联合入路手术治疗复杂胫骨平台骨折

Combined surgical approaches in the treatment of complex tibial plateau fractures

目的:探讨后内侧倒"L"形辅助前外侧联合入路手术治疗复杂胫骨平台骨折的早期临床疗效。方法:自2011年3月至2014年6月,采用后内侧倒"L"形辅助前外侧联合入路手术治疗SchatzkerⅣ、Ⅴ、Ⅵ型胫骨平台骨折34例,其中男23例,女11例;年龄18~67岁,平均34.9岁;左侧19例,右侧15例。按Schatzker分型:Ⅳ型11例,Ⅴ型15例,Ⅵ型8例。按三柱分型:双柱骨折23例,三柱骨折11例。记录X线愈合时间、膝关节活动度,测量并记录患者术后即刻、6、12个月胫骨平台内翻角(TPA)及后倾角(PA),术后3、6、12个月采用美国特种外科医院评分系统(HSS)评定膝关节功能。结果:28例患者获得随访,时间8~39个月,平均(21.6±8.7)个月。骨折全部愈合,X线愈合时间12~24周,平均(14.5±3.6)周;膝关节活动度105°~135°,平均(121.5±5.5)°。术后即刻、6、12个月胫骨平台内翻角分别为(84.3±1.8)°,(85.1±1.3)°和(85.6±1.6)°;后倾角分别为(7.8±1.6)°,(7.8±1.3)°和(7.7±2.3)°;术后即刻、6、12个月胫骨平台内翻角及后倾角比较差异均无统计学意义。术后3、6、12个月HSS膝关节功能评分为71.4±1.4,76.7±1.7和81.6±1.2;术后3、6、12个月HSS膝关节功能评分比较差异均无统计学意义。1例早期膝关节僵硬,经积极功能锻炼,术后1年膝关节伸直受限范围6°;1例术后前外侧伤口裂开,经换药后愈合,未发生深部感染;4例天气变化时出现疼痛。末次随访,无膝关节不稳、膝关节外翻、内固定松动及断裂发生。结论:后内侧倒"L"形辅助前外侧联合入路手术治疗复杂胫骨平台骨折,能够充分显露手术区域,直视下精准复位骨折,同时对塌陷平台进行足量植骨,从而恢复了关节面的平整性,固定牢靠,利于早期功能锻炼,并发症少,临床疗效满意。

Objective ：To explore the early clinical efficacy of a posteromedial inverted ＂L＂shape approach combined an assisted antero lateral assisted approach for the treatment of complex fractures of tibial plateau. Methods： From March 2011 to June 2014 ,the posteromedial inverted ＂L＂shape approach combined with the antero lateral assisted approach in the treatment of Schatzker type Ⅳ, Ⅴ , Ⅵ tibial plateau fracture were performed in 34 cases. There were 23 males and 11 females ,ranging in age from 18 to 67 years old, averaged 34.9 years old; 19 patients had fractures on the left and 15 patients had fractures on the right. According to Schatzker classification, 11 cases of type Ⅳ, 15 cases of type Ⅴ and 8 cases of type Ⅵ. According to the three column classification, 23 cases of double column fractures, 11 cases of three column fractures. The X-ray healing time and knee joint mobility were recorded. The mean tibia1 plateau angle （TPA） and the mean posterior slope angle （PA） were measured and recorded immediately after operation,6 and 12 months after operation. The knee function was evaluated using the Hospital for Special Surgery Score （HSS） 3,6 and 12 months after operation. Results： Among all the patients, 28 patients were followed up ,and the duration time ranged from 8 to 39 months with a mean of （21.6±8.7） months. All the fractures were healed. The healing time in terms of X-ray ranged from 12 to 24 weeks,with a mean of （14.5±3.6） weeks. The range of knee activity ranged from 105° to 135° ,with a mean of （ 121.5±5.5 ）°. Immediately after operation, 6 and 12 months after operation, the mean tibial plateau angle （TPA） was （84.3±1.8）°, （85.1±1.3）°, （85.6±1.6）°,and the mean posterior slope angle （PA） was （7.8± 1.6）°, （7.8± 1.3 ）°, （7.7±2.3）°, respectively, showing no significant difference between the 3 time points. The mean HSS score at 3,6 and 12 months after operation was 71.4±1.4,76.7±1.7,81.6±1.2 respectively, showing no significant differences between the 3 time points. One patient with early knee joint stiffness had 6° of the restricted straight range after the active functional exercise, 1 year after operation. Anterolateral wound dehiscence occurred in 1 cases but was cured by dressing without deep wound infection occurred. The pain occurred in 4 cases when the weather changed. At the end of follow-up,no case of knee joint instability, knee valgus, loosening or breakage occurred. Conclusion：The posteromedial inverted ＂L＂shape approach combined assisted anterior lateral approach for the treatment of complex fractures of tibial plateau can expose the operation area, repair the fracture under the direct vision, and implant a full amount of bone graft for the collapse of the platform. Thus, the smoothness of the articular surface is restored, and the fixation is firm, which is beneficial to the early functional exercise, less complications, and satisfactory clinical curative effects.