足舟骨背侧入路.docx

1、适应症 IndicationsThe dorsomedial approach to the navicular can be used for comminuted, displaced, intraarticular fractures.The talo-navicular joint is very important. Loss of the talo-navicular joint can result in loss of 90% or greater of complex hindfoot motion/circumduction.If fracture care requires a more extensile approach, the advantages of better reduction are balanced against wider dissection causing stripping/loss of blood supply which may impede healing. If the dorsomedial approach is required, care should be taken to minimize dissection.The approach can be extended onto the distal talus. A small distractor can be used. This allows visualization and palpation of the concavity of the navicular to assure anatomical reduction.适用于足舟骨粉碎脱位关节内骨折，距舟关节非常重要，失去距舟关节，将失去90%后足活动。避免广泛皮下剥离，防止发生皮肤坏死。此切口可以延伸至距骨，可在直视下复位骨折块。2、解剖Anatomy The dorsomedial approach to the navicular is made between the tibialis anterior tendon and extensor hallucis longus (EHL) tendon. The approach should be made straight down from skin to periosteum without raising flaps or any unnecessary dissection. A small distractor can be used to aid in medial column alignment/length and to allow visualization and palpation of the talonavicular joint. Once reconstruction, bone grafting (if needed) and provisional fixation are accomplished, a dorsal plate can be applied. If needed, the navicular reconstruction can include bridge plating and screw fixation into the cuneiforms. 背内侧切口位于胫骨前肌和拇长伸肌腱之间，直接经皮切开至骨膜，不要分离皮瓣。 3、皮肤切口Skin incisionThe incision uses the interval between the tibialis anterior and the EHL, roughly directly over the fracture.背内侧切口位于胫骨前肌和拇长伸肌腱之间，舟骨上方。The incision can be extended distally if incorporation of the cuneiforms into the construct is needed.The incision can be extended proximally to allow inspection and palpation of the talonavicular joint.切口可以向远端延伸，如果楔骨有骨折的话，也可向近端延伸探查距舟关节。4、深层分离Deep dissectionOnce down to the periosteum/joint capsule, the tibialis anterior can be retracted medially and the EHL can be retracted laterally. This will expose the dorsum of the navicular.切开至骨膜或关节囊后，将胫前肌向内侧牵开，将拇长伸肌腱向外侧牵开，显露舟骨背侧。5、直视关节Visualization of the jointIn a high-energy injury, the comminution may be severe. Care should be taken not to strip the periosteum or joint capsule from any small pieces. If a piece is attached to a proximal piece of joint capsule, then the best course of action may be to flip it proximally so as not to disrupt its soft-tissue attachments. Once the joint is reconstructed, this “trap-door” piece can be reduced and fixed.在高能量损伤，骨折粉碎严重，注意不要从骨块上剥离骨膜或关节囊，如果骨折块与关节囊连续，不要扰乱其连续性，当关节重建完成，固定与关节囊连续的骨块。6、可增加内侧切口 Additional medial incisionIn some cases additional fixation (screws) can be inserted from the medial side.For the medial approach to the navicular, the area along the medial utility incision over the navicular is used. The incision can be extended proximally to allow access to the talonavicular joint, or distally for access to the cuneiforms, first metatarsal base and naviculo-cuneiform and intertarsal joints.有时，需要从内侧切口以拧入螺钉。7、闭合伤口 Wound closureIn general wounds must be closed without any tension on the skin edges. Since there is not much soft tissue in the midfoot, the deep layer closure may consist of closing the capsule/periosteum in order to take off tension from the overlying skin. The next layer is the subcutaneous layer which is loosely reapproximated using 2-0 vicryl (absorbable braided). The skin is closed without tension using an appropriate running everting suture (absorbable) or staples (less reactive but can last longer). In the case of multiple adjacent incisions (double dorsal Lisfranc approach) nylon can