两种手术入路治疗Topliss分型闭合矢状面Pilon骨折的疗效比较

Comparison of two different surgical approaches for treatment of Topliss dosed sagittal Pilon frac-tures

目的探讨Topliss分型下前外侧入路与后内侧入路内固定治疗闭合矢状面Pilon骨折的指导意义，并比较二者疗效。方法选择2007年-2010年采用切开复位内固定治疗的闭合矢状面Pilon骨折患者57例，其中采用前外侧人路（A组）29例；采用后内侧入路（B组）28例，均为闭合性骨折，伤后手术时间窗均在10-19d之间。比较两组患者性别、年龄、骨折类型、软组织分度、致伤因素、合并腓骨骨折情况、手术时间窗、手术时间、术中出血量、下地时间、皮肤及软组织的感染及坏死率、住院时间、内固定置入后踝关节功能恢复情况及术中X线复位程度。结果术后随访12-26个月，平均20个月。全部患者中仅A组1例失访，总随访率为98％。两组间性别、年龄、骨折类型、软组织分度、致伤因素、合并腓骨骨折情况、手术时间窗选择、手术时间及术中出血量、下地时间差异无统计学意义（P〉0．05）。与B组比较，内固定术后A组皮肤软组织感染及坏死发生率更低，住院时间明显缩短（P〈0．05）。其中A组中2例术后出现趾伸肌腱粘连，内固定取出术中予以松解。15例患者住院期间发生切口感染，其中A组3例，B组12例，均通过换药等处理后治愈。15例患者术中I期同种异体骨充填，11例自体髂骨植骨，均无骨不愈合发生。结论Topliss分型对闭合矢状面Pilon骨折的手术方案选择及手术操作具有明确的临床指导意义。虽然前外侧入路与后内侧入路治疗闭合矢状面Pilon骨折最终均能取得良好的疗效，但前外侧入路治疗高能量损伤所致闭合矢状面Pilon骨折皮肤软组织感染及坏死率低、住院时间短，是一种较为理想的手术入路选择。

Objective To discuss the clinical significance of internal fixation through anterolater- al and posteromedial approaches in the treatment of closed sagittal Pilon fractures of Topliss classification and compare the effects of the two approaches. Methods The study involved 57 patients with closed sagittal Pilon fractures treated with open reduction and internal fixation from 2007 to 2010, including 29 patients treated through anterolateral approach （ Group A） and 28 through posteromedial approach （ Group B）. All patients were with closed fractures, and all surgery time windows were 10-19 days. The two groups were compared in aspects of gender, age, type of fractures, soft tissue graduation, injury factors, condition of combined fibula fracture, surgery time window, operation time, intra-operative blood loss, ambulation time, infection and necrosis rate of skin and soft tissue, length of stay, ankle joint function re- covery after internal fixation, and intra-operative X-ray reduction. Results All patients were followed up for 12-26 months （mean, 20 months） except for one patient in the Group A, with total follow-up rate of 98%. The two groups showed no significant differences regarding the gender, age, type of fractures, soft tissue graduation, injury factors, condition of combined fibula fracture, surgery time window selec- tion, operation time, intra-operative blood loss, and ambulation time （ P 〉 0.05 ）. While, the infection and necrosis incidence of skin and soft tissue, and the hospital stay were si-,nificantlv lower and shorter inthe Group A than that in the Group B （ P 〈 0.05 ） . Two patients in the Group A were complicated with toe extensor tendon adhesion, which was released by removing the fixation. Fifteen patients had wound in- fection during hospitalization, including three patients in the Group A and 12 in the Group B, but they were all cured after treatments like dressing. Fifteen patients were treated with stage I allogeneic bone graft and 11 with autologous iliac bone graft. All the patients obtained bone union. Conclusions To- pliss classification of closed sagittal Pilon fractures has clear clinical significance in surgical plan selection and operative procedures. Both of the anterolateral and posteromedial approaches can achieve good effects in the treatment of closed sagittal Pilon fractures due to high energy injury. However, the anterolateral ap- proach is relatively a better choice, for it brings in a lower incidence of infection and necrosis of skin and soft tissue and a shorter lenzth of hosoital stay.