关节置换术治疗膝骨性关节炎合并胫骨平台骨折

[目的]探讨人工膝关节置换术治疗膝骨性关节炎合并胫骨平台骨折的临床疗效。[方法]2012年7月~2015年4月收治骨性关节炎合并胫骨平台骨折患者12例,男4例,女8例;年龄60~72岁,平均67.5岁;致伤原因:交通伤8例(66.7%),坠落伤3例(25%),其他伤1例(8.3%)。受伤前均患有中重度骨性关节炎,有不同程度的屈曲内翻畸形。按三柱理论分型:后外侧柱骨折9例,外侧柱骨折3例。合并交叉韧带损伤8例,半月板损伤7例,均采用人工膝关节置换进行一次性治疗骨性关节炎合并胫骨平台骨折。随访期间拍摄X线片及记录关节活动度,并按照美国特种外科医院膝关节功能评分法(HSS)对膝关节功能进行评分。[结果]所有患者均获12~26个月随访,平均(20.5±3.1)个月。术后1周、1年的膝关节活动度和HSS评分与术前相比,差异均有统计学意义。术后1年随访时HSS评分:优7例,良3例,一般1例,差1例,优良率83.3%。[结论]人工膝关节置换治疗骨性关节炎合并胫骨平台骨折具有良好的临床疗效,术后患者可以较早下地活动,减少并发症的发生,提高生活质量。     

急性膝关节损伤的X线与CT对比分析和研究

目的分析急性膝关节损伤的CT征象,评价CT在急性膝关节损伤诊断中的应用价值和局限性。方法60例膝关节外伤患者进行X线、薄层CT及三维重建检查,并进行对照分析。结果CT显示60例患者中共有膝关节骨折141处,X线显示骨折104处。普通X线及CT的检出率差异有非常显著性意义(χ2=38.12,P<0.01);CT诊断浮膝骨折44例,X线诊断浮膝骨折38例,占86%;32例胫骨平台骨折中,10例X线片未能显示平台塌陷和骨折,因而分型上与CT不一致。在CT和X线片上分别对平台骨折塌陷距离和骨折劈裂距离进行测量,两数值比较差异有非常显著性意义(平台塌陷:t1=2.35,劈裂移位t2=2.13,均P<0.05)。CT诊断与手术符合的8例半月板损伤,X线均不能显示;CT诊断十字韧带损伤15例,X线诊断9例,有6例因未见韧带附着处的撕脱骨折而漏诊;CT诊断侧副韧带损伤27例,X线应力像诊断19例。本组CT示关节腔积血22例,积气5例,其中脂血征7例。X线片示关节腔积液13例,积气2例,未见脂血征。结论在急性膝关节损伤中,CT能安全、快捷地对骨折脱位、外伤性半月板损伤、十字韧带损伤、侧副韧带损伤、膝关节腔内积气、积血、脂血征、关节损伤的稳定性等作出全面、准确的诊断。但是CT仍存在局限性,只有CT与X线检查相结合才能提高诊断水平,为临床制定治疗方案提供可靠依据。     

MRI在胫骨平台骨折治疗中的应用

目的：探讨MRI在胫骨平台骨折治疗中的应用价值。方法：五年来收治26例胫骨平台骨折患，在常规X线片检查基础上，对其进行了MRI检查，从革命家更加精确评估胫骨平台骨折块劈裂和塌陷的程度，并判断有无合并损伤。结果：26例胫骨平台骨折中累及外侧平台9例，累及内侧平台6例，累及整个平台11例；合并半月板损伤4例，十字韧带及内侧副韧带损伤6例。根据MRI检查，术前得以正确评估胫骨平台碎骨块的移位方向和塌陷的面积。22例进行了手术，其中8例术中植骨治疗。结论：MRI能多方位、立体显示胫骨平台骨折的形态特征，有助于准确评估缺损面积，根据骨折累及范围，选择最佳的治疗方案。     

MRI在胫骨平台骨折治疗中的应用

目的 探讨MRI在胫骨平台骨折治疗中的应用价值。方法 五年来收治26例胫骨平台骨折患者,在常规X线片检查基础上,对其进行了MRI检查,从而更加精确评估胫骨平台骨折块劈裂和塌陷的程度,并判断有无合并损伤。结果 26例胫骨平台骨折中累及外侧平台9例,累及内侧平台6例,累及整个平台11例;合并半月板损伤4例,十字韧带及内侧副韧带损伤6例。根据MRI检查,术前得以正确评估胫骨平台碎骨块的移位方向和塌陷的面积。22例进行了手术,其中8例术中植骨治疗。结论 MRI能多方位、立体显示胫骨平台骨折的形态特征,有助于准确评估缺损面积,根据骨折累及范围,选择最佳的治疗方案。     

MRI在胫骨平台骨折诊治中的意义

目的:探讨MRI在胫骨平台骨折诊治中的价值.方法:胫骨平台骨折患者63例,所有患者都行MRI及X线检查,评价胫骨平台劈裂和塌陷的程度,骨折断端是否有软组织嵌入,以及合并的韧带和半月板损伤,以选择合适的治疗方案.结果:所有患者都合并不同程度的韧带或半月板损伤,单纯劈裂骨折11例,单纯胫骨髁间骨折3例,49例患者有明显的胫骨平台塌陷,骨折端有软组织嵌入17例,X线未发现的隐性骨折7例.13例患者MRI检查后改变了治疗方案和手术方式.结论:MRI能清晰的显示X线不能显示的隐性骨折,并能同时显示骨折的形态和塌陷的程度,以及是否有软组织的嵌入和合并的半月板、韧带损伤,为治疗方案、手术方式和入路的选择提供详细的资料.     

三维CT重建在胫骨平台骨折中的应用

目的：探讨用三维ＣＴ重建评价胫骨平台骨折的临床应用价值。方法：收集胫骨平台骨折２３例。所有患者接受Ｘ线片、ＣＴ扫描和三维ＣＴ重建的检查。从而评估胫骨平台劈裂和塌陷的程度，对骨折进行分型，选择合适的治疗方案。结果：２３例胫骨平台骨折累及外侧平台９例，累及内侧平台６例，累及整个平台８例。根据三维ＣＴ重建，术前得以正确评价胫骨平台劈裂移位方向和塌陷的面积。２１例进行手术治疗，其中１２例给予植骨。结论：三维ＣＴ重建能多方位、立体显示胫骨平台劈裂的形态，帮助术者正确估计平台塌陷的面积。利用平台面的立体重建图像，将平台分为四个象限，根据骨折累及的象限，选择合理的手术入路，准确复位，适当地植骨，坚强的内固定，取得较好的疗效。     

胫骨平台骨折疗效的多因素分析

胫骨平台骨折是影响膝关节功能的常见损伤,治疗方法有多种,对保守治疗、手术治疗及手术适应证等的认识均有分歧.各种方法疗效不一,与多种因素有关,如骨折类型、手术与否、复位质量、内外固定、功能锻炼等.笔者采用逐步回归分析方法,对本院1988年至2003年的49例胫骨平台骨折患者随访资料进行分析,了解各种因素的相对重要性,从而筛选与胫骨平台骨折疗效有关的因素.     

MRI在胫骨平台隐性骨折诊断中的价值与临床意义

MRI不但可以诊断膝部软组织创伤，而且还能清楚显示X线检查不能发现的隐性骨折。且较螺旋CT三维重建省时、廉价、信息更丰富。     

胫骨平台骨折的分类与功能评价

胫骨平台骨折属胫骨近端的关节内骨折。胫骨平台骨折的分类方法，主要包括Hohl修正后分类(1991)、Schatzker分类(1979)及AO分类(1990)。AO分类内容详尽，共分为两型(41-B和41-C)6组18个亚组，对资料积累极为有利，2000年已被美国．JBJS杂志推荐使用，并作为美国创伤骨科学会(OTA)会议与J，Orthop Trauma杂志论文的标准骨折分类。Schatzker分类分为6型，临床实用性很强，目前应用最为广泛。胫骨平台骨折治疗后的功能评价，多选用Rasmussen膝关节功能评分、HSS膝关节临床功能评分；放射学评价早期多用Rasmussen评分标准，远期可参考Resnick-Niwoyama退行性关节疾病评分标准。     

Meniscuses and ligaments injuries in tibial plateau fractures in comparative evaluation of clinical, intraoperative and MR examination]

The diagnosis of the meniscal and ligament injuries accompanying the tibial plateau fractures is difficult and unconvincing. Thus the capsular, ligament and meniscal injuries coexisting with this kind of fractures were questioned for many years. Introducing of MR afforded for the precise evaluation of the bone as well as the soft tissue injury. This article demonstrates the results of MR images of 112 patients with the acute proximal tibia fractures. The number and the degree of the meniscal and ligament injury were estimated and intraoperative verification of MR was made in 66 patients qualified for an operative procedure. The attempt to find the correlation between the type of the fracture and the meniscal and ligament injury was made according to Schatzker classification. MR images revealed that the bone injury was accompanied by the ligament or meniscal injury in 88%. Most commonly the partial tears (77% considering ligament injuries and 70% considering meniscal injuries) occurred. The most frequent extracapsular and intracapsular injury was MCL tear (70%) and LM tear (56%) respectively. No correlation between the type of the fracture and the soft tissue injury was found.     

The accuracy and precision of radiostereometric analysis in monitoring tibial plateau fractures

Background and purpose

The application of radiostereometric analysis (RSA) to monitor stability of tibial plateau fractures during healing is both limited and yet to be validated. We therefore evaluated the accuracy and precision of RSA in a tibial plateau fracture model.

Methods

Combinations of 3, 6, and 9 markers in a lateral condyle fracture were evaluated with reference to 6 proximal tibial arrangements. Translation and rotation accuracy was assessed with displacement-controlled stages, while precision was assessed with dynamic double examinations. A comparison of error according to marker number and arrangement was completed with 2-way ANOVA models.

Results

The results were improved using more tantalum markers in each segment. In the fracture fragment, marker scatter in all axes was achieved by a circumferential arrangement (medial, anterior, and lateral) of the tantalum markers above the fixation devices. Markers placed on either side of the tibial tuberosity and in the medial aspect of the fracture split represented the proximal tibial reference segment best. Using 6 markers with this distribution in each segment, the translation accuracy (root mean square error) was less than 37 μm in all axes. The precision (95% confidence interval) was less than ± 16 μm in all axes in vitro. Rotation, tested around the x-axis, had an accuracy of less than 0.123° and a precision of ± 0.024°.

Interpretation

RSA is highly accurate and precise in the assessment of lateral tibial plateau fracture fragment movement. The validation of our center''s RSA system provides evidence to support future clinical RSA fracture studies.     

The cast brace and tibial plateau fractures

Three hundred six tibial plateau fractures treated at the authors' institutions and in private practice were analyzed in relation to the use of a cast brace or fracture brace. One hundred forty-one of these patients had had a cast brace or fracture brace as part of their treatment program, either as the primary fracture treatment or after open reduction or traction. The aims of this study were (1) to determine if cast bracing could maintain alignment, fracture position, and range of motion and (2) to compare its results with those of other major long-term studies of similar fractures. There were 85 lateral, 24 medial, and 32 bicondylar fractures. Cast bracing was used for one to 17 weeks, with a mean of eight weeks. Ninety-nine of the 141 patients were followed for at least one year. Eighty-two of the patients maintained alignment with less than 5 degrees of deformity, and fracture position was maintained in 85% of cases, with only 15% having 4-8 mm of loss of position. Medial plateau and subcondylar fractures had an increased incidence of fracture position loss. Ninety-seven percent of patients had greater than 90 degrees of flexion, and 90% had full extension, i.e., less than 5 degrees of contracture. Pain was minimal or absent after heavy exercise in 90% of patients using cast bracing. Arthritic changes on roentgenographic analysis were absent or mild in 93.5% and moderate or severe in 6.5% of patients. Complications, including phlebitis, pulmonary emboli, wound infection, hardware slippage, and skin slough, occurred in nine patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

High-energy tibial plateau fractures

The severity of a tibial plateau fracture and the complexity of its treatment depend on the energy imparted to the limb. Low-energy injuries typically cause unilateral depression-type fractures, whereas high-energy injuries can lead to comminuted fractures with significant osseous, soft-tissue, and neurovascular injury. Evaluation includes appropriate radiographs and careful clinical assessment of the soft-tissue envelope. Treatment is directed at safeguarding tissue vascularity and emphasizes restoration of joint congruity and the mechanical axis of the limb. Temporary joint-spanning external fixation facilitates soft-tissue recovery, whereas minimally invasive techniques and anatomically contoured plates can limit damage to the soft tissues and provide stable fixation. Alternatively, the use of limited internal fixation and definitive external fixation can minimize soft-tissue disruption, avoid complications, and allow fracture union. Complications, including infection, loss of fixation, and malalignment, are best avoided by following these biologically respectful treatment principles.     

Impact of MRI on treatment plan and fracture classification of tibial plateau fractures

OBJECTIVE: To evaluate the interobserver agreement for both treatment plan and fracture classification of tibial plateau fractures using plain radiographs, computed tomography (CT) scan, and magnetic resonance imaging (MRI). DESIGN: Prospective study to assess the impact of an advanced radiographic study on the agreement of treatment plan and fracture classification of tibial plateau fractures among three orthopaedic surgeons. SETTING/PARTICIPANTS: Patients presenting with tibial plateau fractures to a level I trauma center were evaluated with plain knee radiographs (anteroposterior, lateral, two oblique views), CT scan, and MRI. Three experienced attending orthopaedic trauma surgeons were randomly presented three sets of studies for each injury: radiographs alone, radiographs with CT, and radiographs with MRI (including soft tissue injuries documented by an experienced MRI radiologist). The surgeons were asked to render fracture classification and treatment plan based upon the blind reading of each individual radiographic set. MAIN OUTCOME MEASURES: Agreement among the three surgeons was measured using kappa coefficients. RESULTS: For fracture classification, radiographs alone yielded a mean kappa coefficient of 0.68, which increased to 0.73 for radiographs with CT scan and 0.85 for radiographs with MRI. Fracture classification (Schatzker) was changed an average of 6% with the addition of the CT scan and 21% based on radiographs with MRI. For the fracture management plan, the mean interobserver kappa coefficient for radiographs alone was 0.72, which increased to 0.77 for radiographs with CT scan and 0.86 for radiographs with MRI. MRI changed treatment plan in 23% of the cases. CONCLUSION: Magnetic resonance imaging increases the interobserver agreement on fracture classification and operative management of tibial plateau fractures.     

Posterior bicondylar tibial plateau fractures

OBJECTIVE: To present a case series of patients with posterior bicondylar tibial plateau fractures treated by direct fracture exposure and fixation through dual incisions. DESIGN: Retrospective clinical study. SETTING: Level 1 trauma centers. PATIENTS/PARTICIPANTS: Eight patients were identified that had posterior bicondylar tibial plateau fractures. Two patients had depressed posterolateral tibial plateau fractures with contained defects and did not have direct fracture exposure. One patient died of medical problems leaving 5 patients who underwent direct fracture exposure, reduction, and fixation. INTERVENTION: Posteromedial followed by posterolateral open reduction and internal fixation of posterior bicondylar tibial plateau fractures. RESULTS: At 6 to 24 months follow-up (mean 13 months), all patients returned to near full activities, each with aching after prolonged standing (8-hour shift). Range of motion averaged 2 degrees to 121 degrees of flexion. Three of 5 returned to manual labor jobs; the others were not employed at the time of injury. CONCLUSIONS: Posterior bicondylar tibial plateau fractures have a high association with lateral meniscal pathology and can be associated with anterior cruciate ligament injury. Reduction of the posterior plateau condyles is easiest with the knee in full extension. Flexion contractures can be a problem, and patients should be encouraged to regain/maintain knee extension. The dual-incision approach to these challenging fractures can result in good to excellent knee function for these patients.     

胫骨平台骨折的手术治疗进展

[目的]胫骨平台是膝关节负荷结构,在人体功能中占重要地位,胫骨平台骨折涉及关节面,往往由车祸及高处坠落等高能量损伤造成,手术风险大,效果不理想。随着对胫骨平台骨折认识的深入,各种新的治疗理念、手术入路、固定方法、固定器材纷纷提出,使治疗效果较前有了很大进步,本文就近期胫骨平台骨折手术治疗的相关问题做一综述。     

胫骨平台复杂骨折内固定手术方案设计正误剖析

[目的]探讨胫骨平台复杂骨折内固定治疗的选择思路。[方法]对124例内固定治疗的胫骨平台复杂骨折术后拍摄正侧位X线片,测量后倾角、塌陷程度、横径宽度,并与健侧对比总结分析。[结果]本组124例发生内固定失效78例,其中关节面发生倾斜12例,后倾角增加5°～12°,平均9.18°±2.22°;关节面塌陷20例,塌陷的程度3～11 mm,平均4.5 mm±0.92mm;胫骨平台横径增宽5～11 mm之间32例,平均7.2 mm±1.26 mm;骨折再移位者14例,余46例因术后石膏长期外固定保护未发生内固定失效,但导至膝关节屈伸活动障碍,屈曲范围20°～85,°平均41°;伸直0°～30°,平均15.6°。按HSS膝关节评分标准,功能评定为良25例,可68例,差31例。[结论]完整的影像资料、骨折损伤机制的综合分析、手术入路及内植物的正确择取、手术的技巧与手术者的经验是保证胫骨平台复杂骨折内固定治疗取得良好效果的重要因素。     

关节镜下手术治疗胫骨平台骨折

目的 探讨关节镜下撬拨复位经皮内固定术治疗胫骨平台骨折的疗效。方法 11例胫骨平台骨折在关节镜下通过撬拨复位重建塌陷的胫骨平台,并经皮用松质骨螺钉固定。结果患者骨折均达到临床骨愈合,无感染和严重骨关节炎等并发症。膝关节功能恢复良好。结论关节镜下撬拨复位经皮内固定术治疗胫骨平台骨折,具有损伤小、操作安全、直视下复位固定确切、能同时处理关节内合并伤等优点,有利于术后早期功能锻炼。