外后侧弧形切口双肌间隙入路治疗胫骨后外侧平台塌陷骨折

 目的 探讨外后侧弧形切口双肌间隙入路治疗胫骨后外侧平台塌陷骨折的临床疗效。方法 回顾性分析 2009年 8月至 2013年 3月，采用外后侧弧形切口双肌间隙入路治疗 32例伴有后外侧劈裂、塌陷的胫骨平台骨折患者资料，男 15例，女 17例；年龄 28~77岁，平均 46.25岁；均为闭合性骨折，均未合并神经及血管损伤；受伤至内固定手术时间为 3~ 18 d，平均 7.13 d。通过外后侧入路在胫前肌、腘肌和比目鱼肌间隙两个间隙分别显露胫骨前外侧髁及后外侧髁，在直视下复位骨折，分别用“高尔夫”与“T”形锁定钢板固定胫骨前外侧和后外侧骨折。术后按 Rasmussen 评分评价胫骨平台骨折复位情况，按美国特种外科医院（hospital for special surgery, HSS）评分评价膝关节功能。结果 32例患者均获得随访，随访时间 6~36个月，平均 15.3个月。术后 X线片均示骨折复位良好，关节面未见明显塌陷。骨折全部愈合，愈合时间 6~ 14周，平均 11.2周。末次随访时，Rasmussen评分为 6~18分，平均 14.06分，其中优 14例，良 15例，可 3例，优良率为 90.62%（29/32）。HSS评分为 57~92分，平均 78.25分，其中优 11例，良 17例，可 3例，差 1例，优良率为 87.5%（28/32）。无一例发生腓总神经损伤及重要血管、神经损伤、手术区皮肤坏死、感染或内固定松动。结论 胫骨平台后外侧塌陷骨折采用外后侧弧形切口双肌间隙入路治疗，在一个切口内既可显露胫骨前外侧平台骨折又可兼顾后外侧塌陷骨折，无须腓骨小头截骨，创伤小，切口间皮瓣坏死及钢板外露的发生率低，是一个值得推广的入路。

The modified posterolateral curved incision with double intermuscular approch in treating posterolateral tibial plateau fractures

Objective To investigate the efficiency of the modified posterolateral curved incision with double intermuscular approach in the treatment of posterolateral tibial plateau fractures. Methods From August 2009 to March 2013, 15 men and 17 women aged 28 to 77 (mean, 46.25) years with posterolateral spitting or collapse tibial plateau fractures were treated to undergo a modified posterolateral approach. All types of fractures were closed, without nerve or artery injury. The duration from injury to fixation was 3-18 (mean, 7.13) days. The modified posterolateral approach was preformed to expose tibial anterolateral condyle and posterolateral condyle through intermuscular space of anterior tibial muscle, popliteus muscle and soleus muscle. After open reduction, anterolateral fractures and posterolateral fractures were fixed by the T-shaped plate and“Golf”shaped plate respectively. Results All of the 32 patients were followed up from 6 months to 36 months (in average of 15.3 months). Postoperative X-ray showed satisfied fractures without obvious collapse of the articular surface. At the last follow-up, the Rasmussen scores were range from 6 to 18 (in average of 14.06), namely 14 cases excellent, 15 cases good, 3 cases fair. The knee joint functions were evaluated according to HSS. The HSS results showed that there were 12 cases excellent, 16 cases good, 3 cases fair and 1 case bad. None of the cases suffered from injuries of crucial blood vessel or nerves. No incision necrosis, wound infection or fixation failure occurred during follow-up. Conclusion Open reduction and internal fixation via modified posterolateral approach can expose posterolateral and anterolateral tibial plateau fracture in one incision. Fibular head osteotomy can be avoided. The present approach could also reduce surgical injury, minimize the possibilities of incision necrosis or plate exposure. The modified posterolateral approach can be recommended in clinical practice.