Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK; University of Liverpool, Liverpool, UK.
Foot (Edinb). 2020 Jun;43:101662. doi: 10.1016/j.foot.2019.101662. Epub 2019 Dec 30.
The aim of this study was to determine the most appropriate approaches for fixation of each type and fragment of posterior malleolar fractures.
A retrospective analysis of a prospectively collected database was performed on 141 posterior malleolar fractures. On the CT scan axial slice, a clock face was drawn using the posterolateral corner of the tibia as the centre and the Achilles tendon as the 6 o'clock axis. A box was then drawn from the fracture plane, with 90-degree lines corresponding to the medial perpendicular line (MPL) and lateral perpendicular line (LPL) extremity of the fracture and a central perpendicular line (CPL) (i.e. orthogonal central plane, for optimum screw placement). It was recorded where the MPL, LPL and CPL exited the clock face. All fracture patterns were further assessed by both senior authors regarding their choice of approach based on CPL and all variances resolved by discussion.
The LPL was equivalent across the groups (except for the 2B medial fragments), indicating a consistent posterolateral corner fragment throughout the posterior malleolar sub types (p = 0.25). The medial aspect (MPL) of the type 1, type 2A and posterolateral fragments of type 2B were equivalent. The MPL of type 3 fractures was significantly more medial than type 1 and 2A fractures (p < 0.05), with the medial extremes of the type 2B posteromedial fragment being further medial. The majority of type 2B fractures (2/3rds) were determined to be best accessed through a combined posterolateral and medial posteromedial approach, with the other third via the posteromedial approach. Almost all type 3 fractures could be appropriately accessed through the PM approach.
This study concludes that the extent of each subtype of posterior malleolar fractures are consistent. To fully expose each fracture differing incisions are necessary and should be in the skill mix for surgeons treating these fractures.
本研究旨在确定固定后踝各类型和各骨折块的最佳方法。
对 141 例后踝骨折患者的前瞻性数据库进行回顾性分析。在 CT 扫描轴位片上，以胫骨后外侧角为中心，跟腱为 6 点轴，画出一个钟面。然后从骨折平面画出一个方框，90 度线分别对应骨折的内侧垂直线（MPL）和外侧垂直线（LPL）以及中央垂直线（CPL）（即最佳螺钉放置的正交中央平面）。记录 MPL、LPL 和 CPL 离开钟面的位置。两位资深作者根据 CPL 评估所有骨折类型，并通过讨论解决所有差异，进一步评估其选择的入路。
除 2B 型内侧骨折块外，各组 LPL 相当，表明后踝子类型中始终存在一致的后外侧角骨折块（p = 0.25）。1 型、2A 型和 2B 型后外侧骨折块的内侧部分（MPL）相当。3 型骨折的 MPL 明显比 1 型和 2A 型更内侧（p < 0.05），2B 型后内侧骨折块的内侧极限更内侧。大多数 2B 型骨折（2/3）最好通过后外侧和内侧后内侧联合入路进行，其余 1/3 通过后内侧入路进行。几乎所有 3 型骨折都可以通过 PM 入路进行适当的治疗。
本研究得出结论，后踝各子类型的范围是一致的。为了充分暴露每个骨折块，需要不同的切口，这些切口应包含在治疗这些骨折的外科医生的技能组合中。
4 级。
