The ankle joint is a very important joint in clinical practice, which mainly includes tibia, talus, fibula, etc., which has the role of shouldering gravity and protecting the body's mobility. The normal ankle joint must maintain good stability and flexibility, but if the ankle joint is affected by various violent factors such as external impact and gravity, it will lead to an imbalance in the stability of the ankle joint, which is the main cause of various traumas and fractures in the ankle joint.
At present, the surgical method for the treatment of ankle fractures in clinical practice usually uses screw internal fixation, and most patients use the posterolateral approach; However, there is significant variation in the efficacy of internal fixation, and some patients may experience slow fracture healing or malunion deformity. Therefore, it is of great clinical value to optimize the surgical treatment plan. Relevant studies have shown that after the posterolateral approach to the fracture fragment, the nail direction can be divided into anterior posterior fixation and posterior forward fixation, and different nail entry directions may affect the fixation and healing effect of the fracture. Based on this, the purpose of this article is to explore the effect of different internal fixation screw insertion directions in the treatment of ankle fractures, so as to provide a basis for selecting the best screw insertion direction for clinical treatment.
01. Surgical method
A total of 82 patients with ankle fracture who underwent screw internal fixation were selected and divided into two groups, 41 cases in each group, according to the direction of nail insertion. During the operation, the patient was anesthetized with a combination of spinal-epidural anesthesia, the healthy side was kept in the decubitus position, the affected limb was on top, and a balloon tourniquet was used at the base of the affected limb's thigh. A posterolateral longitudinal incision of about 12 cm is then made between the posterior border of the fibula and the midpoint of the Achilles tendon. The anterior edge of the incision is pulled anterolateral to separate the subcutaneous tissue and fascia in turn. When the lateral malleolus fracture is revealed, the fracture is reduced and anatomical reduction is achieved. The fracture site is immobilized with screw compression or K-wire temporary fixation. After that, the posterior malleolar fracture fragment was reduced by prying, pushing and other operations, and fixed with 1~3 hollow screws with a length of 4.0mm. The control group was fixed from front to back, while the study group was fixed from back to front.
When the reduction effect is satisfactory, the patient is transferred to the supine position, and an arc-shaped incorporation (the specific length is about 3cm) is taken in the medial malleolus, the subcutaneous tissue is separated, the surgical field is completely exposed, the reduced fracture fragments are dissected, and the K-wire is used to temporarily fix it. When the fluoroscopy results show that the fixing effect is satisfactory, fix it accordingly with hollow screws. After the completion of the reduction and internal fixation of the ankle fracture, the tibial-fibular stress test was performed to assess the stability of the tibia-fibula. If instability occurs, the lower tibia and fibular 3 layers of bone cortex can be fixed with screws from the fibula to the tibia. Finally, the corresponding incision is rinsed and sutured layer by layer. After the anesthesia has completely disappeared, patients are encouraged to perform toe- and ankle-related functional exercises step by step. The anterolateral X-ray of the ankle joint was re-examined 3 days after surgery. Weight walking training can be performed 12 weeks after surgery, and the lower tibialand fibular screws can be removed before weight bearing. The ankle function of the patients was evaluated after 6 months of follow-up (Figs. 1-2).
Fig.1 Posterior malleolar fracture fixed by screws from front to back a: Preoperative anteroposterior X-ray b: Preoperative lateral X-ray c: Preoperative cross-sectional CT non-contrast image d: Preoperative coronal CT non-contrast image e: Postoperative anteropostoperative anteroposterior X-ray f: Postoperative lateral X-ray g: Postoperative lateral X-ray after removal of the internal fixation H: Posterior lateral X-ray after removal of the internal fixation i~k: CT two-dimensional reconstruction after removal of the internal fixation
Fig.2 Posterior malleolar fracture fixed by screws from back to front a: Preoperative anteroposterior X-ray b: Preoperative lateral X-ray c: Preoperative non-contrast coronal CT image d: Preoperative cross-sectional CT non-contrast image E: Postoperative anteroposterior X-ray f: Postoperative lateral X-ray g: Postoperative lateral X-ray after removal of the internal fixation H: Posterior lateral X-ray after removal of the internal fixation
02. Statistical results
1. Surgery-related indicators and fracture healing:
The postoperative hospital stay and fracture healing time in the study group were shorter than those in the control group (P<0.05). See Table 1.
2. Excellent fracture healing rate:
At 6 months after surgery, the excellent fracture healing rate in the study group was higher than that in the control group (P<0.05). See Table 2.
03. Conclusion
Ankle fractures can lead to joint instability, and ankle fractures require early fracture reduction and strong immobilization for functional exercises. Previous studies have suggested that posterolateral approach fixation can fix both medial and lateral malleolus fractures and posterior malleolus reduction, especially for small fragment posterior malleolar fractures that cannot be treated by indirect reduction, and has a good application effect.
After the posterolateral approach exposure surgery, screw fixation methods are divided into anterior-posterior fixation and posterior-forward fixation, both of which have their own advantages and disadvantages:
1. Posterior and forward fixation has the advantages of intuitive and reliable fixation, but it is greatly affected by incision, which may lead to the inability of some fracture fragments to be fixed vertically, thus affecting the fixation effect.
2. Anterior to posterior fixation is more flexible, which can be fixed according to the direction and size of the bone block, and is not easily affected when limited by the posterolateral incision. However, for smaller avulsion fractures, the fixation may not be firm enough and may lead to re-displacement.
The results of this study showed that the postoperative hospital stay and fracture healing time in the study group were shorter than those in the control group, and the excellent fracture healing rate and ankle function rate were higher than those in the control group (P<0.05), indicating that posterior and anterior fixation had a better fixation effect, faster fracture healing, better effect, and more conducive to the recovery of ankle function. In addition, relevant studies suggest that posterior and anterior fixation is more biomechanically dominant and more accurate, especially when the cannominated screw is compressed, while the anterior posterior fixation may cause the threaded part of the canulated screw to fail to fully enter the posterior malleolar fracture fragment, thereby reducing the compression effect.
In summary, in the treatment of ankle fractures with posterolateral approach, the clinical effect of the screw in the direction of the nail in the posterior and forward fixation is better than that of anterior and posterior fixation, and the fracture heals faster and the ankle joint recovers better.
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