胫骨pilon骨折治疗中踝关节外侧结构损伤恢复的重要性

目的 探讨踝关节外侧结构稳定性在胫骨pilon骨折治疗中的意义.方法 从2005年7月至2008年1月共收治18例胫骨pilon骨折伴踝关节外侧结构损伤患者,其中男13例,女5例,平均年龄41.3岁.闭合性骨折16例,开放性骨折2例.AO分型:B1型3例,B2型5例;C1型3例,C2型7例.对于12例闭合性胫骨pilon骨折患者,首先采用后外侧切口进行腓骨复位和内固定,接着采用改良前内侧切口进行胫骨Chaput结节的复位和固定,中间关节面以及内侧骨块参照Chaput结节进行复位.对于2例开放性骨折和4例伴有严重软组织损伤或多发伤的闭合性胫骨pilon骨折患者,采用分期手术治疗,一期腓骨切开复位钢板内固定结合内侧胫骨跨踝关节外固定支架固定,对内侧结构只做克氏针或螺钉临时复位固定,二期(平均14 d后)拆除胫骨外固定支架或行胫骨切开复位钢板内固定. 结果 14例患者术后获8～30个月(平均18.4个月)随访,4例失访.14例骨折均获骨性愈合,平均愈合时间为5.4个月.关节面复位评价:解剖复位9例,一般4例,差1例.临床功能评价:优6例,良3例,可4例,差1例.1例开放性胫骨pilon骨折外固定后出现感染,在抗感染治疗后7周更换内固定,同时放置庆大霉素珠链,术后30周骨折愈合. 结论踝关节外侧结构稳定性的恢复在胫骨pilon骨折治疗中极其重要.

Significance of stabilizing the ankle lateral column in treatment of pilon fractures

Objective To evaluate the significance of stabilizing the ankle lateral column in the treatment of pilon fractures. Methods Eighteen pilon fractures (13 males and 5 females) with injury to ankle lateral column were managed from July 2005 to January 2008. Their average age was 41.3 (range, 23 to 50) years. AO classification: 3 cases of Bltype, 5 cases of B2 type, 3 cases of C1 type, and 7 cases of C2 type. Patients with closed injury underwent fibular reduction and fixation through posterolateral incision fol-lowed by the Chapnt tubercle reduction and fixation through modified anterointernal incision. The articular surface of ankle middle column and bone fragments of medial column were reduced according to the Chaput tubercle. For patients with open fracture, severe soft tissue injury, or multi-injury, we adopted staged man-agement. All patients underwent immediate fibular fixation and placement of a medial spanning external fixator. The ankle medial column was first fixed only temporally with K wire or screws. Next, patients underwent removal of the external fixator and formal open reduction and internal fixation of pilon fractures. Results Fourteen patients were followed up after surgery, but 4 patients were lost. The mean follow-up was 18.4 (range, 8 to 30) months. All the 14 bone fractures united. In evaluation of the articular surface reduction, 9 cases had anatomic reduction, 4 cases had fair result and 1 case poor. In evaluation of ankle function, 6 cases were excellent, 3 cases good, 4 cases fair and 1 case poor. One case of open Pilon fracture was infected after external fixation which was changed into internal plate fixation following treatment with gentamycin-released beads for 7 weeks. The infection was controlled and the bone reunited. Conclusion Restoring stability of the ankle lateral column is extremely important in the treatment of pilon fractures.