跖跗关节复合体损伤的诊治探讨

摘要

目的:探讨跖跗关节复合体(TJC)损伤的诊治方法.方法:2007年1月至2009年12月采用切开复位内固定治疗16例跖跗关节复合体损伤,男12例,女4例;年龄21～45岁,平均34.1岁,均为闭合性损伤.左侧7例,右侧9例,均为直接暴力所伤,其中交通伤4例,高处坠落伤5例,挤压伤7例.楔骨间脱位n例,舟楔关节脱位3例,骰骨骨折2例.跖跗关节损伤均为三柱损伤.根据手术探查和稳定性破坏情况,通常跗骨间关节,内侧、中间柱跖跗关节用螺钉固定,外侧柱用克氏针固定,对跖骨基底部粉碎性骨折和骰骨压缩性骨折等用跨关节微型钢板固定以达到解剖复位、有效固定.采用美国足踝外科协会(AOFAS)中足评分标准从疼痛、功能、对线方面进行临床评估.结果:所有患者均获得随访,时间6～18个月,平均12.6个月.按AOFAS评分:疼痛为(29.3±5.9)分,功能为(32.4±5.6)分,对线为(12.9±2.6)分,总分为(74.6±10.4)分.所有切口均Ⅰ期愈合,未见皮肤坏死,感染,钢板螺钉松动、断裂等并发症.3例患者因后期出现骨性关节炎,疼痛明显,行走困难,Ⅱ期行关节融合术.4例患者影像学表现为骨性关节炎,但临床症状(疼痛)较轻,继续观察随访.结论:解剖复位有效稳定内固定是治疗跖跗关节复合体损伤的关键要素,Ⅰ期切开复位内固定有利于Ⅱ期融合手术.%Objective: To explore the diagnosis and treatment of tarsometatarsal joint complex injury (TJC). Methods: From January 2007 to January 2009,16 patients with tarsometatarsal joint complex injury were treated with open reduction and internal fixation. There were 12 males and 4 females,ranging in age from 21 to 45 years with an average of 34.1 years. Seven cases were left and 9 cases were right and all injuries caused by direct violence. Four cases caused by traffic accident 5 by fall from high and 7 by crush injury. Intereuneiform dislocation were in 1 ] cases, naviculocuneiform joint dislocation in 3 cases and cuboid fracture in 2 cases. All the cases were three column injuries. According to the situation of exploring and the stability, screw fixation was used for intertarsal joint, internal and middle column tarsometatarsal joint, the Kirschner wire fixation for external column and miniature plate fixation for comminuted fracture of metatarsal bones and compressible fracture of cuboid. The criteria of the AOFAS Foot and Ankle Surgery by the United States Association of ankle-rear foot functional scale was used to evaluate the clinical effect. Results: All the patients were followed up, the duration ranged from 6 to 18 months (averaged 12.6 months). According to the score system of AOFAS, the total score was(74.6±10.4 )points,including pain items of (29.3± 5.9) ,the score of functional items of (32.4±5.6) points, and power lines of (12.9±2.6). All the incisions were primarily healed without infection, skin necrosis, fixture broken or loosen. Three cases received arthrodesis due to osteoarthritis. Four cases were followed up continually because they only had the radiologic osteoarthritis without pain. Conclusion: Anatomical reduction and stable fixation is the key point of the treatment of tarsometatarsal joint complex injury. Open reduction and internal fixation at the first stage is good for secondary arthrodesis.