手术Lisfranc损伤复位内固定术.docx
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手术Lisfranc损伤复位内固定术.docx
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手术Lisfranc损伤复位内固定术
1.1、一般考虑 Generalconsiderations
ORIFispreferredtoclosedreductionandpercutaneousfixation.
ScrewfixationispreferredtoK-wirefixation.
内固定最好选择闭合复位经皮固定,螺钉固定效果好于克氏针固定
1.2、解剖及功能机制
TheLisfranc/tarsometatarsal(TMT)articulationisverystrong.ThebaseofthesecondmetatarsalisheldinplacebytheplantarTMTligaments.
Thesignificanceisthatmotionatthebaseofthesecondmetatarsalisrestricted.Thisleadstofracturesatthebaseofthesecondmetatarsal.Unlikeotherareaswiththeir“essential”joints,themidfootareajointsarenot“essential”andthereforemotioncanbesacrificedtoobtainstabilityandfunction.The1,2and3TMTjointscaninfactbefusedforacutepurelyligamentousinjuries.The4and5TMTjointsshouldbestabilizedwithK-wiresassomeretainedmotioninthisareaishelpfulforbetterfunction,becausenormallythereismotionbetweenthe4thand5thmetatarsalandthecuboid.
Asaresult,whentreatingfracturesintheLisfranc/midfootarea,jointsurfacereconstructionmaynotbeascriticalasinotherjoints.
Lisfranc关节非常强壮,第2跖骨基底靠跖跗关节韧带加强。
其意义是第2跖骨基底被限制在此,这导致了它骨折的风险。
不像其他部位的关节必须保留,中足关节活动可以牺牲以便获得稳定和功能。
第1、2,3跖跗关节可以融合以治疗纯粹急性韧带损伤;第4和第5跖跗关节应该通过克氏针保持稳定,保留其活动对于整体功能有帮助的,因为在第4和第5跖骨和骰骨间有轻微活动。
因此在治疗 Lisfranc损伤或中足其它损伤,关节面重建不是那么重要了。
2、手术入路 背侧平行双入路结合内侧维持入路
Dorsaldoubleparallelandmedialminiapproach
Intheforefoot,incisionsshouldbestraight,intheaxisofthefootandshouldneverbeundermined.
ThedorsomedialincisioniscenteredovertheTMTarea,betweentheextensorhallucislongustendon(EHL)andextensorhallucisbrevis(EHB).ThisincisionallowsaccesstothefirstTMTandthemedialbaseofthe2ndTMT.
ThedorsolateralincisioniscenteredovertheTMTarea,roughlyinlinewiththefourthmetatarsal.
Askinbridgeaswideaspossibleshouldbemaintained.But,aslongastheareabetweentheincisionsisnotundermined,theskinbridgeisnotcompromised.
Athirdsmallmedialincision(alongthemedialutilityline)isusedforscrewplacementandpointedreductionclamps.
在前足,切口应采用直行与足轴线平行切口,并不要潜行剥离;背部内侧切口位于跖跗关节正上方,拇长伸肌腱和拇短伸肌腱之间,此切口可以显露第1跖跗关节及第2跖跗关节;背外侧切口同样位于 跖跗关节 上方,与第4跖跗关节平行。
尽可能保留宽的皮条;第3切口及内侧切口做为内置物的置入切口。
2.1可选入路
Alternativeincision
Analternativeapproachistheextensiledorsalsalvageincision(EDSI/Zwipp).
TheEDSIisusefulinextremeinjuries.Itcanbeusedforcombinedfootandleginjuries.Itstartsatthebaseofthesecondtoeandrunsstraightupthefoottotheankle,andifneededitcanbeextendedproximallyalongtheanteriorcompartmentoftheleg.Inthefoot,itcanbeusedfordecompressionaswellasapproachforORIF.However,muchtissuedissectionisrequiredwhenthisisusedforORIFandthiscanleadtosoft-tissuecomplications.
另一种入路是可延伸的背侧切口,在多发骨折中可以应用,如并发足或腿部骨折,起点位于第2足趾直接向上延伸经过足至踝关节,如果需要可以延伸至小腿,在足部可以减压并显露骨折,由于需要分离显露的组织较多,容易造成软组织并发症。
3、复位内固定
Access
Thedorsomedialfull-thicknessincisionallowsaccesstothe1stTMTandmedialareaofthe2ndTMT.Thedorsolateralfull-thicknessincisionallowsaccesstothelateralareaofthesecondTMT.Workbackandforthtoreduceandfixthe2ndTMTtakingcarenottounderminethemiddleareabetweentheincisions.Careshouldbetakennottodisturbtheneurovascularbundlebetweentheincisionsintheflap.
Thejointscanbedistractedwithabonespreaderallowingaccesstosoft-tissueinterpositionandbonyfragments.Thesecanbedebridedandremovedtoallowperfectreductionofthebaseofthe2ndMTintothe“keystone”corneroftheTMTjoint.
背部内侧全厚皮瓣切口允许显露第1跖跗关节和第2跖跗关节内侧,背外侧全厚皮瓣切口允许显露第2跖跗关节外侧,固定第2跖跗关节时注意保护中间的皮条,注意保护皮条内的神经血管束。
切开关节囊,以便显露骨折,并精确复位第2跖骨到“关键点”
复位固定第1跖骨 Reductionandfixationofthefirstmetatarsal
Ourpreferredmethodofachievingfixationisasfollows.
The1stTMTisreducedunderdirectvisualizationandimageintensification.Provisionalfixationcanbedonewithapointedreduction(Weber)clampand/orK-wiresplacedfromthebaseofthefirstmetatarsaltothemedialcuneiform.A“pockethole”ismadealongthedorsalbaseofthefirstmetatarsal.Thepocketholeallowsthescrewheadtoengagethecortexwithoutbreakingthedorsalcortex,whichwouldresultinlossoffixation.
Pearl
A4.0/2.5mmdrillcombinationisusedtoplacethelagscrewfromthedorsalbaseofthefirstmetatarsalintothemedialcuneiform.Usuallyfora4.0screw,a2.5mmdrillcanbeusedinsteadofa2.9mmdrillasfootbonesaresoftandjustapilotholeisneeded.Thescrewwillholdbetterwiththesmallerpilothole.
Asecondscrewcanbeplacedifdesiredfromthedorsalmedialcuneiformthroughtheplantarbaseofthefirstmetatarsal.However,itissometimesdifficulttoinsertthescrewthroughthecrowdedarea.Asmaller-diameterscrewmaybeeasiertoinsert.
我们经常采用的固定步骤如下:
首先复位第1跖跗关节经直视和透视复位满意后,可用克氏针从第1跖骨基底到内侧楔骨临时固定。
在第1跖骨背侧留一个小洞,以便埋头处理。
如果需要拧入第2枚螺钉,可以从内侧楔骨背内侧拧入至第1跖骨基底,然而,多数情况下比较困难,可以选用较小直径螺钉来拧入。
复位及固定第2跖骨 Reductionandfixationofthesecondmetatarsalbase
Oncethedissociationbetweenthefirstmetatarsalandthemedialcuneiformhasbeenreducedandstabilized,themedialarchofthefoothasbeenrestoredandwearereadytoreducethesecondmetatarsal.
Thesecondmetatarsalisreducedintothekeystone(formedbetweenthebaseofthefirstmetatarsalandthefirstcuneiform,thearticularsurfaceofthesecondcuneiform,thelateralsurfaceofthethirdcuneiformandthethirdmetatarsal).
Oncethesecond metatarsalhasbeenreducedintoplaceinthemedialpartofthe“keystone”,itsfixationisaccomplishedwithalagscrewplacedfromthemedialareaofthemedialcuneiform,throughthebaseofthesecondmetatarsal.Asolidfully-threaded4.0mmscrewgivesthestrongestfixation.Ifthereisnotenoughspace,asmaller-diameterscrewcanbeused,butthisweakenstheconstruct.
Ifcannulatedscrewsareused,thereisanincreasedincidenceoffixationfailureandscrewbreakage.Cannulatedscrewsarenotasstrongandtendtobreakwithrepeatedbendingforces.
当第1跖骨与内侧楔骨固定完成并稳定后,足内侧弓恢复,可以复位第2跖骨,第2跖骨复位进入“关键点”(置于第1跖骨基底,内侧楔骨,中间楔骨关节面,外侧楔骨及第3跖骨之间)。
当复位完成后,可以通过内侧楔骨内侧面拧入1枚螺钉至第2跖骨基底,用4.0mm全螺纹螺钉固定,如果空间不够可以选用小直径螺钉。
如果使用空心钉其失败风险增加,由于足弓有弯曲度需要承受更大的力,如下图。
复位固定第3TMT关节 ReductionandfixationofthethirdTMT
The3rdTMTisreducedthroughthedorsolateralincision.Thepositionisheldusingapointedreduction(Weber)clamp,orK-wiresplacedunderimageintensification.Alagscrewisthenplacedfromthedorsalbaseofthethirdmetatarsalintothecuneiformrow.Thescrewcanbeinsertedintoeitherthelateralormiddlecuneiform.
第3跖跗关节可以通过背外侧切口复位,可以用点状复位钳或克氏针复位固定,透视满意后,用拉力螺钉从第3跖骨基底拧入楔骨,可以置入到外侧楔骨或中间楔骨。
复位及固定第4及第5TMT关节 ReductionandfixationofthefourthandfifthTMT
WhenthemoremedialTMTjointsarereduced,the4thand5thTMTjointsoftenmovemediallyandarereducedalongwiththerestofthefoot.Asstatedpreviously,havingsomemotionatthesejointsishelpfulfornormalfootfunction.
The5thmetatarsal ispositionedwithapointedreduction(Weber)clampiffurtherpositioningisneeded.ThejointisthenheldwithpercutaneouslyplacedK-wiresfromtheproximalmetatarsalintothecuboid.
Alternatively,screwscanbeplacedfromthebaseofthe4thor5thmetatarsalintothecuboid.However,asthesejointsarebestleftmobile,thescrewswillhavetoberemovedintheimmediatepostoperativeperiod(8weeks).TheK-wires,whichareplacedpercutaneously,areremovedat6to8weeksintheoffice/clinic.
当内侧TMT关节复位完成后,第4,第5TMT关节移位基本也矫正了,可以沿原顺序固定,把这些关节留下活动度有助于其正常足部功能。
如果需要可以用点式复位钳复位第5跖骨,然后用经皮克氏针从第5跖骨基底至骰骨固定。
也可用螺钉从第4第5跖骨基底固定至骰骨,但要保留关节活动,最好术后8周取出内固定,克氏针经皮固定的话,可以在6-8周取出。
并发损伤
IftheLisfrancinjuryincludesafractureatthebaseofthe2ndmetatarsal,thenfaster,strongerbone-to-bonehealingmaybeexpected.
Inthecaseofapureligamentousinjurywithout afractureatthebaseofthe2ndmetatarsal,post-injuryarthrosisismorelikely.Assuch,immediateprimaryfusionofthefirst,secondandthirdTMTisnowadvocated.Thejointsurfacesarepreparedintheusualmannerforfusion.Thearticularcartilageisremovedandthesubchondralboneisperforated.Thehardwareconstructcanbethesameasdescribedabove,oravariation.
如果损伤伴发第2跖骨骨折,首先是促进骨折愈合;如果单纯韧带损伤没有合并第2跖骨骨折, 术后关节炎常见,可行第1,2,3跖跗关节融合。
Supplementarybonegraftshouldbeusedtofacilitatefusion(shearstrainreliefgrafting–“spotweld”).
Metatarsalfractures/intertarsalinjuries
IntertarsalinstabilitiescanbeaddressedbeforetheLisfrancinjuryisfixed.AnyinstabilitiescanbecompressedwiththepointedreductionforcepsandheldwithK-wires.Screwscanthenbeplacedtransverselybetweencuneiforms.
Cuneiformormetatarsalbasefracturesmayprecludetheuseofscrews.Inthesecases,smalllow-profileplatescanbeusedintheintertarsalarea,orasbridgeplatesfromthemetatarsalshaftacrossthemetatarsalbase/TMTjointstothecuneiforms.
跗骨间不稳定可以在固定Lisfranc 损伤前固定,其可以通过横向克氏针或点式复位钳临时固定,用螺丝钉实现固定,也可使用小钢板固定。
Tightcalf/equinuscontracture
PatientswithLisfranc/midfootinjuriesoftenhaveequinuscontracture.Itisunclearifthisplaysaroleintheinjury,butcertainlyitcancompromisehealingbyexertingforcesthroughthemidfoot.Therefore,ifequinusispresent,acalforAchilleslengtheningmaybeperformedasanadjunctprocedureatthetimeofsurgery.
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