膝前正中加后内侧入路联合三柱钢板内固定治疗复杂胫骨平台骨折

目的 ：探讨膝前正中加后内侧入路联合三柱钢板内固定治疗复杂胫骨平台骨折的手术方法及临床疗效。方法：自2010年1月至2012年12月,采用膝前正中加后内侧入路联合三柱钢板内固定治疗复杂胫骨平台骨折28例。男17例,女11例;年龄28~64岁,平均45.3岁;左侧12例,右侧16例。按Schatzker分型：Ⅴ型12例,Ⅵ型16例。三柱分型：均为涉及三柱。受伤至手术时间6~15 d,平均9.4 d。术前主要临床症状为膝关节肿胀、畸形及活动受限,X线及CT检查均提示复杂性胫骨平台骨折胫骨平台三柱均涉及。术后随访骨折愈合时间,术后1年按照美国特种外科医院膝关节评分（HSS评分）评价临床疗效,比较术后即刻及术后1年胫骨平台内翻角、后倾角、股胫角等力学指标的变化。结果：术后切口均甲级愈合,未发现切口感染及皮肤坏死等并发症。28例术后均获随访,时间12~24个月,平均18.1个月。骨折愈合时间5~10个月,平均7.8个月。骨折愈合后患者膝关节肿痛消退,关节功能基本恢复正常。HSS评分：疼痛27.81±2.17,功能19.52±2.05,活动范围15.82±1.73,肌力8.51±1.32,屈曲畸形8.33±1.08,关节稳定性9.36±0.52,总分89.35±3.19;优20例,良5例,中2例,差1例。术后与术后1年胫骨平台内翻角、后倾角、股胫角比较差异均无统计学意义。结论：采用膝前正中加后内侧入路联合三柱钢板内固定治疗复杂胫骨平台骨折可达到解剖复位、坚强固定及早期功能锻炼的目的,是一种行之有效的手术治疗方法。

Three-column plate internal fixation for the treatment of complex tibial plateau fracture through antero-midline and postero-medial approaches

Objective: To study technique and clinical therapeutic effects of internal fixation with three-column plates for the treatment of complex tibial plateau fractures through antero-midline and postero-medial approaches.Methods: From January 2010 to December 2012,28 patients with complex tibial plateau fractures were treated with internal fixation using three-column plates through antero-midline and postero-medial approaches. There were 17 males and 11 females,with an average age of 45.3 years old(ranged,28 to 64 years old). Twelve patients had injuries in the left side and 16 patients had injuries in the right side. According to Schatzker classification,12 patients were type V,16 patients were type VI. According to three-column classification,all the patients had injuries of lateral,medial and posterior columns. The mean interval from injury to operation was 9.4 days (ranged,6 to 15 days). The main clinical symptoms were knee joint swelling,deformity and limitation of motion before operation. The X-ray and CT showed all patients had complex tibial plateau fractures,which involved in the lateral,medial and posterior columns. The therapeutic effects were evaluated by fracture healing time,hospital for special surgery knee score (HSS) at one year after operation. The indexes such as tibial plateau-tibial shaft angle(TPA),posterior slope angle (PA) and femoral-tibial angle (FTA) were compared between immediate postoperation and one year after operation.Results: All incisions primarily healed without postoperative complications such as infection and cutaneous necrosis. All the patients were followed up,and the duration ranged from 12 to 24 months,with a mean of 18.1 months. The bone union time ranged from 5 to 10 months (mean,7.8 months) after operation. Knee joint swelling and pain disappeared after bony union,and joint function completely recovered. The results of hospital for special surgery knee score (HSS) was 27.81±2.17 in pain,19.52±2.05 in function,15.82±1.73 in passive range of motion,8.51±1.32 in muscle strength,8.33±1.08 in flexion deformity,9.36±0.52 in joint stability, and the total mean score was 89.35±3.19. According to results of HSS,20 patients got an excellent result,5 good,2 fair and 1 poor. There were no significant differences in tibial plateau-tibial shaft angle (TPA),posterior slope angle (PA) and femoral-tibial angle (FTA) between immediate postoperation and one year after operation.Conclusion: Three-column plate internal fixation for the treatment of complex tibial plateau fractures through antero-midline and posteromedial approaches is effective to achieve anatomic reduction,rigid internal fixation and early functional exercise.