两种外固定架治疗Pilon骨折的疗效比较

The comparison of curative effects of 2 types of external fixators in the treatment of pilon fractures

目的探讨两种外同定架治疗Pilon骨折的疗效。方法将1998年5月至2010年1月间Pilon骨折患者38例随机分为两组:A组(不超踝关节半环形外固定架同定治疗组)21例,男16例,女5例;年龄17～54岁,平均32.5岁。按Ovadia和Beals分型,Ⅳ型14例,Ⅴ型7例,开放性骨折6例,闭合性骨折15例,合并伤:腰椎骨折3例、骨盆骨折6例、足部损伤6例、颅脑损伤12例,其他合并伤5例。B组(超踝关节外固定架固定治疗组)17例,男14例,女3例;年龄19～52岁,平均29.3岁,按Ovadia和Beals分型,Ⅳ型11例,Ⅴ型6例,开放性骨折4例,闭合性骨折13例,合并伤:上肢骨折1例、下肢骨折3例、颅脑损伤2例,其他合并伤4例。手术时间:开放性骨折者均在6-8h内手术清创外同定。闭合性损伤肯,告全身状况允许可于8-12h内手术,否则跟骨牵引维持7-10d后手术。对患者近远期并发症、骨折愈合时间、骨折复位影像学、踝关节功能等指标进行比较。结果全部病例均获随访,随访时间6-18个月,平均12.5个月,A组骨折愈合时间(16.3±2.8)周;B组骨折愈合时间(18.5±3.9)周,两组比较差异无统计学意义(P>0.05)临床疗效按Mazur标准评定:A组:优6例,良11例,可3例,差1例,优良率为80.9%。B组:优3例,良7例,可4例,差3例,优良率为58.8%。两组比较差异有统计学意义(P<0.05)。近期并发症为皮肤裂开坏死、钉道感染:A组4例(19.0%);B组4例(23.5%),两组比较差异无统计学意义。远期并发症为骨折延迟愈合或不愈合、畸形愈合、关节僵硬:B组6例(35.2%),两组比较差异有统计学意义(P<0.05)。术后6-22个月,平均8.7个月拆除外同定架。结论高能量Pilon骨折应用细针半环形外围定架不超关节同定治疗可较好恢复踝关节功能,减少术后并发症的发生。

Objective To investigate the clinical effects of 2 types of external fixators in the treatment of pilon fractures. Methods From May 1998 to January 2010, 38 patients with pilon fractures were randomly divided into 2 groups. 21 patients treated with semicircle external fixator not exceeding the ankle joint were assigned into group A, including 16 males and 5 females, with an average age of 32.5 years old （range; 17-54 years）. According to Ovadia and Beals classification, there were 14 type IV cases and 7 type V cases. There were 6 patients with open fractures and 15 patients with closed fractures. Combined injuries including 3 cases of thoracolumbar vertebral fractures, 6 cases of pelvic fractures, 6 cases of foot and ankle injuries, 12 cases of craniocerebral injuries, and 5 cases were associated with injuries at other sites. 17 patients treated with ultra-articular fixation with external fixator were assigned into group B, including 14 males and 3 females, with an average age of 29,3 years old （range; 19-52 years）. According to Ovadia and Beals classification, there were 11 type IV cases and 6 type V cases. There were 4 patients with open fractures and 13 patients with closed fractures. Combined injuries including 1 case of upper limb fractures, 3 cases of lower limb fractures, 2 cases of craniocerebral injuries, and 4 cases were associated with injuries at other sites. All patients with open fractures were treated with surgical debridement and external fixation within 6-8 hours after injury. For patients with closed fractures, the operation could be performed within 8-12 hours following injury, when the patients were in good general condition. If not, the operation should be delayed for 7-10 days with calcaneal traction. The indexes were compared, such as tong-term complications, fracture healing time, radiographic assessment of fracture reduction, ankle joint function and so on. Results All patients were followed up for a mean period of 12.5 months （range; 6-18months）. The average fracture heeling time was 16.3±2.8 weeks in group A, and it was 18.5±3.9 weeks in group B. There ueren＇t statistically significant differences between them （P〉0.05）. According to Mazur evaluation criteria, the results of group A were excellent in 6 cases, good in 11 cases, fair in 3 cases and poor in 1 case, and the excellent and good rate was 80.9%; The results of group B were excellent in 3 cases, good in 7 cases, fair in 4 cases and poor 3 in cases, and the excellent and good rate was 58.8%. There were statistically significant differences between them （P〈0.05）. As to short-term complications, in group A there were 4 cases of skin sloughs and pin tract infection （19.0%）, comparing with 4 cases in group B （23.5%）, and there was no statistically significant difference between them. As to long-term complications, there were 6 cases of delayed bone union, nonunion, bone malunion or stiffness of the joint in group B （35.2%）, and there were significant differences between the 2 groups （P〈0.05）, The frame was removed 8.7 months after surgery on average （range; 6-22 months）. Conclusions The treatment with fine-needle semicircle external fixation not exceeding the ankle joint for high energy pilon fractures can better resume ankle joint function and reduce complications.