前内侧钢板支撑固定治疗胫骨平台后外侧塌陷骨折的临床研究

目的研究前内侧钢板支撑固定胫骨平台后外侧塌陷骨折的手术效果。方法自2011-01—2013-03收治胫骨平台骨折存在外髁劈裂及后外侧塌陷者17例,均采用前内侧钢板支撑后外侧塌陷骨块并联合外侧钢板固定外侧平台劈裂骨折,植骨填补骨缺损,观察骨折固定情况、愈合情况和术后并发症。结果本组手术时间平均2．5h。17例均获得平均8（6～12）个月随访,骨折均解剖复位,下肢长度对线及旋转矫正满意,骨折愈合时间平均3（2—4）个月,无感染、关节僵硬等并发症发生。末次随访时膝关节功能按Rasmussen评分标准评定：优13例,良2例,可1例,差1例。结论前内侧钢板支撑胫骨平台后外侧塌陷骨折块可达到关节面的解剖复位,获得坚强固定,加快恢复膝关节的功能。     

Two-dimensional and three-dimensional computed tomography for the classification and characterisation of tibial plateau fractures

Background

Complex tibial plateau fractures can be difficult to characterise on plain radiographs and two-dimensional computed tomography (2D CT). The present study evaluated whether three-dimensional computed tomography (3D CT) reconstructions can improve the reliability of complex tibial plateau fracture characterisation and classification.

Methods

Forty-five consecutive intra-articular fractures of the tibial plateau were evaluated by six independent observers for classification according to standard systems and for the presence of six characteristics: (1) posteromedial shear fracture; (2) coronal plane fracture; (3) lateral condylar impaction; (4) medial condylar impaction; (5) tibial spine involvement; and (6) separation of tibial tubercle necessitating fixation. Two rounds of characterisation and classification were performed: the first classification after a combination of plain radiographs and 2D CT and the second one after 3D CT information were added.

Results

3D CT improved the average ‘inter’-observer reliability of the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification (κ2D = 0.536, 95% confidence interval (CI): 0.481–0.591 vs. κ3D = 0.545, 95% CI: 0.478–0.612), the Hohl and Moore classification (κ2D = 0.668, 95% CI: 0.605–0.732 vs. κ3D = 0.746, 95% CI: 0.605–0.732) and of the Schatzker classification (κ2D = 0.545, 95% CI: 0.494–0.596 vs. κ3D = 0.596, 95% CI: 0.538–0.654). ‘Intra’-observer reliability also improved non-significantly for all systems after the addition of 3D CT for individual observers.3D CT did improve the ‘intra’-observer reliability for the identification of the following fracture characteristics: coronal plane fracture (average κ2D = 0.700, interquartile range (IQR): 0.551–0.820 vs. average κ3D = 0.774, IQR: 0.692–0.847); lateral condylar impaction (average, κ2D = IQR: 0.675–0.901 to 1.000 vs. average, κ3D = 0.785, IQR 0.737–0.807); medial condylar impaction (average κ2D = 0.631, IQR: 0.537–0.670 vs. κ3D = 0.719, IQR: 0.679–0.895); tibial spine involvement average (κ2D = 0.621, IQR 0.545–0.678 vs. average κ3D = 0.705, IQR: 0.652–0.794); separation of tibial tubercle necessitating fixation (average κ2D = 0.332, IQR: 0.080–0.574 vs. average κ3D = 0.441, IQR: 0.325–0.681). The only improvement that was found to be statistically significant was for recognition of medial condylar impaction as the IQR did not overlap.3D CT had limited influence on average ‘inter’-observer reliability for the recognition of all specific fracture characteristics (κ2D = 0.488 vs. κ3D = 0.485, both moderate agreement for all fracture characteristics) but showed a non-significant improvement of the recognition of coronal plane fractures (fair to moderate; κ2D = 0.398, 95% CI: 0.273–0.523 to κ3D = 0.418, 95% CI: 0.262–0.574) and recognition of impaction of the lateral condyle (κ2D = 0.614, 95% CI: 0.467–0.760 to κ3D = 0.693, 95% CI: 0.538–0.849).

Conclusions

The added value of 3D CT after 2D CT is limited and does not significantly improve reliability of characterisation and classification of tibial plateau fractures.     

胫骨平台后内髁劈裂骨折的手术治疗

目的:探讨膝关节后内侧入路手术复位内固定治疗胫骨平台后内髁劈裂骨折的临床疗效。方法:2006年1月至2009年7月,采用后侧入路手术治疗胫骨平台后内髁劈裂骨折获得随访的患者21例,男14例,女7例;年龄28～68岁,平均36.9岁。致伤原因:车祸伤14例,高处坠落伤7例。合并伤:合并前交叉韧带损伤15例,均为胫骨平台止点撕脱;合并胫骨平台后外侧塌陷骨折14例。采用膝关节后内侧入路手术复位内固定治疗,术后据Rasmussen膝关节功能评定方法评定疗效。结果:21例均获随访,时间12～30个月,平均17.3个月。无切口感染,无内固定松动及断裂,无骨不愈合,无膝关节内、外翻畸形和骨折再移位。术后后内髁骨折均达解剖复位,1例术后小腿内下方感觉麻木。术后根据Rasmussen膝关节功能评定标准:优12例,良7例,可2例。结论:膝关节后内侧手术治疗胫骨平台后内髁劈裂骨折,有利于平台后内髁骨折的复位和固定,具有暴露清楚、内固定安放方便、创伤小及临床疗效好等优点。     

胫骨平台骨折内固定治疗

胫骨平台骨折为一种高能量的损伤，由于常合并严重软组织损伤及关节面损伤，治疗上有一定难度。我院自1998年5月—2002年7月共收治胫骨平台骨折20例，多数伴发严重的软组织损伤。经正确掌握手术时机，采用合理拉力螺钉或钢板内固定，取得较为满意的疗效。     

Three-dimensional computed tomography imaging increases the reliability of classification systems for tibial plateau fractures

Objective

The purpose of this study was to determine whether three-dimensional reconstructed computed tomography (CT) images can improve intra-observer and inter-observer reliability for classification systems of tibial plateau fractures compared to plain radiographs and two-dimensional CT images.

Methods

Twenty-one tibial plateau fractures were classified independently by four attending orthopaedic trauma surgeons using the AO/ASIF and Schatzker classification systems. First, a combination of plain radiographs and two-dimensional (2D) CT images were evaluated. Second, 4 weeks later, plain radiographs and three-dimensional (3D) CT images were assessed. Then, 4 weeks later, these two rounds of evaluation were repeated. The intra-observer and inter-observer reliability were assessed using kappa statistics.

Results

Three-dimensional CT images can improve the inter-observer and intra-observer reliability regarding both AO/ASIF and Schatzker classification systems of tibial plateau fractures compared to 2D CT images. The degree of agreement of the inter-observer and intra-observer reliability among four surgeons increased from ‘substantial’ to ‘almost perfect’.

Conclusion

Three-dimensional CT is a more reliable radiographic modality than 2D CT in evaluation of fracture patterns in tibial plateau fractures. This finding seems to show that more sophisticated imaging techniques can improve the reliability of fracture classification systems.     

经皮鱼嘴钳固定治疗胫骨平台骨折

目的:分析微创技术治疗胫骨平台骨折的疗效。方法:胫骨平台骨折83例,男59例,女24例;年龄18~58岁,平均37岁。交通事故伤36例,坠落伤21例,砸伤10例,摔伤16例。外翻应力伤31例,内翻应力伤9例,垂直压迫或合并旋转应力伤43例。按Schatzker分类:Ⅰ型15例,Ⅱ型26例,Ⅳ型17例,Ⅴ型25例。均行经皮撬拨复位、鱼嘴钳固定治疗。结果:随访81例,时间2~7年,骨折均于3个月内愈合,膝关节完全伸直,屈膝平均127°(95°~145°)。参照Rasmussen胫骨髁部骨折膝关节功能进行评分:优49例,良27例,可4例,差1例。结论:经皮鱼嘴钳固定手术创伤小,固定可靠,能早期进行功能锻炼,避免二次手术取内固定物,是治疗胫骨平台骨折的有效方法。     

Predictors of reduction loss in tibial plateau fracture surgery: Focusing on posterior coronal fractures

IntroductionSome studies have reported that fracture pattern was associated with reduction loss after surgery. The purpose of this study was to evaluate various factors that can influence reduction loss, including fracture patterns in unicondylar and bicondylar tibial plateau fractures.Materials and methodsA total of 138 tibial plateau fractures that underwent open reduction and internal fixation using plates were retrospectively reviewed. The OTA/AO classification, fracture pattern, degree of comminution, and existence of reduction loss were evaluated based on simple radiographs and computed tomography. Patient information, including age, gender, and occupation, were acquired through chart reviews. The effect of each variable on reduction loss was evaluated through multiple logistic regression analysis.ResultsOf 138 knees, reduction loss was observed in 40 knees (29.0%). Reduction loss was found in 11 (20.4%) of the type B knees (54 knees) and 29 (34.5%) of the type C knees (84 knees), according to the OTA/AO classification. The multiple logistic regression analysis for all cases revealed that the existence of comminution and coronal fracture influenced the occurrence of reduction loss, with odds ratios of 9.148 and 4.823, respectively (P < 0.001 and P = 0.001, respectively). In type B and type C, according to the OTA/AO classification, the existence of comminution and coronal fracture had causal relationships with the occurrence of reduction loss. The odds ratios of comminution and coronal fracture for reduction loss for type B were 9.114 and 9.117, respectively (P = 0.019 and P = 0.031, respectively), and the odds ratios for type C were 8.490 and 4.782, respectively (P = 0.001 and 0.009, respectively).ConclusionsWhen a tibial plateau fracture has a coronal fracture, if it is difficult to fix its fragments rigidly with medial or lateral plate fixation; therefore, buttress plating or direct fixation of fragments through the posteromedial, posterolateral, or posterior approach should be considered.     

Use of a virtual 3D software for planning of tibial plateau fracture reconstruction

Objective

Anatomical reconstruction of tibial plateau fractures is necessary to prevent pain, axial malalignment, knee join instability and posttraumatic arthritis. Computed tomography (CT) with 3D reconstruction is helpful in the accurate preoperative evaluation and reduction planning of the fracture site. The aim of this study was to describe the application of a virtual 3D reconstruction and segmentation software in the preoperative planning of tibial plateau fractures.

Patients and methods

CT scans of five tibial plateau fractures were preoperatively evaluated using the 3D planning software. Manual colour-coded segmentation was performed. The amount of time required for each planning session was recorded.

Results

Successful 3D reconstruction and segmentation was achieved in all cases. The mean time required for 3D virtual planning was 174.8 min (range 69-124 min). The mean time required for 3D virtual planning of B-type fractures was 96.5 min (range 69-124 min; SD = 38.891 min; CI = 349.421). The mean time required for planning of C-type fractures was 227 min (range 167-294 min; SD = 63.789 min; CI = 158.460) (Table 1).

Conclusion

Successful segmentation was achieved in all cases. The 3D planning capabilities of this software may be a valuable tool for surgeons in learning about the nature of the injury in tibial plateau fracture cases and in formulating an appropriate surgical plan. However, the time requirement for the 3D reconstruction and segmentation analysis may be a current deterrent for its use in the clinical setting.     

复杂胫骨平台骨折治疗的挑战

<正>胫骨上端膨大而形成两个髁,称为胫骨平台。与股骨髁对应,在半月板、内外侧副韧带、前后交叉韧带、髌骨及其周围附属结构的支持下,构成膝关节。胫骨平台是重要的负荷结构,周围解剖结构复杂,传导躯体重量,完成各种活动。遭受外伤后,常会发生骨折及其附属结构的损伤,骨折线     

自断加压骨栓联合接骨板治疗胫骨平台骨折的疗效

目的:探讨自断加压骨栓联合接骨板治疗胫骨平台骨折的临床效果。方法:回顾性分析2018年7月至2018年12月间应用河北医科大学第三医院创伤急救中心自断加压骨栓联合接骨板治疗的12例胫骨平台骨折患者资料。男8例,女4例;年龄20~65岁,平均45.6岁;左侧6例,右侧6例。根据Schatzker分型：Ⅰ型1例,Ⅱ型3例,...     

人工骨在治疗胫骨平台骨折中的应用

目的 :探讨人工骨植入治疗胫骨平台骨折的临床效果。方法 :回顾分析 2 0 0 0年1月～ 2 0 0 2年 12月收治的胫骨平台骨折 43例 ,对其中随访资料完整的行人工骨移植治疗者2 9例进行分析 ,全部病例术前均行X线正侧位拍片、CT平扫 ,根据骨折情况制定手术方案 ,术中用“T”型或解剖型钢板固定。结果 :随访时间 6个月～ 3年 6个月 ,平均 2 7.3个月 (SD =10 .0个月 ) ,按Merchant评分标准优良率 86.2 %。结论 :应用人工骨植入治疗胫骨平台骨折疗效满意 ,且手术时间短 ,并发症少。     

同种异体骨和自体骨移植在胫骨平台骨折中的应用

[目的]探讨胫骨平台骨折手术中植骨的适应证、方法及使用同种异体骨移植和自体骨移植的优缺点。[方法]通过对2000年1月～2004年8月问手术的105例胫骨平台骨折病例进行回顾性分析。手术中进行植骨的74例分为：A组（自体髂骨组）40例，男29例，女11例。年龄19—75岁，平均45．3岁。Schatzker Ⅱ型13例，Ⅲ型11例，Ⅳ型5例，V型4例，Ⅵ型5例：B组（同种异体骨组）34例，男25例，女9例。年龄21～74岁，平均43．6岁，其中Ⅱ型12例，Ⅲ型11例，Ⅳ型3例，V型4例，Ⅵ型5例；手术采用前正中、髌旁切口，用半螺纹松质骨螺钉、T型、L型或解剖型钢板支撑固定。对不同的分型分别采取相应的植骨方法。对2组患者并发症、平均手术时间，骨折愈合时间、6—12个月平台高度丢失进行比较。功能评定按Lysholm评分标准。[结果]105例手术共植骨74例，占70．5％。术后随访6个月～4a，平均21个月，A组与B组相比：A组手术时间长，平均出血量多，切口愈合时间短，骨折愈合时间无明显差异；术后平台高度丢失、膝关节功能评分均无明显差异。并发症A组主要出现在供骨区，表现在供区不适及骨疼痛7例，髂骨应力骨折1例，B组主要在受骨区，表现伤口渗液4例、延迟愈合1例，细菌培养阴性。[结论]骨移植是胫骨平台骨折治疗的重要步骤之一，掌握好它的适应证和方法对胫骨平台骨折的预后至关重要。适应证和方法主要根据Schatzker分型和结合cT检查来决定。同种异体骨移植和自体骨移植在胫骨平台骨折的治疗中各有优缺点，同种异体骨移植是安全、值得提倡的移植材料。     

Treatment of isolated posterior coronal fracture of the lateral tibial plateau through posterolateral approach for direct exposure and buttress plate fixation

Purpose  To present a case series of patients with isolated posterior coronal fractures of lateral tibial plateau treated by direct exposure and buttress plate fixation through posterolateral approach. Methods  Between May 2007 and April of 2008, eight middle aged patients were identified that had isolated posterior coronal fractures of the lateral tibial plateau. All eight patients underwent direct fracture exposure, reduction under visualization, and buttress plate fixation through posterolateral approach. Results  There were 1 case of split, two cases of pure depression and five cases of split-depression fractures. Four were associated fibular head split fractures without common peroneal nerve injuries. Five patients were injured from a simple fall on riding electrical bicycle while the knee was relaxed in 90° position The articular displacement (8 cases) measured in CT scan was 10.5 mm in average (range 8–15 mm). The cortical split length (from the articular rim to the distal tip, 6 cases) was 2.8 cm in average (range 2.4–3.5 cm). The articular reduction was perfect in seven (absolutely no step-off) and imperfect in 1(<2 mm step-off) as measured by X-ray. With a mean follow-up of 10 months (6 cases > 12 months), the average range of motion arc was 119°, four patients have flexion lag 10°–20°. The average SMFA dysfunction score was 15.8, and average HSS score was 98. All eight patients stated they were highly satisfied. Conclusions  Direct posterolateral approach by dividing lateral border of soleus muscle, provides excellent fracture reduction under visualization and internal buttress plate fixation for posterior coronal fracture of the lateral tibial plateau. Good functional results and recovery can be expected.     

内固定手术治疗胫骨平台骨折临床分析

随着社会的高速发展,交通事故及坠落伤引起的胫骨平台骨折病例逐渐增多。胫骨平台骨折是常见的关节内骨折,治疗不当会出现创伤性关节炎、关节不稳定及关节功能障碍等并发症。目前多主张手术干预。2000年至2006年收治63例胫骨平台骨折,现对内固定手术治疗进行回顾性分析,提出各种具体的治疗方法,以期进一步提高手术的远期效果。     

The clinical scaphoid fracture: early computed tomography as a practical approach

INTRODUCTION

Up to 40% of scaphoid fractures are missed at initial presentation as clinical examination and plain radiographs are poor at identifying scaphoid fractures immediately after the injury. Avoiding a delay in diagnosis is essential to prevent the risk of non-union and early wrist arthritis. We demonstrate the use of CT scanning for the early confirmation of a scaphoid fracture.

PATIENTS AND METHODS

We conducted a retrospective, chronological review of patients who attended an upper limb fracture clinic from January 2001 to October 2003 in a small district general hospital. We performed a CT scan on all ‘clinical scaphoid’ patients who had negative plain X-ray films.

RESULTS

Overall, 70% of patients had a CT scan within 1 week of injury and not from date of accident and emergency attendance; 83% of patients had a CT scan within 2 weeks of injury. Of 118 patients identified, 32% had positive findings and 22% of ‘clinical scaphoid’ patients had scaphoid fractures. The proportion of positive findings for an acute scaphoid fracture was 68%. Additional pathologies identified on CT were capitate, triquetral and radial fractures.

CONCLUSIONS

Our audit shows that it is practical to perform CT on suspicious scaphoid fractures in a small district general hospital. We identified an extremely high false-negative rate for plain X-rays and demonstrate that the appropriate use of CT at initial fracture clinic attendance with ‘clinical scaphoid’ leads to an earlier diagnosis and reduces the need for prolonged immobilisation and repeated clinical review.     

多层螺旋CT对胫骨平台骨折分型及治疗的临床价值

[目的]探讨多层螺旋CT(MSCT)容积重组技术(VRT)和多平面重建(MPR)在胫骨平台骨折(TPF)分型及治疗中的临床应用价值.[方法]2005年8月-2009年2月对45例49侧TPF患者的病例资料进行回顾性分析.其中男32例,女13例;年龄20～65岁(平均46岁).4例为双侧TPF.所有患者均行X线检查和64层螺旋CT扫描仪扫描.在轴位CT扫描后行VRT和MPR成像.按照Schatzker分型标准,应用X线片与64层螺旋CT扫描(包括VRT、MPR成像)分别进行分型和制定相应的治疗方案.[结果]参考VRT、MPR成像后,更改X线分型13侧(13/49)、更改治疗方案8侧(8/49)、发现胫骨髁问嵴骨折15侧(漏诊率46.9%)和腓骨近端骨折6例(漏诊率28.6%).[结论]MSCT(VRT+MPR)可以清晰显示TPF塌陷的范围和程度、细节及隐匿骨折,有助于骨折的正确分型、降低漏诊率和选择合理的治疗方案,是X线片和轴位CT扫描有效的补充手段,具有较高临床应用价值.     

关节镜辅助下微创经皮螺钉内固定治疗胫骨平台骨折

目的:探讨关节镜辅助下微创经皮螺钉内固定治疗胫骨平台骨折的可行性及疗效。方法:自2001年1月-2005年1月,应用膝关节镜检查及监测下经皮螺钉内固定治疗胫骨平台骨折27例,按照Schatzker分类法:Ⅰ型9例,Ⅱ型8例,Ⅲ型5例,Ⅳ型5例。所有病例均行经皮骨折有限显露复位,适当植骨,应用1~3枚松质骨拉力螺钉内固定,术后配合CPM功能锻炼。结果:本组随访6~24个月,平均15个月。骨折临床愈合时间3~4个月,平均3·5个月。无畸形愈合、感染、螺钉断裂。按Sanders膝关节功能评分法评定结果:优12例,良11例,中3例,差1例,优良率85·2%。结论:关节镜辅助经皮螺钉内固定是治疗胫骨平台骨折的有效方法之一,其对膝关节创伤小,可达解剖复位,固定可靠,患肢功能恢复好,并发症少。     

三种固定方式治疗单纯胫骨平台后外侧骨折的疗效分析

目的:分析比较传统前外侧入路、外侧入路和后外侧入路3种方式固定治疗胫骨平台后外侧骨折的优缺点及其疗效。方法:2010年5月至2014年7月收治胫骨平台后外侧骨折病例44例,男21例,女23例;年龄26~61岁,平均42.5岁。根据不同手术入路方式将所有病例分为3组,前外侧入路组(A组)19例,外侧入路组(B组)15例,后外侧入路组(C组)10例。比较3组患者的手术时间及出血量,术后随访观察膝关节功能,评估方式采用HSS评分。结果:前外侧入路组平均手术时间(91.3±10.4)min,术中出血量(175.3±20.3)ml;外侧入路组平均手术时间(86.6±9.2)min,术中出血量(155.8±18.2)ml;后外侧入路组平均手术时间(109.5±10.8)min,术中出血量(235.9±29.1)ml。后外侧入路组手术时间及术中出血量与前外侧入路组、外侧入路组相比差异有统计学意义(P0.05)。随访时间10~35个月,平均14.9个月。末次随访时HSS评分前外侧入路组89.6±7.5,外侧入路组90.2±6.4,后外侧入路组88.9±5.1,3组相比差异无统计学意义(P0.05)。结论:胫骨平台后外侧骨折的治疗可以使用多种方式进行暴露固定,3种方式中,后外侧入路手术时间和术中出血量高于其余2种方式,在短期随访的膝关节功能方面三者并没有明显区别。