通过改良后外侧入路治疗后外侧胫骨平台骨折

发布时间：2018-03-05 01:04

  本文选题：膝关节　切入点：胫骨平台骨折　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景:后外侧胫骨平台骨折在文献中鲜有报道,但近年来随着对关节内骨折的CT平扫使用增加,发现这些骨折的发生率高于预期。由于胫骨平台后外侧区解剖结构复杂,后外侧柱骨折的暴露与固定颇有难度。此外,生物力学原则要求处理胫骨平台骨折时应达到关节的解剖复位,并在平台后方加以抗滑支撑板固定。由于对于胫骨平台后外侧象限直视下操作难以实现,往往无法通过外侧或前外侧入路实现此类骨折的复位与充分固定。Bhattacharyya描述了一种通过伸直位后侧治疗胫骨平台后剪切骨折的入路。但此方法需要对内侧皮肤进行广泛游离,并分离腓肠肌内侧头。Trickey介绍了乆窝中线S形切口,但为了手术视野清晰需要游离更大范围的皮肤,更可能发生对腓肠神经的损伤。由Lobenhoffer最初描述的标准后外侧入路需要对腓骨颈截骨并解离胫骨平台后外侧区,可能导致腓骨截骨不愈合,以及因对组织的广泛解离造成的软组织创伤(关节囊和半月板(冠状)韧带)。Carlson报道了一种后外侧S形入路,此法损伤性较小;然而,手术视野有限。Tao研究出改良型后外侧L形皮肤切口入路,但对于复杂型的骨折,复位及钉板固定容易导致乆窝动脉损伤。Chang提出一种改良型后外侧入路,无需对腓骨近端背侧进行截骨,虽然此法对软组织产损伤小,但因其难以向外扩展,限制了手术范围。为了克服上述问题,Frosch提出了改良型后外侧入路。这种方法涉及外侧关节切开从而看到关节表面,并且通过对平台后外侧解剖实现骨折的复位。此入路可保护后外侧区域软组织及重要韧带。目的:本研究目的为回顾性评估与评价使用无腓骨截骨的改良型后外侧入路外科治疗后外侧胫骨平台骨折的结果。方法:回顾性分析我院2012年1月至2016年12月后外侧胫骨平台骨折患者并行改良型后外侧入路切开复位内固定术的患者共10例,并于进行临床评估。已排除病理性骨折,开放性骨折,骨筋膜室综合征与下肢神经血管损伤。收集患者手术前资料如年龄,性别,损伤机制,损伤部位,相关损伤和软组织损伤的相关病史与数据。获得所有患者的术前标准X线片,CT扫描和三维(3D)重建。采用AO/OTA分型对本研究中的所有骨折进行分型。收集手术时间(天),手术时长(min),骨移植,术中复位等手术相关数据。最后,收集并评价患者术后相关数据,如随访时间(月),骨折愈合时间(周),并发症,运动范围(ROM)和特殊外科医院(HSS)膝盖评分。结果:根据(AO/OTA)分型,其中为1例单纯劈裂骨折,分型为41-B1.1,7例诊断为劈裂塌陷骨折,分型为41 B3.1骨折,1例诊断为关节多发性骨折,分型为41-C3.1,1例诊断为双踝胫骨平台后方骨折。本研究中包括7名男性和3名女性,平均年龄45岁(27至67岁)。患者均在交通事故中受伤。骨折为5例左膝关节骨折和5例右膝关节骨折.相关的骨骼损伤包括腓骨头骨折,踝骨折,骨盆骨折,肩胛骨骨折,鹰嘴骨折和顶骨骨折。相关软组织损伤包括瘀伤/挫伤,外侧半月板损伤和前十字韧带损伤。所有相关的骨与软组织损伤均予以相应处置。从骨折到手术的平均时间为10天(范围:4至30天)。平均手术操作时间为153.3分钟(范围:120至240分钟)。6名患者使用自体骨移植用于支撑塌陷性骨折。术后FTA平均值为172.70±2.35,MPTA的平均值为90.10±2.33,LPSA的平均值为10.00±2.66。随访期间测量上述放射学参数无显着变化(p值0.05)。所有患者解剖复位均达到满意效果。所有患者平均随访时间为18.8个月(范围:6-40个月)。平均骨愈合时间为13周(范围:11-14周),平均完全负重时间为12周。所有患者骨折均愈合良好。膝关节的平均运动范围(ROM)为膝伸展1°(范围:0°-5°),膝的平均屈曲为125.8°(范围:120°-135°),最终随访时平均HSS得分为91.8分(范围:85-96)。没有特殊相关并发症如常见的腓神经受伤记录。在随访期间无病例脱失。结论:改良型后外侧入路实现了骨折部位的直接与完全暴露,有助于实现骨折的解剖复位和稳定的内固定。通过使用该改良型入路,可以获得令人满意的临床疗效和放射学结果。
[Abstract]:Background: posterolateral tibial plateau fractures are rarely reported in the literature, but in recent years, with the increased use of CT intra-articular fracture scanning, found the fracture incidence was higher than expected. The posterolateral tibial plateau area complex anatomical structure after exposure and fixation of lateral column fracture is quite difficult. In addition, the biomechanical principle requires treatment tibial plateau fractures should reach anatomical reduction of joint, and anti slide supporting plate is fixed on the rear platform. Due to the posterolateral tibial plateau under direct vision operation is difficult to achieve, often cannot pass through the lateral or anterolateral approach to achieve reduction of this kind of fracture and fixed.Bhattacharyya describes an extension through the posterior tibial the platform after the shear fractures approach. But this method requires the medial skin extensive free, and separation of the medial head of the gastrocnemius muscle.Trickey introduced people fossa midline S Incision, but in order to clear surgical field to a wider range of free skin, more likely to occur on sural nerve injury. Originally described by Lobenhoffer standard posterolateral approach to the fibular neck osteotomy and dissociation of posterolateral tibial plateau area, may cause the fibular osteotomy healing, and due to extensive dissociation the organization of the soft tissue trauma (meniscus and ligament (coronary)).Carlson reported a S - shaped posterolateral approach, the damage was small; however, the limited operative field.Tao study of modified posterolateral L shaped skin incision, but for complex fracture reduction and plate screw fixation people can easily lead to nest artery injury.Chang proposed a modified posterolateral approach, without the need for proximal fibular dorsal osteotomy, although this method of producing soft tissue damage, but because it is difficult to expand outward, limiting the scope of operation. In order to overcome For the above problems, Frosch proposed a modified posterolateral approach. This method involves the incision to see the articular surface of the lateral joint, and through the platform of posterolateral fracture. The anatomical reduction implementation approach can protect the posterolateral region of soft tissue and ligament. Objective: the purpose of this study was to retrospectively assess and evaluate the use of improved free fibular osteotomy of the posterolateral surgical treatment of posterolateral tibial plateau fractures. Methods: a retrospective analysis of our hospital from January 2012 to December 2016 after the lateral tibial plateau fracture patients underwent modified posterolateral approach to open reduction and internal fixation in patients with a total of 10 cases and clinical evaluation with excluded pathological. Fractures, open fractures, bone compartment syndrome and lower extremity vascular and nerve injury were collected. Preoperative data such as age, gender, injury mechanism, injury site, injury and soft tissue 鎹熶激鐨勭浉鍏崇梾鍙蹭笌鏁版嵁.鑾峰緱鎵，

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