严重Pilon骨折的手术治疗

The surgical treatment of severe Pilon fracture

目的探讨严重Pilon骨折的手术治疗的方法及其临床效果。方法自2006年8月至2011年8月共收治严重Pilon骨折患者189例,获得随访的76例患者中,骨折按AO/OTA分类,均为C型,其中C1型19例,C2型35例,C3型22例。合并腓骨骨折75例。开放性骨折9例,软组织损伤程度按Gustilo分型,9例均Ⅰ型。开放性骨折急诊行清创缝合及跟骨牵引后等待延期手术。闭合性骨折入院后均行跟骨牵引后延期手术。延期手术均在踝部肿胀消退后进行,伤后至手术时间5～14d,平均7.2d。65例行骨折切开复位内侧钢板螺钉内固定术,其中11例加用前或后侧小钢板固定,21例加用螺钉固定。11例采用骨折有限切开固定加超关节外固定架固定。有腓骨骨折者先行腓骨内固定术。61例取自体髂骨植骨。结果 76例患者获得随访,随访时间10～54个月,平均27个月,术后骨折复位情况影像学评估结果(Burwell-Charnley标准):解剖复位33例,复位一般41例,复位差2例。骨折全部愈合,愈合时间12周～73周,平均17.6周,其中骨折延迟愈合9例。皮肤创面浅表坏死7例,浅表感染6例,深部感染2例。发生踝关节创伤性关节炎18例,按美国骨科协会足踝外科分会(AOFAS)评分标准:评分为47～95分,平均82.7分。结论根据骨折类型和软组织损伤程度,对严重Pilon骨折采用手术治疗,通过合理的固定及早期功能锻炼,能取得满意的疗效,有效减少并发症的发生。

Objective To discuss the operative methods and outcomes of severe Pilon fracture. Methods A total of 189 patients with severe Pilon fractures were admitted from August 2006 to August 2011. 76 patients who were followed up were all type C fracture according to AO/ OTA classification, including 19 cases of type C1, 35 cases of type C2 and 22 cases of type C3. Of 76 cases, nine were open fracture and 75 were associated with fibula fracture. According to Gustilo classification, the open fracture cases were all type I . Emergency debridement and calcaneal traction were performed for open fractures ; calcaneal traction was also performed for closed fracture. The definitive internal fixations were carried out in an average time of 7.2 days （ range, 5 to 11 days ） when ankle swelling subsided. 65 cases were treated with open reduction and internal fixation, including 11 cases plus anterior or polsterior small steel plates and 21 cases plus screws. 11 cases were treated with limited internal fixation combined with external fixation. Patients with fibula fracture were performed fibular internal fixtion first and 61 cases underwent autologous iliac bone grafting. Results 76 patients were followed up from 10 to 54 months, with a mean time of 27 months. The outcome of reduction was evaluated by the Burwell-Charnley score ： 33 cases were anatomical reduction, 41 cases were functional reduction and two cases were poor reduction. The healing- time ranged from 12 to 73 weeks, with a mean time of 17. 6 weeks. Delayed union occurred in nine cases. Seven patients experienced skin superficial necrosis. There were superficial infection in six cases and deep infection in two case. 18 cases experienced early traumatic arthritis. According to American Orthopedic Foot Ankle Society （ AOFAS ） scale for ankle joint, the score of the treatment was 47 - 95, 82. 7 in average. Conclusions According to fracture classification and the condition of soft tissue, the surgical treatment and early functional exercises can achieve a satisfactory effect, and effectively reduce complications.