内外翻不同损伤机制导致胫骨Pilon骨折的手术策略

 目的 探讨内外翻不同损伤机制导致胫骨Pilon骨折的特点、手术策略及疗效。方法 2008年6月至2012年8月收治胫骨Pilon骨折32例，内翻损伤17例、外翻损伤15例。内翻损伤组AO/OTA分型B型6例、C型11例，外翻损伤组均为C型。外翻损伤组中3例为GustiloⅡ型开放性骨折。根据主要骨折线及骨折块分布选择相应的手术入路行切开复位内固定，内翻损伤组主要支撑接骨板置于胫骨远端内侧，外翻损伤组置于胫骨远端前外侧；开放性骨折采用有限内固定结合外固定支架治疗。以Burwell-Charnley放射学评价标准判定关节面复位质量，记录美国矫形足踝协会（American Orthopedic Foot and Ankle Society，AOFAS）踝与后足评分。结果 全部病例随访12~24个月，平均16.9个月。两组AO/OTA分型、合并腓骨骨折发生率的差异有统计学意义。内翻损伤组2例并发浅表感染；外翻损伤组4例并发浅表感染，2例深部感染，1例骨折延迟愈合，4例需转移皮瓣修复创面。内翻损伤组解剖复位9例、复位较好7例、复位一般1例，外翻损伤组解剖复位6例、复位较好8例、复位一般1例。术后12个月内翻损伤组AOFAS评分（87.06±2.70）分，外翻损伤组（82.80±3.47）分，差异无统计学意义。结论 内外翻不同损伤机制导致的胫骨Pilon骨折不同，应选择不同的手术方式。对内翻损伤应将主要支撑接骨板置于胫骨远端内侧、外翻损伤置于胫骨远端前外侧，可降低手术并发症发生率，近期临床疗效满意。

Surgical strategies and clinical outcomes of Pilon fractures caused by two different injury mechanism (varus/valgus)

Objective To explore the surgical strategies of Pilon fractures caused by two different injury mechanisms.Methods From June 2008 to August 2012, 32 patients with Pilon fractures were retrospectively analyzed in this study. These patients were divided into two groups (A-varus, B-valgus) according to the injury mechanisms. There were 17 patients in group A and 15 patients in group B. According to the AO/OTA classification, there were 6 type B, 11 type C in group A and 15 type C in group B, with 3 cases of group B being Gustilo type Ⅱ open fractures. In group A, the buttress plate was placed on the medial aspect of distal tibia. However, the buttress plate was placed on the lateral aspect of distal tibia in group B. For those open fractures in group B, external fixation combined with limited internal fixation was performed. After the surgeries, the reduction quality of the joint surface was evaluated by Burwell-Charnley's radiological evaluation system. Clinical outcomes were evaluated by the AOFAS ankle-hindfoot scale. Results 32 cases were followed up for 12-24 months (average 16.9 months). There were statistic differences between group A and B according to both the AO/OTA classification and whether fibula fractures existed. In group A, 2 cases developed wound infection. In group B, 4 cases developed superficial wound infection, 2 deep wound infection, 1 delayed union of bone, and 4 needed flap transplantation to facilitate wound healing. The postoperative reductions were as follows: 9 anatomic, 7 good, and 1 fair in group A; 6 anatomic, 8 good and 1 fair in group B. By 12 months postoperatively, there was no statistic difference between these two groups according to the AOFAS ankle-hindfoot scale, with the average scores of group A and B being 87.06±2.70 and 82.80±3.47 respectively. Conclusion Different injury mechanisms will result in different types of Pilon fractures. Different strategies should be used according to the characteristics of fracture to achieve better clinical outcomes and fewer complications, with the buttress plates being placed on the medial and lateral aspect of distal tibia in varus and valgus injury respectively.