自体髂骨重建胫骨平台在胫骨外侧平台粉碎性骨折中的应用

目的：采用自体髂骨移植修复重建胫骨平台骨折中骨软骨面的大量缺损，并评价其术后临床结果。方法：对胫骨外侧平台粉碎性骨折中因骨软骨严重碎裂、塌陷而无法复位固定所造成的胫骨平台缺损，用自体髂骨移植的方法予以修复重建。结果：术后经过12个月～5年的随访，平均24个月，按膝关节功能评定标准评分为75～100分，平均85.2分。结论：移植物为髂骨，其供区创伤小，无明显的并发症；受区植入方便，容易固定。可以用来重建胫骨平台。     

经关节截骨治疗胫骨后外侧平台陈旧骨折畸形愈合

目的探讨经关节截骨术治疗创伤后后外侧平台骨折畸形愈合的策略和临床效果。方法回顾2007年1月至2012年1月收治的创伤后后外侧平台骨折畸形愈合患者共28例,其中男15例,女13例;年龄28~59岁,平均42.6岁;左侧16例,右侧12例。按Schatzker分型,Ⅱ型19例,Ⅲ型9例。保守治疗导致胫骨平台外翻塌陷畸形8例,创伤术后畸形愈合20例。所有患者入院后均行经关节截骨术。结果随访骨折均愈合良好,平均愈合时间为12~18周(平均14.7周)。术后即刻与术后2年胫骨平台内翻角及股胫角比较,差异无统计学意义(P0.05),所有患者术后膝关节稳定性及功能有明显改善。术后1例患者浅表感染经外科换药治愈,无骨不连,无内固定失效、松动、断裂。结论经关节截骨治疗创伤后后外侧平台骨折畸形愈合获得良好的治疗效果。     

胫骨平台陈旧性骨折及骨折后畸形愈合的手术治疗

目的探讨陈旧性胫骨平台骨折及骨折后畸形愈合的治疗方法。方法陈旧性胫骨平台骨折37例(男31例,女6例),从受伤或第一次手术至本次手术时间平均28.5个月(1个月～6年)。34例行截骨、软骨面抬高、植骨和内固定术;3例同时行自体骨软骨移植术。结果平均随访62.3个月,骨折全部愈合;膝关节屈曲角度比健侧平均减少(15.7±7.5)°;疗效按Merchant评分,优20例,良14例,可3例,优良率91.9%。结论应综合患者的年龄、病情考虑手术方案;依靠胫骨的解剖形态X线检查具有诊断可靠、方便的优点;对手术难度要有充分的认识。     

关节面陈旧性骨折畸形愈合后的重建

因误诊误治导致畸形愈合的陈旧性大块关节面骨折,处理较为困难,常常视为关节固定术和关节成形术的适应证。然而我们认为选择其中一部分病例进行切开复位,仍然可以重建原关节面。近期随访效果满意。     

自体游离髂骨移植重建髋臼后壁陈旧性骨折缺损

目的 探讨用自体游离髂骨移植重建髋臼后壁陈旧性骨折缺损的方法。方法 手术中先去除残留的髋臼后壁骨折块,使脱位的股骨头复位,取长６～８ｃｍ、宽３～４ｃｍ的自体游离髂骨植于髋臼后壁基底处,用２～４枚螺钉固定,以重建髋臼后壁。自１９９０年３月～１９９８年３月,用此法治疗６例车祝伤患者;男４例,女２例;年龄８～４５岁,平均３２岁,全部病例从骨折至重建术的时间为３～１１个月,平均７个月,随访２～１０年。结果 无一例患者发生手术后并发症,髋关节功能均恢复良好,可不扶拐行走,轻度跛行,长距离行走后仅有轻微疼痛,Ｘ线片显示股骨头与重建的髋臼虽未达到解剖学匹配,但股骨头无再脱位,其中髋关节轻度间隙狭窄无退变者１例,间隙狭窄伴轻度退变者３例,股骨头轻度致密改变者２例,结论 自体游离髂骨移植重建术,是治疗年轻患者髋臼后壁陈旧性骨折缺     

大块髂骨重建胫骨平台治疗胫骨髁劈裂塌陷骨折

目的：探讨胫骨平台严重劈裂塌陷的手术方法。方法：自1998年8月-2003年3月，采用大块髂骨重建胫骨平台治疗胫骨髁劈裂塌陷骨折31例，其中男24例，女7例；年龄24～62岁，平均36岁。根据Schatzker分类：Ⅱ型劈裂塌陷型21例，Ⅲ型单纯中央塌陷型6例，Ⅳ型内髁骨折4例。将塌陷的关节面撬起复位至平整后取自体大块髂骨在其下方约1．0cm处水平插入，并在下方再用髂骨块垂直支撑，在关节面下重建坚实可靠的支持平台，然后用AO支持钢板支撑固定，术后石膏固定6周进行功能锻炼，12周后逐步下地负重。结果：随访1～5年，根据Merchant标准综合分析：优19例，良8例，中4例。结论：利用大块髂骨关节面下支撑既可充填缺损，又可构筑可靠的支持平台，保证了关节面的平整和高度；AO支撑钢板固定牢固，有利于早期功能锻炼，防止关节僵硬，疗效满意。     

陈旧性内侧胫骨平台塌陷骨折合并后外侧复合体损伤的治疗

[目的]探讨陈旧性内侧胫骨平台塌陷骨折合并后外侧复合体损伤的临床治疗效果。[方法]随访本院2014年1月～2017年12月诊治的内侧胫骨平台塌陷骨折合并后外侧复合体损伤7例患者,男5例,女2例;左膝4例,右膝3例;受伤至手术时间(57.32±6.74) d;6例为交通事故损伤,1例为运动损伤;根据Fanelli分型:B型1例,C型6例。所有患者均行内侧胫骨平台下撑开截骨,取髂骨植骨,联合后外侧复合体重建术。[结果]术后患者未出现切口感染,步态正常,下肢力线无内翻,胫骨外旋试验(Dial-test)较健侧对比均10°(术前均10°);术后Lysholm评分(83.00±3.79)分,与术前比较差异有统计学意义;所有患者均获得随访,随访时间9～27个月,术前改善至D级,术后改善至A级4例,B级3例,患肢功能均获得明显改善。[结论]内侧胫骨平台塌陷骨折的复位是维持下肢力线的重要因素,应早期切开复位内固定,同时后外侧复合体是膝关节稳定系统的重要组成部分,修复重建可获得满意的疗效。     

自体带骨膜髂骨板移植修复髌骨粉碎性骨折合并软骨面缺损

髌骨粉碎性骨折尤其是开放性粉碎性骨折,常导致髌骨软骨面缺损,髌股关节匹配不良,引起髌股创伤性关节炎,临床治疗上非常棘手,常见的方法是髌骨部分及完全切除术,但效果欠佳.     

应用髂骨内板修复胫骨平台骨折关节面缺损

目的：探讨应用髂骨内板修复复杂胫骨平台骨折关节面缺损的可行性。方法：复杂胫骨平台骨折23例,男17例,女6例;年龄18～51岁,平均28.3岁。关节面缺损1cm×2cm～3cm×3cm,平均6.7cm^2。取带骨膜髂骨内板,修剪成和缺损区匹配的形状,并用直径1.5mm的克氏针间隔3～4mm钻孔,凹面朝上置入缺损区,其下植骨,T形或L形钢板固定。术后石膏外固定4周。结果：23例经随访8个月～3年,平均13.6个月,X线片示骨折全部愈合,关节面平整。采用Rasmussen评价标准,优11例,良8例,可3例,差1例。结论：对于复杂胫骨平台骨折关节面缺损,应用髂骨内板进行修复可恢复关节面平整,使膝关节获得满意功能,方法简单易行,很少发生供区并发症,临床实用性较强,可修复较大面积关节面缺损。     

胫骨平台骨折畸形愈合手术治疗

胫骨平台骨折是负重关节的关节内骨折,诊断失误、术中复位不良、植骨及内固定不理想等均可导致畸形愈合。胫骨平台骨折畸形愈合引起临床症状均为手术矫正的适应证。术前详细采集患者病史并认真体检,影像学资料,尤其是双下肢立位全长X线片非常重要。常用手术矫正方法主要包括重新复位内固定,截骨矫形术、单侧平台干骺端截骨术、关节内软骨下截骨术。高位胫骨截骨术是最常用的手术方案,适用于胫骨平台骨折畸形愈合年轻患者,在计算机辅助技术支持下可达到满意效果。晚期重建的目的在于重建关节稳定性,恢复关节面平整和下肢力线,最大限度地减少膝关节周围并发症发生。     

3D printing-assisted osteotomy treatment for the malunion of lateral tibial plateau fracture

IntroductionOsteotomy and internal fixation are usually the most effective way to treat the malunion of lateral tibial plateau fractures, and the accuracy of the osteotomy is still a challenge for surgeons. This is a report of a series of prospectively study of osteotomy treatment for the malunion of lateral plateau fractures with the aid of 3D printing technology.MethodsA total of 7 patients with malunion of lateral tibial plateau fractures were enrolled in the study between September 2012 to September 2014 and completed follow up. CT image data were used for 3D reconstruction, and individually 3D printed models were used for accurate measurements and detail osteotomy procedures planning. Under the premeditated operation plan, the osteotomy operations were performed. Patients were invited for follow-up examinations at 2 and 6 weeks and then at intervals of 6 to 8 weeks until 12 months or more.ResultsMean age of the patients was 44 years (range 30–52 years), 3 cases were result of fall injuries, 2 were traffic accidents and 2 were sports injuries. Among the cases, one accompanied with craniocerebra trauma, one with pelvic fracture, one accompanied with both. According to the Schatzker Tibial Plateau classification, the original fracture type were 3 type I, 1 type II and 3 type III. The lateral tibial plateau collapse ranges from 4 mm–12 mm, with an average of 9.4 mm. All the operations were successfully completed, the average operation time was 77.1 min (range 70–90 min), the average intraoperative blood loss was 121.4 ml (range 90–180 ml), the mean follow-up time was 14.4 months (range 12–18 months), and the average healing time of the osteotomy fragments was 12 weeks (range 11–13 weeks). The difference between preoperative and postoperative Rasmussen scores were statistically significant (P < 0.05). All the patients were obtained functional recovery, with no complications.Conclusion3D printing technology is helpful to accurately design osteotomy operation, reduce the risk of postoperative deformity, decrease intraoperative blood loss, shorten the operation time, and can effectively improve the treatment effect.     

Arthroscopically assisted percutaneous osteosynthesis of lateral tibial plateau fractures

Background

The aim of our study was to evaluate the results of lateral tibial plateau fractures treated with arthroscopically assisted percutaneous osteosynthesis (AAPO).

Methods

Twenty-one patients (14 men and 7 women) with a mean age of 41 years underwent AAPO to repair low-energy Schatzker I–III tibial plateau fractures. Under pneumatic tourniquet, we reduced and fixed the fracture with 1 or 2 subchondral cannulated screws. Accompanying lesions included 10 meniscus tears, which we partially excised in 9 patients and repaired in 1 patient. On the second postoperative day, patients began range-of-motion exercises. We encouraged partial and full weight-bearing by the sixth and tenth weeks, respectively. The mean follow-up period was 38 (range 12–96) months, and we evaluated the patients using Rasmussen''s clinical and radiologic criteria. We used a t test for statistical analysis.

Results

There were 13 excellent (62%), 6 good (28%) and 2 fair (10%) clinical results, and 11 excellent (52%), 7 good (33%) and 3 fair (14%) radiologic results. We observed mild or moderate arthritic changes in 5 patients (24%). There were no infection or wound problems, but we removed hardware in 4 patients.

Conclusion

Arthroscopically assisted treatment of lateral tibial plateau fractures yields satisfactory results and can be accepted as an alternative and effective method for the treatment of low-energy tibial plateau fractures.     

胫骨平台外侧髁塌陷分离骨折的手术治疗

目的：探讨胫骨平台外侧髁塌陷分离骨折复位困难的原因及手术方法。方法：自2003年1月至2008年10月,采用外侧切口显露外侧半月板外侧缘,复位半月板后再复位平台外髁,对45例胫骨平台外髁塌陷分离骨折进行手术治疗。男27例,女18例;年龄15～76岁,平均37岁。伤后至就诊时间1～14d,所有患者X线片提示胫骨平台外髁塌陷超过2mm或增宽大于5mm。术后采用Rasmussen评分标准评定关节功能,并通过观察患膝有无疼痛,关节活动度,有无感染、下肢深静脉血栓、关节面再塌陷并发症指标对疗效评估。结果：术后X线片示骨折解剖复位31例,近解剖复位14例,钢板螺钉位置均满意。45例中42例得到随访,时间6～12个月,平均10个月。解除外固定后无骨折再移位,无术后感染、下肢深静脉血栓发生,均在10d左右骨折部疼痛消失,3周后无压痛及纵轴叩击痛,3个月后X线提示所有病例骨折完全愈合。据Rasmussen评分标准优37例,良7例,尚可1例。结论：外侧半月板及塌陷骨块嵌顿是导致胫骨平台外髁复位困难的两大因素。     

选择性胫骨外髁U形截骨入路治疗胫骨外侧平台塌陷粉碎骨折

目的:探讨选择性胫骨外髁"U "形截骨入路治疗胫骨外侧平台塌陷粉碎骨折的方法和临床疗效。方法:自2014年1月至2019年10月,采用选择性胫骨外髁" U"形截骨入路对15例胫骨外侧平台塌陷粉碎骨折患者进行手术治疗,其中男9例,女6例;年龄25~70(38.5±7.7)岁。按照胫骨平台外侧髁骨折ABC分型,A型2例,B型6例,BC型4例,C型3例;合并内侧平台骨折5例;左膝8例,右膝7例。伤后至就诊时间1~14(3.4±1.2) d。所有患者CT提示胫骨外侧平台塌陷>2 mm,粉碎骨块>2块,胫骨外侧髁皮质完整。术后12个月采用Rasmussen骨折复位解剖学评分评价骨折复位情况,并采用Rasmussen功能评分评价膝关节功能。结果:15例患者选择性"U "形截骨一次成功,手术时间55~110(85.6±20.0) min,外侧平台手术时间20~60(30.5±10.5) min。所有患者获随访,时间12~24(14.6±2.5)个月。骨折愈合时间12~24(13.6±3.6)周。术后12个月膝关节Rasmussen骨折复位解剖学评分14~18(17.5±0.3)分,其中优13例,良2例。膝关节Rasmussen功能评分13~30(26.8±2.5)分;其中优12例,良1例,可2例。2例外侧平台高度分别丢失2 mm和4 mm,1例膝关节5°外翻畸形,1例关节僵硬(10°~100°)。未发生腓总神经损伤、腘血管损伤,术后无感染、内固定失效等严重并发症。结论:采用选择性胫骨外髁" U"形截骨入路治疗胫骨外侧平台塌陷粉碎性骨折,具有手术切口简单、骨折显露直接、复位固定准确、手术时间短,并发症少等优点,是一种有效、可靠的方法。     

Effect of articular step-off and meniscectomy on joint alignment and contact pressures for fractures of the lateral tibial plateau

OBJECTIVES: To determine the effects of intraarticular step-off and lateral meniscectomy on the alignment of the articular axis, contact area, and pressures for lateral tibial plateau fractures. DESIGN: Biomechanical cadaver study. INTERVENTION: Six fresh cadaveric knees were used. A simulated split fracture of the lateral tibial plateau was reproducibly created by osteotomies, and articular step-offs of zero, one, two, four, and six millimeters were achieved by using support shims. The knee was loaded with 500 newtons in 0 degrees and 350 newtons in 30 degrees of flexion. A digital camera determined changes in the alignment of the articular axis, and F-Scan sensors were inserted into the medial and lateral joint compartments to determine the pressures and pressure distributions. MAIN OUTCOME MEASUREMENT: Each specimen was tested at step-offs of zero, one, two, four, and six millimeters, with the presence or absence of the lateral meniscus. The changes in alignment of the articular axis, the contact area, and the average and maximum contact pressures for each condyle were obtained. RESULTS: Increased articular step-off heights progressively increased valgus angulation and average and maximum contact pressures and progressively decreased contact areas in lateral compartment. At a six-millimeter step-off with 0 degrees of flexion, the valgus angle increased an average of 7.6 degrees, and average contact pressures and maximum contact pressures increased an average of 208 percent and 97 percent, respectively, and contact area decreased an average of 33 percent (p < 0.05). Meniscectomy increased valgus angles by an average of 38 percent and contact pressures by an average of 45 percent and decreased contact areas by 26 percent in the lateral compartment at the same articular step-off heights (p < 0.05). CONCLUSION: The results of this study show the importance of decreasing articular step-off heights in treating lateral tibial plateau split fractures, particularly if a meniscectomy is performed.     

Treatment of bicondylar tibial plateau fractures with lateral locking plates

Bicondylar tibial plateau fractures usually include damage to the soft tissue, and efforts to fix both the lateral and medial columns with plates can result in tissue loss and infection.