Mittlmeier T, Saß M, Randow M, Wichelhaus A
Chirurgische Klinik und Poliklinik, Abt. für Unfall- Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
Unfallchirurg. 2021 Mar;124(3):181-189. doi: 10.1007/s00113-021-00954-3. Epub 2021 Jan 29.
Ankle fractures with involvement of the posterior malleolus have a poor prognosis. The traditional concept of addressing the posterior fragment as the final step in the surgical reconstruction depending on the fragment size manifest in the lateral X‑ray, does not do justice to the anatomic and biomechanical relevance of the posterior malleolus. Intra-articular step-offs and fragment displacement ≥ 2 mm, impacted intercalary fragments, involvement of the fibular notch and instability of the syndesmosis, represent parameters relevant for the surgical reconstruction and the functional and radiomorphological outcome independent of fragment size. A valid assessment of these parameters can only be achieved via computed tomography (CT) including multiplanar 2D and 3D reconstruction. This is the foundation for the classification of posterior malleolar fractures according to Bartoníček et al., it forms the basis of the preoperative analysis of the fracture components and represents a decision-making tool for the indications for surgery. The individual fracture pattern guides the selection of the suitable approach or a combination of approaches and the surgical strategy. Making use of the posterior approaches enables the surgeon to have a direct view of the fracture components of the posterior malleolus as a precondition for an anatomic reduction. This central surgical step is frequently done as the first measure of the surgical reconstruction of the ankle joint. Furthermore, direct reduction and posterior stabilization is more accurate and stable than indirect reduction from an anterior approach with indirect fixation using lag screws. An additional temporary transfixation of the tibiofibular syndesmosis is often dispensable.
累及后踝的踝关节骨折预后较差。传统观念认为，根据侧位X线片显示的骨折块大小，将处理后踝骨折块作为手术重建的最后一步，但这并未充分考虑后踝的解剖学和生物力学意义。关节内台阶样移位和骨折块移位≥2 mm、嵌插性中间骨折块、腓骨切迹受累以及下胫腓联合不稳定，这些参数与手术重建以及功能和影像学结果相关，且与骨折块大小无关。只有通过计算机断层扫描（CT），包括多平面二维和三维重建，才能对这些参数进行有效评估。这是根据巴尔托尼切克等人的方法对后踝骨折进行分类的基础，它构成了骨折组成部分术前分析的基础，并代表了手术适应症的决策工具。个体骨折类型指导合适手术入路或联合入路的选择以及手术策略。采用后入路可使外科医生直接观察后踝的骨折组成部分，这是解剖复位的前提条件。这一核心手术步骤通常是踝关节手术重建的首要措施。此外，直接复位和后方稳定比从前侧入路间接复位并用拉力螺钉间接固定更准确、更稳定。额外临时固定下胫腓联合通常是不必要的。
