粉碎性Pilon骨折软骨关节面手术修复策略

目的 探讨Pilon骨折关节骨软骨面严重粉碎性损伤的手术修复策略.方法 我科2007年4月-2010年5月手术治疗Pilon骨折85例,Ruedi-Allgower Ⅱ型21例,Ⅲ型64例.选择踝关节前内、外侧或后内、外侧入路.粉碎严重的塌陷关节面(碎裂软骨下骨及未游离的关节软骨)直视下应用距骨关节面作为模具,细克氏针、拉力螺钉及可吸收螺钉(聚左旋乳酸可吸收骨固定系统)固定、阻挡、镶嵌挤压、软骨下骨下方植骨等方法修复,后再应用胫骨远端解剖型锁定接骨板重建、支撑固定.术后外固定限制踝部活动4～6周.结果 85例随访11～38个月,平均16.6个月.关节面骨折复位质量采用Matta标准:解剖复位80例,复位满意3例,复位不满意2例,复位满意率97.65%.关节功能恢复情况采用Philips踝关节评分系统评价:优80例,良3例,差2例,优良率为97.65%.结论 通过改进复位策略及技巧提高关节面复位质量及保证良好血供的锁定接骨板固定,可完成粉碎严重的Pilon骨折关节面的重建,明显提高胫骨远端关节骨软骨面的愈合质量及踝关节功能恢复优良率.

Surgical Repair Strategy of Articular Surface of Crushing Pilon Osteochondral Fracture

Objective To investigate the surgical repair strategy of Pilon fracture joint osteochondral surface after serious crushing damage. Methods Among 85 patients with Pilon fractures Surgery during April 2007 and May 2010, there were 21 with Ruedi-Allgower II type and 64 with Ruedi-Allgower III type. Approach from the anterior or posterior inside or outside of the ankle. Serious crushing collapse articular surface （chipped subchondral bone and unionized articular cartilage） took the joint surface as mould by looking straight, with fine Kirschner wire, lag screw and absorbable screw （poly levorotatory lactic acid absorbable bone fixation system） for repairing by fixing, blocking, setting, compress- ing and bone grafting below subchondral bone, followed by application of the distal tibia anatomy type locking blade plate for reconstruction and fixation. After the surgery the ankles were fixed to limit activities for four to six weeks. Results 85 patients were followed up for 11-38 months and the average time was 16.6 months. Joint surface fracture restoration quality was assessed by Matta imaging quality standard ： among 80 patients of anatomic reduction, there were satisfaction in 3 patients and dissatisfaction in 2 patients. The satisfaction rate was 97.65%. The recovery of joint function was assessed by Philips ankle rating system ： excellent in 80 patients, good in 3 and poor in 2, and the fine rate was 94.29%. Conclusion Fixation by locking blade plate, which is to enhance the articular surface repositioning quality and ensure good blood supply by improving the repositioning strategies and skills, can complete the joint reconstruction of serious crushing Pilon fractures, obviously improve the healing quality of the distal tibia bone and cartilage joints and the excel- lent rate of the recovery of ankle function.