Cesari B, Lortat-Jacob A, Dinh A, Katabi M, Decrette E, Benoit J
Hôpital Ambroise Paré, Boulogne.
Rev Chir Orthop Reparatrice Appar Mot. 1996;82(5):417-27.
Fracture of the anterior rim of the distal tibia is a rare injury. This fracture seems less serious than other pilon fractures but its treatment is often difficult and didn't give better results. The aim of this study was to describe problem we dealed with and to suggest solutions in order to improve long term results.
The study included 38 cases, treated in 5 Paris district trauma centers, with a minimal follow-up of 6 months. All patients were asked for clinical and radiological review between september 92 and march 93 ; otherwise, latest review datas were used.
Authors suggest a radiological classification based upon type, width and talus anterior displacement. Different surgical procedures were performed for 33 cases (screw, plate, external fixation) ; conservative treatment was used 5 times (non weight bearing plaster cast). Anatomical reconstruction was analysed. Functional results scoring system included pain, global abilities and ankle range of motion. Ankle arthritis was rated according to 1992 SOFCOT scoring system at 1 and 3 year follow-up.
Follow-up ranges from 6 months to 11 years (average 28 months). 55 per cent of cases were lost for review with 1 year mean follow-up. 45 per cent of patients were recently tested with 4 year mean follow-up. Three ankles had joint fusion 6 to 18 months after trauma. Functional result was poor. For 35 ankles analysed 1 out of 4 remained totally painless (9 cases), 1 out of 2 had a good function (20 cases) and 1 out of 3 normal X-rays (12 cases). Arthritis was found for 2 ankles out of 3 after one year follow-up (16 cases out of 23). Loss of reduction or incomplete reconstruction seemed the most important point (13 cases out 38, 13 cases after 35 surgical procedures).
Many patients didn't get a long term evaluation, and this study has no statistical value. Anyway, function loss was always early on a weight bearing joint. A perfect and stable reconstruction gives a higher rate of good result (11 out of 14). Analysis of cases with anatomic imperfection leads to recommendations: fixation of separation fracture, even undisplaced, bone grafting to correct impaction, appropriate use of external fixation for neutralization.
Better results should come from a better analysis of the bone lesions : separation, impaction or mix fracture. This analysis leads to appropriate surgical procedure which give back a stable and anatomic distal tibia. External fixation can be usefull for immobilization ; this can't avoid open reduction and internal fixation of the fracture. Bone grafting can be useful for impaction fracture.
胫腓骨远端前缘骨折是一种罕见的损伤。这种骨折似乎不如其他Pilon骨折严重，但其治疗往往困难且效果不佳。本研究的目的是描述我们所面临的问题并提出解决方案，以改善长期疗效。
本研究纳入了5个巴黎地区创伤中心治疗的38例患者，最短随访6个月。所有患者均在1992年9月至1993年3月期间接受了临床和影像学复查；否则，使用最新的复查数据。
作者提出了一种基于类型、宽度和距骨前移的影像学分类方法。对33例患者进行了不同的手术操作（螺钉、钢板、外固定）；5例采用保守治疗（非负重石膏固定）。分析了解剖重建情况。功能结果评分系统包括疼痛、整体功能和踝关节活动范围。在1年和3年随访时，根据1992年SOFCOT评分系统对踝关节关节炎进行评级。
随访时间为6个月至11年（平均28个月）。55%的病例失访，平均随访1年。45%的患者最近接受了检查，平均随访4年。3例踝关节在创伤后6至18个月进行了关节融合。功能结果较差。在分析的35例踝关节中，4例中有1例完全无痛（9例），2例中有1例功能良好（20例），3例中有1例X线正常（12例）。1年随访后，3例中有2例出现关节炎（23例中有16例）。复位丢失或重建不完全似乎最为重要（38例中有13例，35例手术操作后有13例）。
许多患者未得到长期评估，本研究无统计学价值。无论如何，负重关节的功能丧失总是较早出现。完美而稳定的重建可获得更高的良好结果率（14例中有11例）。对解剖结构不完善病例的分析得出以下建议：固定分离骨折，即使无移位，植骨以纠正嵌插，适当使用外固定以中和应力。
更好的结果应来自对骨损伤（分离、嵌插或混合骨折）的更好分析。这种分析可导致采取适当的手术操作，从而恢复稳定且解剖结构正常的胫腓骨远端。外固定可用于固定；但这无法避免骨折的切开复位内固定。植骨可用于嵌插骨折。
