改良分期分部策略治疗C3型Pilon骨折

Modified staging strategy in treatment of type C3 Pilon fractures

目的探讨改良分期分部策略治疗C3型Pilon骨折的安全性、可行性及疗效。方法回顾分析2012年1月—2018年1月采用改良分期分部策略治疗的23例C3型Pilon骨折患者临床资料。男14例,女9例;年龄22~61岁,平均47.9岁。23例均为高能量损伤,其中交通事故伤11例、高处坠落伤12例。1例为GustiloⅢA型开放骨折,经早期扩创后创面未见明显感染征象;其余患者均为闭合骨折。受伤至入院时间3~40 h,平均16.4 h。术前疼痛视觉模拟评分(VAS)为(7.22±1.17)分,美国足踝外科协会(AOFAS)评分为0分。踝关节背伸、跖屈活动度分别为(1.13±0.26)、(4.79±0.93)°。22例合并腓骨骨折。一期采用后方入路复位胫骨后柱骨折、外支架临时辅助固定;待软组织危象解除后,二期经前方入路行最终复位内固定。结果23例患者术后均获随访,随访时间12~84个月,平均26.6个月。一期手术前等待时间为4~47 h,平均23.4 h;两期手术间隔时间为6~11 d,平均7.9 d。一期手术时间为60~90 min,平均67.8 min;二期手术时间为110~160 min,平均124.1 min。住院时间为15~28 d,平均23.5 d。二期术后1例(4.35%)出现止血带麻痹症状,2例(8.7%)发生胫前切口延迟愈合;其余患者两期手术切口均Ⅰ期愈合,无手术早期并发症发生。影像学复查示,术后3个月关节面复位质量达优19例、良2例、差2例,优良率为91.3%。末次随访时骨折均达骨性愈合,无骨不愈合以及畸形愈合;7例出现不同程度骨关节炎表现。末次随访时,VAS评分为(0.89±0.88)分,AOFAS评分为(81.3±7.8)分;踝关节背伸、跖屈活动度分别为(10.23±5.05)、(20.97±3.92)°,与术前比较差异均有统计学意义(P<0.05)。结论改良分期分部策略中一期胫骨后柱固定及减压为二期手术提供了关节面复位模板,提高了复位质量,还缩短了两期手术间隔时间和二期手术时间,能获得较好疗效。

Objective To investigate the safety,feasibility,and effectiveness of modified staging strategy in treatment of type C3 Pilon fractures.Methods The clinical data of 23 patients with type C3 Pilon fractures treated with modified staging strategy between January 2012 and January 2018 was retrospectively analyzed.There were 14 males and 9 females with an average age of 47.9 years(range,22-61 years).Twenty-three cases were high-energy injuries,including 11 cases of traffic accidents and 12 cases of falling from height.One case was an open fracture of Gustilo typeⅢA with no obvious sign of infection on the wound after early treatment.The remaining patients were closed fractures.The time from injury to admission was 3-40 hours with an average of 16.4 hours.The preoperative pain visual analogue scale(VAS)score was 7.22±1.17 and American Orthopaedic Foot and Ankle Society(AOFAS)score was 0.The flexion and plantar flexion activities of ankle joint were(1.13±0.26)and(4.79±0.93)°,respectively.Twenty-two patients had a tibiofibular fracture.In the first-stage operation,the posterior approach was used to reduce the posterior column fracture and the external stent was temporarily assisted.After the soft tissue crisis was removed,the final fracture reduction and internal fixation was performed through the anterior approach in the second-stage operation.Results All 23 patients were followed up 12-84 months with an average of 26.6 months.The waiting time before the first-stage operation was 4-47 hours with an average of 23.4 hours.The interval between the two stage operations was 6-11 days with an average of 7.9 days.The first-stage operation time was 60-90 minutes with an average of 67.8 minutes;the second-stage operation time was 110-160 minutes with an average of 124.1 minutes.The hospital stay was 15-28 days with an average of 23.5 days.One patient(4.35%)had a tourniquet paralysis symptom after the second-stage operation,and two patients(8.7%)had delayed anterior incision healing.The other patients had incision healing without early complications.The radiographic review showed that the quality of articular surface reduction was excellent in 19 cases,good in 2 cases,and poor in 2 cases,with an excellent and good rate of 91.3%.At last follow-up,the fractures healed with no bone nonunion and malunion;the different degrees of osteoarthritis occurred in 7 cases.At last follow-up,the VAS score was 0.89±0.88 and the AOFAS score was 81.3±7.8.The flexion and plantar flexion activities of ankle joint were(10.23±5.05)and(20.97±3.92)°,respectively,and the differences between pre-and post-operation were significant(P<0.05).Conclusion The midified staging strategy can not only provide a template for articular surface reduction for the second-stage anterior surgery,but also improve the quality of the reduction.It can also reduce the interval between the two operations and the operation time of the second-stage operation through the first-stage posterior fascial decompression,and can obtain satisfactory effectiveness.