胫骨平台后外侧骨折入路及手术策略进展

Advancements in surgical approaches and strategies for posterolateral tibial plateau fracture

胫骨后外侧平台骨折是目前创伤骨科治疗难点和热点之一。因腓骨小头遮挡,后外角韧带复合体、邻近腓总神经和腘血管限制使得该部位骨折难以显露和固定。入路选择和治疗方法存在很大争议。因此,需要熟悉治疗此类骨折的手术入路及其特点。临床关注的入路主要包括:改良的前外侧入路(Gerdy结节截骨,腓骨头截骨,股二头肌腓骨头截骨,股骨外上髁截骨),后外侧入路(Carlson后外侧入路,经腓骨颈截骨及腓骨小头上)及后内侧入路。胫骨后外侧平台骨折入路需要考虑骨折类型、其他象限受累情况、局部软组织条件及所用内固定进行确定。需要考虑体位、骨折形态、内固定生物力学稳定性对治疗的影响。根据文献报道提出累及后外象限的胫骨平台骨折入路选择和内固定流程。

Posterolateral tibial plateau fractures are a unique challenge and hot issue of current orthopedic trauma. Due to the fibular head block and confinement of adjacent important structures, such as posterolateral corner complex, common peroneal nerve and popliteal vascularity, both exposure and internal fixation of this fracture are difficult. It is still highly controversial what approach and technique should be used for this unique fracture. Therefore, a comprehensive understanding the anatomic characteristics is essential for handling with the fractures, especially related to the surgical approaches, including modified anterolateral approach（Gerdy tubercule osteotomy, fibular head resection, digastric fibular head osteotomy and lateral femoral epicondylar osteotomy）, posterolateral approach（Carlson, transfibular neck osteotomy, and suprafibular head）, and posteromedial approach. As approach selected, one must consider fracture pattern, other tibial plateau quadrants involved, the surrounding soft tissue condition, and the internal fixation device used, as well as patients position, fracture type, and biomechanical stability of internal fixation. Based on the treatment presented in the literature for posterolateral tibial plateau fractures, an algorithm for posterolateral tibial plateau fracture is suggested in this article.