手术-Lisfranc损伤复位内固定术.doc

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1、1.1、一般考虑   GeneralconsiderationsORIFispreferredtoclosedreductionandpercutaneousfixation.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.Thebaseofthesecondmetatarsalisheldinplacebytheplant

2、arTMTligaments.    Thesignificanceisthatmotionatthebaseofthesecondmetatarsalisrestricted.Thisleadstofracturesatthebaseofthesecondmetatarsal.Unlikeotherareaswiththeir“essential”joints,themidfootareajointsarenot“essential”andthereforemotioncanbesacrificedtoobtainstabilityandfunction

3、.The1,2and3TMTjointscaninfactbefusedforacutepurelyligamentousinjuries.The4and5TMTjointsshouldbestabilizedwithK-wiresassomeretainedmotioninthisareaishelpfulforbetterfunction,becausenormallythereismotionbetweenthe4thand5thmetatarsalandthecuboid.Asaresult,whentreatingfracturesintheLi

4、sfranc/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，

5、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DorsaldoubleparallelandmedialminiapproachIntheforefoot,incisionsshouldbestraight,intheaxisofthefootandshouldneverbeundermined.ThedorsomedialincisioniscenteredovertheTMTarea,betweentheextensorhallucislongustendon(EHL)andextensorhallucisbrevis(EHB

6、).ThisincisionallowsaccesstothefirstTMTandthemedialbaseofthe2ndTMT.ThedorsolateralincisioniscenteredovertheTMTarea,roughlyinlinewiththefourthmetatarsal. Askinbridgeaswideaspossibleshouldbemaintained.But,aslongastheareabetweentheincisionsisnotundermined,theskinbridgeisnotcompromise

7、d.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AlternativeincisionAnalternati

8、veapproachistheextensiledorsalsal