100), and 92.9 (range, 86-100), respectively. In the PL group, the mean AOFAS scores were 89.9 (range, 72-100), 91.4 (range, 77-100), and 91.9 (range, 77-100), respectively. At the final follow-up, the median loss of range of motion (ROM) for dorsiflexion and plantaflexion were 0°(0°, 5°) and 0°(0°, 0°), respectively, in both groups. There were no significant differences between the two approaches in AOFAS scores and ROM of the ankle in each period postoperatively (P > 0.05). Two patients in the PL group and 1 in the PM group developed Bargon grade 2 or 3 arthritis. We detected a 2-mm and 3-mm step-off in 1 patient in the PM and PL groups, respectively.
Satisfactory results were obtained by using the two approaches for fixation of posterior malleolus, and the approaches have similar clinical and radiographic outcomes. Surgeons should choose the appropriate approach based on their experience.
比较经前向后与经后向前入路拉力螺钉治疗后踝骨折（PMF）的临床和影像学结果。
我们回顾性分析了2012年1月至2014年12月期间接受切开复位内固定术（ORIF）的48例三踝骨折患者，手术采用后内侧（PM）或后外侧（PL）入路。20例采用PM入路的患者经前向后螺钉固定后踝，28例采用PL入路的患者经后向前螺钉固定后踝。以美国矫形足踝协会（AOFAS）评分和踝关节活动范围（ROM）作为主要结局指标，并在6个月、12个月和末次随访时进行评估。术后X线片和计算机断层扫描用于评估残余间隙/台阶。末次随访时采用Bargon标准评估关节炎程度。还记录了其他并发症以比较两种入路的临床结果。
无论采用何种入路，平均随访时间为21.1个月（范围15 - 54个月）。所有患者均未发生延迟愈合或不愈合。所有患者均在10.7周（范围8 - 16周）实现了功能性骨愈合。PM组术后6个月、12个月和末次随访时的平均AOFAS评分分别为91.4（范围82 - 100）、92.5（范围84 - 100）和92.9（范围86 - 100）。PL组的平均AOFAS评分分别为89.9（范围72 - 100）、91.4（范围77 - 100）和91.9（范围77 - 100）。末次随访时，两组背屈和跖屈活动范围（ROM）的中位数丢失分别为0°（0°，5°）和0°（0°，0°）。两种入路在术后各时期的AOFAS评分和踝关节ROM方面均无显著差异（P > 0.05）。PL组有2例患者和PM组有1例患者发生Bargon 2级或3级关节炎。我们在PM组和PL组分别检测到1例患者有2 mm和3 mm的台阶。
两种入路固定后踝均取得了满意的结果，且两种入路的临床和影像学结果相似。外科医生应根据自身经验选择合适的入路。
