Baumbach S F, Böcker W, Polzer H
Sektion Fuß- und Sprunggelenkchirurgie Campus Großhadern & Innenstadt, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, Nussbaumstr. 20, 80336, München, Deutschland.
Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, Nußbaumstr. 20, 80336, München, Deutschland.
Oper Orthop Traumatol. 2021 Apr;33(2):112-124. doi: 10.1007/s00064-021-00705-y. Epub 2021 Mar 25.
Stabilization of the syndesmotic complex by open reduction and internal fixation (ORIF) of the posterior malleolus, restoration of the tibial articular surface, stability of the ankle, posterior tibiofibular ligament and the incisura tibiae, reduction of the fibula into the incisura tibiae by ligamentotaxis.
Unstable ankle fractures (OTA/AO type 44-B3, C1.3, C2.3, C3.3) with involvement of the posterior malleolus (type II-IV according to Bartoníček and Rammelt).
Critical general condition, circulatory disorders, severe soft tissue swelling (if necessary, first external fixator), percutaneous treatment the better alternative.
Positioning in unstable lateral position, dorsolateral approach dorsally of the peroneal tendons, incision of the superficial and deep fascia, retraction of the flexor hallucis longus tendon medially, visualization of the posterior malleolus, reduction and fixation. To treat the lateral malleolus fracture, preparation of a full-thickness flap above the peroneal tendons on the fibula, treatment according to AO principles. For the treatment of the medial malleolus positioning in supine position without changing the sterile covers, medial approach for the medial malleolus, wound closure.
Six weeks partial weight bearing (20 kg), early functional exercise, exercise of the flexor hallucis longus muscle; transition to full weight bearing after clinical and radiological follow-up after 6 weeks RESULTS: Few clinical results on open ORIF of the posterior malleolus have been published. However, most studies found that ORIF resulted in better reconstruction of the distal articular surface and the tibial incisura, better reduction of the fibula into the tibial incisura, stabilization of the distal tibiofibular joint and better clinical results, regardless of fragment size, when compared to closed reduction or untreated fragments.
通过后踝切开复位内固定（ORIF）稳定下胫腓联合复合体，恢复胫骨关节面，维持踝关节、胫腓后韧带及胫切迹的稳定性，通过韧带牵拉使腓骨复位至胫切迹。
累及后踝的不稳定踝关节骨折（OTA/AO 型 44-B3、C1.3、C2.3、C3.3）（根据 Bartoníček 和 Rammelt 分类为 II-IV 型）。
一般情况危急、循环系统疾病、严重软组织肿胀（必要时先行外固定架固定），经皮治疗为更佳选择。
取不稳定侧卧位，于腓骨肌腱背侧采用背外侧入路，切开浅、深筋膜，将拇长屈肌腱向内侧牵开，显露后踝，进行复位与固定。处理外踝骨折时，在腓骨上的腓骨肌腱上方制备全层皮瓣，按 AO 原则进行治疗。处理内踝骨折时，患者仰卧位，不更换无菌铺巾，采用内侧入路处理内踝，关闭伤口。
六周部分负重（20 千克），早期功能锻炼，锻炼拇长屈肌；六周后经临床及影像学随访，过渡至完全负重。
关于后踝切开复位内固定的临床结果报道较少。然而，大多数研究发现，与闭合复位或未处理骨折块相比，无论骨折块大小，切开复位内固定均能更好地重建远端关节面和胫切迹，使腓骨更好地复位至胫切迹，稳定胫腓远端关节，并取得更好的临床效果。
