Miller Matthew A, McDonald Tyler C, Graves Matthew L, Spitler Clay A, Russell George V, Jones LaRita C, Replogle William, Wise Jeremy A, Hydrick Josie, Bergin Patrick F
1 Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS, USA.
Foot Ankle Int. 2018 Jan;39(1):99-104. doi: 10.1177/1071100717735839. Epub 2017 Oct 23.
We sought to define the rate of syndesmotic instability after anatomic reduction of the posterior malleolus when posterior stabilization of a trimalleolar or trimalleolar equivalent ankle fracture was chosen vs when a supine position and initially conservative management of the posterior elements was chosen.
The types of syndesmotic and posterior malleolar fixation used to treat adult patients with ankle fractures involving the posterior malleolus at our level I trauma center were retrospectively assessed (N = 198). Specifically, both bimalleolar and trimalleolar fractures were included. Exclusion criteria included pilon fractures, trimalleolar fractures with Chaput fragments, and neurologic injury. Demographics, fracture classification, initial operative position, medial clear space, and posterior malleolar fragment size were recorded for each fracture.
In total, 151 patients (76.3%) were initially positioned supine, 27.2% of whom had syndesmotic instability requiring operative stabilization. Almost 25% of supine patients also underwent posterior malleolar stabilization for posterior instability. Overall, 73 (48.3%) patients who were initially treated in the supine position needed some form of additional stabilization. Forty-seven patients (23.7%) were initially positioned prone. Syndesmotic stability was restored in 97.9% of these patients. This 2.1% rate of instability vastly differs from the 13-fold higher syndesmotic instability rate observed in the supine group ( P < .001).
Our data demonstrate that the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent fractures when prone positioning and direct fixation of the posterior malleolus were first performed. Using traditional preoperative estimates of posterior stability to determine the need for posterior malleolar fixation may be inadequate since almost a quarter of patients treated supine received posterior stabilization.
Level III, retrospective comparative series.
我们试图确定在选择对三踝或三踝等效踝关节骨折进行后方稳定固定时，与选择仰卧位并对后方骨折块进行初始保守治疗相比，后踝解剖复位后下胫腓联合不稳定的发生率。
回顾性评估在我们一级创伤中心治疗的涉及后踝的成人踝关节骨折患者（N = 198）所采用的下胫腓联合和后踝固定类型。具体包括双踝和三踝骨折。排除标准包括Pilon骨折、带有Chaput骨折块的三踝骨折和神经损伤。记录每例骨折的人口统计学资料、骨折分类、初始手术体位、内侧间隙及后踝骨折块大小。
总共151例患者（76.3%）初始采用仰卧位，其中27.2%存在下胫腓联合不稳定需要手术稳定。几乎25%的仰卧位患者也因后方不稳定而进行了后踝稳定固定。总体而言，最初采用仰卧位治疗的73例患者（48.3%）需要某种形式的额外稳定固定。47例患者（23.7%）初始采用俯卧位。这些患者中下胫腓联合稳定性恢复的比例为97.9%。这2.1%的不稳定发生率与仰卧位组观察到的高13倍的下胫腓联合不稳定发生率有很大差异（P < .001）。
我们的数据表明，对于三踝及三踝等效骨折，先行俯卧位及后踝直接固定可降低下胫腓联合不稳定的发生率。由于几乎四分之一仰卧位治疗的患者接受了后方稳定固定，因此使用传统术前对后方稳定性的评估来确定是否需要后踝固定可能并不充分。
三级，回顾性比较系列研究。
