后内侧倒“L”形切口联合前外侧切口治疗复杂胫骨平台骨折

Treatment of complex tibial plateau fractures with multiplates through two combined approaches

目的探讨后内侧倒“L”形切口联合前外侧切口治疗复杂胫骨平台骨折的疗效。方法回顾性分析2007年7月至2013年7月采用后内侧倒“L”形切口联合前外侧切口治疗并完整随访的75例复杂胫骨平台骨折患者资料，男53例，女22例；平均年龄46．5岁。骨折Schatzker分型：Ⅲ型10例，Ⅳ型14例，Ⅴ型15例，Ⅵ型36例；内侧柱＋后柱5例，外侧柱＋后柱9例，三柱61例。术后即刻、3个月和1年在X线片上测量胫骨平台内翻角（TPA）和胫骨平台后倾角（PA），以评估内固定情况；末次随访时测量患者的膝关节屈曲和伸直角度，并采用美国特种外科医院（HSS）膝关节评分和健康调查简表（SF-36）评分评估患者膝关节功能恢复和健康状况。结果75例患者术后获12．4～83．8个月（平均48．4个月）随访。骨折愈合时间平均15．4周，完全负重时间平均13．5周。末次随访时患者屈曲平均125．0°，伸直平均2．8°，HSS评分平均95．8分，SF-36评分平均93．9分。术后即刻、术后3个月TPA和PA与术后1年比较差异无统计学意义（P〉0．05）。1例患者术中腘动脉破裂，1例患者腓肠肌营养血管断裂，1例患者术后倒“L”形切口远端皮肤麻木；1例患者前外侧切口深部感染，总并发症发生率为5．3％（4／75）。结论后内侧倒“L”形切口联合前外侧切口治疗复杂胫骨平台骨折提供了充分的手术视野和持续稳固有效的内固定，并发症少，关节功能满意。

Objective To evaluate the outcomes after open reduction and internal fixation of complex fibial plateau fractures with muhiplates through the posterior reversed L-shaped approach combined with the traditional anterolateral approach. Methods From July 2007 to July 2013, 75 comminuted fractures of tibial plateau were treated with multiplates through the above two incisions and available for complete follow-up. They were 53 males and 22 females, with a mean age of 46.5 years. By Schazker classification, 10 cases were type Ⅲ, 14 type Ⅳ, 15 type Ⅴ, and 36 type Ⅵ; by ＂three-column＂ concept, 5 cases were fractures of medial column plus posterior column, 9 fractures of lateral column plus posterior column, and 61 fractures of three columns. The internal fixation was assessed by measuring the tibial plateau angle （TPA） and posterior slope angle （PA） on the X-ray films at immediate postoperation, 3 months and one year after operation. At the final follow-ups, the knee flexion and extension were measured and the health status and functional recovery of the knee assessed using the Hospital for Special Surgery （HSS） score and the Short Form-36 （SF-36） in all the patients. Results The 75 patients were followed up for an average duration of 48.4 months （range, from 12.4 to 83.8 months）. On average, the fractures healed after 15.4 weeks, and full weight-bearing was achieved after 13.5 weeks. At the last follow-ups, the knee flexion achieved 125.0° and the extension 2.8°; the HSS scores averaged 95.8 points and SF-36 93.9 points at one year follow-ups. Comparisons concerning TPA and PA between immediate postoperation, 3 weeks and one year after operation showed no significant differences （ P 〉 0. 05）. Rupture of the popliteal artery occurred in one, the nutrient vessel of the gastrocnemius muscle was cut in one during the operation, skin anaesthesia appeared at the distal posterior reversed L-shaped incision postoperatively, and deep infection was observed at the site of anterolateral incision in one. The total rate of complications was 5.3% （4/75） . Conclusion The treatment of complex tibial plateau fractures with mutliplates through the posterior reversed L-shaped approach combined with the traditional anterolateral approach can result in good exposure, stable fixation, a low complication rate and satisfying knee function.