闭合性胫骨平台骨折合并腘动脉损伤的手术疗效分析

Surgical analysis of closed popliteal artery injury associated with fracture of tibial plateau

目的 探讨闭合性胫骨平台骨折合并腘动脉损伤的手术疗效。方法 回顾分析2005年1月-2014年12月收治且获得随访的68例闭合性胫骨平台骨折合并腘动脉损伤患者资料,男52例,女16例,胫骨平台骨折按Schatzker分型：Ⅳ型13例,V型32例,Ⅵ型23例。腘动脉损伤程度分级：完全断裂10例,部分断裂36例,外膜完整内膜损伤22例。受伤至手术时机：受伤6小时以内实施手术49例,受伤6-24小时实施手术11例,受伤48-96小时实施手术8例。末次随访根据Rasmussen膝关节功能评分标准进行评价。结果 49例6小时以内行血管探查修复并骨折复位固定的患者中,38例血液循环稳定,8例出现迟发性肌肉坏死,经多次清创,创面愈合,3例出现静脉危象,保肢无效。19例6小时以后实施手术的患者中,5例血液循环稳定,5例小腿肌肉部分坏死,经清创、换药、二期植皮后创面愈合;9例术后36-48小时出现血循环障碍,经急诊探查,其中1例患者好转,其余8例患者术后循环未改善,后出现大量肌肉坏死高热、肾衰,最后行高位截肢。根据Rasmussen膝关节功能评价标准：优20例,良26例,可9例,差13例,优良率67.6%。按照膝关节功能评分,手术时机、固定方式以及是否预防减压均有统计学意义。结论 闭合性胫骨平台骨折伴腘动脉损伤患者早期诊断并在6小时内实施手术是保肢成功的关键,外固定架固定及预防性小腿筋膜室切开减压可减少肌肉坏死和感染的发生,降低并发症,改善预后。

Objective To explore the the surgical efficacy of closed fractures of the tibial plateau associated with popliteal artery injury. Methods From Jan 2005 to Dec 2014,68 cases in patients by followed up with closed fibial plateau fracture with popliteal artery injury were analyzed retrospectively at our department. They were 52 male and 16 female. According to Schatzker type, there were 13 cases of Schatzker Ⅳ, 32 ones of Schatzker Ⅴ, and 23 ones of Schatzker Ⅵ. The grade ofpopliteal artery injury, there were 10 cases of complete rupture, 36 cases of partial rupture in them, and 22 cases with intimal membrane injury. According to the time span from the injury to the surgery, there were 49 cases with operation in 6 hours, 11 cases with operation in 6 to 24 hours, and 8 cases with operation in 48 to 96 hours. The knee function was evaluated by the Rasmussen scoring criteria at the last follow-up. Results 49 cases supplied the reduction with fracture and popliteal artery in 6 hours, 38 ones of which had steady blood circulation. 8 cases showed delayed muscle necrosis, which were healed after repeated debridement. Venous crisis occurred in 3 cases and limb salvage were invalid. 19 cases of patients with operation after 6 hours, 5 cases had steady blood circulation, part of the calf muscles necrosis in 5 cases, the wound healed after debridement, dressing change and skin grafting. 9 cases 36 to 48 hours, because of crisis blood-circulation disorder, the circulation did not improved.one patient improved after the emergency exploratory, the remaining 8 cases of patients with postoperative circulation did not improved, after the emergence of a large number of high fever of muscle necrosis, renal failure, the thigh was amputated at the last. According to Rasmussen evaluation criteria, the result was excellent in 20 cases, good in 26cases, fair in 5 cases, and bad in 13, with the excellent-to-good rate of 67.6%. In accordance with the knee function score, the timing of the operation, the fixed way and whether the prevention of decompression have statistical significance. Conclusion Tibial plateau fracture with popliteal artery injury in patients with early diagnosis and within 6 hours after operation is the key to the success of limb salvage, the outside fixed frame fixed and prevention of leg compartment open decompression can reduce the incidence of muscle necrosis and infection, reduce complications and improve the prognosis.