关节镜探查在双反牵引辅助复位内固定治疗胫骨平台骨折中的作用

The role of arthroscopic investigation in the treatment of tibial plateau fracture with homeopathic double reverse traction reduction and internal fixation

目的探讨关节镜探查在双反牵引辅助复位内固定治疗胫骨平台骨折中的作用.方法回顾性分析2019年1月至2021年12月河北医科大学第三医院采用双反牵引辅助复位内固定及关节镜探查治疗的胫骨平台骨折188例,男129例、女59例,年龄(46.7±11.8)岁(范围14~80岁),左侧115例、右侧73例,骨折Schatzker分型:Ⅱ型81例、Ⅲ型15例、Ⅳ型23例、Ⅴ型29例、Ⅵ型40例,受伤至手术时间(10±5)d(范围1~14d).手术均采用双反牵引辅助复位、锁定接骨板和自断式加压螺栓固定;固定后采用关节镜探查骨折复位质量、半月板及韧带损伤情况,对关节内病变进行处理,如半月板部分切除、全部切除或者缝合.术后采用Rasmussen评分评价骨折复位质量,采用纽约特种外科医院(Hospital for Special Surgery,HSS)膝关节评分评价膝关节术后功能.结果所有患者均顺利完成骨折复位固定及关节镜探查.手术时间(95±21)min(范围30~120 min),术中出血量(120±58)ml(范围50~300 ml).所有患者均获得随访,随访时间(18.0±6.5)个月(范围10~24个月).骨折均达到临床愈合,愈合时间(3.0±2.4)个月(范围2.5~6.0个月),其中165例(87.8%,165/188)于术后3个月内愈合,其余23例于术后4~6个月愈合.关节镜探查188例患者骨折复位良好,关节面平整.其中97例(51.6%,97/188)合并半月板损伤,以纵行撕裂(29%,28/97)最常见,于关节镜下缝合处理;其余69例行半月板部分切除术,所有患者末次随访膝关节功能恢复良好.合并十字韧带损伤29例(15.4%,29/188),均未行一期修复,术后采用石膏或支具固定.末次随访时Rasmussen评分为(16.8±2.4)分(范围6~18分),其中优152例、良36例,优良率100%.术后3、6个月及末次随访时HSS膝关节评分分别为(79.8±9.2)分、(85.1±10.1)分和(94.9±7.6)分,差异有统计学意义(F=52.53,P<0.001).术后发生皮肤浅表感染2例,经定期换药及抗生素抗感染治疗痊愈;术后1周内发生深静脉血栓形成7例,给予低分子肝素抗凝治疗.结论采用双反牵引辅助复位内固定后,应用关节镜下检查既可评估胫骨平台骨折复位质量,又可处理合并的半月板损伤及评估十字韧带损伤情况.

Objective To explore the role of arthroscopic exploration in the treatment of tibial plateau fractures with homeopathic double reverse traction reduction and internal fixation.Methods A retrospective analysis was conducted on the data of 188 patients with tibial plateau fractures treated by homeopathic double reverse traction reduction assisted internal fixation and arthroscopic exploration at the Third Hospital of Hebei Medical University from January 2019 to December 2021.There were 129 males and 59 females,aged 46.7±11.8 years(range,14-80 years);115 cases on the left and 73 cases on the right.Schatzker classification of fractures:81 cases of type II,15 cases of type III,23 cases of type IV,29 cases of type V,and 40 cases of type VI.The time from injury to surgery was 1-14 days,with an average of 10±5 days.The surgery was performed with double reverse traction assisted reduction,locking bone plate and self-breaking compression bolt fixation.Then,arthroscopy was used to explore the quality of fracture reduction,meniscus and ligament damage,and the corresponding intra-articular lesions were treated,such as partial meniscus resection,complete meniscus resection,or suturing.The Rasmussen score was used to evaluate the quality of fracture reduction after surgery,and the Hospital for Special Surgery(HSS)knee joint score was used to evaluate the postoperative function of the knee joint.Results All patients successfully completed fracture reduction,fixation,and arthroscopic exploration.The average surgical time was 95±21 min(range,30-120 min);The average intraoperative bleeding volume was 120±58 ml(range,50-300 ml).All patients were followed up for 10-24 months,with an average of 18±6.5 months.All patients'fractures achieved clinical healing after surgery,with a healing time of 2.5-6.0 months,with an average of 3±2.4 months.Among them,165 patients(87.8%,165/188)healed within 3 months after surgery,while the remaining 23 patients healed within 4-6 months after surgery.Arthroscopic exploration revealed that 188 patients had good fracture reduction and a flat articular surface.Among them,97 cases(51.6%,97/188)were complicated with meniscus injury,with longitudinal tear(29%,28/97)being the most common,suture treatment was performed under arthroscopy;the remaining 69 patients underwent partial meniscectomy.All the patient's knee function recovered well at the last follow-up.29 cases(15.4%,29/188)were complicated with cruciate ligament injury,none of them underwent primary repair and were fixed with plaster or brace after operation.The Rasmussen score for the final follow-up after surgery was 16.8±2.4 points(range,6-18 points),with 152 cases being excellent and 36 cases being good,with a 100%excellent and good rate.The HSS knee joint scores were 79.8±9.2 points,85.1±10.1 points,and 94.9±7.6 points at 3,6 months after surgery,and at the last follow-up,respectively,with statistically significant differences(F=52.53,P<0.001).Superficial skin infection occurred in 2 cases after operation,which was cured by regular dressing change and anti-infection treatment with antibiotics.Deep vein thrombosis occurred in 7 cases within 1 week after operation,and low molecular weight heparin anticoagulation therapy was given.Conclusion After using double reverse traction assisted reduction and internal fixation,arthroscopic examination can not only evaluate the quality of reduction for tibial plateau fractures,but also handle combined meniscus injuries and evaluate the condition of cruciate ligament injuries.