| 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 expose 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.内踝截骨可以显露距骨体内侧并可保护胫骨后动脉后内侧三角分支（这是距骨体主要血液供应）。此入路通常显露距骨骨折伴脱位复位困难，距骨体骨折和距骨颈粉碎骨折。Anatomy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 blood supply to the body of the talus and lead to avascular necrosis.距骨体血运是复杂的，大部分的血运来自胫后动脉后侧分支，足背动脉和腓动脉供应颈部和外侧1/3，骨折并脱位很容易并发距骨体血液供应障碍并引起距骨坏死。Note the deltoid branches of the posterior tibial artery and the artery of the tarsal canal. A posteromedial 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.注意胫后动脉分支、跗骨分支，距骨体后内侧入路可能破坏血运。因此，如果不得不显露体部，可以利用内踝截骨。Blood supply to the talusThe deltoid branches are important 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 least contribution laterally.三角分支是内侧距骨颈和距骨体的重要血供。足背动脉（胫前动脉）供应距骨头和大部分距骨颈，胫骨后动漫供应大部分距骨体。腓动脉供应距骨外侧。IncisionSkin incision皮肤切口This incision follows from the medial malleolus proximally to the base of the first metatarsal 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.切口起自内踝尖至第1掌骨基底，一般情况这个切口足够，如骨折粉碎严重，可继续向上延伸切口。Deep dissection 深层分离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 allows one accurate positioning of the medial malleolar osteotomy.关节囊应该打开，以明确内踝顶点和胫骨关节平面。同时确定截骨的平面。Planning of the osteotomy 计划截骨The osteotomy must be in such a way that it avoids the distal tibial plafond.截骨必须避免损伤胫骨关节平面。The articular surface is violated only in the infratectal region.关节面仅可在非负重区截骨（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 penetrate the articular cartilage.内踝应预钻孔、攻丝，然后用摆锯在与预钻孔呈90的位置截骨，不要穿透关节软骨。The medial malleolus is then cracked and displaced distally for access to the talus.劈裂内踝，反转，显露距骨。In that fashion, the articular surface can be re-apposed without articular loss at the end of the operation.在样，术后关节面可以完全回置而不损伤关节面。Osteotomy 截骨After pre-drilling and pre-tapping (for the lag screws), the saw cut goes almost to the articular surface.预钻孔和攻丝后，用摆锯不要穿透关节软骨。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.前面和后面用尖牵开器牵开，以保护距骨穹窿和胫后肌腱。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.当内踝让开后，就可以清楚显示骨折脱位，或距骨体颈骨折Repair of the osteotomy修复截骨Once the talar reconstruction is complete, the medial malleolus is reduced and fixed with the pre-drilled and pre-tapped lag screw. This secures absolutely stable fixation of the osteotomy.距骨重建完成后，内踝可以用一枚拉力螺钉固定。 |
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