CAJ | 학술논문

　　目的探讨跖跗关节复合体损伤的诊断及不同手术方式治疗的临床疗效。方法回顾性分析2008年2月至2011年5月，收治的34例跖跗关节复合体损伤的患者，男23例，女11例，均为单足损伤；年龄17～62岁，平均39.5岁。按照 Myerson 分类：中柱损伤7例，中柱合并内侧柱损伤16例，三柱损伤11例。其中应用闭合复位经皮内固定13例，开放复位内固定19例，一期关节融合术2例。采用美国矫形足踝协会( american orthopedic foot and ankle society，AOFAS )足评分标准对患足术后的功能进行疗效评价。结果所有患者均获得12～36个月随访，平均22个月，切口均一期愈合。依据 AOFAS 评分标准对术后的功能进行评价：优6例，良17例，可9例，差2例，优良率67.6%；其中闭合复位经皮内固定与一期关节融合术后优良率均100%，开放复位内固定术后优良率为42.1%。术后并发症中克氏针松动8例(闭合复位经皮内固定术3例、开放复位内固定术5例)，螺钉断钉2例(闭合复位经皮内固定术与开放复位内固定术各1例)，创伤性关节炎7例(均为开放复位内固定术)。结论跖跗关节损伤常规摄足正、侧位和30°内斜位X线片，必要时与健侧足X线片对比；CT 诊断在跖跗关节损伤中具有重要作用，易发现隐匿性骨折；MRI 不仅能显示骨折，还能显示 Lisfranc 韧带损伤。闭合复位经皮内固定术创伤小，并发症低，能有效治疗跖跗关节复合体损伤；开放复位内固定术创伤大，并发症高，仅适用于闭合复位失败或者骨折－脱位较严重者；一期关节融合术并发症低，但影响患者功能，适用于韧带撕裂、关节内粉碎性骨折或脱位、创伤性关节炎发生率高的患者。
　　목적탐토척부관절복합체손상적진단급불동수술방식치료적림상료효。방법회고성분석2008년2월지2011년5월，수치적34례척부관절복합체손상적환자，남23례，녀11례，균위단족손상；년령17～62세，평균39.5세。안조 Myerson 분류：중주손상7례，중주합병내측주손상16례，삼주손상11례。기중응용폐합복위경피내고정13례，개방복위내고정19례，일기관절융합술2례。채용미국교형족과협회( american orthopedic foot and ankle society，AOFAS )족평분표준대환족술후적공능진행료효평개。결과소유환자균획득12～36개월수방，평균22개월，절구균일기유합。의거 AOFAS 평분표준대술후적공능진행평개：우6례，량17례，가9례，차2례，우량솔67.6%；기중폐합복위경피내고정여일기관절융합술후우량솔균100%，개방복위내고정술후우량솔위42.1%。술후병발증중극씨침송동8례(폐합복위경피내고정술3례、개방복위내고정술5례)，라정단정2례(폐합복위경피내고정술여개방복위내고정술각1례)，창상성관절염7례(균위개방복위내고정술)。결론척부관절손상상규섭족정、측위화30°내사위X선편，필요시여건측족X선편대비；CT 진단재척부관절손상중구유중요작용，역발현은닉성골절；MRI 불부능현시골절，환능현시 Lisfranc 인대손상。폐합복위경피내고정술창상소，병발증저，능유효치료척부관절복합체손상；개방복위내고정술창상대，병발증고，부괄용우폐합복위실패혹자골절－탈위교엄중자；일기관절융합술병발증저，단영향환자공능，괄용우인대시렬、관절내분쇄성골절혹탈위、창상성관절염발생솔고적환자。
Objective To investigate the diagnosis and clinical results of different surgical procedures of tarsometatarsal joint complex injuries. Methods From February 2008 to May 2011, 34 cases of tarsometatarsal joint complex injuries were retrospectively analyzed. There were 23 males and 11 females, who all had single-foot injuries. Their average age was 39.5 years old ( range;17-62 years ). According to the Myerson classification, there were 7 cases of middle column injuries, 16 cases of medial-middle column injuries and 11 cases of three-column injuries. 13 patients were treated with close reduction and percutaneous internal fixation, and 19 patients were treated with open reduction and internal fixation. 2 patients were treated with one-stage arthrodesis. The curative effects on the function of affected feet were evaluated using the american orthopedic foot and ankle society ( AOFAS ) midfoot score. Results All patients were followed up for an average period of 22 months ( range;12-36 months ). All incisions healed by first intention. The postoperative function was evaluated according to the AOFAS midfoot score:6 cases had excellent results, 17 good, 9 fair and 2 bad, and the excellent and good rate was 67.6%. After close reduction and percutaneous internal fixation and one-stage arthrodesis, the excellent and good rate was 100%, which was 42.1% after open reduction and internal fixation. Postoperative complications included looseness of K-wires in 8 patients ( 3 patients receiving close reduction and internal fixation and 5 patients receiving open reduction and internal fixation ), screw breakage in 2 patients ( 1 patient receiving close reduction and internal fixation and 1 patient receiving open reduction and internal fixation ) and traumatic arthritis in 7 patients ( all 7 patients receiving open reduction and internal fixation ). Conclusions Anatomical reduction and stable fixation are the basic principles in treating tarsometatarsal joint complex injuries. For patients with tarsometatarsal joint complex injuries, the anteroposterior, lateral and 30° oblique X-ray films of the affected feet may be compared with that of the contralateral feet, if necessary. CT plays an important role in diagnosing tarsometatarsal joint complex injuries, based on which occult fractures can be easily found. Fractures and Lisfranc ligament injuries can both be shown on MRI. The patients with tarsometatarsal joint complex injuries can be effectively treated with close reduction and percutaneous internal fixation, with small trauma and low complications;With large trauma and high complications, open reduction and internal fixation can only be used when close reduction is failed or in patients with more severe fracture–dislocation. One-stage arthrodesis has low complications, but affects the function of patients, which can be used in patients with torn ligaments, intra-articular comminuted fractures or dislocation and frequently-occurring traumatic arthritis.