改良Carlson膝关节后外侧入路治疗胫骨平台单纯后外侧柱骨折的解剖学研究及其应用

发布时间：2018-01-04 01:10

本文关键词：改良Carlson膝关节后外侧入路治疗胫骨平台单纯后外侧柱骨折的解剖学研究及其应用　出处：《苏州大学》2016年硕士论文　论文类型：学位论文

【摘要】：胫骨髁骨折,因常影响胫骨平台关节面,临床上亦被称为胫骨平台骨折,在致伤过程中还可合并半月板,甚至交叉韧带或/和侧副韧带,因而易造成不良结果,如关节疼痛、僵硬、不稳定或畸形。由于有生理性膝外翻角的存在,外侧平台骨折最为多见。胫骨平台后外侧柱骨折是外侧平台骨折中较为特殊的类型,是胫骨平台骨折在冠状面上单纯累及后外侧髁的骨折,通常表现为单纯后外侧关节面的塌陷、单纯后外侧皮质的劈裂、后外侧皮质的劈裂合并关节面塌陷。切开复位结合钢板内固定技术(open reduction and internal fixation,ORIF)已成为通过手术治疗胫骨平台骨折的主要治疗方式,目的是将其关节面恢复平整。由于此种类型骨折的骨折块位置偏后外侧,普通X片对其诊断有局限性,有一定的漏诊率。通过CT及MRI进一步检查,不仅容易发现此类骨折,而且对于确定骨折类型、损伤范围及指导治疗优势明显。目前对于这种骨折的手术治疗方法没有统一的标准,但任何手术入路及方式均应以创伤小、暴露充分和坚强内固定为目的。通过标准外侧入路或前外侧入路及后侧入路均难以同时满足此目的。从生物力学角度讲,对骨折块进行支撑钢板直接加压固定最为可靠。Carlson在1998年报道了涉及内外侧平台关节面的胫骨髁后侧骨折,通过膝关节后内及后外双侧切口来进行暴露,并予以钢板固定治疗。但Carlson运用的后外侧切口因不是专门针对治疗单纯的后外侧柱骨折,切口偏外,其切口与膝关节后外侧重要神经走行相交叉,术中容易造成神经损伤,术后切口疤痕亦容易卡压神经,造成神经麻痹。另外,对于后外侧柱骨折中涉及后交叉止点的部位,暴露不充分,对于治疗后交叉止点骨折固定造成一定难度。由于膝关节后外侧入路所涉及的解剖结构较为复杂,手术操作存在难度,熟悉和掌握膝关节后外侧入路相关的骨性结构、韧带结构、肌腱肌肉位置、血管及神经行径及其支配,对于减少该部位手术创伤、保留骨折块血运和提高疗效具有重要意义。目的:通过对膝关节后外侧入路所涉及的主要血管、神经等结构的解剖学观察、测量和分析,确定通过此入路能暴露并安全操作的范围及是否有足够空间放置内固定。在解剖学研究的基础上,结合临床实际,探讨改良carlson膝关节后外侧入路治疗胫骨平台后外侧骨折的手术方法及临床疗效。方法:(1)解剖学观察及测量:取20例成尸下肢标本,男10例,女10例。取膝关节后侧正中切口,起自大腿中下1/3,向远侧延伸到小腿中段,逐层剥离皮肤、皮下组织和筋膜,对腓肠外侧皮神经及腓总神经的发出点、走向及相关距离进行测量,确定手术切口的安全范围,逐层分离,观察膝关节后外侧主要韧带、肌肉位置及附着特点、附着范围,明确手术入路的间隙;完整剥离腓肠肌和比目鱼肌,暴露乆血管神经束,对影响切口暴露的乆血管神经束、胫前动脉和膝下外侧动脉进行观察和解剖学测量,以确定该入路暴露范围的可实施性。所得数据进行统计学处理。(2)临床实践:自2010年1月至2013年12月,按不同治疗方案分为对照组及观察组,分别采用前外侧入路(对照组)及改良carlson后外侧切口(观察组)显露胫骨平台后外侧,分别对随机抽取的各48例胫骨平台后外侧骨折进行手术治疗,男56例,女40例,年龄19-65岁,平均41岁。术后采用hss及rasmussen等评分标准评定关节功能,通过观察患膝有无疼痛、关节活动度、有无感染、下肢深静脉血栓、tpa及pa角度及并发症等指标,评估此改良手术的疗效。结果:(1)解剖学观察和测量:腓肠外侧皮神经距腓骨头内侧缘的水平距离1.696±0.396cm;腓肠外侧皮神经从腓总神经发出点距腓骨头上缘的垂直距离5.755±1.607cm;膝下外侧动脉起点距腓骨头上缘的垂直距离1.839±0.364cm,距腓骨头内侧缘的水平距离1.707±0.272cm;胫前动脉起点到小腿骨间膜裂孔的距离2.397±0.304cm;小腿骨间膜裂孔至腓骨头上缘的垂直距离4.794±0.354cm,至腓骨头内侧缘的水平距离0.947±0.217cm。改良carlson膝关节后外侧入路需要暴露胫骨后外侧平台,应将比目鱼肌及乆肌在胫骨后方的止点适度剥离;膝下外侧动脉会对外侧平台的显露及乆血管神经束向内侧牵开有一定限制,术中可予以结扎;由于胫前动脉的阻碍,小腿骨间膜裂孔平面以下的胫骨骨面显露受到限制,乆动脉向内侧牵拉也会受到一定限制,可通过扩大骨间膜裂孔,适当增加血管牵拉范围。(2)临床实践:所有患者术后获12-18个月(平均15.7个月)随访,术后3-4个月x片示所有骨折均获愈合。观察组膝关节功能hss评分为90.0-100.0分,平均94.3分。观察组患者骨折愈合时间及术后完全负重时间、术后引流等明显少于对照组,随访过程中未见平台关节面高度丢失,膝关节伸0°屈曲度105.0°~135.0°,平均128.8°。无手术切口相关并发症发生,无腓总神经损伤症状、感染、内固定失效及螺钉断裂等并发症发生。观察组病例膝关节功能恢复优良率为95.83%,对照组优良率为83.34%,两组比较差异有统计学意义(P0.05)。结论:(1)在熟悉解剖结构的前提下,用改良Carlson膝关节后外侧入路治疗单纯后外侧柱骨折是一种良好的选择,其具有创伤小、显露充分、复位良好和固定坚强的优点,因胫前血管束在骨筋膜裂孔处较为固定,对于损伤力度较大,骨折线在骨间膜裂孔水平线以下的病例要慎用。(2)改良Carlson膝关节后外侧入路能够充分显露手术区域,最大限度提供平台后外侧内固定的生物力学强度,术后出血少,骨愈合快,早期负重,较传统的平台截骨内固定治疗更有优势,是治疗胫骨平台后外侧骨折的优先选择入路,值得临床推广。对于合并内侧平台骨折,此入路及固定方法需结合其他方式运用。
[Abstract]:Fracture of tibial condyle, because often affect the articular surface of tibial platform, also known as the clinical fracture of tibial plateau in the injury process can also merge the meniscus, cruciate ligament and / or even the lateral collateral ligament, thus easy to cause adverse outcomes, such as joint pain, stiffness, instability or deformity. Due to physiological knee the valgus angle, lateral platform fracture is the most common. Posterolateral tibial plateau fracture is a special type of column lateral tibial plateau fracture, fracture of the lateral condyle in the coronal plane only involving the posterior tibial plateau fractures, usually for posterolateral articular surface and posterolateral cortical splitting after the lateral cortex splitting with articular surface collapse. Open reduction combined with internal fixation technique (open reduction and internal fixation, ORIF) has become the main treatment for surgical treatment of tibial plateau fractures, to be locked up The nodal plane healing. Due to the fracture of this type of fracture block position after partial lateral, ordinary X sheets have limitations on the diagnosis, there is a certain rate of misdiagnosis. Further examination by CT and MRI, not only easy to find such fractures, and to determine the type of fracture, injury and guide the treatment of the operation have obvious advantages. The treatment method of this kind of fracture is no uniform standard, but any surgical approaches and methods should be fully exposed to trauma, and internal fixation for the purpose. Through the standard lateral approach or the anterolateral and posterior approach are difficult to meet this objective. From the perspective of Biomechanics, fracture block support steel plate directly pressure fixed the most reliable.Carlson reported in 1998 involving the articular surface of the tibial platform and lateral posterior fractures, through the knee joint after and after bilateral incisions were exposed, and steel plate The use of Carlson fixation. But the posterior lateral incision because not specifically for the treatment of simple lateral posterior column fracture, partial incision, the incision and lateral knee joint important nerves cross, likely to cause nerve injury during operation, postoperative incision scar is easy to nerve entrapment, causing paralysis. In addition, for posterolateral fractures involving posterior cruciate insertion sites are not fully exposed, for the treatment of posterior cruciate check point fixed fracture caused certain difficulty. Because of very complicated posterolateral approach to the surgical operation is difficult, familiar with and master the posterolateral knee into the bone structure, related to the road the structure of muscle tendon ligament, position, blood vessels and nerves and acts of domination, to reduce the position of surgical trauma and retention is important fracture block blood supply and improve curative effect. Objective: to knee joint posterolateral approach The main vascular road to the anatomical observation of neural structures, measurement and analysis, determined by the scope of this approach can expose and safe operation and whether there is enough space for internal fixation. Based on anatomical studies, combined with clinical practice, to explore the operative method and clinical effect of modified Carlson knee joint posterolateral approach the treatment of posterolateral tibial plateau fractures. Methods: (1) the anatomical observation and measurement: 20 cases of adult cadaver lower limb specimens, 10 cases were male, 10 were female. The knee joint posterior median incision, since lower thigh 1/3 extends distally to the small middle leg, peeling off the skin and subcutaneous tissue. The fascia, the lateral sural cutaneous nerve and common peroneal nerve were measured to a point, and the correlation distance, the safety range of surgical incision, layer separation, observation of posterolateral knee ligaments, muscles attached position and characteristics of attachment, Ming The gap is the surgical approach; the complete separation of the gastrocnemius muscle and soleus muscle, exposure of people to people the neurovascular bundle, neurovascular bundle incision of anterior tibial artery and inferior lateral genicular artery were observed and anatomic measurement to determine the exposure range approach can be implemented. The data were analyzed statistically. (2) clinical practice: from January 2010 to December 2013, according to the different treatment plan is divided into control group and observation group, respectively, using the anterolateral approach (control group) and improved Carlson posterolateral incision (observation group) revealed posterolateral tibial plateau, respectively, 48 cases of tibial plateau were randomly selected for posterolateral fracture surgery the treatment, 56 cases were male, 40 were female, age 19-65 years, average 41 years old. The HSS and Rasmussen standard for evaluation evaluation of joint function after operation, through the observation of the knee with no pain, joint activity, there is no infection, deep vein thrombosis, and TPA PA index angle and complications, evaluating the curative effect of the improved operation. Results: (1) the anatomical observation and measurement: the horizontal distance of the lateral sural nerve from the medial margin of the fibular head was 1.696 + 0.396cm; lateral sural cutaneous nerve from the peroneal nerve from the upper edge of the vertical distance of fibular head distance 5.755 + 1.607cm; vertical distance 1.839 + 0.364cm lateral inferior genicular artery fibular head from the upper edge of the starting point, from the medial edge of the fibular head horizontal distance was 1.707 0.272cm; the anterior tibial artery to the starting point of leg interosseous membrane hole distance was 2.397 0.304cm; interosseous membrane split vertical distance 4.794 + 0.354cm hole to the fibular head of the upper edge of the horizontal distance to the medial margin of the fibular head 0.947 + 0.217cm. modified Carlson knee posterolateral to expose lateral tibial plateau, soleus muscle and muscle of people should be in a moderate stop stripping the posterior tibial; inferior lateral genicular artery will outside platform significantly Dew and kind of the neurovascular bundle medially to a certain limit, may be due to ligation; anterior tibial artery obstruction, crural interosseous membrane of tibial bone surface crack hole below the level of exposure is limited to the medial artery, people pull will be subject to certain restrictions, by expanding the interosseous membrane hole. Appropriate increase in vascular stretch range. (2) clinical practice: all patients for 12-18 months (average 15.7 months) follow-up, 3-4 months after operation X-ray showed that all fractures were healed. The observation group HSS score of knee joint function was 90.0-100.0, an average of 94.3 points. The fracture healing time and postoperative full weight-bearing time groups of patients, postoperative drainage was significantly less than the control group during the follow-up, no articular height loss, knee extension and flexion of 0 degrees 105 degrees ~135.0 degrees, with an average of 128.8 degrees. No incision complications, no symptoms of common peroneal nerve injury infection, internal fixation Failure and screw fracture and other complications. Observation group cases of knee joint function recovery rate is 95.83%, the control group was 83.34%, there was significant difference between two groups (P0.05). Conclusion: (1) in the familiar with the anatomy of the premise, using the improved Carlson posterolateral approach in the treatment of posterolateral column fracture is a good choice, it has less trauma, good exposure, good reduction and fixation advantages because of anterior tibial artery in osteofascial hole at the beam is fixed, the larger the damage strength, the fracture line in the interosseous membrane following Kong Shui split flat line cases (2) improved should be used with caution. Carlson knee posterolateral approach can expose the operation area, to maximize the platform for posterolateral fixation: a biomechanical strength, less postoperative bleeding, bone healing, early weight-bearing, platform osteotomy and internal fixation for the treatment of more than the traditional advantages, is the treatment of The preferred approach for posterolateral fractures of tibial plateau is worthy of clinical promotion. For the patients with medial platform fractures, this approach and fixation method should be combined with other ways.

【学位授予单位】：苏州大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R687.3

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