Zylinski A, Grossterlinden L
Zentrum für Orthopädie, Unfall- und Wirbelsäulenchirurgie, Asklepios Klinik Altona, Paul-Ehrlich-Straße 1, 22763, Hamburg, Deutschland.
Oper Orthop Traumatol. 2020 Feb;32(1):73-81. doi: 10.1007/s00064-019-0617-5. Epub 2019 Jul 3.
Anatomical reduction and fixation of complex talar fractures (Hawkins type III and IV, Marti type III and IV) using a medial approach.
Displaced talar fractures (Hawkins type III and IV, Marti type III and IV) with the need for a medial malleolar osteotomy or the simultaneous treatment of a medial malleolus fracture.
High perioperative risk, severe soft tissue injuries in the medial approach area, infected soft tissues.
Medial arch-shaped approach about 12 cm in length over the medial malleolus using a simultaneous medial malleolus fracture or via an additional medial malleolar osteotomy. Dissection and retraction of the terminal branches of the saphenous vein and the saphenous nerve. Protection of the blood supply in the area of the medial talus and in the sinus tarsi. Reduction of the talar joint surfaces and reconstruction of the anatomical axes according to the preoperative planning by means of native radiological and computed tomographic imaging. Osteosynthesis adapted to the fracture type using Kirschner wires, conventional screws, cannulated screws, double-threaded screws, resorbable pins, magnesium screws, small fragment plates.
Lower leg splint or orthesis for 6 weeks, partial weight-bearing with 20 kg for 10-12 weeks. Early range of motion exercise of the ankle, subtalar and mid-tarsal joints.
In the past 5 years, 11 patients with either Hawkins type III and IV or Marti type III and IV fractures were treated operatively using the arch-shaped approach. No soft tissue problems were seen related to the arch-shaped approach. Of the 7 patients who could be followed up after an average of 2 years, the mean American Orthopedic Foot and Ankle Score was 73. Avascular necrosis occurred in 3 cases (43%). These were partial necroses of less than one third of the talar body with asymptomatic course at the time of examination. In 4 patients (57%) radiographic signs of osteoarthritis occurred within 2 years, whereby in two of those cases (29%) an arthrodesis of the upper ankle was performed.
采用内侧入路对复杂距骨骨折（Hawkins III型和IV型、Marti III型和IV型）进行解剖复位和固定。
移位的距骨骨折（Hawkins III型和IV型、Marti III型和IV型），需要进行内踝截骨术或同时治疗内踝骨折。
围手术期风险高、内侧入路区域严重软组织损伤、软组织感染。
在内踝上方采用约12厘米长的内侧弓形入路，可同时处理内踝骨折或通过额外的内踝截骨术。解剖并牵开大隐静脉和隐神经的终末分支。保护距骨内侧区域和跗骨窦的血供。根据术前规划，借助X线平片和计算机断层扫描成像，复位距骨关节面并重建解剖轴线。根据骨折类型，使用克氏针、传统螺钉、空心螺钉、双螺纹螺钉、可吸收钢针、镁螺钉、小钢板进行内固定。
小腿夹板或矫形器固定6周，10 - 12周内部分负重20千克。早期进行踝关节、距下关节和中跗关节的活动度锻炼。
在过去5年中，11例Hawkins III型和IV型或Marti III型和IV型骨折患者采用弓形入路进行了手术治疗。未发现与弓形入路相关的软组织问题。在平均随访2年的7例患者中，美国矫形足踝协会平均评分为73分。3例（43%）发生缺血性坏死。这些均为距骨体不到三分之一的部分坏死，检查时无症状。4例（57%）在2年内出现骨关节炎的影像学表现，其中2例（29%）进行了踝关节上关节面融合术。
