不同受伤机制Pilon骨折的临床特点和手术策略

目的 探讨不同受伤机制Pilon骨折的临床特点、手术策略及疗效。方法 回顾性分析2009年2月—2015年7月收治的64例Pilon骨折患者的临床资料,根据不同骨折类型的影像学特点,将病例分为内翻、外翻、背伸、跖屈和垂直压缩5种损伤类型,其中内翻型18例、外翻型15例、背伸型12例、跖屈型10例、垂直压缩型9例。采用后内侧入路6例、前正中入路9例、前外侧入路12例、后外侧入路18例、前内侧入路19例,分别应用解剖型锁定接骨板或1/3管型接骨板支撑固定压缩骨块。术后6个月采用Burwell-Charnleys标准评估关节面复位质量;术后12个月采用美国足踝外科医师协会(AOFAS)踝-后足评分系统评价踝关节功能,采用改良Baird和Jackson的主观和X线评价标准进行综合疗效评定。结果 64例患者均获随访,随访时间15～48个月(平均31个月);骨折愈合时间为13～18周、平均(15.54±0.2)周,平均AOFAS评分(85.82±0.2)分,综合疗效优52例、良12例。内翻型中,关节面获得解剖复位9例、较好8例、一般1例,AOFAS评分(87.52±0.2)分,综合疗效优15例、良3例;外翻型中,解剖复位6例、较好7例、一般2例,AOFAS评分(86.41±0.1)分,综合疗效优12例、良3例;背伸型中,解剖复位7例、较好4例、一般1例,AOFAS评分(85.34±0.4)分,综合疗效优10例、良2例;跖屈型中,解剖复位5例、较好3例、一般2例,AOFAS评分(85.25±0.1)分,综合疗效优8例、良2例;垂直压缩型中,解剖复位2例、较好4例、一般3例,AOFAS评分(84.63±0.3)分,综合疗效优7例、良2例。内翻型浅表感染1例、皮肤坏死1例,外翻型浅表感染3例、深部感染1例,背伸型浅表感染1例,跖屈型创伤性关节炎1例,垂直压缩型深部感染1例、骨折延迟愈合2例、创伤性关节炎2例。结论 不同受伤机制Pilon骨折有其临床特点,根据骨折移位方向采用合适手术入路直接暴露骨折块,支撑接骨板固定,临床疗效肯定。

Surgical strategies and clinical outcomes of Pilon fractures caused by different injury mechanism

Objective To explore the surgical strategies and clinical outcomes of Pilon fractures caused by different injury mechanisms. Methods From February 2009 to July 2015, 64 patients with Pilon fractures were retrospectively analyzed in this study. These patients were divided into five groups (varus, valgus, back stretch, plantar flexion and vertical compression) according to the injury mechanisms and the imaging findings of anatomic features.There were 18 patients in varus, valgus group 15 patients, back stretch group 12 patients, 10 patients of plantar flexion group, vertical compression group 9 patients. Sixty-four patients were treated with internal fixation. By adopting the corresponding approaches on the injury mechanism, there were used posterormedial approach 6 patients, middle approach 9 patients, anterolateral approach 12 patients, posterolateral approach 18 patients, anteromedial approach 19 patients; the buttress plate was placed on the compression fracture of distal tibia. Six months after surgery, the reduction quality of the joint surface was evaluated by Burwell-Charnleys radiological evaluation system. Twelve months after surgery, the function of ankle joint was assessed by utilizing American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score system, and the total effect was evaluated by improved Baird-Jackson score system. Results Sixty-four cases were followed up for 15-48 months(average 31 months). The average healing time ranged from 13.0 to 18.0 weeks [mean (15.54±0.2) weeks ]. Mean AOFAS score was 85.82. Radiological evaluation of curative effect: excellent in 52 patients, good in 12 patients. The postoperative reductions were as follows: 9 anatomic, 8 good, and 1 fair in varus group; 6 anatomic, 7 good, and 2 fair in valgus group; 7anatomic, 4 good, and 1 fair in back stretch group; 5 anatomic, 3 good, and 2 fair in plantar flexion group; 2 anatomic, 4 good, and 3 fair in vertical compression group. Postoperative follow-up of ankle function, AOFAS score and radiological evaluation of curative effect were 87.52±0.2, excellent 15 patients, good 3 patients in varus group; 86.41±0.1, excellent 12 patients, good 3 patients in valgus group; 85.34±0.4, excellent 10 patients, good 2 patients in back stretch group; 85.25±0.1, excellent 8 patients, good 2 patients in plantar flexion group; 84.63±0.3, excellent 7 patients, good 2 patients in vertical compression group. In group varus, 1 patient developed superficial wound infection and 1 patient epidermal necrosis; In group valgus, 3 patients developed superficial wound infection, 1 patient deep wound infection; In group back stretch 1 patient developed superficial wound infection; In group plantar flexion 1 patient developed traumatic arthritis; In group vertical compression 1 patient deep wound infection, 2 patients delayed union of bone, 2 patients developed traumatic arthritis. Conclusions Different injury mechanisms will result in different types of Pilon fractures. Different strategies should be used according to the characteristics of fracture with the buttress plates being placed on compression fracture of distal tibia to achieve better clinical outcomes.