| The ankle joint is the largest human flexion and extension joint, and its main function is walking and weight-bearing. This makes the ankle joint become one of the most vulnerable joints in our bodies to sustain injuries, this incidence of ankle fractures accounted for the first fracture in the body joints. Due to the anatomy of the ankle joint with special structural and functional characteristics, prone to edema, slow healing, infection, deformity, anchylosis after injuries, and remains of severe joint dysfunction. Seriously affect the function of weight bearing and walking, which reduce the quality of the patients, life and the exercise function. For larger, more violent damage, and complex mechanism of trimalleolar fractures, if the treatment is poor it can easily lead to traumatic arthritis. Profoundly grasping the damage mechanism and shifting laws is the key to success in treating trimalleolar fractures. For the treatment of trimalleolar fracture traditional methods of treatment include using plywood or gypsum for external fixation, but it is difficult to obtain totally or nearly anatomic reduction with those methods. Even after a good reset, with the limb swelling subsided and during early functional exercise the fracture fragments are prone to shift. Open reduction and plate screw fixation can achieve totally or nearly anatomic reduction. However, this method damages local blood circulation and soft tissue around the fractures, which will increase the likelihood of infection of the treated area, and fracture healing is slower. Long time fixation also is likely to lead to osteoporosis, loose fixation, broken fixtures, etc in the fixed position. Using external fixation for treatment of fractures can maximize protection of the blood supply to the fracture, at the same time, providing a strong fixation in the early stage of a fracture and providing flexibility fixed in the middle and late stages, eventually to obtaining a satisfactory clinical outcome.But now, there is a lack of systematic research for the trimalleolar fracture displacement law at home and abroad. Academia has no specific system of classification of trimalleolar fractures. There is no recognized authoritative classification method to guide the clinical treatment of trimalleolar fractures thus limiting the effect of treatment of trimalleolar fractures is increased. In our clinical studies we found, we can classify the trimalleolar fracture according to the talar shift directions and if there has been a separating with the inferior tibiofibular joint or not. The independent classification of trimalleolar fracture, profoundly reveals the damage mechanism and displacement of trimalleolar fracture pattern, can be used to guide the treatment of ankle fractures especially in guiding Bone-setting manipulation combined with external fixation for treatment of trimalleolar fractures, we used the independent classification of the trimalleolar fracture to guide the clinical treatment, and obtained satisfactory clinical outcome. However, due to lack of basic research, the independent classification of trimalleolar fracture system was limited used in clinical use. Therefore, the aid of finite element analysis method to strengthen basic research of the independent classification of trimalleolar fracture was needed, to further clear the damage mechanism and displacement law of trimalleolar fracture, to guide and improve the method of bone-setting manipulation and needle threader in treating trimalleolar fracture, to develop normative programs of bone-setting manipulation combined with external fixation in treating trimalleolar fracture, to avoid the operation complications, and improve the clinical effect.1Finite element analysis of independent classification of trimalleolar fractures1.1PurposeVerify the scientific plausibility of independent classification of trimalleolar fractures by finite element analysis, to further clear the damage mechanism and displacement law of trimalleolar fractures, to strengthen the understanding of trimalleolar fractures, to guide bone-setting manipulation combined with and external fixator for treatment of trimalleolar fracture.1.2Object and MethodTake the CT images from a50years old healthy female’s right leg from her heel to under1/3of the tibia, on the basis of "tendon restraint bone" theory, we establish the three-dimension finite element model for bone and tendon structures of trimalleolar fractures. Application of Ansys software in independent classification of trimalleolar fracture finite element analysis,clarify the biomechanical mechanism and shift law of trimalleolar fractures.Verify the scientific plausibility of an independent classification of trimalleolar fracture system. 1.3ResultsWe can classify of trimalleolar fractures depending on the dislocation of talus and tibiofibular syndesmosis separation with or without. We view trimalleolar fractures with talus dislocation as unstable, and view trimalleolar fractures without talus dislocation as stable. Because trimalleolar fractures are often caused by strong violence therefore, the stable type fractures make up a law of proportion. Under the direction of the talar shift we divided the unstable trimalleolar fractures into three types:talus dislocation to outside, talus dislocation to outside and at the same time dislocation to backside, talus dislocation to backside. Different types of ankle injuries have different stability. Simple twisting of the ankle can cause dislocation of talus to the outside, Talus outward rotation caused injury of distal tibiofibular syndesmosis, Cause a reduction in stability of the ankle mortise,increased activity of the talus, produce impact on the fibula, combined with the effects of gravity the severity of the injury will increase conduction along the fibula, finally leading to an oblique fracture of the fibula,destruction of the internal and external stability of the ankle.In such a damaging situation the posterior malleolar injury will mostly occur with small pieces of avulsion fracture caused by ligament traction, so the anteroposterior direction of the ankle is stable. In the case of talus dislocation to the outside and at the same time dislocation to backside, the reason for these injuries is the combined effects of violent rotation and direct violent motion from front to back, in the case the posterior malleolar can occur chunks can occur from fractures,both the lateral and posterior structures of the ankle are destroyed,the stability of the ankle internal to external direction and anteroposterior direction were destroyed.The direct violent motion from front to back often caused the talus dislocation to the backside, the posterior structures were more heavily destroyed, the posterior malleolar occur chunks can occur from fractures. Due to less violent rotate or lighter lateral bony structures or soft tissue injury, lateral stability was not seriously damaged; anteroposterior stability of the ankle joint was severely damaged. The experiment found that in addition to Lauge-Hansen outside the description of bone and ligament injuries, there also have been tibial and talar cartilage injuries, deepen the understanding of medial malleolus fractures in the varying degrees of damage. For large posterior malleolus fractures and posterior dislocation of the talus, powerful direct violence is the reason, when there is no direct violence involved in the injury process; posterior tibiofibular ligament pulling is the main reason for posterior malleolus fractures.To sum up, the stability of the ankle and the direction of the talus shift after injures are affected by where the direct violence and rotational force is balanced, the degree of soft tissue injury of the ankle, the magnitude and direction of the damage violence, etc. Through this test the injury mechanism, the stability of the ankle joint after injury, the characters in each type of trimalleolar fractures which have been described by the independent classification of trimalleolar fractures were validated, and the science of the independent classification of trimalleolar fracture was validated too. This system can be applied to guide diagnosis and treatment of trimalleolar fractures with bone-setting manipulation combined with external fixation, and improves the efficacy of trimalleolar fractures.1.4ConclusionsThe science of the independent classification of trimalleolar fracture was validated, and the safety transfixation scheme of the tibial was established. We can guide the bone-setting manipulation and external fixation according to those results.2Tibial transfixation anatomy studys2.1PurposeEstablish a safe transfixation scheme based on the tibial anatomy research. Using the conclusions to guide the treatment of trimalleolar fractures use bone-setting manipulation combined with external fixation.2.2Object and MethodSelect four calf cadaver specimens, gain an anatomy of their anterior tibia arteries, the deep-peroneal nerves, and the superficial peroneal nerve. Choose a suitable height on the tibia for the needle, to determine whether this method will hurt the artery and nerve.2.3ResultsUse12cm to15cm above the ankle and2mm above of the tibial medial surface trailing edge as the needle insertion point, pin tail down to25degrees with the horizontal is the safety pin insertion method.2.4ConclusionThe safety transfixation scheme of tibial was established. We can guide the bone-setting manipulation and external fixation according to those results.3Treating trimalleolar fractures with external fixation accounting to the independent classification of trimalleolar fractures:a controlled clinical study3.1PurposeGuiding by independent classification of trimalleolar fractures, combined with cadaveric anatomy and clinical controlled study to further validation of the safety of bone setting manipulation combined with external fixation for the treatment of trimalleolar fractures. To improve the method of bone-setting manipulation and needle threadeding, to develop normative programs of bone-setting manipulation combined with external fixation in treating trimalleolar fractures. And improve the clinical effect.3.2Object and MethodUse the result which was revealed by the finite model analyses of the independent classification of trimalleolar fractures as a guide, combined with autopsy results, guiding bone-setting manipulation combined with external fixation for the treatment of44cases of trimalleolar fracture patients. Use open reduction and plate screw internal fixation methods for the treatment of50cases of trimalleolar fracture patients. Evaluate the treatment effect according to the early subjective feeling and late AOFAS score of patients and anatomy score.3.3ResultsApplication of bone setting manipulation combined with external fixation for the treatment of44cases of trimalleolar fracture patients, useing open reduction combined with internal fixation with plate and screw in50cases of trimalleolar fracture patients. Respectively selecte40cases of patients with complete data of in the experimental group and control group, the two groups patients were followed for6months to36months.Taking AOFAS scoring system to evaluate the efficacy of treatment six months after treatment. The experimental group had an excellent result of92.55%, the control group was95%. By statistical analysis, two groups of data in the age structure, gender composition, injury type, preoperative subjective scoring, there was no significant difference in the two groups. Statistic on the data six months after the operation, subjective score and AOFAS score have no significant difference, but the anatomy score in the control group is higher than experimental group. To match two groups of patients according to fracture type and age, application of paired Wilcoxon test method to organize the data, there were no significant differences in subjective scoring, AOFAS scoring and anatomy scores in the two groups. We can consider that the two methods in treatment of trimalleolar fractures have no difference.3.4ConclusionsThe security of bone setting manipulation combined with external fixation for the treatment of trimalleolar fractures has been further validation. Determine the Bone-setting manipulation combined with external fixation for the treatment of trimalleolar fractures standardization clinical treatment scheme.4Study ConclusionsThe science of independent classification of trimalleolar fractures was validated.This system can be applied to guide the diagnosis and treatment of the trimalleolar fracture, through research on cadavers, developed security method in treatment of trimalleolar fractures with external fixation, developed normative programs of bone-setting manipulation combined with external fixation in treat trimalleolar fracture. |
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