半患侧卧位前后联合切口治疗复杂胫骨平台骨折

Combined approaches with a semilateral position for complex tibial plateau fracture

目的 探讨半患侧卧位前后联合切口治疗复杂胫骨平台骨折的手术适应证、手术技巧及其疗效.方法 2011年4月至2013年6月,采用固定的半患侧卧位前外侧切口联合后内侧倒“L”型切口多钢板固定治疗复杂胫骨平台骨折25例,男15例,女10例;年龄30～70岁,平均49.7岁.车祸伤21例,骑车摔伤4例.均为闭合性三柱骨折,Schatzker骨折分型均为Ⅵ型.受伤至手术时间为5～21 d,平均9.5 d.通过后内侧倒“L”型切口处理后髁及内侧髁骨折,以解剖型锁定钢板及斜“T”型钢板固定;自前外侧切口处理前外侧髁骨折,以解剖型锁定钢板固定.结果 手术时间150～250 min,平均197.6 min;术中出血量150～300 ml,平均232 ml.25例患者均获得随访,随访时间12～24个月,平均17.8个月.骨折愈合时间为16～24周,平均19周.末次随访X线片均示关节面平整,膝关节无明显内、外翻畸形.术后1年膝关节活动度屈曲100°～130°,平均115.2°;伸直均可达到0°.术后Rasmussen胫骨平台骨折复位放射学评分14～18分,平均16.6分;优11例,良14例.术后1年KSS膝关节功能评分66～96分,平均88.6分,优良率为96％（24/25）.2例患者术后出现前外侧切口脂肪液化、切口裂开,局部皮缘坏死,经清创换药,二期缝合后顺利愈合.结论 多钢板固定治疗复杂胫骨平台骨折有效、安全,通过固定的半患侧卧位可以完成手术,能够允许膝关节进行早期功能锻炼,术后疗效满意,膝关节功能恢复好.

Objective To explore the operation indication feasibility,operation technique and clinical effect of complex tibial plateau fractures with semilateral position through combined approaches.Methods From April 2011 to June 2013,data of 25 patients with complex tibial plateau fractures who were treated by open reduction and interal fixation with semilateral position through anterior lateral incision and an inverse L shaped incision were retrospectively analyzed.There were 15 males and 10 females,with an average age of 49.7 years old （range,30 to 70 years old）.21 cases were traffic accident injuris and 4 cases were hurt by falling injuries from bicycle.All of the fracture patterns were three pillars of closed fracture of type Ⅵ according to Schatzker classification.The time at surgery was 5-21 days （mean,9.5 days） after injuries.The posterior condylar and medial condylar fractures were dealt with inverse L shaped incision,and fixated with anatomical locking plate and T shaped plate.The lateral condyle fractures were dealt with anterior lateral incision,and fixated with anatomical locking plate.Results Operating time was 150-250 min with an average time of 197.6 min.Intraoperative blood loss was 150-300 ml with an average of 232 ml.25 patients were followed-up,and the average duration of follow-up was 17.8 months （range,12-24 months）.Fracture healing time was 16-24 weeks with an average of 19 weeks.At the time of the latest follow-up,X-ray showed all the knee joint had smooth surface,and there was no obvious varus or valgus deformity.One year later,the flexion of the knees achieved 115.2° （range,100°-130°）,and the straighten reached 0°.The mean Rasmussen＇s score of all the patients were 14-18 （average,16.6）,and there were excellent in 11 cases and good in 14.Bassed on the KSS score,the mean score was 88.6 （range,66-96） one year after operation.The excellent and good rate was 96% （24/25）.2 patients had fat liquefaction of anterolateral incision wound dehiscence,local skin necrosis,and they got good outcomes after debridement dressing and secondary suture.Conclusion Multi plate fixation is more effective and safty treatment for complex tibial plateau fractures which can be operated completely through fixed half lateral position,and the knee joint is allowed to do early functional exercise,achieving good clinical efficacy and good knee function.