距骨手術入路----內踝截骨術

1、1、Indications   指征An osteotomy of the medial malleolus exposes the medial aspect of the body of the talus and allows the surgeon to protect the posteromedial deltoid branches from the posterior tibial artery which is the main blood supply to the body of the talus.This approach is used to e

2、xpose an irreducible fracture dislocation of the talus as well as fractures of the body of the talus and complex fractures of the neck with posterior extensions.內踝截骨可以顯露距骨體內側并可保護脛骨后動脈后內側三角分支（這是距骨體主要血液供應）。此入路通常顯露距骨骨折伴脫位復位困難，距骨體骨折和距骨頸粉碎骨折。          Ana

3、tomy  解剖The blood supply to the body of the talus is complex. Most of the blood supply to the body is through the deltoid branches of the posterior tibial artery. The dorsalis pedis and peroneal artery supply the neck and the lateral third. Fracture dislocations can easily compromise the b

4、lood supply to the body of the talus and lead to avascular necrosis.距骨體血運是復雜的，大部分的血運來自脛后動脈后側分支，足背動脈和腓動脈供應頸部和外側1/3，骨折并脫位很容易并發(fā)距骨體血液供應障礙并引起距骨壞死。         Note the deltoid branches of the posterior tibial artery and the artery of the tarsal canal. A posteromed

5、ial approach to the body of the talus would destroy its blood supply. Therefore, if the body has to be exposed, one utilizes an osteotomy of the medial malleolus.注意脛后動脈分支、跗骨分支，距骨體后內側入路可能破壞血運。因此，如果不得不顯露體部，可以利用內踝截骨。      Blood supply to the talusThe deltoid branches are i

6、mportant to supply blood to the medial talar neck and talar body. Branches from the dorsalis pedis supply the talar head and most of the dorsal talar neck. The artery of the tarsal canal coming from branches off of the posterior tibial artery supply most of the talar body.The peroneal artery has the

7、 least contribution laterally.三角分支是內側距骨頸和距骨體的重要血供。足背動脈（脛前動脈）供應距骨頭和大部分距骨頸，脛骨后動漫供應大部分距骨體。腓動脈供應距骨外側。         IncisionSkin incision      皮膚切口This incision follows from the medial malleolus proximally to the base of the first meta

8、tarsal distally. Only that portion needed is used, but is often extended proximally for more complex fractures.Importantly, the deltoid branch of the posteromedial vasculature must be preserved as it supplies a majority of the medial talus. 切口起自內踝尖至第1掌骨基底，一般情況這個切口足夠，如骨折粉碎嚴重，可繼續(xù)向上延伸切口。 

9、0;         Deep dissection    深層分離By extending the anteromedial incision proximally, one reaches the medial malleolus.The capsule should be opened in order to identify the apex between the medial malleolus and the plafond of the tibia.This

10、allows one accurate positioning of the medial malleolar osteotomy. 關節(jié)囊應該打開，以明確內踝頂點和脛骨關節(jié)平面。同時確定截骨的平面。         Planning of the osteotomy     計劃截骨The osteotomy must be in such a way that it avoids the distal tibial plafond.截骨必須避免損傷脛骨

11、關節(jié)平面。The articular surface is violated only in the infratectal region.關節(jié)面僅可在非負重區(qū)截骨（低位）。This is done first by visualizing the joint surface before cutting. The medial malleolus is predrilled and pretapped. Then an oscillating saw cuts the bone at 90 degrees to the screw position but does not penetrat

12、e the articular cartilage.內踝應預鉆孔、攻絲，然后用擺鋸在與預鉆孔呈90°的位置截骨，不要穿透關節(jié)軟骨。The medial malleolus is then cracked and displaced distally for access to the talus.劈裂內踝，反轉，顯露距骨。In that fashion, the articular surface can be re-apposed without articular loss at the end of the operation.在樣，術后關節(jié)面可以完全回置而不損傷關節(jié)面。

13、60;               Osteotomy   截骨After pre-drilling and pre-tap  ping (for the lag screws), the saw cut goes almost to the articular surface.預鉆孔和攻絲后，用擺鋸不要穿透關節(jié)軟骨。       

14、60;       Anterior and posterior small flat retractors are inserted around the malleolus into the joint before the osteotomy is completed to protect the dome of the talus and the posterior tibialis tendon. 前面和后面用尖牽開器牽開，以保護距骨穹窿和脛后肌腱。    

15、0;      Then an osteotome is used to crack the medial malleolar piece and to reflect it distally on its retained soft tissue and blood supply.Once the medial malleolus is out of the way, one has excellent access and one can then deal with an irreducible dislocation of the body, or fractures of the body and neck of the talus.當內踝讓開后，就可以清楚顯示骨折脫位，或距骨體頸骨折             Repair of the os