胫骨平台后柱骨折的手术治疗

目的 介绍胫骨平台后柱骨折的骨折类型、手术方法 及临床疗效,讨论三柱理论在决定后侧平台骨折治疗方案中的作用.方法 2005年2月至2006年8月间,共收治涉及胫骨平台后柱骨折患者36例,均采用支撑钢板内固定.单纯后侧入路20例,其中男13例,女7例;年龄29～52岁(平均38.5岁).前后联合入路16例,其中男11例,女5例;年龄27～49岁(平均37.3岁).结果 经12～15个月(平均14.5个月)随访,36例全部愈合.平均X线愈合时间为15.7周(11～16周),完全负重时间平均为17.6周(13～21周).术后1年膝关节HSS评分68～92分,平均83.4分.1例患者术中内侧腓肠肌膝下内侧血管损伤,术后1例出现切口裂开,1例发生切口皮缘部分坏死,均经保守治疗痊愈.3例术后出现小腿内下方感觉麻木,无螺钉松动、断裂及内固定失效等其他并发症发生.所有病例术后即刻、术后12个月胫骨平台内翻角(TPA)及内、外侧胫骨平台后倾角(PA)度数的F和P值分别为1.186,0.169;4.923,0.536;1.931,0.212,差异均无统计学意义.结论 通过胫骨平台CT水平面三柱结构决定骨折类型后,单纯后侧或前后联合入路支撑钢板固定是治疗胫骨平台后柱骨折的一种有效方法 .     

Anterior tibial plateau fracture: An often missed injury

Background:

In most classifications of tibial plateau fractures, including one used most widely-Schatzker classification, fractures are described as a combination of medial and lateral condyle, primarily in the sagittal plane. Coronal component of these fractures, affecting the posterior tibial condyle is now well recognized. What is not described is anterior coronal component of the fracture, what we are calling “anterior tibial condyle fracture”. These fractures are often missed on routine antero-posterior and lateral knee X-rays due to an overlap between the fracture and the normal bone.

Materials and Methods:

Eight cases of anterior tibial condyle fractures with posterior subluxation of the tibia, six of which were missed by the initial surgeon and two referred to us early, are described. Two of the six late cases and both the early ones were operated. Reconstruction of the anterior condyle and posterior cruciate ligament reconstruction was done. Primary outcome measures such as union of the fracture, residual flexion deformity, range of motion and stability were studied at the end of 6 months.

Results:

All operated fractures united. There was no posterior sag in any. In those presenting late and were operated, the flexion deformity got corrected in all (average from 15° to 0°) and mean flexion achieved was 100° (range: 80-120°). In those presenting early and were operated, there was no flexion deformity at 6 months and a mean flexion achieved was 115° (range: 100-130°). None of the operated patients had instability.

Conclusion:

This article attempts to highlight that this injury is often missed. They should be suspected, diagnosed early and treated by reconstruction of anterior condyle, posterior cruciate ligament reconstruction.     

内外侧小切口治疗复杂性胫骨平台骨折

胫骨平台骨折是一种常见的关节内骨折,但复杂性胫骨平台骨折因为合并症多,治疗一直是骨科的一个难题。自1996-2004年共收治复杂性胫骨平台骨折29例,疗效满意,现报告如下。1临床资料本组共29例,男21例,女8例;年龄16~61岁,平均37·6岁。损伤原因:车祸伤22例,砸压伤4例,其他3例,其中开放性骨折4例。伴有半月板损伤6例,前十字韧带止点撕脱3例,合并血管及神经损伤2例。按Schatzker[1]分型:Ⅳ型6例,Ⅴ型11例,Ⅵ型12例。2治疗方法全麻或硬膜外麻醉后,患者取平卧位,大腿根部放置空气止血带,手术常规采用前外侧联合前内侧切口进行,通过前外侧切口翻…     

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.     

Lateral tibial plateau fracture

The patient was a 30-year-old man who was initially seen by a physical therapist for a chief complaint of left knee pain. Due to concern for a fracture, the physical therapist ordered radiographs of the left knee, which revealed a fracture of the left lateral tibial plateau. J Orthop Sports Phys Ther 2012;42(9):819. doi:10.2519/jospt.2012.0416.     

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.     

Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns

OBJECTIVES: Bicondylar tibial plateau fracture management remains therapeutically challenging, partly because of multiplanar articular comminution. This study was performed to evaluate the frequency and morphologic characteristics of the posteromedial fragment in this injury pattern. DESIGN: Retrospective chart and radiographic review. SETTING: Urban Level 1 university trauma center. PATIENTS: Fifty-seven patients sustaining 57 Orthopedic Trauma Association (OTA) C-Type bicondylar tibial plateau fractures formed the study group. MAIN OUTCOME MEASURE: Between May 2000 and March 2003, 170 OTA C-Type bicondylar tibial plateau fractures were identified using an orthopaedic database. One hundred and forty-six fractures had computed tomographic (CT) scans performed prior to definitive fixation and were reviewed using the Picture Archiving and Communication System (PACS). Sixty-six (45.2%) injuries had fractures that involved the medial articular surface. Nine with suboptimal CTs were excluded, leaving 57 injuries for review. Forty-two patients demonstrated coronal plane posteromedial fragments. Morphologic evaluation of the posteromedial fragment included articular surface area, maximum posterior cortical height (PCH), and sagittal fracture angle (SFA). RESULTS: Forty-two of 57 injuries (74%) demonstrated a posteromedial fragment that comprised a mean of 58% of the articular surface of the medial tibial plateau (range, 19%-98%) and a mean of 23% of the entire tibial plateau articular surface (range, 8%-47%). Mean posteromedial fragment height was 42 mm (range, 16-59 mm), and mean sagittal fracture angle was 81 degrees (range, 33 degrees to 112 degrees). Six patients demonstrated fracture patterns not accurately identified by the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fracture classification system. CONCLUSIONS: A posteromedial fragment was observed in nearly one third of the bicondylar plateau fractures evaluated. The morphologic features of this fragment may have clinical implications when using currently available laterally applied fixed-angle screw/plate implants to stabilize these injuries. Alternate or supplementary fixation methods may be required when managing this injury pattern.     

胫骨内侧平台骨折伴骨折脱位患者的两种术式临床体会

目的分析比较内侧入路治疗胫骨内侧平台骨折伴骨折脱位两种术式的疗效。方法回顾性分析2009年8月～2016年8月,本院收治的胫骨内侧平台骨折伴骨折脱位54例患者临床资料。依据患者采用的手术类型,分为双钢板组29例,单钢板组25例。两组患者分别接受内侧入路双钢板内固定治疗和前内侧入路单钢板联合前后位拉力螺钉内固定治疗,比较两组患者的治疗效果。结果 Harris量表评分比较结果:术前和术后1 d,两组间量表评分,差异无统计学意义(P0.05),但术后和3个月间两组差异有统计学意义(P0.05)。Rasmussen放射学评分结果比较:术前,两组患者评分差异无统计学意义(P0.05);术前不同时间点间差异有统计学意义(P0.05);术后1 d和术后3个月,双钢板组评分明显高于单钢板组,差异有统计学意义(P0.05)。术后1 d和3个月,患者胫骨平台后倾角与内翻角比较,双钢板组患者均显著优于单钢板组,两组间差异均有统计学意义(P0.05)。两组间在住院时间、手术时间、术中出血量及术后并发症方面的差异无统计学意义(P0.05)。结论采用双钢板内侧单切口入路内固定方法治疗胫骨内侧平台骨折伴骨折脱位效果更好。     

钢板内固定治疗胫骨平台骨折

目的探讨内固定治疗胫骨平台骨折的疗效。方法对65例胫骨平台骨折患者行钢板内固定术。结果 58例获得随访,时间12～15（13.6±1.4）个月。骨折愈合时间2.5～5.2（3.5±1.2）个月。HSS评分85～95分。无一例出现软组织感染坏死,内固定无松动断裂。结论钢板内固定治疗胫骨平台骨折减少了软组织感染的风险,提供了持续的稳定,临床效果满意。但对于并发交叉韧带、内外侧副韧带损伤或合并干骺端骨折的骨折类型仍有其局限性。     

胫骨内侧平台骨折手术治疗失败的原因分析

目的 分析胫骨内侧平台骨折手术治疗失败的原因，并为内侧平台骨折提出具体分型，以指导治疗，减少并发症。方法对1998年6月～2004年9月间手术治疗失败的17例胫骨内侧平台骨折进行回顾性分析，对骨折类型、固定方法、骨折复位质量及术后康复等因素进行综合评估，分析造成手术失败的可能原因；同时根据内侧平台骨折的影像学资料及临床特点进行具体分型。结果17例失败患者伴有严重的膝关节功能障碍，HSS膝关节功能评分平均为41分（24～54分）。手术治疗失败原因：手术方法不当4例，固定方法选择不当11例，术后康复治疗错误2例。结论骨折复位不良、固定方法选择不当、对软组织情况及肢体力线缺乏足够的认识与重视及术后错误的康复治疗均是胫骨内侧平台骨折手术失败的原因，根据具体的骨折类型及软组织条件制订适当的治疗计划是手术成功的关键。     

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。     

胫骨平台骨折的并发症

解剖复位、坚强固定以及压缩骨折植骨是治疗胫骨平台骨折的关键因素，近年来出现了微创内固定系统(LISS)、关节镜下治疗胫骨平台骨折等新技术，但是复位不良、感染、膝周软组织损伤、骨折不愈合、创伤性关节炎以及膝关节僵硬等并发症的发生仍然不可避免，本文介绍了胫骨平台骨折并发症的发生机制，处理以及预防措施。     

3D modelling of tibial plateau fractures: Variability in fracture location and characteristics across Schatzker fracture types

IntroductionNumerous classifications have been developed to assess tibial plateau fractures (TPF). Of these, the Schatzker system is the most widely reported in the literature yet this system is limited in its characterisation of morphological fracture features underlying the fracture location. The purpose of this study was to compare 3D morphological features of TPFs across different Schatzker types.MethodsThis study retrospectively analysed preoperative TPF imaging data to reconstruct 3D models of the fractures. Ninety-one fractures (29 female, 62 male) were analysed and classified using Schatzker. Fracture location across Schatzker types was compared based on division of the articular surface into six ‘zones’. Additionally, morphological characteristics of the fractures were compared based on fracture type, including; the number, volume and shape of the fragments.ResultsSchatzker II, IV and VI fractures were most common, making up 41%, 16% and 20%, respectively. Type II fractures commonly involved both the lateral and central aspect of the tibial plateau, similarly, type IV fractures incorporated the lateral condyle in most cases. Considering the morphological metrics, statistically significant differences were observed between Schatzker types for the number of; total, articular, cortical and volumetrically significant (all P < 0.001) fragments along with the volume of both primary (P < 0.001) and secondary (P = 0.02) fragments.DiscussionAssessment of underlying fracture characteristics in addition to fracture location can serve to provide greater detail relating to fracture morphology, which has the potential to assist with both surgical decision making and assessment of postoperative outcomes. Incorporating this information as part of a hierarchical or multifactorial framework for classifying fractures may help distinguish subtle differences between fracture types that are classifiable using the most current systems.     

胫骨平台骨折的现代治疗

现代胫骨平台骨折的治疗方向是有限切开、直接或间接复位、生物学固定。治疗方法包括关节镜辅助手术、经皮螺钉接骨板微创固定、环状和组合式外固定器应用、临时跨越式外固定支架固定、内固定与外固定器的联合使用或上述方法分期进行治疗。注重骨折治疗的同时,也注意关节韧带、半月板等组织的保护和治疗。对于开放性高能量双髁骨折可分期治疗,强调早期的关节面恢复,重点保护软组织,可行肌皮瓣移位修复保护创面,植骨可在二期进行。微创内固定系统(LISS)是治疗胫骨平台骨折的一项新技术。     

膝关节镜下手术治疗胫骨平台骨折

目的 探讨关节镜技术在胫骨平台骨折治疗中的应用及效果。方法 2001年1月至2005年2月,共对31例SchatzkerⅠ～Ⅵ型胫骨平台骨折患者在关节镜辅助下复位、于关节面下开窗植骨,并采用中空钉或支持钢板固定。随访12～24个月。结果 解剖复位率为90．3％（关节面塌陷小于2mm）。采用LKSS评分标准,优良率达87．1％。无感染、深静脉栓塞及小腿肌筋膜室综合征等并发症发生。结论 关节镜下治疗胫骨平台骨折,具有创伤小、复位直观、固定可靠等优点,不仅适用于SchatzkerⅠ～Ⅲ骨折,对于Ⅳ～Ⅵ骨折也可取得良好疗效。     

复杂性胫骨平台骨折的治疗(120例随访分析)

[目的] 探讨手术治疗复杂胫骨平台骨折的方法及临床疗效.[方法] 对手术治疗120例复杂胫骨平台骨折病例进行回顾性研究,做出综合评价.[结果] 120例病人术后随访12个月～6年,平均32个月,优良率达88%.[结论] 对于复杂的胫骨平台骨折,术中需尽可能恢复关节面的平整,对复位后的平台下骨缺损,应进行充分的填充植骨,根据骨折具体类型,选用可靠的内固定,同时,重视合并伤的处理.     

Medial buttress versus lateral locked plating in a cadaver medial tibial plateau fracture model

OBJECTIVE: To compare the mechanical stability of a medial tibial plateau fracture model secured with a lateral locking periarticular plate versus a medial buttress plate in cyclic testing and load to failure. METHODS: Medial tibial plateau fractures were created in 6 matched pairs of fresh cadaveric tibias. In each pair of tibias, 1 side was randomly selected to be fixed with a lateral locking plate on 1 side and the contralateral limb to be fixed with a medial buttress plate. The fixated tibias then underwent cyclic testing followed by single-cycle failure compressive loading. Displacement of the medial tibial plateau was measured in both cyclic and failure testing. RESULTS: Statistical analyses revealed relevant trends in fixation strength during cyclic testing, but neither the mean maximum displacement during nor mean residual displacement after cyclic testing were statistically different between the 2 fixation techniques. Statistically significant differences were observed for the mean forces to failure however. The medial buttress plate construct provided greater fixation strength with its failure force of 4136 +/- 1469 N compared with the lateral locking plate mean failure force of 2895 +/- 1237 N (P < 0.05). CONCLUSION: In the setting of a vertically oriented fracture in a medial tibial plateau without comminution, the medial buttress plate provides significantly greater stability in static loading, and a trend toward improved stability with cyclic loading. Clinical correlation is necessary to substantiate these findings.     

胫骨平台骨折伴软组织损伤的临床分析

目的 分析胫骨平台骨折伴软组织损伤情况，以全面了解胫骨平台骨折损伤程度。方法 回顾性分析486例胫骨平台骨折患者的临床资料，对骨折进行分类，统计患者伴随损伤。结果 本组病例发现的胫骨平台骨折伴随损伤主要包括：腘动脉损伤3．9％(19／486)、半月板损伤14．4％(70／486)、侧副韧带损伤9．67％(47／486)、交又韧带损伤8．43％(41／486)、腓总神经损伤1．85％(9／486)、骨筋膜室综合征7．41％(36／486)。结论 胫骨平台骨折伴软组织损伤较多，临床工作中应予以高度重视并早期发现、早期治疗，以防止引起严重后果。