16层螺旋CT及其三维重建与多平面重组在胫骨平台骨折诊断中的应用

目的探讨16层螺旋CT(16层SCT)及其三维重建(3-D)与多平面重组(MPR)在胫骨平台骨折诊断中的应用价值。方法39例胫骨平台骨折病例经膝关节常规X线平片检查后，采用16层SCT进行膝关节的多层面螺旋CT扫描，在工作站上作3D及MPR影像后处理，就胫骨平台骨折的平片与16层SCT影像进行比较及综合分析。结果39例胫骨平台骨折中，X线平片漏诊1例髁间隆突骨折、1例内髁骨折及1例双髁骨折，此3例(7．69％)平片漏诊的骨折均为16层SCT予以诊断。16层SCT的3-D影像可清晰显示胫骨平台骨折的立体形态；MPR影像则可明确显示胫骨平台内部的骨质损伤情况如骨折的具体部位、关节面碎裂及塌陷程度、骨折移位距离。结论16层SCT能够显示X线平片难于诊断的胫骨平台隐匿性骨折；3-D及MPR成像技术十分有利于全面观察胫骨平台骨折的形态变化，是16层SCT横轴位扫描的重要补充。     

螺旋CT三维重建影像在胫骨平台骨折诊疗中的价值

目的探讨螺旋CT三维重建影像在胫骨平台骨折诊断和治疗中的临床使用价值。方法2001年8月～2005年4月收集38例胫骨平台骨折分别行X线片和螺旋CT三维重建影像检查,对照术中所见,分析比较螺旋CT三维重建影像在临床诊断和治疗中的作用。结果X线片检查2例无法明确诊断,骨折分型错误6例;螺旋CT三维重建诊断、分型均正确。X线片与螺旋CT三维重建影像在确立诊断方面未见明显差异,但在分型和指导治疗方面,螺旋CT三维重建影像明显优于前者。结论螺旋CT三维重建影像能直观、立体地显示胫骨平台骨折的形态,有助于骨折的分型及治疗。     

Surgical treatment of complex tibial plateau fractures by closed reduction and external fixation. A review of 32 consecutive cases operated

Abstract Complex tibial plateau fractures are a challenge in trauma surgery. In these fractures it is necessary to anatomically reduce the articular part of the fracture and to obtain stable fixation. The aim of this study is to review the results of a surgical technique consisting of fluoroscopic closed reduction and combined percutaneous internal and external fixation. Thirty-two complex tibial plateau fractures in 32 patients were included. Twenty-one fractures were closed, 4 were open Gustilo grade I, 3 were Gustilo grade II and 4 were Gustilo grade III. The mean age was 37.8 years (range 21–64 years). Surgery was performed with patients in transcalcaneal traction and the knee flexed at 30° was used. Through a 1-cm incision centred over the tibial metaphysis of the tibia, a 3.2-mm hole was drilled in the antero-medial tibial aspect. The tibial plateau fracture fragments were elevated using either 1 or 2 curved Kirschner wires under fluoroscopy to control the reduction. Then the fragments were fixed with 2 cannulated AO screws inserted through small incisions into the medial aspect of the tibial plateau. Knee rehabilitation started postoperatively. Weight bearing started after 8–12 weeks depending upon the radiographic appearance. All external fixators were removed in outpatient facilities. All patients were clinically and radiographically evaluated at a mean follow-up of 48 months (range 38–57 months). Clinical results were evaluated according to the Knee Society clinical score. Average healing time was 24 weeks (range 18–29 weeks). In 1 patient a non-union occurred. This patient was treated with open reduction and plate fixation. In 2 patients a varus knee deformity occurred and a surgical correction was performed. There were no surgical complications. Mean knee range of motion was 105° (range 75–125°) and mean Knee Society clinical score was 89. Twenty-five results were scored as excellent, 4 good, 2 fair and 1 poor. Using this technique there is limited soft tissue damage and virtually no periosteum damage to the fracture fragments. However anatomical reconstruction of the joint can be obtained. Furthermore knee rehabilitation can be started immediately after surgery. We think that these factors were responsible for the optimal clinical long-term results.     

Simultaneous Bilateral Tibial Tuberosity Avulsions—Over 6-Year Follow-up

Abstract Simultaneous bilateral avulsions of the tibial tuberosity are rare injuries. The authors found only five reported cases in the orthopedic literature. We add a further case of bilateral avulsions of the tibial tuberosity with the longest reported follow-up.     

胫骨平台解剖型钢板的结构特点及临床运用

目的探讨解剖型钢板治疗胫骨平台骨折的结构特点。方法2001年1月-2003年12月,应用解剖型钢板治疗胫骨平台骨折34例,其中男20例,女14例;年龄23~54岁,平均38.7岁。结果34例均获得随访,随访时间8~28个月,平均19个月。术后1个月膝关节屈曲70°~120°,平均90.2°;术后3个月膝关节屈曲90°~135°,平均110.3°;术后半年膝关节屈曲100°~135°,平均125.0°。按Merchant评分,终末随访时优18例,良12例,可4例。术后无切口皮肤坏死、感染和钢板松动及断裂。结论解剖钢板治疗胫骨平台骨折效果满意,其三维结构符合胫骨平台解剖特点,可以提供持续坚强的固定,有利术后膝关节早期活动,骨折愈合率高,并发症少。     

关节镜辅助下微创经皮螺钉内固定治疗胫骨平台骨折

目的:探讨关节镜辅助下微创经皮螺钉内固定治疗胫骨平台骨折的可行性及疗效。方法:自2001年1月-2005年1月,应用膝关节镜检查及监测下经皮螺钉内固定治疗胫骨平台骨折27例,按照Schatzker分类法:Ⅰ型9例,Ⅱ型8例,Ⅲ型5例,Ⅳ型5例。所有病例均行经皮骨折有限显露复位,适当植骨,应用1~3枚松质骨拉力螺钉内固定,术后配合CPM功能锻炼。结果:本组随访6~24个月,平均15个月。骨折临床愈合时间3~4个月,平均3·5个月。无畸形愈合、感染、螺钉断裂。按Sanders膝关节功能评分法评定结果:优12例,良11例,中3例,差1例,优良率85·2%。结论:关节镜辅助经皮螺钉内固定是治疗胫骨平台骨折的有效方法之一,其对膝关节创伤小,可达解剖复位,固定可靠,患肢功能恢复好,并发症少。     

Possible injury to the branches of the peroneal nerve during fibular osteotomies

Conclusions The peroneal nerves and their blood supply are at risk during high tibial osteotomies. Fixation of nerves by fibrous tissues, compression by tendinous arcades of the peroneus longus tendon, and narrow passages for nerves crossing dense fibrous septa are all factors which favor the development of peroneal nerve lesions. Intraoperative soft tissue retraction and pull by retractors may damage nerves and vessels. The muscle branch for the extensor hallucis longus muscle is particularly at risk during the fibular osteotomy since it runs directly on the bone.     

屈膝过程中的胫股运动特性分析

本文采用三维位移测量方法，测试１０例离体人膝标本的胫股关节三维运动特性。发现屈膝过程中，胫股运动也具有典型的三维运动特点。其中在屈膝初期的３０°内，胫骨内旋最明显并伴有胫骨内翻现象，平均内旋８°，内翻６－７ｍｍ，膝关节完全伸直时胫股扣锁使膝关节稳定，屈曲时胫股“解锁”使膝关节松弛，具重要的临床意义，同时提示，在解释传统的胫股扣锁现象时不应遗漏伴随发生的胫骨内／外翻现象。     

微创内固定系统在高能量胫骨平台骨折中的应用

目的:探讨微创内固定系统治疗高能量胫骨平台骨折的方法和临床疗效。方法:本组27例,男19例,女8例;年龄21~59岁,平均36岁;其中左侧12例,右侧15例。按Schatzker分型:Ⅴ型9例,Ⅵ型18例。其中合并前交叉韧带撕脱骨折3例,后交叉韧带断裂2例,半月板损伤3例。用改良内外侧联合切口,行微创内固定系统结合有限接触加压钢板(LC-DCP)内固定,其中3例半月板损伤,2例给予修补,另1例部分切除;3例前交叉韧带撕脱骨折给予钢丝固定;2例后交叉韧带断裂行Ⅱ期手术。术后2周、1、3、6个月、1年随访,行摄片及关节活动度检查,测定胫骨平台内翻角(TPA)及后倾角(PA);术后1年行膝关节HSS评分。结果:术后与术后1年TPA及PA平均值的差异无显著性统计学意义(TPA:t=1·012,P=0·356;PA:t=0·667,P=0·521)。术后1年膝关节HSS评分平均为86·9分(56~98分),根据此评分标准:优15例,良7例,中4例,差1例。结论:微创钢板治疗高能量胫骨平台骨折是理想、有效的方法,它具有手术创伤小、并发症少,骨折愈合率高,长期稳定性良好,膝关节功能恢复满意等优点。