解剖型胫骨髁钢板治疗胫骨平台骨折

[目的]探讨胫骨平台骨折内固定的方法，评估内固定手术的疗效。[方法]对本科2000～2006年收治的22例胫骨平台骨折手术内固定患者进行随访，并进行回顾性分析，全部患者均采用德国LINK解剖型髁钢板内固定。[结果]本组患者平均随访33．3个月，骨折均于3个月愈合。膝关节功能恢复情况根据关节活动度、疼痛、关节稳定性进行HSS评分，平均89．5分。[结论]解剖型胫骨髁钢板可很好的治疗各型胫骨平台骨折，手术操作简单，治疗效果满意，是治疗胫骨平台骨折的良好的内固定材料。     

双侧锁定钢板治疗复杂性胫骨平台骨折

目的 探讨双侧锁定钢板治疗复杂性胫骨平台骨折的临床疗效.方法 自2006年1月～2009年1月我们采用双侧锁定钢板共治疗16例复杂性胫骨平台骨折,按照Schatzker分类法: Ⅴ型7例 , Ⅵ型9例.13例闭合性损伤,3例开放性损伤,现对这些临床资料进行回顾性分析.结果 16例均获得12～32个月的临床随访,平均18.3月.参照Merchant功能评定标准,优6例,良8例,中1例,差1例,优良率87%.结论 采用双侧锁定钢板治疗复杂性胫骨平台骨折能够为胫骨平台提供良好的复位及力学稳定性,便于早期功能锻炼,关节功能满意.     

微创内固定术治疗复杂胫骨干骨折

由于胫骨特殊的解剖位置结构,胫骨干骨折是骨科的常见损伤,复杂的胫骨干骨折由于血供薄弱,力学不稳定,其治疗对于外科医生是一项巨大的挑战。微创内固定系统（less invasive stabilization system,LISS）主要用于治疗股骨下端和胫骨近端骨折,2004年1月至2005年12月我们使用LISS治疗11例复杂胫骨干骨折,发现LISS治疗复杂胫骨干骨折有其独特优势。     

Aggressive debridement and early soft tissue coverage of 3d degree open tibial fractures

93 patients with grade III open tibial fractures were treated without a treatment protocol from 1980 to 1982. This group is compared to 147 pts. managed between 1983 to 1986 according to a standardized prospectively designed protocol with aggressive debridement augmented by pulsatile Jet-lavage. Serial debridement were performed at 48-hour intervales until early soft-tissue coverage were obtained using local or free muscle-flaps. The mean follow-up was 80 months respectively 44 months. --The aggressive regimen led to a statistically significant decrease in infection (30% vs 12%), nonunion (16% vs 6%), amputation (18% vs 6%) and combined hospitalization-periods (137 vs 74 days) [all p less than 0.001]. The aggressively treated groups showed a trend toward early fracture-healing (30 vs 23 weeks) although this was not statistically significant.     

改良Ilizarov外固定器治疗胫骨中下1/3骨折

胫骨中下1／3骨折是临床常见骨折。自2001年1月至2006年6月，采用改良Ilizarov外固定器治疗胫骨中下1／3骨折29例，取得良好疗效，同时也获得了一些体会，报告如下。     

同侧股骨干、胫骨多段骨折的治疗

目的同侧股骨干、胫骨多段骨折固定的意义。方法本组32例分别采用加压钢板、带锁髓内钉、单边外固定架固定。结果随访6个月～3年，骨折愈合，肢体功能恢复参照HSS计分方法，优25例，占80．6％；良4例，占12．9％；差2例，占6．4％。结论同侧股骨干、胫骨多段骨折采用急诊手术固定，选择对骨折端扰乱较小的外固定架和加压钢板、带锁髓内钉固定治疗，是防止并发症，降低致残率，早期功能锻炼，恢复肢体功能的较好方法。     

Treatment of complicated tibial plateau fractures with dual plating via a 2-incision technique

The operative treatment of complicated bicondylar fractures of the tibial plateau remains a challenge to most surgeons. This retrospective study was designed to evaluate the clinical and radiological outcomes of dual plating via a 2-incision technique for the repair of complicated bicondylar tibial plateau fractures. A series of consecutive patients with bicondylar tibial plateau fractures treated by open reduction and internal fixation with a double buttress plate or a combination of locking plate and buttress plate via a 2-incision technique between March 2004 and March 2008 were retrospectively analyzed. Radiological and clinical results and complications of the 2 different fixation methods were compared. Seventy-nine patients matching the criteria of this study were followed up for at least 24 months. All of the fractures healed, with 3 cases of deep infection, 7 cases of secondary loss of reduction, 3 cases of secondary loss of alignment, and 10 cases of knee instability. At 24-month follow-up, mean Hospital for Special Surgery scores were 77.8±9.4 and 79.0±7.9 in the double buttress plate group and combination group, respectively. No significant differences in clinical or radiographic outcomes were found between the 2 groups, except that the combination group needed less bone graft. Dual plating with 2 incisions provided good exposition for the reduction and fixation of complicated bicondylar tibial plateau fractures. Using a combination of locking plate and buttress plate reduced the amount of bone graft compared with the double buttress plate technique.     

Displaced malleolar fractures associated with spiral fractures of the tibial shaft

A displaced fracture of the lateral malleolus, of the posterior tibial margin (posterior malleolus), or of both requiring open reduction and internal fixation was observed in association with ipsilateral spiral tibial shaft fracture in five patients. The malleolus fracture components all were managed using AO (ASIF) instrumentation. The tibial shaft fracture was treated nonoperatively in three patients and with interfragmentary screw fixation in two with more severe initial displacement. The bony healing of all fractures was uneventful. These combined injuries amounted to 0.9% of all admitted tibial shaft fractures and 3.9% of those with spiral configuration. An associated displaced malleolar fracture in tibial shaft fractures, sometimes even indiscernible in the anteroposterior view, may be overlooked unless roentgenograms are focused on the ankle joint. Examination of the joints above and below the fracture is of particular importance in clinics advocating functional treatment of tibial shaft fractures.     

Treatment of tibial shaft fractures by intramedullary locking nailing]

Authors analyzed consecutive series of 56 tibial shaft fractures (43 men and 13 women) treated by intramedullary locking nails in years 1993-2004. Age of patients ranged from 17 to 83 years (mean 38 years). The final result was analyzed in 51 patients (91%). The bone union was observed in 50 patients. Fractures united within 6 months in 45 patients (88%), between 8 and 15 months in 5 patients. Operative treatment of non-union was necessary in one patient. The fractures united in anatomical axis in 45 cases, small (less than 10 degrees) valgus deviation was noticed in four patients, whereas five patients with fractures localized in distal part of the tibia had 11-30 degrees valgus deviation. The limb length inequality more than 1 cm was noticed in one case. There was neither infection nor compartment syndrome. One patient died because of fatal pulmonary embolism.     

Treatment of unstable closed tibial shaft fractures by external fixation

The fracture of tibia shaft is one of the most common fracture of long bones. The authors bring out the results of the treatment of 90 patients with unstable closed tibial shaft fractures treated by the use of Mitkovic external fixation systems. Within the analayzed group there were 66 (73%) male and 24 (27%) female. The average patients age was 43.9 years (range 15 to 82). Excellent result in treatment of unstable closed tibial shaft fractures with external fixation were achieved in 15 (16,7%) patients, very good in 38 (42,2%) patients, good in 24 (26,7%), poor in 9 (10%) and bad in 4 (4,4%) patients. With 4 (4,4%) patients pseudoarthrosis was formed. Additional treatment of patients with pseudoarthrosis (spongioplastic and placing of CD device) led to pseudoarthrosis healing. Within the analyzed group in all patients treated with extenal fixation there were no registered cases of postoperative osteitis. External fixation by the use of Mitkovic external fixation is one of the method of choose in the treatment of unstable closed tibial fractures, providing dynamic and balanced biomehanical conditions for fracture healing.     

Treatment of low-energy tibial shaft fractures: plaster cast compared with intramedullary nailing

We analyzed data from 87 patients who had displaced closed or open grade I simple or spiral wedge tibial shaft fractures caused by low-energy impact. Fifty-four patients were treated with plaster cast and 33 with intramedullary locking nail (IMLN). Delayed union only occurred in 8 patients after plaster cast treatment. Forty-two patients in the IMLN group and one in the plaster cast group suffered from anterior knee pain. Final treatment outcome, healing time, hospitalization time and duration of sick leave were assessed on the basis of 25 matched pairs of patients. Mean healing time, hospitalization time and sick leave in the plaster cast and IMLN groups were 19 (SD 6.7) and 12 (SD 4.4) weeks (P<0.001); 8 (SD 4.8) and 7 (SD 2.7) days (P=0.686); and 195 (SD 81) and 106 (SD 31) days (P=0.001), respectively. No difference was found between plaster cast and IMLN groups when the outcome was evaluated using the criteria of Johner and Wruhs.     

Insertion of intramedullary nails from the suprapatellar pouch for proximal tibial shaft fractures. A technical note

Intramedullary nailing of proximal tibial fractures can be difficult when using the standard entry portal. We evaluated the suprapatellar portal, using a midline quadriceps tendon incision, to perform intramedullary nailing of the tibia. Seven patients were treated with this adaptation of the standard intramedullary nailing procedure. An arthroscopy was done before and after the nailing procedure. No special equipment was used to perform the intramedullary nailing. We evaluated the handling and necessary modifications of the standard intramedullary technique to introduce the locked tibial nail through the suprapatellar approach. We found this technique not necessarily more difficult than the standard intramedullary nailing of the tibia through the infrapatellar entry portal. Although the patients did not complain of patellofemoral discomfort after the suprapatellar nailing, definitive scuffing of the cartilage in the lower part of the femoral trochlea was visible. Introduction of a locked tibial nail via the suprapatellar approach was found to be possible and even advantageous for some complex upper tibial shaft fractures in compromised limbs. Some possible downsides of this approach need to be taken into account but, in some cases, they can be outweighed by the benefits.     

Treatment of type IIIA open fractures of tibial shaft with Ilizarov external fixator versus unreamed tibial nailing

Introduction The aim of this study was to compare the radiographic results and clinical outcome of unreamed tibial nailing (UTN) and Ilizarov external fixation (IEF) for the treatment of type IIIA open fractures of the tibia. Materials and Methods Sixty-one patients with open type IIIA tibial shaft fractures were treated with an IEF (n = 32) or UTN (n = 29). Both groups were compared for union time, secondary outcomes of nonunion, infections, mechanical failure of the implant, and malunion. Results The average time-to-bone healing was 19 weeks (range 14–23 weeks) for IEF and 21 weeks (range 16–36 weeks) for UTN; it was significantly shorter in the IEF group (P = 0.039). One patient had refracture in the IEF group. Malunion occurred in four patients for each group. Posttraumatic osteomyelitis occurred in two patients in the IEF group and in three patients in the UTN group. In the IEF group, additional surgical procedures were indicated in three cases including sequestrectomy (n = 1), and pin replacement (n = 2). In the UTN group, seven patients needed additional surgery including bone grafting (n = 3), nail exchanged (n = 1), and posttraumatic osteomyelitis (n = 3). Conclusion The results of the current study showed that IEF technique had a notable incidence of pin-tract infection, joint contracture, and shorthening related to treatment of the delayed union. The UTN technique had the disadvantage of a posttraumatic osteomyelitis and delayed union requiring additional surgery. We believe that the decision to use IEF or UTN should be made on a case-by-case basis.     

锁定加压钢板桥接技术治疗粉碎性胫骨干骨折

目的 探讨锁定加压钢板(LCP)桥接技术治疗粉碎性胫骨干骨折的疗效。方法 2005年1月至2010年3月采用LCP治疗78例粉碎性胫骨干骨折患者,男46例,女32例;年龄23～ 69岁,平均36.4岁;左侧41例,右侧37例。骨折根据AO分型：均为42C型,其中C1型38例,C2型26例,C3型14例。闭合性骨折63例,开放性骨折15例。闭合性骨折待水肿消退后选用4.5或5.0mm LCP经皮桥接技术置入。开放性骨折经严格清创后同法置入LCP。术后鼓励患者进行屈髋、屈膝及下肢肌力训练。结果 78例患者术后获平均19个月（6～35个月）随访。所有患者无感染发生。骨折愈合时间平均为22周（13 ～42周）。77例患者获骨性愈合,1例因骨不连发生钢板断裂。末次随访时患者膝关节活动度为100°～130°,平均123°。膝关节功能按美国特种外科医院膝关节评分系统评分为89 ～96分,平均92.1分。踝关节功能按美国足踝外科学会制定的功能评分为82 ～97分,平均93.6分。结论 对于粉碎性胫骨干骨折,LCP桥接技术能提供可靠有效的内固定,并允许患者早期进行功能锻炼,是治疗粉碎性胫骨f骨折的有效方法之一。     

Treatment of open tibial shaft fractures using tightly fitted interlocking nailing

Between 2000 and 2003 we treated 23 patients who sustained open tibial shaft fractures with tightly fitted interlocking intramedullary nailing. There were three grade I, eight grade II, nine grade IIIa, and three grade IIIb open fractures. Nail diameters were decided on using preoperative and intraoperative radiographs. Nails were introduced after gentle passage with a 7- to 8-mm hand reamer. Union was obtained in all cases. Nine (37.5%) fractures, however, required additional procedures before union. Three of them gained union through exchange nailing, bone graft, and bone transport, respectively. The remaining six underwent dynamisation. Two of them required an additional exchange nailing for non-union; thereafter one healed and the other gained union through an additional bone graft. Deep infection occurred in one case. Screw breakage occurred in one case only. Tightly fitted nailing produced a significantly lower incidence of locking screw breakage. However, even with this advantage, this technical modification has failed to show clinical advantage in terms of higher healing rate or lower rate of secondary procedures.

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Résumé Entre 2000 et 2003, nous avons traité 23 patients qui présentaient une fracture ouverte de la diaphyse tibiale par clou verrouillé intra médullaire. Il s’agissait de 3 Grades I, de 8 Grades II et de 9 Grades IIIa ainsi que 3 Grades IIIb. Le diamètre du clou a été décidé d’après les radiographies préopératoires, durant l’intervention et en fonction des résultats de la radiographie per-opératoire. Les clous ont été introduits après un passage d’alésoires de 7 à 8 mm. La consolidation a été obtenue dans tous les cas. 9 fractures (37,5%) ont nécessité une procédure additionnelle pour obtenir la consolidation, 3 ont pu être consolidées après le changement de clou avec une greffe ou un transport osseux. Les six patients restant ont nécessité une dynamisation du montage. Deux d’entre-eux ont nécessité un changement de clou pour pseudarthrose. Les deux ont consolidé grace à une greffe. Nous avons observé une infection profonde dans un cas, des fractures de vis dans un cas. Cette attitude thérapeutique nous semble tout à fait justifiée et présente des avantages pour obtenir une consolidation assez rapide ou tout au moins une consolidation retardée, secondaire assez précoce.

     

Injury of knee ligament associated with ipsilateral femoral shaft fractures and with ipsilateral femoral and tibial shaft fractures

A series of 110 patients with 114 fractures of the femur were reviewed an average of 3.9 years after injury. Demonstrable knee ligament laxity was present in 31 (27 per cent) of these patients, while 13 (11 per cent) complained of instability. Thirty-three patients with 34 ipsilateral femoral and tibial shaft fractures were examined an average of 3.7 years after injury. Demonstrable knee ligament laxity was present in 18 (53 per cent) of these patients, while 6 (18 per cent) complained of instability.

Most of the patients with instability had a rupture of the anterior cruciate ligament with or without damage to other ligaments.

We conclude that knee ligament injury is more common with ipsilateral fracture of the femur and tibia than with just a single ipsilateral femoral fracture. We advocate careful assessment of the knee in all cases of fracture of the femur.