“四踝”骨折的内固定方式与固定顺序
研究者提出了一种固定三踝骨折同时伴有胫骨前结节(“四踝”)或腓骨前缘(“类四踝”)骨折的新技术。24例患者平均年龄60岁，均采用切开复位内固定治疗。四踝骨折17例，类四踝骨折骨折6例。一名患者除三踝骨折外，合并胫骨前部和腓骨撕脱骨折。
20例采用俯卧位后踝直接切开复位内固定术，4例采用仰卧位后踝前后螺钉内固定术。所有四踝骨折固定后，术中检查时只有1例(4%)患者需要下胫腓联合螺钉治疗韧带联合不稳定。没有感染及伤口愈合问题。
[Summary: We present a technique of fixation of trimalleolar fractures with additional fracture of the anterior tibial tubercle (“quadrimalleolar”) or anterior fibular rim (“quadrimalleolar equivalent”). Twenty-four patients with a mean age of 60 years were treated with open reduction and internal fixation of all 4 malleoli. There were 17 quadrimalleolar and 6 quadrimalleolar equivalent fractures. One patient had both anterior tibial and fibular avulsion fracture in addition to a trimalleolar ankle fracture. Surgical approaches and internal fixation were tailored individually. Twenty patients were operated in the prone position with direct ixation of the posterior malleolus and 4 patients in the supine position with anterior to posterior screw fixation of the posterior malleolus. After fixation of al 4 malleoli, only 1 patient (4%) required a syndesmotic screw for residual syndesmotic instability on intraoperative testing. There were no infections and no wound healing problems. All patients went on to solid union. Nineteen patients (79%) were followed for a mean of 77 months (range, 15–156 months). The Foot Function Index averaged 15 (range, 50 to 0), the Olerud and Molander Score averaged 79 (range, 45–100), and the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale averaged 87 (range, 39–100). Fixation of the anterior and posterior tibial fragments increases syndesmotic stability by providing a bone-to-bone fixation. Anatomic reduction of the anterior and posterior tibial rim restores the physiological shape of the tibial incisura and therefore facilitates fibular reduction.]
Surgical technique（手术技术）
⑦ 固定后常规检查下胫腓联合稳定性。
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