Black Alexandra T, Stowers Jered M, Tran Son, Mata Karla De La, Sherman Alain E, RahnamaVaghef Ali
Fellow, Foot and Ankle Specialists of Central Ohio, Newark, OH.
Fellow, Foot and Ankle Institute Fellowship, Indianapolis, IN.
J Foot Ankle Surg. 2022 Nov-Dec;61(6):1303-1307. doi: 10.1053/j.jfas.2022.04.007. Epub 2022 Apr 25.
Currently, there is no consensus on surgical approach for posterior malleolar fracture fragments with significant posteromedial involvement. The Bartonicek type III/Haraguchi type II posterior malleolar morphologies typically involve large posteromedial fragments, behaving like a pilon injury and have been reported as pilon variant fractures. We performed a retrospective chart review at 2 large healthcare institutions, evaluating patients that underwent surgical management of pilon variant posterior malleolar fractures and determining clinical outcomes including: time to union, union rates, soft tissue complications, infection and time to weight bearing. A total of 68 patients were included (51 females, 17 males). A total of 51 direct (19 posterolateral, 31 posteromedial), 6 indirect, and 11 no-fixation approaches were identified. Significantly different time-to-union was found between direct fixation (mean = 85.1 days), indirect fixation (mean = 74 days) and no-fixation (mean = 174.3 days) (p < .001). A posteromedial approach (mean = 63.0 days, SD = 16.6) was associated with significantly shorter time to union when compared to a posterolateral approach (mean = 124.8 days, SD = 59.4; p < .001). Fixation (direct or indirect) was associated with significantly increased likelihood of union of the overall ankle fracture pattern (52/57 = 91%) when compared to no fixation of the posterior malleolar component (9/14 = 64%), p = .01. Patients who underwent direct fixation had significantly lower incidence of neurovascular damage (6%) when compared to patients who underwent indirect fixation (33%) or no-fixation (29%) (p = .02). There was no significant difference between the groups in terms of tendon damage (p = .54), infection rates (p = .45) and time to weight bearing (p = .66). The authors suggest that surgical management and specifically direct approaches have better outcomes in the short-term follow up.
目前，对于后踝骨折块伴有明显后内侧累及的手术入路尚无共识。Bartonicek III型/原口II型后踝形态通常累及较大的后内侧骨折块，表现类似pilon损伤，已被报道为pilon变异型骨折。我们在2家大型医疗机构进行了一项回顾性病历审查，评估接受pilon变异型后踝骨折手术治疗的患者，并确定临床结果，包括：愈合时间、愈合率、软组织并发症、感染和负重时间。共纳入68例患者（51例女性，17例男性）。共确定了51例直接入路（19例后外侧，31例后内侧）、6例间接入路和11例非固定入路。直接固定（平均=85.1天）、间接固定（平均=74天）和非固定（平均=174.3天）之间发现愈合时间有显著差异（p<.001）。与后外侧入路（平均=124.8天，标准差=59.4；p<.001）相比，后内侧入路（平均=63.0天，标准差=16.6）的愈合时间明显更短。与后踝部分不固定（9/14 = 64%）相比，固定（直接或间接）与整个踝关节骨折模式愈合的可能性显著增加相关（52/57 = 91%），p =.01。与接受间接固定（33%）或非固定（29%）的患者相比，接受直接固定的患者神经血管损伤发生率显著更低（6%）（p =.02）。各组之间在肌腱损伤（p =.54）、感染率（p =.45）和负重时间（p =.66）方面无显著差异。作者认为，手术治疗，特别是直接入路，在短期随访中具有更好的结果。
