围关节线钢板治疗伸直内翻型胫骨平台骨折

Internal fixation for tibial plateau fractures involving anteromedial margin caused by hyperextension varus injury

目的探讨采用围关节线钢板治疗累及前内侧皮质骨的伸直内翻型胫骨平台骨折的临床疗效。方法回顾性分析2013年12月至2015年12月期间收治的11例累及前内侧皮质骨的伸直内翻型胫骨平台骨折患者资料。男6例，女5例；年龄19～65岁，平均42．3岁；单纯内侧柱骨折2例，内侧柱＋外侧柱骨折4例，内侧柱＋后侧柱骨折3例，三柱骨折2例。术中均采用自行裁剪制成的围关节线钢板固定前内侧皮质骨骨折。术中依据骨质缺损状况行植骨术。结果9例患者术后获12～30个月（平均17．6个月）随访，骨折均愈合。X线愈合时间平均为11．4周（9～14周），完全负重时间平均为16．1周（14—19周）。术后即刻Rasmussen评分平均为16．9分（14—18分），术后12个月膝关节HSS评分平均为89．1分（75—94分），优良率为92．3％。术后12个月膝关节活动度平均为2．3°～125．1°。所有患者术后即刻、术后12个月的胫骨平台内翻角及内侧平台后倾角分别与术前比较差异均有统计学意义（P〈0．05）；而所有患者术后12个月胫骨平台内翻角及内侧平台后倾角与术后即刻比较差异均无统计学意义（P〉0．05）。术后1例患者发生切口皮缘部分坏死，经伤口换药治疗后痊愈。1例患者术前即合并腓总神经损伤，足背感觉减退，给予营养神经药物治疗后康复。无螺钉松动、断裂及内固定失败等并发症发生。结论伸直内翻型胫骨平台骨折治疗复杂，灵活应用围关节线钢板可有效固定胫骨平台前内侧关节缘的骨折块，临床疗效满意。

Objective To report the operative procedures and clinical outcomes of open reduction and internal fixation for the treatment of tibial plateau fractures involving anteromedial margin caused by hyperextension varus injury. Methods From December 2013 to December 2015, 11 patients with tibial plateau fracture involving anteromedial margin caused by hyperextension varus injury were treated at our department. They were 6 males and 5 females with a mean age of 42. 3 years （range, from 19 to 65 years） . Simple medial column fracture happened in 2, fractures of medial and lateral columns in 4, fractures of medial and posterior columns in 3, and 3-column fractures in 2 cases. The cortical bone fractures of anteromedial margin were fixated by open reduction and internal fixation using self-clipped joint line plating. Bone grafting was conducted if necessary. Results The 9 patients were followed up for an average of 17.6 months （range, from 12 to 30 months） . All the fractures healed. The average time for radiographic bony union and full weight bearing was 11.4 weeks （range, from 9 to 14 weeks） and 16. 1 weeks （range, from 14 to 19 weeks）, respectively. On average, the Rasmussen＇s radiological grading scored 16.9 （range, from 14 to 18） immediately after operation; the Hospital for Special Surgery scores of all the patients at 12 months postoperatively averaged 89. 1 （range, from 75 to 94）, yielding an excellent to good rate of 92.3%. The average range of motion of the affected knee was from 2. 3° to 125.1°. There were significant differences in both tibial plateau angle and posterior slope angle on radiography between preoperation and postoperation （ P 〈 0. 05）. There were no significant differences in either tibial plateau angle or posterior slope angle on radiography between immediate postoperation and 12 months postoperation （P 〉 0. 05） . Partial incision necrosis occurred postoperatively in one case which was uneventfully healed after wound management. One case complicated with preoperative common peroneal nerve injury reported dorsal sense of numbness which was healed after administration of neurotrophic drugs. No screw loosening, plate breakage or fixation failure was found during follow-ups. Conclusions It is difficult to treat the tibial plateau fractures involving anteromedial margin caused by hyperextension varus injury. Internal fixation with joint line plating is an appropriate treatment for this fracture pattern, leading to satisfactory clinical outcomes.