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     

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。     

胫骨平台骨折手术治疗及疗效分析

目的总结胫骨平台骨折手术治疗的临床结果,分析影响手术效果的因素。方法回顾分析2001年1月～2003年12月收治的39例胫骨平台骨折手术患者,骨折类型按Schatzker分型,Ⅰ型5例,Ⅱ型12例,Ⅲ型8例,Ⅳ型5例,Ⅴ型6例,Ⅵ型3例。Ⅰ型患者采用闭合复位空心加压螺钉内固定,Ⅲ型有3例患者在关节镜下复位植骨石膏外固定。其余病例分别采用切开复位,钢板内固定,有骨缺损者自体植骨。术后3个月开始部分负重,5个月完全负重。结果39例患者均获随访,平均时间1.8年,采用Rasmussen临床和放射评分方法,优良率分别为89.7%和87.2%。4例患者出现创伤性骨性关节炎,2例患者有严重的骨质疏松,术后出现不同程度关节面塌陷。结论手术是治疗胫骨平台骨折的有效方法,稳定的内固定,尽可能减少对骨折块的血运干扰,保护关节附属结构,正确关节功能康复治疗,对提高疗效有明显影响。     

Open reduction and fixation of medial Moore type II fractures of the tibial plateau by a direct dorsal approach

Introduction  Moore type II Entire Condyle fractures of the tibia plateau represent a rare and highly unstable fracture pattern that usually results from high impact traumas. Specific recommendations regarding the surgical treatment of these fractures are sparse. We present a series of Moore type II fractures treated by open reduction and internal fixation through a direct dorsal approach. Patients and methods  Five patients (3 females, 2 males) with Entire Condyle fractures were retrospectively analyzed after a mean follow-up period of 39 months (range 12–61 months). Patient mean age at the time of operation was 36 years (range 26–43 years). Follow-up included clinical and radiological examination. Furthermore, all patient finished a SF36 and Lysholm knee score questionnaire. Results  Average range of motion was 127/0/1° with all patients reaching full extension at the time of last follow up. Patients reached a mean Lysholm score of 81.2 points (range 61–100 points) and an average SF36 of 82.36 points (range 53.75–98.88 points). One patient sustained deep wound infection after elective implant removal 1 year after the initial surgery. Overall all patients were highly satisfied with the postoperative result. Conclusion  The direct dorsal approach to the tibial plateau represents an adequate method to enable direct fracture exposure, open reduction, and internal fixation in posterior shearing medial Entire Condyle fractures and is especially valuable when also the dorso-lateral plateau is depressed.     

膝前正中加后内侧入路联合三柱钢板内固定治疗复杂胫骨平台骨折

目的 ：探讨膝前正中加后内侧入路联合三柱钢板内固定治疗复杂胫骨平台骨折的手术方法及临床疗效。方法：自2010年1月至2012年12月,采用膝前正中加后内侧入路联合三柱钢板内固定治疗复杂胫骨平台骨折28例。男17例,女11例;年龄28~64岁,平均45.3岁;左侧12例,右侧16例。按Schatzker分型：Ⅴ型12例,Ⅵ型16例。三柱分型：均为涉及三柱。受伤至手术时间6~15 d,平均9.4 d。术前主要临床症状为膝关节肿胀、畸形及活动受限,X线及CT检查均提示复杂性胫骨平台骨折胫骨平台三柱均涉及。术后随访骨折愈合时间,术后1年按照美国特种外科医院膝关节评分（HSS评分）评价临床疗效,比较术后即刻及术后1年胫骨平台内翻角、后倾角、股胫角等力学指标的变化。结果：术后切口均甲级愈合,未发现切口感染及皮肤坏死等并发症。28例术后均获随访,时间12~24个月,平均18.1个月。骨折愈合时间5~10个月,平均7.8个月。骨折愈合后患者膝关节肿痛消退,关节功能基本恢复正常。HSS评分：疼痛27.81±2.17,功能19.52±2.05,活动范围15.82±1.73,肌力8.51±1.32,屈曲畸形8.33±1.08,关节稳定性9.36±0.52,总分89.35±3.19;优20例,良5例,中2例,差1例。术后与术后1年胫骨平台内翻角、后倾角、股胫角比较差异均无统计学意义。结论：采用膝前正中加后内侧入路联合三柱钢板内固定治疗复杂胫骨平台骨折可达到解剖复位、坚强固定及早期功能锻炼的目的,是一种行之有效的手术治疗方法。     

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.     

胫骨平台骨折术后感染原因分析及治疗对策

目的 分析胫骨平台骨折钢板固定术后伤口感染的原因,探讨总结应用小腿近侧蒂肌皮瓣治疗方法的疗效.方法 2005年1月至2009年5月,经治胫骨平台骨折钢板内固定术后并发伤口感染不愈、软组织缺损、钢板外露、创伤性骨髓炎52例.彻底扩创、清理死骨、对髓腔开放者清理髓腔,并取不同层次炎性肉芽组织送实验室细菌学及药敏测试,对钢板固定失效者更换外固定架.创腔内放置载万古霉素或妥布霉素硫酸钙人工骨,骨缺损较大者,取自体髂骨混合植骨,选取小腿近侧蒂皮瓣填充覆盖修复创面.放置引流,抗生素静脉注射3至4周,定期拍摄X线片直至骨折愈合.结果 52例组织缺损均得到满意修复.随访时间最长5年,最短1年,骨折愈合最快4个月,最长1年.2例术后分别于第3、4个月骨髓炎复发再次手术治愈.3例术后6个月骨折不愈再次手术植骨后4～6个月愈合.结论 胫骨平台骨折钢板内固定术后并发伤口感染不愈软组织缺损、创伤性骨髓炎的治疗需要综合措施,应用小腿近侧蒂相应肌皮瓣填充创腔、覆盖闭合修复缺损创面、改善局部血供、促进骨折愈合是取得治疗成功不可或缺的方法之一.

Abstract：

Objective To analyze the reason of post-operative infection of tibial plateau fracture, the therapeutic effect of using pedicle musculocutaneous flaps of proximal leg was researched and summarized. Methods There were 52 patients of tibial plateau fracture after internal fixation complicated by disunion of infected wound and soft tissue defects, traumatic osteomyelitis from January 2005 to May 2009. After pre-operative physical examination, laboratory examination, X-ray, CT scan and bacterial culture of the secretion,the operation, such as debridement, dead bone moving, medullary cavity cleaning, transferring to the external fixation when the internal fixation lost efficacy and bacterial culture of granulation tissue of different levels. The cavity was filled with RBK combined with vancomycin or tobramycin. If the cavity was rather large, autografts from the iliac bone were combined. The tissue defects were covered with pedicle musculocutaneous flaps of proximal leg, and the wound had effective drainage. The antibiotic was used for 3-4 weeks, and the X-rays were given at fixed period until the fracture was cured. Results The soft tissue defects of all 52 patients were repaired well. They were followed from 1 year to 5 years, and the time of bone union ranged from 4 months to 1 year. Two patients of osteomyelitis had a relapse after 3,4 months, then they were cured by the second operation. Three patients had unhealed fracture after 6 months, then they were cured by bone grafting again after 4-6 months. Conclusion Patients of tibial plateau fracture after internal fixation complicated by disunion of infected wound and soft tissue defects, traumatic osteomyelitis should be cured by comprehensive treatments, one of the crucial treatment for success is using pedicle musculocutaneous flaps of proximal leg to fill in lacuna, close wound, improve the local blood supply and promote bone union.     

胫骨平台内侧髁后缘骨折合并后交叉韧带止点撕脱性骨折的手术疗效观察

目的：探讨单块桡骨远端钢板固定治疗胫骨平台内侧髁后缘骨折合并后交叉韧带（PCL）止点撕脱性骨折的临床疗效。方法：2008年9月至2011年11月,采用手术治疗因膝关节过伸致胫骨平台内侧髁后缘骨折合并PCL止点撕脱性骨折的患者5例,其中男3例,女2例;年龄25～42岁,平均35岁;左膝3例,右膝2例;运动伤2例,车祸3例;均为急诊收治。手术采用胭窝入路,对骨折端行解剖复位,单块桡骨远端钢板内固定。术后观察并发症,通过X线片观察术后愈合情况,并采用HSS评分系统对术后疗效进行评估。结果：5例患者均荻随访,时间1—4年,平均2年。切口均为Ⅰ期愈合。膝关节屈曲均达120。以上,稳定性良好,无膝关节疼痛、神经血管损伤、感染和内固定失败等并发症发生。术后HSS评分为94．40±6．09,结果均为优。结论：单块桡骨远端钢板对胫骨平台内侧髁后缘骨折固定稳定性好、成功率高,且膝关节功能恢复良好。     

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。     

应用CT三维重建和关节镜监视下治疗胫骨平台骨折

目的:探讨应用CT三维重建和关节镜监视下治疗胫骨平台骨折中的价值。方法:收集22例胫骨平台骨折病例,术前常规进行X线摄片,按Schatzker分类:Ⅰ型4例,Ⅱ型5例,Ⅲ型2例,Ⅳ型6例,Ⅴ型3例,Ⅵ型2例。然后对骨折在3D重建图像后再分型:前外象限4例,后外象限8例,前内象限4例,后内象限2例,涉及内和外象限4例。在关节镜监视下结合3D重建对骨折进行复位和内固定。结果:22例胫骨平台骨折3D重建图像分型与关节镜术中的诊断一致。平台骨折需要植骨15例。松质骨螺钉固定4例,单侧支撑钢板内固定8例,双侧支撑钢板内固定4例,单侧支撑钢板加松质骨螺钉固定6例。随访3个月~2年,根据HSS膝关节评分标准:优18例,良2例,可2例。结论:螺旋CT及3D重建补充了在胫骨平台三维空间上新的骨折分型,对手术入路、复位和内固定有指导意义。关节镜监视下有助于骨折复位,对骨折块的血运干扰少,骨折愈合快。     

关节镜下复位微创经皮钢板内固定治疗胫骨平台骨折

目的:研究关节镜下微创经皮钢板内固定(MIPPO)治疗胫骨平台骨折的手术方法和临床效果。方法:关节镜监视下治疗胫骨平台骨折55例,男31例,女24例;年龄18~75岁,平均47岁。SchatzkerⅡ型18例,Ⅲ型20例,Ⅳ型9例,Ⅴ型5例,Ⅵ型3例。合并半月板损伤23例,前交叉韧带损伤9例,侧副韧带损伤8例。术中通过皮肤微小切口经皮插入解剖型支撑钢板,骨缺损处用自体髂骨或同种异体骨植骨,术后配合早期的功能训练。结果:所有患者均得到随访,随访时间35~50个月,平均45·6个月。采用Lysholm评分标准评价临床疗效,优46例,良5例,可3例,差1例,优良率为92·7%。结论:关节镜下应用MIPPO技术治疗胫骨平台骨折能够以最小的创伤重建关节面平整,使骨折得到坚强固定。早期行膝关节功能锻炼,以获得满意疗效。     

关节镜下复位微创经皮钢板内固定治疗胫骨平台骨折

目的:研究关节镜下微创经皮钢板内固定（MIPPO）治疗胫骨平台骨折的手术方法和临床效果。方法:关节镜监视下治疗胫骨平台骨折55例,男31例,女24例;年龄18⁷5岁,平均47岁。SchatzkerⅡ型18例,Ⅲ型20例,Ⅳ型9例,Ⅴ型5例,Ⅵ型3例。合并半月板损伤23例,前交叉韧带损伤9例,侧副韧带损伤8例。术中通过皮肤微小切口经皮插入解剖型支撑钢板,骨缺损处用自体髂骨或同种异体骨植骨,术后配合早期的功能训练。结果:所有患者均得到随访,随访时间35⁵0个月,平均45·6个月。采用Lysholm评分标准评价临床疗效,优46例,良5例,可3例,差1例,优良率为92·7%。结论:关节镜下应用MIPPO技术治疗胫骨平台骨折能够以最小的创伤重建关节面平整,使骨折得到坚强固定。早期行膝关节功能锻炼,以获得满意疗效。     

胫骨平台前缘塌陷骨折漏诊特定方位X线分析与手术治疗

1993年8月-2004年9月，收治胫骨平台骨折168例，其中X线漏诊12例，经加摄特定方位X线片确诊胫骨平台前缘塌陷骨折，行补教手术治疗后效果满意，现分析如下。     

胫骨内侧平台大块劈裂骨折手术方式和疗效分析

目的 :探讨经内侧入路保护内侧结构,两个不同方向内固定治疗以内侧大块劈裂为主的胫骨平台骨折的可行性和有效性。方法:自2010年1月至2016年1月采用膝内侧切口保护内侧软组织结构,不同方向固定胫骨内侧骨折块治疗涉及大块劈裂的胫骨内侧平台骨折患者21例,男17例,女4例;年龄27~63(39.2±3.2)岁。术前影像学检查(X线或CT)确诊,取膝关节内侧切口入路,保护膝内侧结构同时行内侧和内后侧钢板支撑内固定术;合并外侧平台骨折予外侧或外后侧切口复位固定。术后即刻根据Rasmussen放射学评分标准评价骨折复位情况,术后1年随访时根据美国特种外科医院(Hospital for Special Surgery,HSS)膝关节评分系统评定疗效。术后通过X线及临床检查判断骨折愈合时间,记录并发症及相应转归。结果:术后患者切口均Ⅰ期愈合,未见明显并发症。21例患者术后均获随访,时间10~24(17.2±1.7)个月。骨折均愈合,愈合时间为9~16(11.1±3.2)周。术后骨折复位Rasmussen放射学评分1~18(16.7±1.5)分;优16例,良3例,可2例。末次随访时HSS膝关节评分60~100(87.3±6.7)分;优18例,良2例,可1例。结论:对于大块劈裂的胫骨内侧平台骨折,内侧切口、充分保护膝内侧结构、两个不同方向支撑钢板固定方法可行,近期疗效满意。     

Flexion-valgus unicondylar tibial plateau depression fracture pattern: Classification and treatment

PurposeThe authors have identified a subset of unicondylar tibial plateau depression fracture patterns caused by a flexion-valgus force. The purpose of this study was to describe this fracture pattern and suggest a modified lateral approach that may allow for improved reduction and stabilization.MethodsThe preoperative radiographs and CT scans of 102 patients who sustained unicondylar tibial plateau fractures (OTA 41B) were reviewed. Twenty-six fracture patients had posterolateral (PL) tibial plateau depression fractures. By medical record review and telephone follow-up, the injury mechanism of the 22 unicondylar tibial plateau fractures was confirmed as a flexion-valgus force. The radiographic features of those cases were analyzed and measured. To address this specific fracture pattern, a modified approach combined with a novel intra-articular osteotomy was applied.ResultsAccording to the morphological characteristics, this tibial plateau fracture pattern could be divided into two subtypes: type A was a confined, basin-like articular surface depression fracture located in the PL quadrant, and type B was a cancellous fracture involving the PL tibial plateau resulting in a decrease in the posterior slope. One radiographic hallmark of this fracture pattern is an anatomically or a mechanically intact posterior column wall. The novel approach was applied to both types. The postoperative radiographic measurements revealed excellent reduction quality. On axial scans, the distance between the most posterior rafting screw and the tangent line of the tibial plateau rim was 3.0 ± 2.07 mm (from −1.9 to 4.3), and the angulation between them was 8.9 ± 3.02° (from −7.3 to 15.6). These results indicated excellent PL quadrant coverage from the rafting screws.ConclusionFlexion-valgus force-induced unicondylar tibial plateau depression fracture is a unique injury pattern. We suggest a novel surgical approach to address this injury’s key features, which may facilitate exposure and enhance fixation strength.     

关节镜监视下和切开内固定治疗低能量胫骨平台骨折疗效比较

目的：探讨关节镜辅助下内固定与切开复位内固定治疗低能量胫骨平台骨折的临床疗效。方法：45例低能量胫骨平台骨折，治疗组23例采用关节镜监视下闭合或切开复位内固定，其中男13例，女10例；年龄19—64岁，平均44．3岁；SchatzkerⅠ型10例，Ⅱ型7例，Ⅲ型6例。对照组22例行切开复位内固定，其中男14例，女8例；年龄21—65岁，平均45．7岁；SchatzkerⅠ型11例，Ⅱ型2例，Ⅲ型9例。采用HSS膝关节功能评分评价比较两组的临床疗效。结果：45例随访10—36个月，平均16个月。治疗组疗效优于对照组，且术时X线暴露率治疗组低于对照组，治疗组的Ⅱ期手术率低于对照组。结论：关节镜监视下复位内固定比切开复位内固定临床疗效好，减少切口感染、创伤性关节炎等并发症，减少了术中X线的暴光率，减少Ⅱ期手术率。     

Articular coronal fracture angle of posteromedial tibial plateau fragments: A computed tomography fracture mapping study

Objectives

The purpose of this study is to analyze posteromedial fragment morphology using two-dimensional computed tomography fracture mapping and to compare posteromedial fragment morphology in various Schatzker type tibial plateau fractures.

关节镜辅助下经皮球囊扩张骨水泥充填治疗SchatzkerⅡ、Ⅲ型胫骨平台骨折

目的：探讨关节镜辅助下经皮球囊扩张骨水泥充填治疗SehatzkerⅡ、Ⅲ型胫骨平台骨折的临床疗效。方法：回顾性分析2011年12月,2013年3月,关节镜辅助下经皮球囊扩张骨水泥填充治疗SehatzkerⅡ、Ⅲ型胫骨平台骨折12例。男4例,女8例,年龄61—73岁（平均66岁）,骨折按Schatzker分型Ⅱ型3例,Ⅲ型9例。所有患者采用关节镜辅助下经皮球囊扩张复位后,骨水泥充填骨缺损区。术后根据Rasmussen放射学及膝关节功能评分标准评价患肢功能。结果：12例患者术后获12—26个月随访（平均18月）。膝关节功能按照Rasmussen评分为优8例,良3例,可1例,优良率为91．7％。结论：关节镜辅助下经皮球囊扩张骨水泥充填治疗SchatzkedⅡ、Ⅲ型胫骨平台骨折具有创伤小,复位良好的优点,不需二次取出内置物,可使患肢早期负重,及早进行功能锻炼,获得更好的膝关节功能。     

Hoffa fracture associated with femoral shaft and proximal tibial fractures: report of two cases

Solitary coronal shear fractures of femoral condyle, such as Hoffa’s fracture, are usually associated with supracondylar or intercondylar fractures of the femur. These fractures are rare and seen in the context of high energy mechanism leading to multiple injuries; therefore a thorough workup of the patient is required to rule out other significant injuries. Hoffa’ s fracture associated with femoral shaft and proximal tibial fractures is extremely rare and no such injury has been reported previously. We report two such cases which were managed with standard operative fixation techniques and demonstrated good to excellent functional outcome after a follow-up of one year. This report emphasizes that high index of suspicion is required for diagnosis of these injuries and a thorough workup is mandatory to rule out other associated injuries. We also propose a possible mechanism of injury.