复杂过伸型胫骨平台骨折的形态特征及手术策略

目的探讨复杂过伸型胫骨平台骨折的形态特征、手术策略及临床疗效。方法回顾性分析2017年10月至2019年1月治疗27例复杂过伸型胫骨平台骨折患者资料,男19例,女8例;年龄23~68岁,平均43.4岁。根据胫骨平台骨折Schatzker分型:Ⅳ型8例,Ⅴ型5例,Ⅵ型14例;三柱理论分型:双柱骨折8例,三柱骨折19例。双髁骨折采用内侧和前外侧入路,内侧Tomofix锁定钢板固定,前外侧"L"型锁定钢板固定;胫骨内髁骨折采用扩大内侧入路,分别于前内侧"T"型钢板固定和内后侧锁定钢板固定;合并胫骨前缘骨折患者采用改良前正中入路,胫骨前缘采用水平带状钢板固定。修复合并软组织或骨损伤。术后和终末随访通过X线片及CT扫描评估骨折愈合、复位情况。采用Rasmussen放射学标准评估胫骨平台骨折复位情况,采用美国特种外科医院(hospital for special surgery,HSS)评分评估术后12个月膝关节功能。结果27例患者均顺利完成手术,手术时间为130~350 min,平均165 min。27例患者均获得随访,随访时间12~24个月,平均15.8个月。所有骨折均获得骨性愈合,骨折临床愈合时间10~18周,平均13.5周。术后12个月Rasmussen胫骨平台骨折复位放射学评分为13~18分,平均16.7分,其中优19例,良8例,优良率为100%(27/27)。术后12个月HSS膝关节评分82~98分,平均93.2分,其中优22例,良4例,可1例,优良率96.2%(26/27)。结论复杂过伸型胫骨平台骨折常出现胫骨双髁骨折、胫骨内侧髁或胫骨前缘骨折,根据不同的骨折位置选择手术入路和固定方式,同时修复韧带软组织结构,重建膝关节稳定性,可取得满意的疗效。

Morphological characteristics and surgical strategy of complex hyperextension tibial plateau fracture

Objective To explore the morphological characteristics,treatment strategies and clinical results of complex hyperextension tibial plateau fractures.Methods From October 2017 to January 2019,data of 27 patients with complex hyperextension tibial plateau fractures were retrospectively analyzed.There were 19 males and 8 females with an average age of 43.4 years(range,23-68 years).According to Schatzker classification of tibial plateau fractures:there are 8 cases of type IV,5 of type V,and 14 of type VI;according to the three-column theory classification:there are 8 cases of two-column fracture and 19 cases of three-column fracture.Bicondylar fractures were treated with medial Tomofix locking plate and anterolateral L-shaped locking plate through medial and anterolateral approach;tibialmedial condylar fractures was treated with T-shaped plate and posteromedial locking plate through extended medial approach.Patients with anterior tibial fractures were treated with horizontal strip plate through modified anterior median approach.Combined soft tissue or bone injury was repaired.The fracture healing and reduction were evaluated by X-ray and CT scan.The reduction of tibial plateau fracture was evaluated by Rasmussen radiology standard,and the knee joint function was evaluated 12 months after the operation by the score of American hospital for special surgery(HSS).Results All the 27 surgeries were performedsuccessfully.The operation time was 130-350 minutes,with an average time of 165 minutes.Twenty-seven cases were followed up for 12-24 months,with an average period of 15.8 months.All fractures were healed.The average clinical healing time was 13.5 weeks(range,10-18 weeks).Twelve months after operation,Rasmussen's radiology score was 13-18,with an average of 16.7 points,among them there were 19 excellent and 8 good.Twelve months after the operation,the score of HSS knee joint was 82-98,with an average score of 93.2 points,and there were 22 cases excellent,4 cases good and 1 case fair.The excellent and good rate was 96.2%(26/27).Conclusion Complex hyperextension tibial plateau fractures often combined with tibial bicondylar,medial tibial condyle or anterior tibial fractures.According to the morphological characteristics of complex hyperextension tibial plateau fractures,using appropriate surgical approach and internal fixation,repairing ligament soft tissue structure and reconstructing knee joint stability can achieve satisfactory results.