联合入路双钢板固定治疗陈旧性Schatzker Ⅳ型胫骨平台骨折

Double plate fixation via combined approaches for the treatment of old tibial plateau fractures of Schatzker type Ⅳ

目的:探讨膝前正中联合内后纵行入路双锁定钢板固定治疗陈旧性SchatzkerⅣ型胫骨平台骨折的临床疗效。方法:自2013年7月至2015年7月,采用膝前正中联合内后侧纵行手术入路、重建锁定钢板固定后内侧骨块及解剖锁定钢板固定内前侧骨块治疗15例陈旧性胫骨平台骨折患者,男9例,女6例;年龄21~61岁,平均49.2岁;左侧8例,右侧7例。均为SchatzkerⅣ型。受伤至手术时间21~65 d,平均26.5 d。术前主要症状体征为膝关节肿胀、疼痛、畸形及活动受限,X线及CT检查确定骨折类型。通过X线片比较术后即刻及末次随访胫骨平台内翻角、股胫角及后倾角等形态学变化,采用美国特种外科医院(Hospital for Special Surgery,HSS)膝关节评分评价临床疗效。结果:术后2例发生切口并发症,经处理愈合;1例继发创伤性关节炎。15例患者均获随访,时间13~24个月,平均16.6个月。无感染、下肢深静脉血栓、内固定松动断裂、骨折再移位及关节面塌陷等并发症发生。骨折愈合时间3~8个月,平均6.07个月。胫骨平台内翻角、股胫角及后倾角,术后即刻分别为(86.81±1.67)°、(168.00±3.29)°及(10.20±1.47)°,末次随访分别为(86.47±1.67)°、(168.53±3.03)°及(10.54±1.21)°,差异无统计学意义(P>0.05);HSS膝关节评分:疼痛26.33±3.86,功能20.00±1.79,活动度16.00±1.55,肌力8.67±0.94,屈曲畸形8.53±1.67,稳定性9.33±0.94,总分88.86±8.92;优10例,良4例,中1例。结论:膝前正中联合后内侧入路、双锁定钢板固定治疗陈旧性SchatzkerⅣ型胫骨平台骨折,具有显露充分、复位固定可靠及便于膝关节早期功能锻炼等优点,术后近期疗效满意。

Objective：To explore the clinical efficacy of double plate fixation for the treatment of old tibial plateau fractures with Schatzker type Ⅳ through anterior midline and posteromedial approaches. Methods：From July 2013 to July2015,15 patients with old tibial plateau fractures were treated with internal fixation using locking reconstructive plate for the posteromedial fragment and anatomical locking plate for anteromedial fragment through antero midline and posteromedial approaches. There were 9 males and 6 females,with an average age of 49.2 years old（ranged,21 to 61 years old）. Eight patients had injured in the left side and 7 in the right side. According to Schatzker classification,all patients were type Ⅳ. The mean interval from injury to operation was 26.5 days（ranged,21 to 65 days）. The main clinical symptoms before operation were knee joint swelling,pain,deformity and limitation of motion. The X ray and CT confirmed the fracture type. The indexes such as tibial plateau tibial shaft angle（TPA）,femoral tibial angle（FTA） and posterior slope angle（PSA） were compared between immediate postoperation and final follow up using postoperative X ray film. The knee functions were evaluated using the HSS（Hospital for Special Surgery） knee score system. Results：Two patients had incision complications which healed by correct treatment,1 patient had traumatic arthritis. All patients were followed up for mean 16.6 months（ranged,13 to 24 months）. No infections,deep venous thrombosis,implant loosening and breakage,fragment displacement,plateau surface collapse and bone nonunion found. The bone union time ranged from 3 to 8 months（mean 6.07 months） after operation. The average immediate postoperative value of TPA,FTA and PSA were（86.81±1.67）°,（168.00±3.29）° and（10.20±1.47）° respectively; and（86.47±1.67）°,（168.53±3.03）° and（10.54±1.21）° respectively at the final follow up evaluation,showing no statistical differences（P〈0.05）. According to the HSS score system,26.33±3.86 in pain,20.00±1.79 in function,16.00±1.55 in range of motion,8.67±0.94 in muscle strength,8.53±1.67 in flexion deformity,9.33±0.94 in joint stability,and the total mean score was 88.86±8.92.The outcomes were excellent in 10 cases,good in 4,and fair in 1. Conclusion：Double plate fixation via combined anterior midline and posteromedial approaches is an ideal surgical method for old tibial plateau fractures with Schatzker Ⅳ type,showing satisfactory exposure,reliable reduction and fixation,and benefiting for early functional exercise. The short term clinical results was satisfactory.