基于四柱理论指导治疗Pilon内侧柱骨折的疗效及预后评价

The Clinical Efficacy and Prognostic Evaluation of Locking Compression Plate in the Treatment of Pilon Medial Column Fracture Based on Four-column Theory

目的探讨基于四柱理论指导锁定接骨板Pilon内侧柱骨折治疗的临床疗效以及预后评价。方法回顾性分析自2013年4月至2015年4月由大连医科大学附属第一医院创伤骨科收治的27例应用胫骨远端内侧加压锁定接骨板治疗的Pilon内侧柱患者,男性20例,女性7例,年龄16-78岁,平均年龄47.80岁;其中左侧12侧,右侧17侧,双侧2例。按照AO/OTA分型,43B2型14侧,43C1型7侧,43C2型3侧,43C3型5侧。按照Ruedi-Allgower分型,I型7侧,Ⅱ型13侧,Ⅲ型9侧。按照Pilon骨折的四柱理论分型均为累及内侧柱的骨折。其中闭合性骨折24侧,开放性骨折中GustiloⅡ型4侧,GustiloⅢc型1侧。26侧经胫骨远端内侧切口行复位内固定术,3侧行闭合复位外固定术。术后3d进行无负重下的膝关节功能训练,2周时在指导下行踝关节的背伸跖屈训练。术后分别采用Burwell-Charnley影像学评估标准,美国足踝外科医师协会踝-后足评分系统及Tornetta Pilon骨折临床治疗评价系统对骨折固定复位的情况以及临床疗效进行评价。结果平均手术时间（90.52±12.75）min,术中平均出血量（77.25±3.27）mL,平均住院时间（8.32±1.28）d。所有27例患者均获得随访,随访时间5.2个月（1-7个月）。术后出现切口感染1例,经积极清创以及抗感染治疗1周后切口愈合。其余病例未出现化脓、深静脉血栓、皮肤坏死、骨折延迟愈合或者不愈合及骨髓炎等并发症。Burwell-Charnley的影像学评估标准：复位优良率达到89.6%（26/29）;术后随访美国足踝外科医师协会（American orthopaedic foot and ankle society,AOFAS）踝-后足评分平均为80.43分（68-92分）;Pilon骨折临床治疗结果的优良率为86.20%（25/29）。结论对于累及胫骨远端内侧柱的Pilon骨折,依据四柱理论制定理想的手术策略,可有效地减少软组织损伤,降低术后并发症,获得良好的临床疗效及预后评价。

Objective To discuss the clinical efficacy and prognostic evaluation of locking compression plate in the treatment of Pilon medial column fracture with the guidance from four-column theory.Methods We retrospectively analyzed 27 cases of patients from April 2013 to April 2015 with the admittance to the department of Orthopedic Trauma in the first affiliated hospital of Dalian Medical University,diagnosed as Pilon medial column fracture and underwent surgical therapies by locking compression plate（LCP）,aging from 16 to 78,47.80 on average.There were 20 male cases and 7female cases.12 sides were on the left side,17 sides were on the right side,2 cases were on both side.According to AO/OTA classification,there were 14 sides of type 43B2,7sides of type 43C1,3sides of type 43C2,5sides of type 43 C 3.On the basis of Ruedi-Allgower classification,there were 7 sides of Type I,13 sides of TypeⅡ,9 sides of TypeⅢ.Medial columns of all cases were interfered based on four-column theory.24 sides were close fractures,while 5 sides were open injuries.4 sides were classified to GustiloⅡ,1side GustiloⅢc.26 sides were treated by open reduction internal fixation through distal tibial medial approach and 3 sides by close reduction external fixation by LCP.Patients were required for knee joint functional practice with non-weight bearing in post-operative 3 days,ankle joint of extension and flexion practice in post-operative 2 weeks.Its clinical efficacy was respectively assessed on the basis of Burwell-Charnley radiograhic standard,Hind-foot and ankle scoring system by AOFAS and Tornetta clinical evaluation standard.Results The operative time was（90.52±12.75）min,mean intra-operative blood loss was（77.25±3.27）mL and mean length of stay was（8.32±1.28）d.All cases had been followed up from 1to 7months.Incision infection occurred in 1 cases after operation,the wound healed 1 weeks after debridements and antibiotic therapies.There was no complications for therest cases shown as incision infection,suppuration,deep vein thrombosis,peripheral soft tissue necrosis,delayed union/union or osteomyelitis.The excellence rate of reduction was 89.60%（26/29）.Post-operative follow-up indicated that ankle joint evaluated by AOFAS ankle-posterior foot scoring system scored from 68 to 92.The clinical excellence rate of Pilon fractures was 86.20%（25/29）.Conclusion As for Pilon fractures with medial column interfered,it can reduce soft tissue injuries and lower the incidence of postoperative complications to obtained an expected clinical curative effect and prognostic evaluation under the guidance from four-column theory to conceive a suitable surgical strategy.