组合式外固定支架治疗胫骨远端骨折

Treatment of distal tibial fractures with a hybrid external skeletal fixator

目的探讨组合式外固定支架治疗胫骨远端骨折的疗效。方法回顾性分析2006年1月至2013年6月采用组合式外固定支架固定治疗的39例胫骨远端骨折患者资料，男26例，女13例；年龄23～65岁，平均40．1岁。骨折根据AO分型：A3型15例，B2型8例，B3型10例，C2型2例，c3型4例。开放性骨折12例，根据Gustilo分型：Ⅱ型8例，Ⅲa型3例，Ⅲb型1例。Tscherne软组织损伤分类：1级4例，2级24例，3级11例。开放性骨折先行彻底清创。合并腓骨骨折者先行切开复位内固定腓骨，然后复位胫骨远端骨折，视骨折类型辅以有限内固定和植骨，然后应用组合式外固定支架稳定骨折，其中超踝关节固定5例。记录受伤至手术时间、手术时间、失血量等情况；术后12个月根据Maryland评分评定踝关节功能。结果39例患者术后获12～18个月（平均14．5个月）随访，临床疗效满意。37例患者术后切口均一期愈合，2例开放性骨折患者伤口延迟愈合，经换药后4周愈合。38例骨折正常愈合，平均外固定支架固定时间为13．5周，x线片上骨折线完全融合时间平均为19．7周。1例患者发生骨折延迟愈合，去除外固定支架后使用锁定钢板内固定并自体骨植骨术后骨折愈合；1例患者并发针道感染，经扩创及保持针道引流通畅8周后去除外固定支架，钉道愈合。无神经、血管损伤并发症发生。术后12个月根据Maryand评分评定踝关节功能：优8例，良24例，可7例，优良率为82．1％。结论组合式外固定支架固定胫骨远端骨折，可有效保护皮肤软组织，减少对其剥离，降低皮肤坏死和伤口感染的发生；外固定支架可以灵活穿针与构型，便于对开放伤口的处理和照料，对于开放性骨折更为适合。

Objective To report the clinical results of managing distal tibial fractures with a hybrid external skeletal fixator. Methods From January 2006 to June 2013, 39 patients with distal tibia fracture were managed with limited-close or limited-open reduction and a hybrid external skeletal fixator. They were 26 men and 13 women, with an average age of 40. 1 years （range, from 23 to 65 years）. According to AO classi- fication, 15 fractures were of type A3, 8 of type B2, 10 of type B3, 2 of type C2 and 4 of type C3. According to Gustilo classification, of the 12 open fractures, 8 were of type lI, 3 of type Ill a and one of type ]lIb. According to Tscherne classification of soft tissue injury, 4 cases were of grade 1, 24 of grade 2, and 11 of grade 3. Open fractures were managed first with radical debridement. Those complicated with fibular fracture were managed first with open reduction and internal fixation of distal fibula followed by close or limited-open reduction and minimal internal fixation depending on the position of distal tibial fracture. Next, the hybrid external skeletal fixation was applied. Five cases were immobilized with trans-articular fixators. The data were recorded regarding interval from injury to surgery, operation time, perioperative blood loss, hospital stay, time of external fixation, time of bony union, and complications. The ankle function was evaluated clinically with the Maryland Scale system at the final follow-ups. Results The 39 patients were followed up for 12 to 18 months （average, 14.5 months）. Pri- mary incision healing was achieved in 37 cases, but the other 2 patients with open fracture suffered delayed wound healing which was cured by dressing changes for 4 weeks. Altogether, 38 cases achieved normal fracture union and their average time of external fixation was 13.5 weeks. The time for complete infusion of fracture lines on X-rays averaged 19.7 weeks. Delayed union occurred in one case whose fracture united after removal of the external fixator, internal fixation with a locking plate and autogenous bone grafting. One ease was complicated with pin track infection which was healed after debridement, drainage for 8 weeks and removal of the external fixator. No neurovascular complications were observed. According to the Maryland Scale system, the ankle function was excellent in 8 eases, good in 24 and fair in 7, with an excellent and good rate of 82. 1%. Conclusions The hybrid external skeletal fixator is good for distal tibial fractures, because it can effectively protect the skin and minimize invasion to the soft tissues, reducing incidences of skin necrosis and wound in- fection. Moreover, since it is flexible in screwing and structure formulation, it facilitates wound management, especially in the management of open fractures.