单臂外固定架治疗胫骨远端骨折22例

目的探讨单臂外固定架治疗胫骨远端骨折的疗效。方法根据骨折分型确定外固定针的安放部位，A型骨折在骨折两端置外固定针；远端骨折块过小不能容纳外固定针者以及B和C型骨折在骨折近端和跟骨及距骨安放外固定针。撑开复位，复位困难者部分切开复位，植骨螺钉或克氏针固定，合并腓骨骨折同时行切开复位内固定。结果22例外固定架固定3．5-8个月，平均5个月，骨折均愈合，无严重深部感染、骨髓炎、骨折不愈合等严重并发症。随访10-32个月，平均20个月，拆除外固定架康复6个月以上，按Tornetta胫骨远端骨折治疗标准，优11例，良7例，可3例，差1例。结论单臂外固定架固定联合有限切开内固定是治疗胫骨远端骨折简单有效的微创治疗方法之一。     

Distal tibial metaphyseal fractures: the role of fibular fixation

Distal tibial extra-articular fractures are often a result of complex high-energy trauma, which commonly involves associated fibular fractures and soft tissue injury. The goal of tibial fixation is to maximise fracture stability without increasing soft tissue morbidity from surgical intervention. The role of adjunctive fibular fixation in distal tibial metaphyseal fractures has been controversial; although fibular fixation has been shown to improve stability of distal tibial fractures, there has been increased potential for soft tissue-related complications and a delay to tibial fracture healing. Adjunctive fixation of concomitant fibular fractures without associated syndesmotic or ankle pathology is not necessary in surgically stabilised extra-articular metaphyseal fractures of the distal tibia.     

Bicondylar tibial plateau fractures treated with fine-wire circular external fixation

Bicondylar tibial plateau fractures are serious injuries to a major weight-bearing joint. These injuries are often associated with severe soft tissue injuries that complicate surgical management. We reviewed 54 consecutive patients who sustained bicondylar tibial plateau fractures that were treated with limited open reduction and cannulated screw fixation combined with fine-wire circular external fixation. Forty-six patients met the inclusion criteria of this retrospective review. Eight patients were excluded because they did not complete a minimum of 1-year follow-up. Thirty-six patients had Schatzker type-VI, and ten patients had Schatzker type-V fractures. All fractures were united without loss of reduction; there were no incidences of wound complications, osteomyelitis or septic arthritis. The average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin track infection was the most common complication encountered. This review concludes that fine-wire circular external fixation, combined with limited open reduction and cannulated screw fixation, consistently produces good functional results without serious complications.     

Limited open reduction and Ilizarov external fixation in the treatment of distal tibial fractures

The authors reviewed 31 distal tibial fractures (16 involving the tibial plafond) treated with Ilizarov external fixation. The study population was composed of 19 males and 12 females, with an average age of 54. The fractures were classified according to the AO classification: A1 (3), A2 (6), A3 (6), C1 (2), C2 (8), C3 (6). There were six open injuries. In 14 pilon cases, open reduction of the intra-articular fragments and bone grafting via a limited incision was performed. Clinical follow-up averaged 28 months (range 18-42). All but one fracture united with an average healing time of 13.9 weeks. Nearly all patients with AO type A fracture had excellent or good functional scores. The 14 cases of AO C2 and C3 group had five (38%) good results, five (38%) fair results and three (24%) poor results. This method yielded results comparable with previous studies using open reduction and internal fixation. Twenty-nine percent of the patients had pin track infection, which remained the most important complication of this method.     

胫骨远端骨折两种治疗方法的疗效比较

目的：评价两种不同方法治疗胫骨远端骨折的临床适应证、并发症及其疗效。方法：45例闭合性胫骨远端骨折采用不同手术方法：A组25例,男18例,女7例;按AO／ASIF分类：A型4例,B型14例,C型7例;采用切开复位解剖型钢板内固定。B组20例,男12例,女8例;A型5例,B型9例,C型6例;采用微创经皮锁定钢板内固定。术后观察患者疼痛程度、切口皮肤坏死、深部感染发生率等并发症以及骨折愈合时间、踝关节运动功能进行对比研究。结果：患者术后随访10-15个月,平均12个月。按视觉模拟量袁（VAS）评分：A组中度-重度,B纽轻度-中度;骨性愈合时间：A组平均（16．0±4．2）周,B组平均（13．0±3．2）周,差异有统计学意义（火0．01）。A组术后并发症发生率高于B组（P〈0．05）。踝关节功能评定按照Kofoed评分标准,术后踝关节功能恢复B组总体优良率明显高于A组（P〈0．05）。结论：微创经皮锁定钢板内固定较切开复位解剖型钢板内固定治疗胫骨远端骨折具有手术创伤小,对骨骼血供影响小,骨折愈合快,并发症少,踝关节功能恢复好的优点,符合生物力学内固定。     

Acute treatment of segmental tibial fractures with the Ilizarov method

Objectives

We evaluated the results of acute application of the Ilizarov external fixator for segmental tibial fractures and also examined the experience with these special type fractures.

Methods

Twenty-four patients (19 males, 5 females) with a mean age of 37.8 years (range 22-66) with segmental tibial fractures were treated with the use of an Ilizarov type circular fixator. According to the categorisation of Melis et al., the fractures were types I, II, III and IV in seven, nine, five and three patients, respectively. Seven fractures were closed and 17 were open (9 grade IIIa, 5 grade IIIb, 2 grade II, 1 grade I according to the Gustilo classification). The mean time from the injury to surgery was 14 h (range 4-36). Eight patients with partial-thickness soft-tissue defects with no bone exposure were managed by split thickness skin grafting. Flap procedures were performed in four patients. All patients had good lower leg viability with a MESS score 6 and below. No patients had bone defects of 3 cm or more at the fracture level. Functional and bone results were made using the criteria proposed by ASAMI. The mean follow-up 28 months (range 12-70).

Results

We obtained excellent results in 20 and good results in 4 patients in terms of bone assessment. Functional results were excellent in 19 and good in 5 patients. All radiological evaluations showed normal alignment except in two patients. Both united with a residual procurvatum deformity. No rotational deformity was seen. Bone grafting was performed in one patient with a distal fracture. Complete union was achieved in all patients. None of the patients required amputation. There were no refractures after frame removal. Pin-tract infection occurred in 13 of the 24 patients. There were no incidents of chronic osteomyelitis secondary to pin-tract infection. The mean time for proximal fracture union was 36.4 weeks (range 10-78) and 39.8 weeks (range 12-80) for the distal fractures (p > 0.05). Callus and consolidation occurred earlier posterolaterally. There were no implant failures.

Conclusion

Ilizarov external fixator is a successful method in the acute management of segmental tibial fractures. This method is particularly effective in the treatment of distal segmental fractures of the tibia when the distal segment is short. This method allows for control of complications by decreasing the need for new operations even in the presence of infection.     

微创经皮钢板内固定治疗胫骨远端骨折

胫腓骨远端骨折在胫腓骨骨折中最为常见，由于其创伤解剖的特殊性，治疗方法的选择有一定的难度，特别是远端粉碎性骨折，术后易发生骨不连、切口皮肤坏死、感染及关节功能障碍等并发症。自2001年3月-2004年7月我院应用微创经皮钢板内固定（MIPPO）治疗胫骨远端骨折32例，疗效满意，报告如下。     

Clinical and Patient reported outcomes following open reduction and internal fixation for distal tibial intra-articular fractures

IntroductionIntra-articular distal tibial plafond fractures are rare injuries, provide a challenge for the surgeon and can often have poor outcomes. The aim of this paper was to report long term patient reported functional outcomes, health related quality of life (QoL) scores and rates of complications in order to fully counsel the patient on likely outcomes and set realistic post-operative expectations for the patient.MethodsWe conducted a retrospective review of 20 patients with distal tibial intra-articular fractures that presented to our institution between September 2014 and September 2020. All patients underwent open reduction and internal fixation (ORIF). Clinical, radiological and patient reported outcome measures (PROMS), quality of life (QoL) scores and complications were collected.ResultsThe mean age of the patients at the time of surgery was 50.6 years (24−71). There were 7 males and 13 females. There were 4 open and 16 closed fractures. There were 7 Rüedi and Allgöwer (RA) Type 1, 9 Type 2 and 4 Type 3 fractures. The mean follow-up was 3.8 years [1–7]. The mean OMAS score was 54.3, reaching a peak at 2 years from injury. The mean QoL score (EQ5D5L) was 0.602, representing only 70 % of aged matched, UK population based norms.ConclusionsWhilst clinical outcomes are comparable with other studies, this report highlights this is a devastating injury, with most people taking 2 years to reach peak recovery. QoL outcome scores only reach 70 % normal and only 35 % of patients return to within 10 % of age matched population based norms.     

A retrospective analysis of comminuted intra-articular fractures of the tibial plafond: Open reduction and internal fixation versus external Ilizarov fixation

Intra-articular fractures of the tibial plafond are complex injuries which continue to challenge orthopaedic surgeons in achieving anatomic reduction, while allowing early weight bearing and return to activity. Although a wide range of treatment options has been described for fixation of pilon fractures, the unique characteristic of each injury makes it difficult to advocate a general method of choice. We have attempted to compare a subset of AO/OTA type C pilon fractures treated either by a staged procedure of external fixation and conversion to open reduction and internal fixation (ORIF) versus definitive external Ilizarov fixation. Between 1998 and 2004, 42 patients admitted to our level 1 trauma centre underwent either procedure and were followed prospectively. Twenty-eight patients were treated with ORIF and 14 were treated by Ilizarov ring fixator. The outcome measures included time to union, as well as the rates of union, nonunion, malunion and infection. Although the ORIF group had a longer time to heal, the rates of nonunion, malunion and infection were lower compared to the Ilizarov group. However, these differences between the groups were not statistically significant. Thus, based on these results, no clinical recommendation can be made as to which procedure is better and safer for the patient. Future prospective randomised trials are required to determine with more scientific accuracy the optimal treatment strategy for these challenging injuries.     

髓内钉与钢板内固定治疗胫骨远端关节外骨折的比较研究

目的通过对已发表文献进行汇总分析,根据现有数据资料总结髓内钉与钢板内固定治疗胫骨远端关节外骨折预后的比较。方法通过系统检索1975年1月～2011年5月发表的关于钢板或髓内钉治疗胫骨远端关节外骨折的英文文献。2位作者全文阅读并决定是否符合纳入标准或排除标准,收集相关结果和数据,通过循证医学分析方法,加权汇总分析两种治疗方案的功能预后和并发症。结果有22篇文献纳入研究,包括880例手术患者。髓内钉组的平均手术时间长于钢板组,但差异无统计学意义。髓内钉组的平均愈合时间显著短于钢板组。髓内钉组的感染率低于钢板组,但差异无统计学意义。髓内钉组的畸形愈合率显著高于钢板组。髓内钉组骨折的延迟愈合率和不愈合率与钢板组无统计学差异。髓内钉组的二次处理率(13.6%)高于钢板组(8.9%),但差异无统计学意义。结论根据此项研究结果,髓内钉内固定治疗胫骨远端关节外骨折可以更快愈合,使患者更早进行功能锻炼,但畸形愈合的概率高于钢板组,因此,具体的术式选择还应该根据患者的具体情况和医生的习惯决定。     

The treatment of severely comminuted intra-articular fractures of the distal radius

Comminuted fractures of the distal end of the radius are caused by high-energy trauma and present as shear and impacted fractures of the articular surface of the distal radius with displacement of the fragments. The force of the impact and the position of the hand and carpal bone determine the pattern of articular fragmentation and their displacement and the amount and the extent of frequent concommitant ligament and carpal bone injury. The result of the osseous lesion in comminuted fractures was termed "pilon radiale", which emphasizes the amount of damage to the distal radius and the difficulties to be expected in restoring the articular congruity. Besides this the additional injury, either strain of disruption of the ligaments and the displacement of the carpus and/ or the triangular fibrocartilage complex will equally influence the functional outcome. This review will expand on the relevant anatomy, correct classification and diagnosis of the fracture, diagnostic tools and operative treatment options. Current treatment concepts are analysed with regard to actual literature using the tools of evidence based medicine criteria. A new classification of severely comminuted distal radius fractures is proposed using CT data of 250 complex intraarticular radius fractures. Finally a standardized treatment protocol using external fixation in combination with minimal invasive internal osteosynthesis is described.     

跨腕关节外固定器治疗不稳定性桡骨远端骨折

目的 回顾分析闭合复位、单侧外固定器跨腕关节固定治疗不稳定性桡骨远端骨折的效果。方法 2000年6月～2005年3月，利用外固定器跨腕关节固定治疗45例50侧不稳定性桡骨远端骨折，年龄15～78岁（平均44．8岁）。骨折按AO分型：A3型5例5侧，B3型4例4侧，C1型3例3侧，C2型9例9侧，C3型24例29侧。手法或外固定器协助复位，外固定器静力性固定，骨折愈合后拆除外固定器。随访8～48个月（平均20个月）。结果 骨折愈合时间6～8周，平均7．6周。4例4侧出现针道表浅感染，经口服抗生素及局部换药后好转。最后一次随访时，影像学评估（Stewan改良的Sarmiento评分）：优39例42侧，良6例8侧。腕关节功能按Garland与Werley功能评分标准：优34例37侧，良8例9侧，可3例4侧，优良率为92％。结论 闭合复位、单侧外固定器跨腕关节静力性固定桡骨远端骨折，通过选择合适的外固定针置入部位，可以避免桡神经损伤及第二掌骨医源性骨折，减少针道感染及松动等并发症的发生，并有利于术后早期行手部功能锻炼；无需辅助性植骨促进骨折愈合，是不稳定性桡骨远端骨折的有效治疗方法。     

微创技术加外固定支架治疗桡骨远端骨折

目的：探讨微创技术加外固定支架治疗桡骨远端骨折的方法及疗效。方法本组19例22侧桡骨远端骨折均采用微创技术加外固定支架治疗,术后6~8周拆除外固定支架,行腕关节功能锻炼。结果根据改良Mcbride评分和纽约骨科医院腕关节评估标准评定,优14侧,良5侧,可3侧。结论应用微创技术加外固定支架治疗青壮年及老年人复杂的桡骨远端骨折,不仅复位满意,且固定牢靠,关节功能恢复满意,是一种有效的治疗方法。     

Hybrid external fixation of distal tibial fractures: new strategy to place pins and wires without penetrating the anterior compartment

Introduction Impalement of the anterior compartment musculature remains a problem in the hybrid external fixation of distal tibial fractures. The purposes of this study were to develop a tensioned wire configuration which does not violate the anterior compartment and to analyze the biomechanical implications of new wire configuration.Materials and methods Thirty-seven adult volunteers without known pathology around either tibia were recruited. Axial computed tomography of the distal tibia was performed at 5-mm slices from the plafond to the upper margin of the syndesmosis. The wire convergence angle was measured at the 1-, 2-, and 2.5-cm levels using the following landmarks: tibialis anterior tendon (TA), tibialis posterior tendon (TP), peroneus brevis tendon (PB), anterolateral border of the lateral malleolus (LM). Two straight lines were drawn by connecting TA and PB and connecting TP and LM. The wire convergence angle was defined as an acute angle between these two lines. Then the orientation of the bisector axis of the wires was measured. As a second part of this study, a validated three-dimensional hybrid external fixator model was developed using finite elements modeling to analyze the stiffness of the frames constructed according to the measured wire convergence angle and orientation. Five simulated configurations were tested. The stiffness of each frame was analyzed under four load conditions: torsion, axial compression, side bending, and anteroposterior bending.Results The mean convergence angle was 30° irrespective of the level. The bisector axis was oriented towards the anterolateral direction about 20° from the coronal plane. The stiffness of the frame constructed with a wire convergence angle of 30° and an anterolateral wire orientation of 20° was 20–30% less than that of the frame constructed with 60° wires oriented in a coronal plane. The addition of an anteromedial half-pin increased the stiffness significantly.Conclusions Two tensioned wires may be placed without violating the anterior compartment by using the above four clinically identifiable landmarks. Addition of a half-pin on the anteromedial surface of the distal articular fragment makes the frame markedly stiffer than is possible using the standard wire configuration.     

混合式外固定器结合有限内固定治疗胫骨远端骨折

目的探讨混合式外固定器结合有限内固定治疗胫骨远端骨折的临床价值。方法2002年3月至2005年1月,使用混合式外固定器结合有限内固定治疗胫骨远端骨折22例,男17例,女5例;年龄20～48岁,平均33岁。所有骨折均在踝上5cm之内。关节内骨折18例,按Ruedi等分型标准,Ⅱ型4例,Ⅲ型14例;关节外骨折4例。闭合损伤18例,Tornetta等根据改良Tscherne分度方法对软组织损伤进行分度,Ⅱ度16例,Ⅲ度2例;开放性骨折4例,按Gustilo分度,Ⅱ度2例,Ⅲ度2例。对关节内骨折,先采用有限切开撬拨及点状复位钳钳夹复位带有关节面的移位骨块,钢针及螺钉固定;然后再用外固定器进行固定。对关节外骨折移位,仅通过外固定器复位固定。结果术后伤口一期愈合20例,2例开放性骨折患者伤口延迟愈合,经换药后4周愈合。术后2例针道感染患者,经扩创及保持针道引流通畅8周后去除外固定器,伤口愈合。22例全部获得随访,随访时间8～28个月,平均18个月。骨折平均愈合时间3.2个月。根据Tornetta等制定的评估标准,关节内骨折18例,优10例,良5例,可3例,优良率83%。关节外骨折4例,优3例,良1例。骨折畸形愈合1例,胫骨向前成角10°。干骺端骨折不愈合1例,经二次手术行自体骨植骨加钢板内固定后骨折愈合。结论使用混合式外固定器结合有限内固定治疗胫骨远端骨折,损伤小,对软组织的干扰少,皮肤坏死率和伤口感染率明显减少,可早期活动。     

外固定支架结合内固定治疗桡骨远端骨折合并同侧掌指骨骨折

目的探讨外固定支架结合内固定治疗桡骨远端骨折合并同侧掌、指骨骨折的临床疗效。方法对32例桡骨远端骨折合并掌、指骨骨折行Orthofix公司的超关节微型单侧多功能外固定支架结合内固定治疗。结果随访4～11月,平均5．2个月,骨折愈合时间6～12周,平均8周。腕关节功能按Sarmiento标准进行评定：优22例,良8例,可2例;按TAFS评分标准进行功能评估,优28例,良4例。结论对桡骨远端骨折合并掌、指骨骨折,采用超关节微型单侧多功能外固定支架结合内固定治疗,是一种安全实用、简便有效的治疗方法。     

有限切开结合外固定支架治疗桡骨远端不稳定性骨折

目的探讨微创手术治疗桡骨远端不稳定骨折的临床疗效。方法对采用克氏针结合外固定支架治疗的23例26侧桡骨远端不稳定骨折的临床资料进行回顾性分析。结果术后随访3～24个月,平均6个月,均获得骨折愈合且对位良好,患者术后腕关节活动范围明显改善,疗效依照Dienst功能评估标准进行评定:优19侧,良4侧,可3侧,优良率为88%。结论克氏针有限内固定结合外固定支架治疗桡骨远端不稳定性骨折是一种微创手术,操作简单、固定可靠、疗效满意。     

Distal tibial fractures treated with hybrid external fixation

Management of distal tibia fractures remains challenging. The purpose of this study was to evaluate whether hybrid external fixation, as definite treatment, was associated with satisfactory results and low rate of complications. Between November 1999 and October 2006, 48 patients (33 men and 15 women) with a mean age of 45.6 years and a median ISS of 14.3 were admitted to our department with a distal tibia fracture and treated with the use of a hybrid external fixator. Eight patients had an open fracture. Mean follow-up was 14 months (range, 9-36 months). In 40 patients, radiographic evidence of union was observed at 3.6 months (range, 3-6 months). Delayed union was observed in three patients. There were five non-unions (10.4%) with three of them were septic. When compared to previously reported series, with conventional open reduction and internal fixation, the use of hybrid external fixation with or without open reduction and internal fixation of the fibula, was associated with satisfactory clinical and radiographic results and limited complications.     

有限内固定结合单臂外固定架治疗胫骨开放性骨折

胫骨开放性骨折常伴有严重的软组织损伤和污染,骨折移位明显,易发生感染、钢板外露和骨不连等,处理相当棘手.2003年1月～2008年12月,我科应用有限内固定结合单臂外固定架治疗胫骨开放性骨折25例,疗效满意.