“反漂浮”体位在累及后柱胫骨平台骨折手术治疗中的应用

目的 探讨在“反漂浮”体位在手术治疗累及后柱的胫骨平台骨折中的临床应用效果。方法 回顾性研究。纳入2018年9月—2020年8月安徽医科大学附属安庆医院创伤中心累及后柱的胫骨平台骨折患者19例。其中,男12例,女7例;年龄28~70岁,平均38.5岁;SchatzkerⅡ型1例,Ⅳ型4例,Ⅴ型7例,Ⅵ型7例;累及后柱+外侧柱1例,后柱+内侧柱4例,后柱+内侧柱+外侧柱14例。所有患者在“反漂浮”体位下行切开复位内固定手术,其中胫骨平台后柱+内侧柱骨折4例患者采用膝关节后内侧倒“L”入路,余15例患者采用膝关节后内侧倒“L”入路联合前外侧入路,术中骨折端暴露良好。观察患者手术时间、术中出血量以及切口愈合时间。术后定期随访,行患膝X线检查,评估内固定是否失效以及骨折愈合时间;测量对比患者术后即刻以及术后1年胫骨平台内翻角和胫骨平台后倾角。术后1年采用美国特种外科医院（HSS）膝关节评分评估患膝关节功能。结果 19例患者均在“反漂浮”体位下顺利完成切开复位内固定术。手术时间60~115 min,平均91.6 min。术中出血量50~200 mL,平均108 mL。患者术后恢复良好,切口均一期愈合。19例患者均获得随访,随访时间12~18个月,平均13.5个月。随访期间无一例患者出现内固定松动、断裂,骨折愈合时间17~25周,平均19.2周。患者术后即刻胫骨平台内翻角为87.16°±2.24°、后倾角为9.41°±0.85°,术后1年胫骨平台内翻角为85.98°±3.59°、后倾角为9.55°±0.97°,差异均无统计学意义（t=1.29、2.01,P值均>0.05）。术后1年采用HSS膝关节评分标准评定患膝功能优9例、良8例、中2例。结论 在“反漂浮”体位下手术治疗累及后柱的胫骨平台骨折,术野显露较好,手术安全,内固定稳定有效,关节功能恢复满意。

Surgical treatment of tibial plateau fractures involving the posterior column in a "reversed floating" position

Objective To investigate the clinical efficacy of "reversed floating" position in the treatment of tibial plateau fractures involving the posterior column. Methods The clinical data of 19 patients (12 males and 5 females) who had tibial plateau fractures involving the posterior condylar and were admitted to the Department of Trauma Center of Anqing Hospital Affiliated to Anhui Medical University from September 2018 to August 2020 were analyzed retrospectively. Their average age was 38.5 years (range of 28-70 years). They were categorized according to Schatzker classification: 1 patient in type Ⅱ, 4 patients in type Ⅳ, 7 patients in type Ⅴ, and 7 patients in type Ⅵ. Their column fractures were classified as follows: 1 patient with posterior column fracture combined with lateral column fracture, 4 patients with posterior column fracture combined with medial column fracture, and 14 patients with posterior column fracture combined with lateral column fracture and medial column fracture. All patients were operated in a "reversed floating" position. An inverted "L" incision behind the medial knee joint was made for the 4 patients with posterior column fracture combined the medial column fracture of the tibial plateau. The remaining 15 patients was made an "L" incision and anterolateral incision of the knee joint. The fracture was well exposed during the operation. Operation time, intraoperative bleeding, and wound healing were observed and recorded. Regular follow-up and X-ray examination of the injured knee were performed to evaluate the clinical efficacy of internal fixation and fracture healing. Varus angle and posterior angle of tibial plateau were measured and compared immediately after surgery and 1 year after surgery. The knee function was assessed by the hospital for special surgery (HSS) knee score one year after surgery. Results All 19 patients underwent open reduction and internal fixation successfully in the "reversed floating" position. The operation time was 60-115 min, with an average of 91.6 min. Intraoperative blood loss was 50-200 mL, with an average of 108 mL. The patients recovered well after operation, and all the incisions healed. All 19 patients were followed up for 12-18 months, with an average of 13.5 months. None of the patients had internal fixation loosening or fracture during the follow-up period, and the fracture healing time was 17-25 weeks, with an average of 19.2 weeks. Immediately after surgery, the varus angle of tibial plateau was 87.16°±2.24° and the posterior angle of tibial plateau was 9.41°±0.85°. One year after surgery, the varus Angle of tibial plateau was 85.98°±3.59° and the posterior Angle of tibial plateau was 9.55°±0.97°. There was no significant difference in varus Angle and posterior Angle of tibial plateau immediately after operation and 1 year after operation (t=1.29, 2.01, all P values> 0.05). HSS knee score was used to evaluate knee function 1 year after operation: excellent in 9 cases, good in 8 cases and moderate in 2 cases. Conclusion The treatment of tibial plateau fractures involving the posterior column through the reversed floating position can result in good exposure, safe operation, stable and effective fixation, and satisfactory function.