手术Lisfranc损伤复位内固定术.docx

手术-Lisfranc损伤复位内固定术1.1、一般考虑   General considerationsORIF is preferred to closed reduction and percutaneous fixation.Screw fixation is preferred to K-wire fixation.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        The Lisfranc / tarsometatarsal (TMT) articulation is very strong. The base of the second metatarsal is held in place by the plantar TMT ligaments.       The significance is that motion at the base of the second metatarsal is restricted. This leads to fractures at the base of the second metatarsal. Unlike other areas with their “essential” joints, the midfoot area joints are not “essential” and therefore motion can be sacrificed to obtain stability and function. The 1, 2 and 3 TMT joints can in fact be fused for acute purely ligamentous injuries. The 4 and 5 TMT joints should be stabilized with K-wires as some retained motion in this area is helpful for better function, because normally there is motion between the 4th and 5th metatarsal and the cuboid.As a result, when treating fractures in the Lisfranc / midfoot area, joint surface reconstruction may not be as critical as in other joints.     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Dorsal double parallel and medial mini approachIn the forefoot, incisions should be straight, in the axis of the foot and should never be undermined.The dorsomedial incision is centered over the TMT area, between the extensor hallucis longus tendon (EHL) and extensor hallucis brevis (EHB). This incision allows access to the first TMT and the medial base of the 2nd TMT.The dorsolateral incision is centered over the TMT area, roughly in line with the fourth metatarsal. A skin bridge as wide as possible should be maintained. But, as long as the area between the incisions is not undermined, the skin bridge is not compromised.A third small medial incision (along the medial utility line) is used for screw placement and pointed reduction clamps.        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Alternative incisionAn alternative approach is the extensile dorsal salvage incision (EDSI/Zwipp).The EDSI is useful in extreme injuries. It can be used for combined foot and leg injuries. It starts at the base of the second toe and runs straight up the foot to the ankle, and if needed it can be extended proximally along the anterior compartment of the leg. In the foot, it can be used for decompression as well as approach for ORIF. However, much tissue dissection is required when this is used for ORIF and this can lead to soft-tissue complications.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          The dorsomedial full-thickness incision allows access to the 1st TMT and medial area of the 2nd TMT. The dorsolateral full-thickness incision allows access to the lateral area of the second TMT. Work back and forth to reduce and fix the 2nd TMT taking care not to undermine the middle area between the incisions. Care should be taken not to disturb the neurovascular bundle between the incisions in the flap.        The joints can be distracted with a bone spreader allowing access to soft-tissue interposition and bony fragments. These can be debrided and removed to allow perfect reduction of the base of the 2nd MT into the “keystone” corner of the TMT joint.        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   Reduction and fixation of the first metatarsalOur preferred method of achieving fixation is as follows.The 1st TMT is reduced under direct visualization and image intensification. Provisional fixation can be done with a pointed reduction (Weber) clamp and/ or K-wires placed from the base of the first metatarsal to the medial cuneiform. A “pocket hole” is made along the dorsal base of the first metatarsal. The pocket hole allows the screw head to engage the cortex without breaking the dorsal cortex, which would result in loss of fixation.Pearl A 4.0/2.5 mm drill combination is used to place the lag screw from the dorsal base of the first metatarsal into the medial cuneiform. Usually for a 4.0 screw, a 2.5 mm drill can be used instead of a 2.9 mm drill as foot bones are soft and just a pilot hole is needed. The screw will hold better with the smaller pilot hole.A second screw can be placed if desired from the dorsal medial cuneiform through the plantar base of the first metatarsal. However, it is sometimes difficult to insert the screw through the crowded area. A smaller-diameter screw may be easier to insert.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  Reduction and fixation of the second metatarsal baseOnce the dissociation between the first metatarsal and the medial cuneiform has been reduced and stabilized, the medial arch of the foot has been restored and we are ready to reduce the second metatarsal.The second metatarsal is reduced into the keystone (formed between the base of the first metatarsal and the first cuneiform, the articular surface of the second cuneiform, the lateral surface of the third cuneiform and the third metatarsal).Once the second metatarsal has been reduced into place in the medial part of the “keystone”, its fixation is accomplished with a lag screw placed from the medial area of the medial cuneiform, through the base of the second metatarsal. A solid fully-threaded 4.0 mm screw gives the strongest fixation. If there is not enough space, a smaller-diameter screw can be used, but this weakens the construct. If cannulated screws are used, there is an increased incidence of fixation failure and screw breakage. Cannulated screws are not as strong and tend to break with repeated bending forces.       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    Reduction and fixation of the third TMTThe 3rd TMT is reduced through the dorsolateral incision. The position is held using a pointed reduction (Weber) clamp, or K-wires placed under image intensification. A lag screw is then placed from the dorsal base of the third metatarsal into the cuneiform row. The screw can be inserted into either the lateral or middle cuneiform.       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     Reduction and fixation of the fourth and fifth TMTWhen the more medial TMT joints are reduced, the 4th and 5th TMT joints often move medially and are reduced along with the rest of the foot. As stated previously, having some motion at these joints is helpful for normal foot function. The 5th metatarsal is positioned with a pointed reduction (Weber) clamp if further positioning is needed. The joint is then held with percutaneously placed K-wires from the proximal metatarsal into the cuboid.Alternatively, screws can be placed from the base of the 4th or 5th metatarsal into the cuboid. However, as these joints are best left mobile, the screws will have to be removed in the immediate postoperative period (8 weeks). The K-wires, which are placed percutaneously, are removed at 6 to 8 weeks in the office/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     If the Lisfranc injury includes a fracture at the base of the 2nd metatarsal, then faster, stronger bone-to-bone healing may be expected. In the case of a pure ligamentous injury without  a fracture at the base of the 2nd metatarsal, post-injury arthrosis is more likely. As such, immediate primary fusion of the first, second and third TMT is now advocated. The joint surfaces are prepared in the usual manner for fusion. The articular cartilage is removed and the subchondral bone is perforated. The hardware construct can be the same as described above, or a variation.         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。Supplementary bone graft should be used to facilitate fusion (shear strain relief grafting “spot weld”).  Metatarsal fractures / intertarsal injuriesIntertarsal instabilities can be addressed before the Lisfranc injury is fixed. Any instabilities can be compressed with the pointed reduction forceps and held with K-wires. Screws can then be placed transversely between cuneiforms.Cuneiform or metatarsal base fractures may preclude the use of screws. In these cases, small low-pro can be used in the intertarsal area, or as bridge plates from the metatarsal shaft across the metatarsal base / TMT joints to the cuneiforms.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。 Tight calf / equinus contracturePatients with Lisfranc / midfoot injuries often have equinus contracture. It is unclear if this plays a role in the injury, but certainly it can compromise healing by exerting forces through the midfoot. Therefore, if equinus is present, a calf or Achilles lengthening may be performed as an adjunct procedure at the time of surgery. 14 / 14