University of California, San Diego, San Diego, California.
Rady Children's Hospital, San Diego, San Diego, California.
J Bone Joint Surg Am. 2020 Apr 15;102(8):679-686. doi: 10.2106/JBJS.19.01170.
The treatment of transitional ankle fractures (Tillaux and triplane) is often dictated by the amount of displacement at the articular surface. Although >2 mm is a common indication for operative management, this practice has not been strongly supported by either the pediatric or adult literature. The purpose of this study was to determine whether operative treatment of transitional fractures with 2 to 5 mm of intra-articular gap leads to superior functional outcomes compared with cast management.
A retrospective review of all patients treated for distal tibial fractures at a single institution between 2009 and 2017 was conducted. Computed tomographic images obtained after closed reduction were reviewed to identify patients with 2 to 5 mm of displacement (either gap or step-off) at the articular surface of the tibial plafond. Complications were classified according to the modified Clavien-Dindo system. Only patients with functional outcome data (Foot and Ankle Ability Measure [FAAM]) at a minimum of 2 years after treatment were included. Two multivariable linear regression models were developed using backward stepwise regression with either the FAAM Sports score or the Single Assessment Numerical Evaluation (SANE) Sports score as the dependent variables.
Fifty-seven patients (34 with triplane fractures and 23 with Tillaux fractures) with a mean follow-up of 4.5 years (range, 2.0 to 9.2 years) met inclusion criteria. Thirty-four patients were treated operatively, and 23 patients were treated with closed reduction and cast application. Nonoperative treatment, greater intra-articular gap, and presence of a grade-III complication were associated with worse functional outcomes in both multivariable regression models. A gap after closed reduction remained a negative predictor of functional outcome even in patients who were treated operatively. Patients who were treated nonoperatively and had ≤2.5 mm of gap had a significantly higher mean SANE Sports score at 90% than those patients with >2.5 mm of gap at 75% (p = 0.03).
In Tillaux and triplane fractures with 2 to 5 mm of gap at the tibial plafond, a greater gap after closed reduction, nonoperative treatment, and complications were negative predictors of functional outcome at a mean follow-up of 4.5 years. Surgical management likely conveys the greatest functional benefit when the intra-articular gap exceeds 2.5 mm.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
对于踝关节过渡骨折（Tillaux 和三平面）的治疗，通常取决于关节面的移位程度。虽然>2mm 是手术治疗的常见指征，但这一做法在儿科和成人文献中都没有得到强有力的支持。本研究的目的是确定对于关节面有 2 至 5mm 间隙的过渡骨折，手术治疗是否比石膏固定能带来更好的功能结果。
对一家机构 2009 年至 2017 年间治疗的所有胫骨远端骨折患者进行回顾性分析。对闭合复位后的 CT 图像进行回顾，以确定关节面有 2 至 5mm 位移（间隙或台阶）的患者。并发症根据改良 Clavien-Dindo 系统进行分类。只有在治疗后至少 2 年有功能结果（足踝能力测量[FAAM]）数据的患者才被纳入。使用向后逐步回归法建立了两个多变量线性回归模型，以 FAAM 运动评分或单一评估数值评估（SANE）运动评分作为因变量。
57 例患者（34 例三平面骨折，23 例 Tillaux 骨折），平均随访 4.5 年（2.0 至 9.2 年），符合纳入标准。34 例患者接受手术治疗，23 例患者接受闭合复位和石膏固定。非手术治疗、更大的关节内间隙和 III 级并发症与两种多变量回归模型中的功能结果较差相关。即使在接受手术治疗的患者中，闭合复位后的间隙仍然是功能结果的负预测因素。非手术治疗且间隙≤2.5mm 的患者 SANE 运动评分的平均得分显著高于间隙>2.5mm 的患者（90%比 75%，p=0.03）。
在 Tillaux 和三平面骨折中，胫骨平台有 2 至 5mm 的间隙，闭合复位后间隙更大、非手术治疗和并发症是功能结果的负预测因素，平均随访 4.5 年。当关节内间隙超过 2.5mm 时，手术治疗可能带来最大的功能益处。
治疗性 III 级。请参阅作者说明以获取完整的证据水平描述。
