Schatzker Ⅳ型胫骨平台骨折的分型及治疗

Clinical research on Schatzker type Ⅳ tibial plateau fracture

目的 探讨SchatzkerⅣ型胫骨平台骨折的损伤特点、疗效差的原因和改进的方法。方法 根据SchatzkerⅣ型胫骨平台骨折的骨折特点 ,将 1993～ 2 0 0 2年间诊治的 5 1例患者分为劈裂型、整髁型和塌陷型。对劈裂型和整髁型骨折 ,无关节面塌陷者 ,采用内侧切口 ;CT检查示有关节面塌陷者 ,采用正中切口纠正塌陷并植骨 ;劈裂型支撑钢板在内后侧固定 ,整髁型支撑钢板在内侧固定 ,或双侧支撑钢板固定。对塌陷型骨折 ,采用内侧切口 ,行复位、植骨、支撑钢板内侧固定。 33例患者术后平均随访 4 1个月 ,对影响骨折预后的因素进行分析。结果 随诊的 33例患者膝关节活动度为30°～ 14 7°(平均 110°) ;Lysholm评分平均为 83 2分 ,优 8例、良 9例、中 14例、差 2例。平台非解剖复位、平台增宽 >4mm、平台向外侧移位 >8mm是预后较差的相关因素 (χ2 值分别为 5 10、6 0 8、8 0 2 ,P<0 0 5、<0 0 5、<0 0 1) ,也易导致骨性关节炎的发生。结论 应根据分型和CT检查结果选择手术入路和固定方法 ,膝内翻畸形、平台增宽 >4mm或向外侧移位 >8mm是影响预后的因素。

Objective To study the characteristic,treatment and prognosis of tibial plateau fracture Schatzker type Ⅳ. Methods According to the roentgenogram and CT scan in 51 patients,Schatzker type Ⅳ injury is divided into 3 types:split,total condylar,depression. In the treatment of split and total condylar injury,if there was no articular depression on CT scan,reduction is done through medial approach;if CT scan demonstrated articular depression,middle approach was used to reduce the depression and bone graft. In split injury,buttress plate was fix on posteriormedial side. In total condylar injury,buttress plate is fix on medial side. In depression injury, fracture was reduced through medial approach,bone graft and buttress plate was fix on medial side. Thirtythree patients were followed up in 41 months averagely. And the statistical analysis was done. Results The average Lysholm score of 33 patients was 83.2. Eight patients were excellent,9 were good,14 were fair,2 were poor. The range of motion from 30° to 147° (average 110°). The factors that caused bad results were:the fracture was not anatomical reduced; tibial plateau is more than 4 mm wider than femoral condylar or lateral subluxation exceed 8 mm; varus deformity of knee. They also caused the increase of osteoarthritis. Conclusions In order to get anatomical reduction and stable fixation,the approach and fix pattern should be chosen on the bases of classification and CT scan of SchatzkerⅣ injury. The factors which influence the prognosis are :(1) tibial plateau is more than 4mm wider than femur condylar, or lateral subluxation more than 8 mm; (2) Varus deformity. Attention should be paid to avoid these during operation.