联合入路多钢板固定治疗Rüedi-AllgowerⅡ、Ⅲ型Pilon骨折

Combined approach of the internal fixation plates in Rüedi-AllgowerⅡ、Ⅲ Pilon fractures

目的探讨治疗Rfiedi-AllgowerⅡ、Ⅲ型Pilon骨折的入路选择及钢板固定方式。方法回顾性分析2010年1月～2015年12月采用联合入路多钢板固定治疗32例Riiedi-AllgowerⅡ、Ⅲ型Pilon骨折并获得随访的患者资料，其中骨折分类Riiedi-AllgowerII18例，Ⅲ型14例。根据患者术前CT选择前内侧＋后外侧联合入路手术14例，改良前内侧入路＋后外侧入路手术15例，后内侧＋前外侧入路手术3例。固定方式采用3．5mm有限接触动力加压钢板＋腓骨解剖钢板固定8例，3．5mm锁定加压钢板＋腓骨解剖钢板固定10例，3．5mm锁定加压钢板＋桡骨远端T板＋腓骨解剖钢板固定10例，一期外固定＋二期多钢板固定4例。手术方式分为急诊手术和二期延迟手术。二期延迟手术时间为7～18天，平均10天。采用美国足踝外科协会（American Orthopaedics Foot and Ankle Society,AOFAS）踝与后足的主观评分标准评价踝关节功能及疼痛视觉模拟评分（VAS）评价疼痛情况。结果32例患者手术时间120～180分钟，平均150分钟；术后3例患者前内侧切口发生皮肤坏死伤口延迟愈合，其中1例术后发生感染皮肤坏死后再次清创行股前外侧穿支皮瓣修复创面。其余切口愈合时间14～17天。32例患者例患者术后获12～16个月（平均14个月）随访。末次随访时，骨折均愈合，愈合时间18-26周，平均20.3周；其中3例因高龄、营养状况差，原始骨折块粉碎移位严重而发生延迟愈合，经延长下地负重时间后，分别于术后22、24、25周获得骨性愈合；8例1年后踝关节x线片示创伤性骨关节炎，其中4例较长距离行走后出现踝关节明显疼痛口服塞来昔布及双醋瑞因后症状缓解。末次随访时AOFAS评分为50～93分，平均（78．15±2.31）分，VAS评分为0-6分，平均3．5分。优良率为70％。结论治疗Rtiedi．AllgowerⅡ、Ⅲ型Pilon骨折时，正确的入路选择及坚强的内固定是影响Pilon骨折疗效的关键因素，允许患者早期功能锻炼，尽快恢复踝关节功能。

Objective To study the choice of approach and the menthed of Plate fixed for treatment of Riiedi-Allgower Ⅱ, Ⅲ Pilon fractures. Methods From Jan 2010 to Dec 2015, data of 32 patients of Riiedi-Allgower Ⅱ, Ⅲ pilon fractures treated by the the internal fixation plates through combined approach were retrospectively analyzed. The treatment of Rii edi-Allgower Ⅱ, Ⅲ Pilon fractures through anterior and posterior approach have 14 cases; improved anterior and posterior approach 15 cases; posteromedial and anterolateral approach 3cases. The fixed way through 3.Smm LC-DCP and fibular anatomical plate have 8 cases; 3.5mm LCP and fibular anatomical plate 10cases. 3.5mm LCP and fibular anatomical plate and distal radius T-plate 10cases. Surgical procedure is divided into emergency surgery and delayed surgery.patients under- went surgery about 7 to 18d （average, 10d） after injury. The clinical results were evaluated by the American Orthopaedics Foot and Ankle Society （AOFAS） and visual analogue scale （VAS）. Results The average operation duration was 150 min （range, 120 to 180 min）. After surgery, 3 patients had delayed healing .one case occured skin necrosis was headed by debride and anteriolateral thigh perforator flap. wound healing time of the rest cases were 12 to 14 d. All the patients were followed up for 12 to 16 months （average, 14 months） Bone union was obtained in all patients, and the bone union time ranged from 18 to 26 weeks （average, 20.3 weeks.） 3 patients due to advanced age and poor nutritional status and severe lumps displacement fracture had delayed healing. And these 3 patients finally acquired bone union by prolonging the time of weight-bearing activity. The bone union time was 22, 24, 25weeks. There was no varusor valgus malunion. X-ray showed 8 patients suffered from traumatic arthritis. 4 cases suffered from ankle pain after walking for a long distance sufferedfrom ankle significant pain got better by using cel- ecoxib and diacerein drugs. No deep infection oc- curred. The AOFAS score were 50 to 93 points （average, 78.15±2.31 point）, The average VAS pain score was 0 to 6 points （average, 3.5 point）, The good rate was 70 %. Coneluslon The right choice of approach and stable fixation were the key factors for treatment of Ruedi-All- gower Ⅱ, Ⅲ Pilon fractures, allow patients with early functional exercise, and to restore the ankle function as soon as possible.