胫骨平台骨折的临床分析

胫骨平台骨折是一种比较常见的关节内复杂骨折,治疗不当将产生创伤性关节炎、关节不稳定及关节功能障碍等.我们依据AO分类原则和塌陷程度,分为B、C两种类型,本组52例胫骨平台骨折,采用不同的治疗和康复方法,获得了满意的治疗效果,现报告如下.……     

Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau

ObjectiveEvaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures.DesignRetrospective case series.SettingUniversity hospital.PatientsFrom January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation.InterventionTransfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau.Main outcome measurementsComplications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function.ResultsTwo patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60–100, S.D:11).ConclusionThe transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction.Level of evidenceTherapeutic level IV.     

胫骨平台骨折CT分类的研究

目前,胫骨平台骨折分类包括:胫骨平台骨折三柱分型、胫骨平台骨折四象限分型、胫骨平台骨折八"段"分型和十"段"分型、四柱九段分型等。本文综述胫骨平台骨折各种CT分类的方法、优缺点和手术入路选择。胫骨平台骨折的CT分型的精髓更加注重冠状面骨折线,尤其后方的冠状面骨块。将胫骨平台关节面的四象限分类与胫骨平台周缘皮质的四柱分类相结合,再辅以非关节面结构(髁间棘、胫骨结节、腓骨头),有可能对胫骨平台骨折提供更加完整的描述,但也可能因为配对组合太多,太过繁杂,临床使用困难。     

高能量胫骨平台骨折的处置

[目的]探讨高能量胫骨平台骨折的处置。[方法]本组对1998年1月～2003年6月收治高能量胫骨平台骨折46例的处理进行回顾性研究。[结果]43例术后随访1～4a，膝关节功能均基本恢复，据Merchant标准评分，优良率82．4％。[结论]高能量胫骨平台骨折应重视围手术期综合处理。术前对骨折的复杂程度及合并伤正确评估；术中必须考虑骨损伤和伴有软组织损害，如果不能进行完全切开复位内固定，可采取有限切开、间接复位、杂合固定，力求恢复关节功能，尽量维持正常的力轴线，确保关节稳定，术后早期密切观察患肢情况，加强膝关节早期功能锻炼，采取综合有效的对策，可使受损的膝关节功能达到最大程度恢复。     

Balloon tibioplasty for tibial plateau fractures

BackgroundTibial plateau fractures are complex intra-articular injuries. The aim of treatment is to restore joint congruity and alignment. Balloon tibioplasty is a novel, minimally invasive technique to reduce the fracture and restore the continuity of the articular surface. A systematic review was performed according to the PRISMA guidelines in order to assess the outcomes from this procedure.Sources of dataThe online databases of Pubmed, Google scholar, the Cochrane Library, EMBASE and CINAHL were searched. Articles of interest were retrieved and evaluated, including case series, randomised controlled trials and cadaver studies.Areas of agreementEight studies (one randomised controlled trial, four case series and three cadaver studies) were included in the final review. The studies demonstrated adequate fracture reduction with favourable clinical and imaging outcomes from balloon tibioplasty. Very few complications were described.Areas of controversyThere is a small volume of literature currently available on balloon tibioplasty with an overall low level of evidence. The overall number of reported cases is also small.Growing pointsFurther research is necessary, with adequately powered randomised controlled trials. Further areas of research include type of bone substitute and the use of arthroscopically assisted surgery.     

胫骨平台骨折的微创处理

目的 在关节镜监视下处理胫骨平台骨折。方法与结果 治疗不同类型胫骨平台骨折88例。术前X线、CT和三维CT重建。常规关节镜检查,镜下将胫骨平台骨折分为:裂纹型、边缘型、裂隙型、塌陷型、粉碎型、胫骨嵴骨折型和合并骨折型。根据骨折分型,确定治疗原则,在关节镜监视下不切开关节,进行骨折复位和有限切口内固定。同时诊断和处理关节内半月板和交叉韧带等损伤。术后遵循早期活动、后期负重原则。平均2.5年随访,优良率89.6％(Hohl评分法)。结论 胫骨平台骨折的关节镜下微创处理有利于正确复位和内固定,及时发现并处理关节内伴随损伤,允许早期不负重活动,提高关节稳定性和减少并发症产生。     

胫骨平台骨折与Pilon骨折的诊断与治疗

<正>胫骨骨折十分常见,亦为骨科医师所熟悉,伤及关节面的胫骨骨折在临床治疗更为棘手。伤及关节面的胫骨骨折主要包括累及胫骨上关节面的胫骨平台骨折和累及胫骨下关节面的Pilon骨折。现就胫骨平台骨折[1-4]、Pilon骨折[5-7]的诊断与治疗等问题做一总结与归纳。1胫骨平台骨折胫骨平台骨折是下肢常见的关节内骨折。骨折可产生不同程度的膝内外翻畸形,严重者还可合并     

Part I: Arthroscopic management of tibial plateau fractures

Arthroscopy is a valuable tool for the assessment of tibial plateau fractures and is the treatment of choice for associated intra-articular pathology. In addition, (all)-arthroscopic reduction and internal fixation (ARIF) is recommended for type III fractures and is a consideration for types I, II, and IV. Published outcome studies of ARIF of tibial plateau fractures describe results that appear to equal outcomes of open reduction and internal fixation, but these studies suffer from susceptibility bias.     

Complications and unplanned outcomes following operative treatment of tibial plateau fractures

IntroductionThe operative management of tibial plateau fractures is challenging and post-operative complications do occur. The purpose of this study was three-fold. 1). To report complications and unplanned outcomes in patients who had sustained tibial plateau fractures and were operatively managed 2). To report predictors of these post-operative events 3). To report if differences in clinical outcomes exist in patients who sustained a post-operative event.MethodsOver 11 years, all tibial plateau fractures were prospectively followed. Clinical outcomes were assessed using the validated Short Musculoskeletal Functional Assessment (SMFA) score. Demographics, initial injury characteristics, surgical details and post-operative events were prospectively recorded. Student’s t-tests were used for continuous variables and chi-squared analysis was used for categorical variables. Binary logistic regression and multivariate linear regression were conducted for independent predictors of post-operative events and complications and functional outcomes, respectively.Results275 patients with 279 tibial plateau fractures were included in our analysis. Ten patients (3.6%) sustained a deep infection. Six patients (2.2%) developed a superficial infection. One patient (0.4%) presented with early implant failure. Two patients (0.7%) developed a fracture nonunion. Eight patients (2.9%) developed a venous thromboembolism. Seventeen patients (6.2%) went on to re-operation for symptomatic implant removal. Nine patients (3.3%) underwent a lysis of adhesions procedure. Univariate analysis demonstrated bicondylar tibial plateau fractures (P < 0.001), Moore fracture-dislocations (P = 0.005), open fractures (P = 0.022), and compartment syndrome (P = 0.001) to be associated with post-operative complications and unplanned outcomes. Long-term functional outcomes were worse among patients who developed a post-operative complication or unplanned outcome (P = 0.031).ConclusionOrthopaedic trauma surgeons should be aware of complications and unplanned outcomes following operatively managed tibial plateau fractures, along with having the knowledge of factors that are associated with development of post-operative events.     

复杂胫骨平台骨折的手术治疗

目的 探讨复杂胫骨平台骨折的手术治疗方法。方法 手术治疗复杂胫骨平台骨折48例，骨折类型按schatzker分型，其中Ⅲ型12例，Ⅳ型9例，V型14例，Ⅵ型13例，均经切开复位、钢板内固定，骨缺损者同时予以植骨。结果 48例中46例获1-4年随访，优良率77％。结论 复杂胫骨平台骨折宜手术治疗，手术方法根据不同的骨折类型而异。     

微创植入钢板治疗胫骨平台骨折

目的探讨微创植入钢板在治疗胫骨平台骨折中的临床效果. 方法采用微创植入钢板治疗胫骨平台骨折26例. 结果全部病例随访6个月～4年,平均2.1年,均获得骨折愈合,按Merchant标准,优20例,良5例,可1例. 结论应用微创植入钢板治疗胫骨平台骨折,创伤小,固定牢靠,可早期功能锻炼,并发症少.     

胫骨平台骨折52例临床分析

目的 比较胫骨平台骨折的几种治疗方法，选择治疗胫骨平台骨折的最佳方案。方法 本组总结胫骨平台骨折52例，按A0分型和塌陷程度分为B、C两种类型。B1、B2型骨折主要采用手法整复骨牵引或石膏外固定；B3、C1型骨折主要采用撬拨复位，植骨后采用松质骨螺钉固定；C2、C3型骨折主要采用坚强固定。结果 52例胫骨平台骨折获得随访47例，膝关节功能恢复按关节功能、活动范围、膝关节轴线、关节稳定性及骨折复位综合评定，膝关节功能优良41例(87.24％)，可及差6例(12.76％)。结论 胫骨平台骨折的治疗应以关节面损伤程度为中心，选择恰当的治疗方案，早期膝关节功能练习能够获得满意的治疗效果。     

有限切开间接复位治疗胫骨平台骨折

目的探讨有限切开间接复位治疗胫骨平台骨折的临床效果。方法采用有限切开间接复位治疗胫骨平台骨折41例，采用Schatzker分型：Ⅰ型6例，Ⅱ型13例，Ⅲ型11例，Ⅳ型6例，Ⅴ型3例，Ⅵ型2例。Ⅰ型骨折用点状复位钳闭合复位，经皮拉力螺钉固定。Ⅱ、Ⅲ、Ⅳ型骨折恢复关节面平整后植骨，点状复位钳复位，经皮支撑钢板固定；Ⅴ、Ⅵ型用骨折牵开器及点状复位钳间接复位，经皮支撑钢板固定。结果36例获得随访，随访6～60个月，平均30．2个月。36例全部获得骨折愈合，膝关节功能按Rasmussen评分标准，优25例，良8例，可3例，优良率为91％。结论应用有限切开间接复位治疗胫骨平台骨折，创伤小，固定牢靠，可早期功能锻炼，关节功能恢复好，并发症少。     

胫骨平台高能骨折的手术治疗

目的: 探索胫骨平台高能骨折手术治疗的临床疗效。方法: 回顾分析本院从 1997年 1月 ~2004年 3月共收治胫骨平台高能骨折即SchatzkerⅣ、Ⅴ和Ⅵ型骨折的 56例, 高能创伤造成的高能骨折均行切开复位“AO”钢板内固定治疗, 高能量创伤不仅对软组织损伤严重而且对肌肉有持续影响。结果: 随访 10个月 ~5年, 平均 1年 8个月。采用Merchant标准综合评定, 优良率达 85 .3%。结论: 胫骨平台骨折分型是高能骨折治疗的基础, 牢固可靠的内固定和早期正确处理软组织损伤是手术治疗和功能恢复的关键。     

Revisiting the Schatzker classification of tibial plateau fractures

Tibial plateau fractures have a broad spectrum of presentations, depending on the mechanism and energy of the trauma. Many classification systems are currently available to describe these injuries. In 1974, Schatzker proposed a classification based on a two-dimensional representation of the fracture. His classification with the six-principles types became one of the most utilized classification systems for tibial plateau fractures. More than four decades after this original publication, we are revisiting each fracture type in the light of information made available by computed tomography, which today comprises a standard tool in assessing articular fractures. The classification we are proposing relies on the fact that the tibial plateau has two anatomical columns, lateral and medial. We are introducing a virtual equator which splits the articular surface in the coronal plane. The equator divides each column into two quadrants, the anterior (A) and the posterior (P). Unicondylar fracture types (I to IV) have now additional modifiers A (anterior) and P (posterior) to describe the exact spatial location of the primary fracture plane. Bicondylar fracture types (V and VI) have the modifiers (A and P) of the main fracture plane for each column, and lateral (L) and medial (M) to denote the column. We are introducing the concept of the main fracture plane. Recognition of the exact location of the principal fracture plane is essential for preoperative planning of patient positioning, surgical approach and for determining where to apply the hardware to achieve stable fixation. The new three-dimensional classification is based on the template of the original Schatzker classification. It covers the mechanism of the injury, the energy of the trauma, the morphologic characteristics of the fracture and its location in three dimensions.     

螺旋CT三维重建在胫骨平台骨折中的应用

目的探讨螺旋CT三维重建在胫骨平台骨折中的临床应用。方法回顾性分析1999～2004年38例胫骨平台骨折病例,手术前均行X线摄片,而后行螺旋CT三维重建并与手术对照。螺旋CT的扫描参数为层厚2～5mm,床速3～5mm,重建间距1.5～3mm。结果所有病例螺旋CT三维重建明确地显示了骨折,螺旋CT三维重建在骨折的分型和碎骨的描述上较平片优越,与手术中所见一致。结论螺旋CT三维重建能够更为精确地显示胫骨平台的骨折情况,对治疗方法的选择具有指导意义。     

胫骨平台骨折的分类与功能评价

胫骨平台骨折属胫骨近端的关节内骨折。胫骨平台骨折的分类方法，主要包括Hohl修正后分类(1991)、Schatzker分类(1979)及AO分类(1990)。AO分类内容详尽，共分为两型(41-B和41-C)6组18个亚组，对资料积累极为有利，2000年已被美国．JBJS杂志推荐使用，并作为美国创伤骨科学会(OTA)会议与J，Orthop Trauma杂志论文的标准骨折分类。Schatzker分类分为6型，临床实用性很强，目前应用最为广泛。胫骨平台骨折治疗后的功能评价，多选用Rasmussen膝关节功能评分、HSS膝关节临床功能评分；放射学评价早期多用Rasmussen评分标准，远期可参考Resnick-Niwoyama退行性关节疾病评分标准。     

The role of arthroscopy in the management of tibial plateau fractures

The value of arthroscopy in the management of tibial plateau fractures was evaluated in a series of 29 patients from 1979 to 1984. It was determined that arthroscopy is of value in the management of these fractures; acute fractures and associated soft tissue injuries can be precisely defined, allowing for timely management decisions; based on direct arthroscopic observation, selected fractures can be reduced and stabilized, and appropriate postoperative management determined; and healed but symptomatic fractures may benefit from arthroscopic surgery.     

Minimally invasive fixation in tibial plateau fractures using an pre-operative and intra-operative real size 3D printing

The purpose of our study was to compare the outcome after minimally invasive reconstruction and internal fixation with and without the use of pre- and intra-operative real size 3D printing for patients with displaced tibial plateau fractures (TPFs). We prospectively followed up 40 consecutive adult patients with closed TPF who underwent surgical treatment of reconstruction of the tibial plateau with the use of minimally invasive fixation. Sixteen patients (group 1) were operated using a pre-operative and intra-operative real size 3D-model, while 24 patients (group 2) were operated without 3D-model printing, but using only pre-operative and intra-operative 3D Tc-scan images. The mean operating time was 148.2 ± 15.9 min for group 1 and 174.5 ± 22.2 min for group 2 (p = 0.041). In addition, the mean intraoperative blood loss was less in group 1 (520 mL) than in group 2 (546 mL) (p = 0.534). After discharge, all patients were followed up at 6 weeks, 12 weeks, 6 months, 1 year and then every year post surgically and radiographic evaluation was carried out each time using clinical and radiological Rasmussen’s score, with no significant differences between the two groups. Two patients (group 2) developed infection which resolved within 3 weeks after usage of antibiotics. Neither superficial nor deep infections were present in group 1. In all patients, no non-union occurred. No intraoperative, perioperative, or postoperative complications, such as loss of valgus correction, bone fractures, or metallic plate failures were detected at follow-up. In patients operated with the use of 3D-model printing, we found a significant reduction in surgical time. Moreover, the technique without a 3D-model increased the patient’s and the surgeon’s exposure to radiation.