膝关节镜引导下胫骨平台骨折的微创治疗

Arthroscope assisted treatment for tibial plateau fractures

目的探讨在膝关节镜引导下胫骨平台骨折微创治疗的手术方法及近期临床疗效。方法2001年7月～2007年3月该院共治疗胫骨平台骨折34例,均为新鲜闭合性骨折,按Schatzker分型Ⅰ型5例,Ⅱ型8例,Ⅲ型l6例,Ⅳ型3例,V型2例。合并半月板损伤7例,前交叉韧带损伤7例,侧副韧带损伤5例。术前摄取X片、CT片(含三维重建)或行MR检查,术中在关节镜引导下辅助C型臂X线机进行小切口复位内固定术,首先处理关节内合并损伤,然后对骨折进行解剖复位,复位后应用松质骨拉力螺钉或解剖支撑钢板内固定,骨缺损处用自体髂骨或同种异体骨植骨,术后配合早期功能锻炼。结果所有患者均获得随访,随访时间10～40个月,平均27.6个月。X片显示所有患者均在术后3、4个月获得骨性愈合,未出现切口及关节内感染、皮肤坏死或创口延迟愈合及螺钉断裂等并发症。随访期间无创伤性膝关节炎和膝关节内翻、外翻畸形发生。采用Lysholm评分标准评价临床疗效,优28例,良3例,可2例,差1例,优良率为91.2%。结论采用膝关节镜引导下的有限切口结合少量固定的微创手术治疗SchatzkerI～V型胫骨平台骨折,具有创伤小、可达解剖复位并同时处理关节腔内的其他损伤等优势,可获得骨折愈合快、膝关节功能恢复良好和并发症少的临床疗效,是一项值得临床推广的技术。

[Objective] To discuss the method and recent clinical results of a micro-invasive surgical treatment for tibial plateau fractures under arthroscope. [Methods] A total of 34 cases with fresh and closed tibial plateau fractures were treated by arthroscopic fixation from July 2001 to March 2007. According to Schatzker criteria, 5 cases were classified as type Ⅰ fracture,8 cases as type Ⅱ, 16 as type Ⅲ, 3 type Ⅳ and 2 type Ⅴ. Of all the cases in this study, 7 cases were complicated by meniseal injury, 7 by anterior cruciated ligament injury and 5 by collateral ligament injury. Before operation, X-ray examination, three-dimensional CT reconstruction or MR examination were done. During operation, the fractures were reduced and fixed under arthroscope and C-ann fluoroscope. The intraarticular complications were treated firstly. Then, the dissociative fragments were managed with anatomic reduction and fixated with cancellous screws or anatomic strut plate. The autografts of ilium or bone allografts were applied where the bone was defected. Moreover, the early rehabilitation training was carried out in patients after operation. [Results] All the cases were followed up for 10 to 40 months （27.6 months on average）. The X-ray findings showed bone union in all the 34 cases in 3-4 postoperative months. There was no incision or joint infection, skin necrosis, delayed union or screw rupture. During the followed-up no traumatic knee osteoarthritis, inversion or eversion of the knee occurred. According to Lysholm knee rating system, 28 cases were excellent, 3 were good, 2 were fair and 1 was poor, the excellent and good rate was 91.2%. [Conclusions] A.rthroscope assisted limited incision combined with some fixation techniques has advantages of minimal invasion, anatomic reduction, management of associated intra-articular injuries, early recovery and less complications in treatment of Schatzker type Ⅰ-Ⅴ tibial plateau fractures. It is worth of further clinical application.