后内侧倒“L”形切口三间隙显露联合前外侧入路治疗复杂胫骨平台骨折

Posteromedial inverted L-incision for exposing three windows combined with anterolateral approach in the treatment of complex tibial plateau fractures

目的探讨后内侧倒"L"形切口三间隙显露联合前外侧入路治疗复杂胫骨平台骨折的临床疗效。方法自2013年3月至2017年3月,采用后内侧倒"L"形切口三间隙显露联合前外侧入路手术治疗复杂胫骨平台骨折21例,其中男15例,女6例;年龄21～65岁,平均32.7岁;左侧13例,右侧8例。按Schatzker分型:Ⅳ型7例,Ⅴ型10例,Ⅵ型4例:按三柱分型:双柱骨折14例,三柱骨折7例。记录每位患者的手术时间、骨折愈合情况及愈合时间、随访时间。术后3 d查术膝正侧位X线片及CT平扫+多平面重建+三维重建。手术结束后第3、6、9、12个月,随访复查相关项目,并进行HSS评分及Rasmussen评分。结果本组21例胫骨平台骨折患者平均手术时间为(179.4±42.3)min。21例患者骨折均达到骨性愈合,平均愈合时间(16.5±5.6)周。21例患者均获随访,平均随访(22.6±5.7)月。末次随访膝关节功能评估(HSS评分)为66～100(85.3±4.2)分,优良率95.2%。末次随访胫骨平台骨折复位放射学评估(Rasmussen评分)为7～18(15.8±1.6)分,优良率90.5%。术后1例患者发现伤口开裂,1例患者伤口表皮坏死,均经保守治疗痊愈;1例患者发生小腿内下方麻木;内固定松动1例,为螺钉松动,未影响骨折愈合,无内固定物断裂等其他并发症发生。结论后内侧倒"L"形切口三间隙显露联合前外侧入路治疗复杂胫骨平台骨折,能够充分显露手术区域,直视下精准复位骨折,从而最大限度的实现了关节面的解剖复位,有利于早期功能锻炼,并发症少,临床疗效满意。

Objective To observe the clinical outcome of posteromedial inverted 'L' incision for exposing three windows combined with anterolateral approach in the operation of complex tibial plateau fracture.Methods Twenty-one patients with complex tibial plateau fracture treated with posteromedial inverted 'L' incision combined with anterior lateral approach from March 2013 to March 2017 were enrolled,and there were 15 male and 6 female,aged from 21 to 65 years old,in whom 13 cases of fracture located on the left and 8 cases on the right.According to Schatzker classification,the fractures were diagnosed as type Ⅳ in 7,type Ⅴ in 10,type Ⅵ in 4.According to Three-Column classification,there were 14 cases of two-column fracture,7 cases of three-column fracture.The operation time,condition and time of fracture healing,follow-up time in each patient were recorded.On the 3 rd day after operation,positive and lateral X-ray of knee,CT plain scan,multiplanar reconstruction and 3 D reconstruction of knee were performed.At 3-,6-,9-,12-month,the related examinations were performed for all patients,and the knee joint functions were assessed by Hospitial for Special Surgery(HSS)score and Rasmussen knee function score.Results The mean operation time was(179.4±42.3) min,and all the patients gotbony union.The average healing time was(16.5±5.6)weeks,and mean followed-up was(22.6±5.7)months.At the last follow-up,HSS score was 66-100(85.3±4.2),with excellent and good rate of 95.2%;Rasmussen score of reduction and radiology for tibial plateau fractures ranged from 7 to 18(15.8±1.6),with an excellent and good rate of 90.5%.After operation,there were 1 case of wound dehiscence and 1 case of wound epidermal necrosis,cured by conservative treatment.Numbness under the calf and internal fixation loosening were respectively found in one patient,but did not affect fracture healing.No other complications(such as breakage of internal fixator and so on) occurred.Conclusion The posteromedial inverted 'L' incisionfor exposing three windows combined with anterolateral approach could fully expose the operative area and have accurate reduction of fracture under direct vision,which is conducive to early functional exercise,fewer complications and satisfactory clinical effect.