胫骨平台骨折畸形愈合的再手术治疗

Reoperation strategy of malunited tibial plateau fracture

目的探讨胫骨平台骨折畸形愈合的再手术治疗,分析常见的四种翻修手术的要点及其临床效果。方法收集2012年1月至2016年12月共18例于我院进行胫骨平台骨折畸形愈合翻修治疗的患者资料,男5例,女13例,年龄35~60岁,平均49.7岁。二次翻修手术至初次手术时间2~24个月(平均10.4个月)。再手术治疗方法如下:判断有无感染,如存在感染则改为外固定支架控制感染;判断患者有无条件行翻修内固定,如患者年龄>65岁或局部骨量较差则行全膝关节置换术。余患者根据胫骨平台畸形特点分为以下四种手术方式:①原骨折线截骨复位内固定;②胫骨结节截骨+原骨折线截骨复位内固定;③胫骨干骺端开窗顶棒复位植骨内固定;④腓骨头截骨+原骨折线截骨复位内固定。结果本组18例均获得随访,随访时间12~30个月,平均16.8个月。手术时间120~300 min,平均185 min。2例术前存在感染,行感染清创内固定拆除后改为外固定支架固定,二期改行切复内固定或者继续外固定;1例采用全膝关节置换术;3例采用干骺端开窗顶棒植骨复位内固定术;6例采用原骨折线截骨复位内固定术;4例采用胫骨结节截骨+原骨折线截骨复位内固定术;2例采用腓骨头截骨+原骨折线截骨复位内固定术。所有患者末次随访时均获得骨性愈合,骨折愈合时间3~6个月,平均3.6个月;术后VAS痛觉评分1.1分,较术前4.2分明细改善(t=8.960,P=0.001);术后Rasmussen评分平均22.9分,较术前14.4分明显改善,差异有统计学意义(t=-10.169,P=0.001);术后膝关节活动度平均94.5°,较术前55°明显改善,差异有统计学意义(t=-5.773,P=0.001)。3例关节面仍遗留2 mm塌陷,3例仍存在轻度外翻(<5°),骨折复位优12例,良5例,优良率100%,2例出现术后切口浅表感染。结论胫骨平台骨折畸形愈合翻修难度较大,需进行详细的术前规划,采用合适的再手术治疗可取得较满意的临床效果,依据患者不同的骨折畸形特点采用不同的再手术方法是取得治疗成功的关键。

Objective To explore the revision strategy of the malunited tibial plateau fracture and to analysis the main points of four common revision operations and the clinical effect. Methods From January 2012 to December 2016, 18 patients (5 males and 13 females) aged 35-60 years (average 49.7 years) underwent tibial plateau revision surgery in our hospital were collected. The time from the second revision operation to the first operation was 2-24 months (average 10.4 months). Our revision strategies were as follows: Firstly, to determine whether there is an infection or not. If there was infection, we changed the original internal fixation to external fixator to control infection. Secondly, todetermine whether the patient could suffer re-reduction and internal fixation. If the patient was older (>65 years old) or with severe local bone defect, total knee arthroplasty should be performed. Thirdly, patients were divided into four operation modes according to the tibial plateau fracture malunion type: 1. the original fracture line osteotomy;2. the tibial tubercle + original fracture line osteotomy;3. tibial metaphyseal window-rod reduction;4. the osteotomy of fibula head and original fracture line osteotomy. Results All patients were followed up for 12-30 months (average 16.8 months), and the operation time was 120-300 min (average 185 min). 2 cases were infected before operation and the original internal fixation were removed to instead of external fixator;1 patient underwent total knee arthroplasty;3 cases were treated with metaphyseal open window-rod reduction and internal fixation;6 cases were operated with the original fracture line osteotomy and internal fixation;4 cases were treated with tibial tubercle osteotomy+original fracture line osteotomy and internal fixation;2 patients underwent fibular head osteotomy+ original fracture line osteotomy and internal fixation. All patients achieved bony union at the last follow-up. The healing time was 3-6 months (mean 3.6 months). The postoperative knee Rasmussen score was 19-29 (average 22.9), compared with average 14.4 points before operation (t=-10.169, P=0.001). The postoperative range of motion of knee joint was 60-110 degrees (mean 94.5 degrees), compared with average 55 degrees before operation (t=-5.773, P=0.001). The postoperative VAS pain score was average 1.1 points, compared with average 4.2 points before operation (t=8.960, P=0.001). Fracture reduction was excellent in 12 cases and good in 5 cases, with the excellent and good rate of 100%. 3 patients still had 2mm collapse on the articular surface, while 3 patients still had mild valgus (less than 5 degrees). There were 2 cases of superficial infection of the wound surface after operation. Conclusion It was difficult to revise the malunion of tibial plateau fracture and it was necessary to make a detailed operation plan before the operation. Satisfactory clinical effects could be obtained for the patients by correct revision strategy. The key to success was the proper revision strategy which was adopted according to the different characteristics of the tibial plateau fracture malunion of the patients.