改良前外侧入路锁定钢板内固定治疗孤立性后外侧胫骨平台骨折疗效分析

目的探讨改良前外侧入路锁定钢板内固定治疗孤立性后外侧胫骨平台骨折的临床疗效。方法回顾性分析自2015-01—2018-04采用改良前外侧入路锁定钢板内固定治疗的23例孤立性后外侧胫骨平台骨折。末次随访时采用HSS评分标准评价膝关节功能。结果 23例均获得随访,随访时间平均15.4(12～23)个月。骨折均骨性愈合,骨折愈合时间平均12(10～16)周。术后骨折复位情况根据Rasmussen评分标准评定:优17例,良6例。术后1年随访时均未见明显关节面复位丢失。术后即刻X线片测量胫骨平台内翻角为(87.3±0.5)°,术后1年为(87.7±1.2)°。术后即刻X线片测量胫骨平台后倾角为(7.3±0.7)°,术后1年为(7.5±1.2)°。术后1年随访时膝关节活动度平均125.5°(105°～135°)。末次随访时膝关节功能HSS评分:优12例,良9例,可2例。结论采用改良前外侧入路锁定钢板内固定治疗孤立性后外侧胫骨平台骨折可清晰地显露骨折部位并完成有效固定,较好地维持膝关节稳定性,有利于患者术后早期功能锻炼。     

Carlson后内侧或后外侧入路内固定治疗胫骨平台后侧骨折

目的探讨Carlson后内侧或后外侧入路内固定治疗胫骨平台后侧骨折的可行性及近期疗效。方法对2010年4月至2012年1月15例胫骨平台后侧骨折患者行Carlson后侧入路切开复位内固定治疗并进行随访,做疗效分析。结果 15例均获随访,随访时间6～15个月,平均11个月,骨折愈合后以美国特种外科医院（the hospital forspecial surgery,HSS）膝关节评分标准进行膝关节功能评估。骨折愈合后HSS评分72～94分,平均85.3分。结论 Carlson后内侧或后外侧入路对胫骨平台后侧骨折可以很好的显露并复位内固定,术后膝关节功能恢复较满意。     

改良前外侧入路胫骨近端锁定加压钢板固定治疗胫骨平台后外侧骨折

目的 探讨改良前外侧入路胫骨近端锁定加压钢板固定治疗胫骨平台后外侧骨折的近期临床疗效.方法 2010年6月至2012年3月采用改良前外侧入路胫骨近端锁定加压钢板固定治疗胫骨平台后外侧骨折并获得随访的患者19例,男11例,女8例;年龄26～55岁,平均38.3岁.均为新鲜闭合性骨折.车祸伤10例,高处坠落伤7例,跌伤2例.合并胫骨平台前十字韧带止点撕脱骨折2例.受伤至手术时间3～15 d,平均7.5 d.手术均采用膝关节前外侧“S”形皮肤切口,较常规切口偏向后上,用胫骨近端锁定加压钢板固定,术后早期行膝关节功能锻炼.术后复查X线片和CT三维重建,3个月内每月复查X线片,采用Rasmussen膝关节功能评分标准评价膝关节功能.结果 手术时间80～120 min,平均95 rin;术中出血量100～400 ml,平均180 ml.随访时间12～24个月,平均16.2个月.全部获得骨折愈合,愈合时间8～14周.随访期间无内固定松动、断裂、骨不愈合,无膝关节内、外翻畸形和骨折再移位,无膝关节不稳.18例患者达到解剖复位;1例后外侧粉碎骨折脱位患者术后CT提示存在2 mm关节面台阶,患者行走2 km后出现膝关节轻度疼痛,膝关节伸屈0°-105°.1例患者膝关节伸屈5°-90°.Rasmussen膝关节功能评定13～30分,平均(22.9±4.9)分,优10例、良7例、可2例,优良率89.5％.结论 改良前外侧入路胫骨近端锁定加压钢板固定治疗胫骨平台后外侧骨折操作简单安全,固定可靠,并发症少.     

后侧入路T形支撑钢板内固定治疗胫骨平台后柱骨折

[目的]探究后侧入路T形支撑钢板内固定治疗胫骨平台后柱骨折的临床疗效。[方法]2014年1月～2017年1月本院收治的65例胫骨平台后柱骨折患者为研究对象,均行后侧入路T形支撑钢板内固定术治疗。回顾分析手术资料、骨折愈合情况、膝关节功能评分及末次随访时膝关节功能优良率,并探索影响临床结果的因素。[结果]所有患者手术顺利,平均手术时间(98.32±19.64) min,平均术中出血量(73.24±17.59) ml,未发生血管、神经损伤、切口感染等严重并发症。所有患者随访(14.61±2.50)月,骨折平均愈合时间(3.42±0.84)月,完全负重时间(4.72±0.41)月。术后6个月及末次随访时比较患者Lysholm评分和HSS评分差异均无统计学意义(P0.05),但两时间点间,膝屈伸活动度有显著改善(P0.05)。影像评估方面,术后骨折复位良好,力线恢复正常,术后即刻、术后6个月及末次随访时患者平台内翻角度、内侧平台后倾角、外侧平台后倾角差异均无统计学意义(P0.05)。末次随访时患者Lysholm评分优良率为81.54%(53/65),HSS评分优良率为86.15%(56/65),年龄≤50岁、单纯后柱骨折、未合并半月板损伤患者的Lysholm评分和HSS评分优良率显著高于年龄50岁、合并侧柱骨折及合并半月板损伤的患者,差异有统计学意义(P0.05)。[结论]对于胫骨平台后柱骨折患者,后侧入路T形支撑钢板内固定治疗疗效满意。但是,高龄、合并侧柱骨折及半月板损伤为恶化临床效果的因素。     

腓骨头纵形截骨入路治疗后外侧胫骨平台骨折

[目的]介绍腓骨头纵形截骨入路切开复位内固定治疗胫骨平台后外侧骨折的手术技术和初步临床疗效。[方法] 2012年1月～2017年12月,手术治疗21例单纯胫骨平台后外侧骨折患者。取俯卧位,行膝后外侧切口,腓骨头内1/2处进行纵向截骨,注意保护腘腓韧带、腘肌腱、股二头肌腱、外侧副韧带等结构,暴露胫骨近端后外侧,撬拨复位,植骨,"T"型钢板固定。[结果]所有患者均顺利手术,无严重并发症。末次随访时,屈膝30°、90°小腿外旋试验均为阴性,内翻应力试验为阴性,膝关节活动度(122.50±18.25)°,膝关节HSS评分平均为(85.50±9.65)分。影像方面,术后X线片显示骨折均达到解剖复位,Rasmussen放射评分平均(17.55±1.65)分。末次随访时骨折均愈合。[结论]腓骨头纵形截骨入路手术治疗胫骨平台后外侧骨折,暴露视野充分,有利于骨折的复位以及内固定的置入。     

经后外侧入路治疗胫骨平台后外侧骨折

目的探讨经后外侧入路治疗胫骨平台后外侧骨折的临床疗效。方法手术治疗21例胫骨平台后外侧骨折患者,采用后外侧入路显露胫骨后外髁,对骨折进行支撑钢板内固定,关节面塌陷者采用异体骨或自体髂骨植骨。结果 21例均获随访,时间13~19个月。1例膝关节伸直轻度受限(-5.0°),其余患者无膝关节伸直障碍。膝关节总伸屈度95.0°~135.0°(122.6°±12.8°)。骨折均愈合,愈合时间9~16周。Rasmussen放射学评分:术后即刻13~18(16.2±2.7)分,末次随访时11~18(15.5±3.2)分。后倾角:术后即刻6.0°~9.0°(7.8°±1.5°),末次随访5.5°~10.0°(7.6°±1.8°)。HSS膝关节评分65~98(83.9±8.2)分。结论经后外侧入路治疗胫骨平台后外侧骨折尽管暴露范围较局限,但可直视下进行复位固定位置,具有一定优势,是一种比较理想的入路。     

前后联合入路治疗累及后外侧平台劈裂C型胫骨平台骨折

目的 探讨前后联合入路治疗累及后外侧平台劈裂C型胫骨平台骨折的手术方法及临床疗效.方法 7例患者术前均经CT扫描及三维重建,均采用后路和前外侧联合入路后侧和前外侧支撑钢板固定.采用DeCoster评定标准评定骨折复位情况、测定胫骨平台内翻角和采用HSS法行膝关节功能评定.结果 术后X线片检查示达到解剖复位5例,复位良好1例,差1例.1例发生膝内翻.7例均获随访,时间6～18(12±6)个月.骨折全部愈合,愈合时间14～16(15±1)周.胫骨平台内翻角术后1年和术后初次摄片无变化;膝关节功能HSS评分为78～90(80±4)分.结论 前后联合入路并后侧入路支撑钢板固定是治疗累及后外侧孤立劈裂C型胫骨平台骨折的有效方法.     

后外侧倒L形入路3.5mm T形支撑钢板内固定治疗单纯后外侧胫骨平台骨折疗效观察

目的总结后外侧倒L形入路3.5 mm T形支撑钢板治疗单纯后外侧胫骨平台骨折的临床疗效。方法 2011年3月—2016年1月,采用后外侧倒L形入路3.5 mm T形支撑钢板内固定治疗单纯后外侧胫骨平台骨折13例。男6例,女7例;年龄28~52岁,平均43岁。左侧5例,右侧8例;致伤原因:交通事故伤6例,摔伤3例,高处坠落伤4例。术前行X线片、CT三维重建和MRI检查,均为单纯后外侧胫骨平台骨折;Schatzker分型:Ⅱ型4例,Ⅲ型9例。受伤至手术时间5~9 d,平均7 d。结果术后1例患者切口皮肤坏死,给予清创植皮后创面愈合;余均Ⅰ期愈合。13例患者均获随访,随访时间10~16个月,平均13个月。所有患者术后3个月X线片示骨折线均模糊,术后12个月骨折线均消失。无切口感染、重要血管神经损伤、内固定物松动或断裂以及关节面再次移位塌陷等并发症发生。末次随访时按改良美国特种外科医院(HSS)膝关节功能评分评价膝关节功能,获89~97分,平均94分;均达优。结论后外侧倒L形入路3.5 mm T形支撑钢板内固定可作为治疗单纯后外侧胫骨平台骨折的首选手术方式之一。     

改良后外侧入路治疗胫骨平台后外侧塌陷骨折的临床效果

目的探讨改良后外侧入路治疗胫骨平台后外侧塌陷骨折的临床疗效。方法选取2014年10月至2019年10月间在本院行改良后外侧入路手术治疗的胫骨平台后外侧塌陷骨折的患者86例,均为闭合型骨折,其中男性54例,女性32例,术后定期复查X线,记录患者骨折愈合时间以及出现并发症情况,评估末次随访时患者的膝关节功能评分,主要包括美国特种外科医院(HSS)评分及Rasmussen膝关节功能评分。结果所有患者未出现血管神经损伤,随访时间6～36个月,平均(19.3±7.9)个月。骨折愈合时间6～15个月,平均(10.8±2.4)个月,未发现膝关节内外翻畸形或膝关节不稳定患者,末次随访时患者的HSS评分为81～94分,平均(91.2±3.1)分。Rasmussen膝关节功能评分显示,58例患者为优,21例患者为良,7例患者为可,优良率为91.86%。结论经改良后外侧入路治疗胫骨平台后外侧塌陷骨折能够较好的显露骨折处,有助于骨折复位,可获得满意的临床疗效。     

手术治疗胫骨平台后外侧髁骨折的临床体会

目的探讨后外侧入路治疗胫骨平台后外侧髁骨折的临床疗效。方法对12例胫骨平台后外侧髁骨折采用后外侧切口,C型臂X线机透视下撬拨复位骨折,以桡骨远端T形钢板内固定。结果 12例均获12～52个月随访,平均(26.7±7.6)个月。术后住院时间为9～21 d,平均(11.6±4.8)d。无切口感染、内固定松动及关节面再次塌陷。骨折愈合时间为3.5～6个月,平均(6.4±3.1)个月;患肢完全负重时间为4～8个月,平均(7.5±1.6)个月。按照Hohl评分标准进行膝关节功能评定:优7例,良3例,可2例。结论手术治疗胫骨平台后外侧髁骨折疗效可靠。     

改良后外侧入路治疗胫骨平台后外侧骨折23例

目的探讨改良后外侧入路治疗胫骨平台后外侧骨折的临床疗效。方法对23例胫骨平台后外侧骨折患者行后外侧入路行支撑钢板内固定治疗。结果 23例均获随访,时间8~19个月。骨折均愈合,愈合时间9~16周。HSS膝关节评分67~96分。结论改良后外侧入路手术治疗胫骨平台后外侧骨折,有利于骨折的复位和固定,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。     

Muscle-sparing posterolateral thoracotomy

We have developed a technique for posterolateral thoracotomy that allows adequate exposure for most thoracic operations, yet spares both the latissimus dorsi and serratus anterior muscles. Postoperative pain is decreased, functional recovery is improved, and patients can frequently be discharged earlier from the hospital. Although the time for opening is slightly prolonged, closing time is less and the incision can easily be converted to the standard muscle-splitting approach if more room is required.     

Anatomical evaluation of the modified posterolateral approach for posterolateral tibial plateau fracture

Objective

The study was undertaken to evaluate the efficacy and safety of a posterolateral reversed L-shaped knee joint incision for treating the posterolateral tibial plateau fracture.

Methods

Knee specimens from eight fresh, frozen adult corpses were dissected bilaterally using a posterolateral reversed L-shaped approach. During the dissection, the exposure range was observed, and important parameters of anatomical structure were measured, including the parameters of common peroneal nerve (CPN) to ameliorate the incision and the distances between bifurcation of main vessels and the tibial articular surface to clear risk awareness.

Results

The posterolateral aspect of the tibial plateau from the proximal tibiofibular joint to the tibial insertion of the posterior cruciate ligament was exposed completely. There was no additional damage to other vital structures and no evidence of fibular osteotomy or posterolateral corner complex injury. The mean length of the exposed CPN was 56.48 mm. The CPN sloped at a mean angle of 14.7° toward the axis of the fibula. It surrounded the neck of the fibula an average of 42.18 mm from the joint line. The mean distance between the opening of the interosseous membrane and the joint line was 48.78 mm. The divergence of the fibular artery from the posterior tibial artery was on average 76.46 mm from articular surface.

Conclusions

This study confirmed that posterolateral reversed L-shaped approach could meet the requirements of anatomical reduction and buttress fixation for posterolateral tibial plateau fracture. Exposure of the CPN can be minimized or even avoided by modifying the skin incision. Care is needed to dissect distally and deep through the approach as vital vascular bifurcations are concentrated in this region. Placement of a posterior buttressing plate carries a high vascular risk when the plate is implanted beneath these vessels.     

The voluntarily evoked posterolateral drawer sign in the knee with posterolateral instability

Posterolateral instability of the knee refers to a ligamentous lesion that allows abnormal posterior and posterolateral subluxation of the tibial plateau. This condition is caused by injuries of the posterolateral structures (arcuate ligament complex) and the posterior cruciate ligament. Ten patients could produce the instability voluntarily by active muscle pull. Electromyographic studies clearly demonstrated that the biceps femoris muscle acted as a major subluxor and the popliteus as a reducer. The operative findings of the patients were not different from those of the patients who could not subluxate voluntarily. The active muscle pull of the popliteus is a key to treatment of posterolateral instability.     

胫骨平台后外侧临床解剖学研究

目的:对膝关节外后方的主要神经血管结构进行解剖测量,为临床手术提供解剖学基础。方法:解剖20具成人下肢标本,解剖并测量与膝关节后外侧入路相关的主要血管、神经的走形特点。结果:膝关节后外侧主要神经有腓总神经、腓肠外侧皮神经和腓肠肌外侧头肌支,主要血管有膝下外侧血管、胫前动脉和腓动脉。结论:膝关节后外侧入路临床解剖学为治疗胫骨平台后外侧骨折提供了应用解剖学基础。     

Results of a modified posterolateral approach for the isolated posterolateral tibial plateau fracture

Background:

There are few posterolateral approaches that do not require the common peroneal nerve (CPN) dissection. With the nerve exposure, it would pose a great challenge and sometimes iatrogenic damage over the surgical course. The purpose was to present a case series of patients with posterolateral tibial plateau fractures treated by direct exposure and plate fixation through a modified posterolateral approach without exposing the common peroneal nerve (CPN).

Materials and Methods:

9 consecutive cases of isolated posterior fractures of the posterolateral tibial plateau were operated by open reduction and plate fixation through the modified posterolateral approach without exposing the CPN between June 2009 and January 2012. Articular reduction quality was assessment according to the immediate postoperative radiographs. At 24 month followup, all patients had radiographs and were asked to complete a validated outcome measure and the modified Hospital for Special Surgery (HSS) Knee Scale.

Results:

All patients were followedup, with a mean period of 29 months (range 25–40 months). Bony union was achieved in all patients. In six cases, the reduction was graded as best and in three cases the reduction was graded as middle according to the immediate postoperative radiographs by the rank order system. The average range of motion arc was 127° (range 110°–134°) and the mean postoperative HSS was 93 (range 85–97) at 24 months followup. None of the patients sustained neurovascular complication.

Conclusions:

The modified posterolateral approach through a long skin incision without exposing the CPN could help to expand the surgical options for an optimal treatment of this kind of fracture, and plating of posterolateral tibial plateau fractures would result in restoration and maintenance of alignment. This approach demands precise knowledge of the anatomic structures of this region.     

Examination of posterolateral corner injuries

Physical examination of patients with a suspected posterolateral corner injury must be comprehensive. Mechanical alignment, gait, and any hyperextension or varus thrust should all be evaluated. The status of all ligaments of the knee also must be thoroughly assessed. Detecting the presence or absence of a PCL can be difficult but is essential (Table). The dial test is easy to perform and is the most standard and accepted test to assess and follow posterolateral rotatory instability of the knee.     

Congenital posterolateral diaphragmatic hernia.

The infant who is born with a posterolateral diaphragmatic hernia who becomes symptomatic at or soon after birth requires urgent care. Surgical reduction of the diaphragmatic hernia must be accomplished quickly. Respiratory and metabolic acidosis must be treated appropriately. The parents should be informed of the gravity of their infant's problem and reassurred by appropriate explanation of the nature of the defect and the therapeutic requirements. If the infant dies, the parents are in need of empathy, reassurance, and adequate explanation so that they do not have lingering doubts regarding the etiology of the anomaly and the adequacy of the therapy. If the infant lives, the medical team can share the feeling of a job well done.