扩展前外侧入路治疗伴后外侧骨块的胫骨平台骨折

Extended anterolateral approach for thetreatment of tibial plateau fractures with posterolateral bone fragment

目的 探讨扩展的前外侧入路治疗伴后外侧骨块的简单或复杂胫骨平台骨折中的区别和临床效果的差异。方法 收集2013年1月至2015年12月共46例于我院接受治疗的伴后外侧骨块的胫骨平台骨折患者资料,统一使用扩展的前外侧入路进行后外侧平台骨块的复位与固定。按Schatzker骨折分型将Ⅱ型骨折患者作为简单骨折组,将Ⅴ、Ⅵ型骨折患者作为复杂骨折组,另按胫骨平台骨折三柱分型将患者分为单柱组、双柱组及三柱组,比较各组患者的手术时间、出血量、骨折愈合时间、术后膝关节Rasmussen评分、膝关节活动度、骨折复位与固定情况及术后并发症,并比较有无关节镜辅助下骨折复位的情况。结果 46例均获得随访,时间23-45个月,平均31.9个月。简单骨折组24例,复杂骨折组22例。简单骨折组手术时间平均（124±33.8） min,复杂骨折组（175±65.5） min,差异有统计学意义（t=-2.302,P=0.025）;简单骨折组出血量平均（118±93.5） ml,复杂骨折组（190±149.4） ml,差异有统计学意义（t=-1.905,P=0.028）。12例使用关节镜辅助治疗。所有患者在末次随访时均获得骨性愈合,日常活动不受限;简单组骨折愈合时间平均4.58个月,复杂组5.54个月。骨折复位优秀率简单组83.3%,复杂组27.3%（χ2=14.679,P=0.000）。后外侧骨块简单组4例未完全固定（16.7%）,复杂组8例未完全固定（36.4%）。简单组膝关节Rasmussen功能评分（26.8±2.1）分,膝关节活动度100°-120°（平均115.5°±6.2°）;复杂组膝关节Rasmussen功能评分平均（23.5±3.4）分,膝关节活动度95°-115°（平均106.3°±7.4°）,均无显著性差异。按三柱骨折分型系统,单柱组6例,双柱组24例,三柱组16例。3组的手术时间、术中出血量组间比较存在显著性差异（F手术时间=5.039,P手术时间=0.000;F出血量=5.215,P出血量=0.000）,骨折复位优秀率比较存在显著性差异（χ2=7.003,P=0.030）,而骨折愈合时间、后外侧骨块未完全固定率、膝关节Rasmussen功能评分和活动度比较无显著性差异。关节镜辅助骨折复位优秀率83.3%,未使用者为47.1%（χ2=4.749,P=0.002）。1例出现术后切口感染。结论 扩展的前外侧入路可良好的进行存在后外侧骨块的胫骨平台骨折的复位与固定,无论是简单骨折或是复杂骨折均可获得满意的临床结果,而在简单胫骨平台骨折中手术操作相对简单,后外侧骨块可获得更好的复位与固定,关节镜辅助治疗有助于改善骨折复位。

Objective To investigate the differences and clinical effects of extended anterolateral approach in the treatment of simple/complex tibial plateau fractures with posterolateral bone fragment. Methods From January 2013 to December 2015, forty-six patients with posterolateral tibial plateau fractures treated in our hospital were included in our research. The posterolateral plateau fractures were reduced and fixed by the extended anterolateral approach. According to Schatzker fracture classification, patients with type II fractures were treated as simple group and patients with type V and type VI fractures were treated as complex group. According to tibial plateau three column classification, patients were divided into single column group, double column group and three column group. The operative time, bleeding volume, fracture healing time, postoperative Rasmussen score, knee mobility, reduction and fixation of fractures and postoperative complications were compared among the groups. Results All 46 patients were followed up for 23-45 months, with an average of 31.9 months. There were 24 cases in simple fracture group and 22 cases in complex fracture group. The mean operation time of simple group was 124±33.8 min, and that of complex group was 175±65.5 min, with significant difference （t=2.302, P=0.025）; the mean bleeding volume of simple group was 118±93.5 ml, and that of complex group was 190±149.4 ml, with significant difference （t=1.905, P=0.028）. 12 cases were treated with arthroscopy. Bone union was achieved in all patients at the last follow-up, and daily activities were not limited. The average healing time was 4.58 months in simple group and 5.54 months in complex group. The excellent rate of fracture reduction was 83.3% in simple group and 27.3% in complex group （χ2=14.679, P=0.000）. Posterolateral bone fragment was not completely fixed in 4 cases （16.7%） in simple group and 8 cases （36.4%） in complex group. The average Rasmussen function score was 26.8±2.1 and the range of motion of knee joint was 100°-120° （average 115.5°±6.2°） in simple group; The average Rasmussen function score was 23.5±3.4 points and the range of motion of knee joint was 95°-115° （average 106.3°±7.4°） in complex group, neither with no significant differences. According to the three-column fracture classification system, there were 6 cases in the single-column group, 24 cases in the double-column group and 16 cases in the three-column group. There were significant differences in the operative time （F=5.039, P=0.000）, bleeding volume （F=5.215, P=0.000） and the excellent rate of fracture reduction （χ2=7.003, P=0.030） between these three groups. But there was no significant difference in the time of fracture healing, un-fixation rate of posterolateral bone fragment, knee joint Rasmussen score and knee jointactivity. The excellent rate of fracture reduction was 83.3% in arthroscopy assisted cases and 47.1% in arthroscopy un-assisted cases respectively （χ2=4.749, P=0.002）. Postoperative wound infection occurred in 1 patient. Conclusion Extended anterolateral approach could provide good reduction and fixation of tibial plateau fractures with posterolateral bone fragment with satisfactory clinical outcomes obtained in both simple and complex fractures. The operation was relatively simple and posterolateral bone fracture could get better reduction and fixation in simple tibial plateau fractures, and arthroscopy treatment was helpful to improve fracture reduction.