目的:治疗Lisfranc骨折脱位最常用的手术方法是双切口入路,这经常会导致各种并发症,如皮肤坏死,旋转复位术的第一掌掌关节(TMTJ)和外侧柱足背骨复位术。我们介绍了一种三切口入路治疗Lisfranc骨折脱位,术后并发症少,足部功能良好。
方法:我们前瞻性选择了30名以前健康的患者,年龄从18岁到60岁,但是只有23名患者完成了随访,因此最终被纳入了研究,平均年龄38.1±12.9岁。所有患者均有Lisfranc骨折脱位,累及所有三柱;13.0%(3/23)为Myerson分型A型(内侧),A型(外侧)占47.8%(11/23),C2型占39.1%(9/23)。所有患者均通过三切口入路进行治疗:沿第二射线的外侧边界制作的长切口用作工作切口,以可视化并减少前三个TMTJ,以及应用内固定器械;在第一个TMTJ的内侧做一个2厘米的内侧切口作为检查切口,确保在内侧和足底视图中第一个TMTJ良好复位;在第四/第五个TMTJ的背侧再做1厘米的检查切口,以防止侧柱矢状位半脱位。平均值±SD用于定量数据,如手术时间,随访时间和足部功能评分。记录术后并发症,使用美国骨科足踝协会评分评估足部功能,随访时足功能指数和马里兰足评分。同一患者的受伤足和对侧足的足功能在随访结束时,统计学分析采用独立样本t检验。
结果:中位手术时间为117.9±14.6min(范围93-142min)。所有并发症均发生在术后3个月内,包括伤口延迟愈合(17.4%),浅表感染(8.7%),复杂区域疼痛综合征(4.3%)和神经瘤(4.3%)。术后无皮肤坏死或畸形。在14.1±1.2个月(范围12-16个月)的随访结束时,美国矫形足和踝关节协会的中位评分为89.7±5.7,中位足功能指数为21.7±9.9,中位马里兰足评分为88.7±4.8.手术侧和对侧之间没有显着差异,在足部功能方面,随访结束时(p>0.05)。
结论:三切口入路可以提供所有TMTJ的充分可视化,以确保解剖复位并提供足够的工作空间来应用内固定器械,有效治疗三柱Lisfranc骨折脱位,软组织并发症轻微,功能恢复满意。
OBJECTIVE: The most popular surgical approach to manage Lisfranc fracture-dislocations is the double-incision approach, which frequently causes a variety of complications, such as skin necrosis, rotational malreduction of the first tarsometatarsal joint (TMTJ) and lateral column dorsoplantar malreduction of the TMTJ. We introduce a three-incision approach to treat Lisfranc fracture-dislocations with only minor postoperative complications and good foot function.
METHODS: We prospectively selected 30 previously healthy patients, ranging from 18 to 60 years of age, but only 23 patients completed the follow-up and thus were finally included, with an average age of 38.1 ± 12.9 years. All patients have sustained Lisfranc fracture-dislocations involving all three-column; 13.0% (3/23) were Myerson classification type A (medial), 47.8% (11/23) were type A (lateral), and 39.1% (9/23) were type C2. All patients were treated via a three-incision approach: a long incision made along the lateral border of the second ray was used as a working incision to visualize and reduce the first three TMTJs, as well as to apply internal fixation instrumentation; a 2 cm medial incision was made at the medial side of the first TMTJ as an inspecting incision, ensuring good reduction of the first TMTJ in medial and plantar view; another 1 cm inspecting incision was made at the dorsal side of the fourth/fifth TMTJ to prevent sagittal subluxation of the lateral column. Mean ± SD was used for quantitative data such as operation time, follow-up time and foot function scores. Postoperative complications were documented, and foot function was evaluated using the American orthopaedic foot & ankle society score, foot function index and Maryland foot score at follow-up. The foot function of the injured foot and contralateral foot of the same patient was at the end of follow-up, and independent sample t-test was used for statistical analysis.
RESULTS: The median operation time was 117.9 ± 14.6 min (range 93 - 142 min). All complications occurred within three months after the operation, and included delayed wound healing (17.4%), superficial infection (8.7%), complex regional pain syndrome (4.3%) and neuroma (4.3%). There was no case of postoperative skin necrosis or malreduction. At the end of follow-up of 14.1 ± 1.2 months (range 12-16 months), the median American orthopaedic foot & ankle society score of the operated foot was 89.7 ± 5.7, the median foot function index was 21.7 ± 9.9, and the median Maryland foot score was 88.7 ± 4.8. There were no significant differences between the operated and contralateral sides, in terms of foot function, at the end of followup (p > 0.05).
CONCLUSIONS: The three-incision approach can provide adequate visualization of all TMTJs to ensure anatomical reduction and offer sufficient working space to apply internal fixation instrumentation, which is effective in treating three-column Lisfranc fracture-dislocations with minor soft tissue complications and satisfactory functional recovery.