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目的 通过观察后踝骨折块大小及固定与否对于累及后踝的踝关节骨折预后的影响,探讨后踝骨折的手术适应证.方法 回顾性分析2004年1月至2011年12月手术治疗的73例累及后踝的踝关节骨折患者的病例资料.骨折按照AO分型:44A型19例,44B型37例,44C型17例.本组73例患者中固定后踝30例(45.2％),未固定后踝43例(54.8％).采用美国足踝外科协会(AOFAS)踝-后足评分和简明健康调查量表(SF-36)评分作为功能评价的指标,X线片的关节平整度和关节退变程度作为影像学评价标准,并比较骨折块≥25％的患者后踝固定与否以及骨折块＜25％的患者后踝固定与否的AOFAS踝-后足评分和SF-36评分. 结果 65例患者获得2～84个月(平均44.3个月)随访.4例随访时出现关节平整度欠佳,5例出现轻中度关节退变.2例外踝皮肤术后早期出现缺损感染,1例内固定位置欠佳,但功能恢复均良好.后踝骨折块≥25％的患者骨折块固定组AOFAS踝-后足评分[(94.2±9.8)分]和SF-36评分[(107.5±11.8)分]均高于未固定组[(87.4±6.7)分和(92.8±18.5)分],差异均有统计学意义(P＜0.05)；后踝骨折块＜25％的患者骨折块固定组AOFAS踝-后足评分[(91.3±13.2)分]和SF-36评分[(104.2±14.2)分]和未固定组[(91.8±10.9)分和(102.3±16.6)分]比较,差异均无统计学意义(P＞ 0.05). 结论 后踝骨折块≥25％时,应行复位内固定术；当后踝骨折块＜25％时,可以采取保守治疗.

Objective To explore the indication for surgical treatment of posterior malleolar fracture by observing the effects of bone fragment size and fixation on the fracture healing.Methods We retrospectively analyzed 73 patients with posterior malleolar fracture who had undergone surgical treatment from January 2004 to December 2011.By AO classification,there were 19 cases of type 44A,37 cases of type 44B and 17 cases of type 44C.Fixation of the posterior malleolus was conducted in 30 cases (45.2％) and not in 43 cases (54.8％).American Orthopaedic Foot and Ankle Society (AOFAS) score and the Mos 36-item Short Form Health Survey (SF-36 score) were used for functional evaluation.Articular smoothness and degeneration in the X-ray films were considered as image evaluation criteria.The AOFAS and SF-36 scores were compared between the fixation and non-fixation groups as well as between the ≥25％ bone fragments and the ＜ 25％ones.Results Sixty-five patients completed the follow-ups which ranged from 2 to 84 months (average,44.3 months).Irregular articular surface was observed in 4 cases and mild to moderate degeneration in 5 cases.Infective infection of the lateral malleolar skin occurred early in 2 cases and poor internal implantation in one,but their functional recovery was not affected.The AOFAS and SF-36 scores for patients with ≥25％bone fragments in the fixation group were respectively 94.2 ± 9.8 and 107.5 ± 11.8 points,significantly higher than those in the non-fixation group (87.4 ± 6.7 and 92.8 ± 18.5 respectively) (P ＜ 0.05).The AOFAS and SF-36 scores for patients with ＜ 25％ bone fragments in the fixation group were respectively 91.3 ± 13.2 and 104.2 ± 14.2 points,with no significant differences from those in the non-fixation group (91.8 ± 10.9 and 102.3 ± 16.6 respectively) (P ＞ 0.05).Conclusions When a posterior fragment is larger than 25％ of the articular surface,open reduction and internal fixation should be considered.When a posterior fragment is less than 25％ of the articular surface,conservative treatment may be a better choice.