术前充分复位联合微创技术治疗极远端pilon骨折

Preoperative full reset combined with minimally invasive treatment of extreme distal pilon fractures

目的探讨术前采用充分复位联合微创技术治疗极远端pilon骨折的临床疗效。方法回顾性分析2011年1月-2015年1月手术治疗34例（35踝）胫骨极远端关节面附近pilon骨折患者的临床资料，其中男21例，女13例；年龄20～71岁，平均36．2岁。致伤原因：交通伤32例，高处坠落伤2例。AO/创伤骨科协会（OTA）分型：43-B33例，43-C15例，43-C218例，43-C38例。术前充分利用跟骨牵引结合手法复位矫正骨折移位，软组织肿胀消退后可单一或联合选择踝关节内侧、前内、前外侧微创接骨板固定术（MIPPO）入路，粉碎严重的塌陷关节面在定位直视下以距骨关节面作为模具、细克氏针（1—1．5mm）及细螺钉（2．1～2．7mm系列）固定稳定、软骨下骨下方打压植骨等方法修复，后再应用胫骨远端解剖型短小锁定接骨板多方位固定，远端排钉支撑，早期进行踝关节功能锻炼。术后采用Burwell—Charnley影像学评价标准评定关节面骨折复位质量，采用Teeny—Wiss评分系统评估踝关节临床症状和功能。记录术后并发症的发生情况。结果34例患者获随访11～38个月，平均16．6个月。无感染、切口不愈合、钢板外露等手术并发症。Burwell—Charnley影像学评价标准：解剖复位32例，不满意1例，差1例。Teeny—Wiss踝关节评分：优31例，良2例，差1例，优良率为97％。术后创伤性关节炎3例，口服止痛药物，疼痛明显缓解。结论通过术前充分复位矫正骨折移位、微创联合使用锁定钢板、远端排钉、打压植骨及有限固定骨折块稳定技术治疗胫骨极远端pilon骨折，复位满意，固定牢靠，可早期进行踝关节功能锻炼，临床疗效好。

Objective To investigate the clinical efficacy of preoperative full reset combined with minimally invasive treatment of extreme distal pilon fractures. Methods A retrospective analysis was made on 34 patients （35 ankles） with tibial fractures extremely close to the distal articular surface treated surgically between January 2011 and January 2015. There were 21 males and 13 females, aged 20- 71 years （ mean, 36.2 years）. Injury resulted from traffic accidents in 32 patients and high falls in two. Using the AO/OTA fracture classification system, type 43-B3 was noted in three patients, 43-C1 in five patients, 43-C2 in 18 patients and 43-C3 in eight patients. Calcaneal traction combined with manipulative reduction was used to correct fracture displacement preoperatively. All fractures were stabilized by minimally invasive percutaneous plate osteosynthesis （MIPPO） through single or combined medial, anteromedial and anterolateral approaches while minimizing damage to bone attachment and continuity of soft tissue, after soft tissue swelling subsided. For the patients with articular surface collapsing with severe comminution, a series of procedures were done under direct vision including using the talus articular surface as a mold, stable fixation with fine Kirschner （1-1.5 mm） and thin screws （2. 1-2.7 mm series） and impaction bone grafting below subchondral bone. Thereafter, distal tibia anatomical short multi-directional locking plate fixation, distal nail support and early ankle joint functional exercise were done. Burwell-Charnley radiological evaluation system was used for radiological assessment, and Teeny- Wiss scoring system for ankle clinical symptoms and function. Postoperative complications were recorded. Results Follow-up lasted for 11-38 months （mean, 16.6 months）. No infection, wound disunion, or plate exposure occurred. Burwell-Charnley radiological evaluation system showed anatomic reduction in 32 patients, unsatisfactory reduction in one, and poor reduction in one. According to the Teeny-Wiss scoring system, the results were excellent in 31 patients, good in two and poor in one, with the excellent- good rate of 97%. Three patients suffered traumatic arthritis after operation and alleviated after oral administration of painkiller. Conclusion With use of full reset combined with manipulative reduction to correct fracture displacement, minimally invasive locking plate, distal row of nails, impaction bone grafting and limited fixation, the patients with extremely distal tibial pilon fractures achieve satisfactory reduction, stable fixation, and early functional exercise.