Zídek T, Urban J, Holub K, Peml M, Kloub M
Oddělení úrazové chirurgie Nemocnice České Budějovice, a.s.
Acta Chir Orthop Traumatol Cech. 2019;86(2):141-146.
PURPOSE OF THE STUDY The purpose of the study was to assess two therapeutic procedures of temporary fixation of displaced ankle fractures, namely the plaster fixation or Kirschner wire (KW) transfixation via the sole of the foot. MATERIAL AND METHODS Group of patients The randomised prospective study conducted in the period 02/2016-02/2017 compared two methods of temporary fixation of displaced ankle fractures. In total, 38 patients were included in the study (18 patients treated with plaster fixation, 20 patients treated with KW). Methods During the randomisation (by envelopes, drawing of lots by the patient), in one group of patients, temporary stabilisation by plaster fixation was performed, whereas the other group was treated by percutaneously inserted KWs. The attention was focused on the quality of achieved reduction, its retention until the final treatment, and soft tissue status. After one year, the final examination was performed, in which we focused on the assessment of the clinical condition of the ankle joint with the use of the Olerud-Molander Ankle Score (OMAS), the AOFAS (American Orthopedic Foot and Ankle Society) score, and the Visual Analogue Scale (VAS) measuring the overall satisfaction. Moreover, in both the methods potential incidence of arthritic changes was monitored on radiographs. RESULTS Both the methods achieved 100% successful reduction rate. The group with plaster fixation reported a loss of reduction in six patients (33.3%) as against the KW group where no loss of reduction occurred. This difference was significant (p = 0.007). In plaster fixation method, after its removal local complications occurred on skin in 56%, of which skin necrosis in 16.7%, and it always occurred in association with the loss of reduction, which was statistically significant (p = 0.245). In KW method, local complications on skin were present in 25% only. In the group of patients with KW, there was not a single case of surface or deep infection reported. No KW migration was observed. DISCUSSION Potential complications of conservative treatment of displaced fractures with plaster fixation include the migration of fragments and widening of the ankle fork during the further course which may threaten the vitality of soft tissues. A total of six patients (33.3%) treated with plaster fixation showed a failure of reduction, which is by approximately 10% more than described in literature. In seven cases after the plaster fixation removal bullae were observed (38.9%) and in three cases skin necrosis was present (16.7%), which occurred in re-displaced fractures only. The bullae were present whether the reduction was successfully maintained or not. In literature, local complications after plaster fixation removal are reported in roughly 14%. Temporary percutaneous ankle KW transfixation is applied to maintain the reduced fracture in a favourable position and to facilitate monitoring and treating the soft tissues. Prior to the final surgical solution, bullae were observedin four cases (20%), of which skin necrosis in one case (5%). Bullae formation and necrosis are most likely related to the initial damage to soft tissues due to the injury and were not caused by the KW insertion. The literature describes local complications in 7% with respect to the KW technique, however, the type of complications is not specified. In our group, at a one-year follow-up arthritic changes grade I and II according to Kellgren and Lawrence scale were reported in 70% of cases with KW technique. Whether the osteoarthritis was caused by fixation or the fracture itself and what would be the percentage of individual types of osteoarthritis after several years of follow-up is a question. CONCLUSIONS Plaster fixation or Kirschner wires for temporal fixation of displaced ankle fractures shall be applied on a case by case basis. Based on our findings, the application of plaster fixation to displaced ankle fractures does not provide adequate stability of the reduced fracture and in case of re-displacement the status of soft tissues deteriorates. The impossibility to control the status of soft tissues in plaster fixation and the lower complication rate in fixation with K wires constitute additional reasons why this fixation technique via the sole of the foot appears to reap more benefits. Key words:displaced ankle fractures, temporal fixation, plaster fixation, Kirschner wire transfixation, complications.
研究目的 本研究的目的是评估两种用于移位踝关节骨折临时固定的治疗方法，即石膏固定或经足底克氏针（KW）固定。
材料与方法
患者组 在2016年2月至2017年2月期间进行的随机前瞻性研究比较了两种移位踝关节骨折临时固定方法。共有38例患者纳入研究（18例接受石膏固定治疗，20例接受KW治疗）。
方法 在随机分组过程中（通过信封，由患者抽签），一组患者采用石膏固定进行临时稳定，而另一组则采用经皮插入KW治疗。重点关注复位质量、直至最终治疗时复位的维持情况以及软组织状况。一年后进行最终检查，我们重点使用奥勒鲁德 - 莫兰德踝关节评分（OMAS）、美国矫形足踝协会（AOFAS）评分以及测量总体满意度的视觉模拟量表（VAS）评估踝关节的临床状况。此外，两种方法均通过X线片监测关节炎改变的潜在发生率。
结果 两种方法均实现了100%的成功复位率。石膏固定组有6例患者（33.3%）出现复位丢失，而KW组未出现复位丢失。这种差异具有统计学意义（p = 0.007）。在石膏固定方法中，去除石膏后56%的患者出现局部皮肤并发症，其中16.7%为皮肤坏死，且总是与复位丢失相关，具有统计学意义（p = 0.245）。在KW方法中，仅25%的患者出现局部皮肤并发症。在KW治疗的患者组中，未报告有浅表或深部感染病例。未观察到KW移位。
讨论 石膏固定保守治疗移位骨折的潜在并发症包括在后续过程中骨折块的移位和踝关节叉的增宽，这可能威胁软组织的活力。共有6例（33.3%）接受石膏固定治疗的患者出现复位失败，这比文献报道的高出约10%。在去除石膏后，7例患者（38.9%）观察到水疱，3例患者（16.7%）出现皮肤坏死，且仅发生在再移位骨折中。无论复位是否成功维持，均出现水疱。文献报道去除石膏后的局部并发症约为14%。临时经皮踝关节KW固定用于将复位的骨折维持在有利位置，并便于监测和治疗软组织。在最终手术解决方案之前观察到4例（20%）水疱，其中1例（5%）出现皮肤坏死。水疱形成和坏死最可能与损伤导致的软组织初始损伤有关，而非由KW插入引起。文献报道KW技术的局部并发症为7%，但未明确并发症类型。在我们的研究组中，在KW技术治疗的病例中，根据凯尔格伦和劳伦斯量表，70%的患者在一年随访时出现I级和II级关节炎改变。骨关节炎是由固定引起还是由骨折本身引起，以及经过数年随访后各种类型骨关节炎的百分比是多少，这是一个问题。
结论 对于移位踝关节骨折的临时固定，应根据具体情况应用石膏固定或克氏针。根据我们的研究结果，对移位踝关节骨折应用石膏固定不能为复位后的骨折提供足够的稳定性，并且在发生再移位时软组织状况会恶化。石膏固定无法控制软组织状况以及KW固定较低的并发症发生率构成了经足底这种固定技术似乎更具优势的额外原因。
移位踝关节骨折；临时固定；石膏固定；克氏针固定；并发症
