外支架辅助间接复位MIPO治疗胫骨远侧干骺端骨折

External fixator assisted indirect reduction in minimally invasive plate osteosynthesis for tibial distal metaphyseal fractures

[目的]探讨平衡牵引外支架辅助间接复位在胫骨远侧干骺端骨折前外侧入路微创接骨板接骨术(MIPO)中的应用效果。[方法]回顾性分析2012年8月～2017年8月治疗的32例胫骨远侧干骺端骨折临床资料,术中先用单针双边外支架平衡牵引、复位与临时固定,而后MIPO手术。记录手术时间,包括复位时间和透视时间。术后根据正侧位X线片分别测量胫骨内-外翻、前-后屈成角的角度,评估复位质量。记录手术并发症和骨折愈合时间。末次随访应用Johner-Wruhs评分评价功能。[结果]32例中简单骨折13例,粉碎性骨折19例,两者之间的复位时间、透视时间和手术时间差异无统计学意义(P>0.05)。两者术后内-外翻与前-后屈成角均不超过5°,两者之间差异无统计学意义(P>0.05)。所有患者均获得术后随访12～21个月。两者之间骨折愈合时间差异无统计学意义(P>0.05)。术后1例浅表感染,2例敏感性瘢痕,均发生在远侧微创切口。1例骨折不愈合,二期植骨后愈合,无畸形愈合及内固定失效,骨折愈合率96.88%。末次随访Johner-Wruhs评分优良率93.75%。[结论]平衡牵引外支架辅助MIPO手术,间接复位效果可靠,可重复性强,尤其适用于胫骨远侧干骶端粉碎性骨折前外侧入路微创手术。

[Objective] To evaluate the preliminary outcomes of external fixator assisted indirect reduction in minimally invasive plate osteosynthesis (MIPO) for tibial distal metaphyseal fractures.[Methods] From August 2012 to August 2017, 32 patients with tibial distal metaphyseal fractures were treated using MIPO technique, and the clinical data were retrospectively analyzed. Under distraction by a single pin-bilateral configuration external fixation, the fracture reduction was achieved and maintained, and then a MIPO procedure was conducted through anterolateral approach. The operative time, including reduction by external fixator, the time consumed for intraoperative fluoroscopy, and total operation time, as well as complications were recorded. In addition, the varus-valgus angle, the anteroposterior angulation and fracture healing time were assessed on the postoperative radiographs. At the last follow up, Johner-Wruhs scoring was used to assess the functional outcomes.[Results] Of the 32 patients, 13 had simple fracture and 19 had comminuted fractures. No significant differences were noticed regarding to reduction time, fluoroscopy time and total operation time between the two groups (P>0.05). The postoperative residual varus-valgus and anteroposterior angulations proved no statistically significant between the two groups (P>0.05), without angulations >5° in any patient of them. All patients were followed up for 12~21 months. No significant difference in fracture healing time was proved between the simple and comminuted fractures (P>0.05), associated with a total fracture healing rate of 96.88%(31/32). In term of postoperative complications, there were 1 case of superficial infection and 2 case of sensitive scars at the distal window, which did not lead serious consequences, 1 case of nonunion that healed after revision bone grafting. No malunion and hardware failure occurred in anyone of them. At the latest follow- up, the clinical outcomes were graded as excellent and good in 93.75% according to Johner-Wruhs criteria.[Conclusion] The application of balanced distraction by external fixator does efficiently and reproducibly assist fracture reduction in MIPO technique through anterolateral approach for tibial distal metaphyseal fractures, especially for comminuted fractures.