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目的 探讨外移前内侧入路联合后外侧入路延期切开复位胫骨远端锁定加压钢板固定治疗Rüedi-Allg(o)werⅢ型pilon骨折的手术时机及近期临床疗效.方法 回顾性分析2008年3月至2013年5月采用外移前内侧入路联合后外侧入路切开复位内固定治疗27例Rüedi-Allg(o)werⅢ型新鲜闭合性pilon骨折并获得随访的患者资料,男21例,女6例;年龄22～64岁,平均39.5岁;坠落伤14例,车祸伤8例,重物砸伤5例;受伤至手术时间11～19d,平均14.3 d.采用美国足踝外科协会(American Orthopaedics Foot and Ankle Society,AOFAS)踝与后足的主观评分标准评价踝关节功能.结果 27例患者手术时间120～150 min,平均140 min;出血量100～300 ml,平均210 ml;术后3例患者前内侧切口发生延迟愈合,愈合时间分别为18d、20 d和21d,其余切口愈合时间12～14 d.27例患者随访时间12～26个月,平均18.6个月.末次随访时,骨折均愈合,愈合时间16～24周,平均18.2周;其中2例因高龄、骨折块粉碎移位严重而发生延迟愈合,经延长下地负重时间后,分别于术后20、24周获得骨性愈合;6例X线片示创伤性骨关节炎,其中4例较长距离行走后出现踝关节中度疼痛,未予处理;2例行走后出现踝关节明显疼痛者口服非甾体类消炎镇痛药后症状明显缓解;无一例发生深部感染.AOFAS踝与后足评分为46～96分,平均(84.3±15.7)分,其中优9例,良12例,可4例,差2例,优良率为78％(21/27).结论 外移前内侧入路可同时暴露胫骨内侧柱和外侧柱骨折,避免术中对切口软组织过度牵拉和剥离,利于术中复位固定骨折块;延期切开复位Rüedi-Allg(o)werⅢ型pilon骨折可大幅降低术后切口皮瓣坏死、伤口愈合困难或感染等严重并发症的发生.“,”Objective To investigate the timing of surgery and short-term clinical efficacy of the delayed internal fixation through combined anterior and posterior approach for Rüedi-Allg(o)wer Ⅲ pilon fractures.Methods From March 2008 to May 2013,data of 27 patients of Rüedi-Allg(o)wer Ⅲ pilon fractures treated by the delayed internal fixation through combined anterior and posterior approach were retrospectively analyzed.There were 21 males and 6 females,aged from 22 to 64 years (average,39.5 years).All cases were fresh closed fractures including fall injury (14 cases),traffic accident (8 cases) and weight hitting (5 cases).Patients underwent surgery about 11 to 19 d (average,14.3 d) after injury.The clinical results were evaluated by the American Orthopaedics Foot and Ankle Society (AOFAS).Results The average operation duration was 140 min (range,120-150 min),and the average intraoperative blood loss was 210 ml (range,100-300 ml).After surgery,3 patients had delayed healing in the medial ankle incision with respectively 18 d,20 d and 21 d of healing time,and wound healing time of the rest cases were 12-14 d.All the patients were followed up for 12 to 26 months (average,18.6 months).Bone union was obtained in all patients,and the bony union time ranged from 16 to 24 weeks (average,18.2 weeks).2 patients due to advanced age and severe lumps displacement fracture had delayed healing.And these 2 patients finally acquired bone union by prolonging the time of weight-bearing activity.There was no varusor valgus malunion.X-ray showed 6 patients suffered from traumatic arthritis.4 cases suffered from ankle pain after walking for a long distance,and no special treatment was given.2 cases who suffered from ankle significant pain got better by using cane-assisted and non-steroidal anti-inflammatory drugs.No deep infection occurred.The AOFAS score were 46-96 point (average,84.3± 15.7 point),of which excellent in 9 cases,good in 12,fair in 4,and the excellent and good rate was 78％ (21/27).Conclusion The modified anterior approach can simultaneously exposed the medial and lateral column fractures of tibia,and avoid excessively towing and peeling the soft tissue.The delayed internal fixation for Rüedi-Allg(o)wer Ⅲ type pilon fractures can greatly reduce the incision flap necrosis,untoward wound healing,infection and other serious complications.