胫骨平台骨折手术入路和术后并发症的综述

发布时间：2018-08-10 18:20

【摘要】：目的:胫骨平台骨折是一种常见但复杂的损伤,包括各种各样的骨折类型,也常常与重要软组织损伤有关联。偶尔,相关的关节内损伤也需要解决。他们可以发生在任何年龄,但呈现双峰分布,高能量损伤通常发生在年轻的具有良好骨质量的成年人而低能量骨折通常发生在骨质量差的老年患者。这主要与轴向、弯曲和旋转力或这些力相结合有关。手术治疗有位移及不稳定的骨折是越来越常见。这些骨折常用Schatzker和AO/OTA分类系统来描述。对于手术治疗时机的选择,了解膝关节周围软组织的损伤程度是至关重要的,除非利用一个纯粹的经皮方法。虽然手术执行越早技术上来说复位也越简单,但手术延迟对降低伤口并发症的风险有意义。理想的手术入路不仅仅是显露骨折部位,足以促使骨折复位和固定植入物的应用,也能使伤口感染、骨折不愈合等并发症的风险降到最低。精细的解剖和防止损伤软组织的操作是必要的,以避免神经与血管的损伤或对软组织的医源性损伤。因此,外科医生准备操作这些骨折必须从各种手术入路中选择最恰当的。入路的选择主要取决于骨折类型,同时考虑软组织的情况、患者自身因素和其他损伤(如需要血管修复或筋膜切开术),偶尔需要改变手术方案。计算机断层扫描(CT)的使用大大提高了我们对损伤类型的理解能力。矢状面和冠状CT扫描可以获得所有胫骨近端骨折的重建。如果根据受伤情况外固定是必要的,CT扫描可以推迟到外固定后,闭合复位之前进行。骨折类型的详细分析,特别是骨折断面,关节表面的位移、粉碎,对骨折复位和固定植入物的应用是必要的,因此决定手术入路是至关重要的。胫骨近端骨折的早期治疗技术依赖直接的前正中线方法,需要剥离大量软组织皮瓣来显露相应的骨折。为了处理相关的侧韧带和半月板损伤,改良使用一个倒“L”型切口在标记的关节线以上。随着时间的推移,软组织管理的重要性和解剖复位导致的相关结果引导了骨折的具体治疗方法。自从Tscherne和Lobenhoffer 20年前发表了他们的观点后,髌周切口在减少使用,后内侧的和后外侧入路的说明及常用的双入路技术在逐步演进。由于膝关节和胫骨上端皮下部分中间没有太多的软组织,这些损伤可造成明显的软组织损伤。对于高能量膝关节损伤或胫骨平台骨折来说,周围软组织通过成功的处理恢复满意,是至关重要的好结果。对大多数患者来说,膝关节缺少软组织保护,尤其是由于创伤或内部原因(骨折碎片的的移位)引起的胫骨近端软组织挫伤,会增加患者的易感性。这就增加了高能量损伤所致胫骨近端骨折的治疗中产生并发症的风险。胫骨平台骨折的治疗是具有挑战性的,病人要面对包括感染、畸形愈合、骨不连和僵硬等不良预后的风险。准确的诊断和早期治疗可以减轻这些并发症的影响。我们将胫骨平台骨折分为单髁与双髁两类来总结该类损伤的术后风险和并发症处理策略。与单髁胫骨平台骨折相比,双髁损伤通过相应手术治疗后出现的并发症明显高。它们通常由高能量创伤引起,例如严重的粉碎性骨折、开放性骨折、血管损伤,以及骨筋膜室综合征的风险。此外,双髁骨折可能需要更广泛的手术分离及术中对软组织的操作,这对已经脆弱的软组织造成了额外伤害。因此,胫骨平台骨折,特别是双髁骨折,现在需要一套独特的要求。良好的结果需要仔细的术前规划,复位,和尽全力保护软组织,并早期识别和治疗术后急性并发症。方法:通过查找大量相关外文文献,本文归纳总结了胫骨平台骨折各种常用手术入路、相关软组织损伤和术后并发症的治疗方案,为此类骨折的临床治疗提供帮助。
[Abstract]:OBJECTIVE: Tibial plateau fractures are common but complex injuries, including a variety of fracture types, and are often associated with important soft tissue injuries. Occasionally, the associated intra-articular injuries need to be addressed. They can occur at any age, but are bimodal in distribution. High-energy injuries usually occur in young adults with good bone quality. In adults, low-energy fractures usually occur in elderly patients with poor bone mass. This is mainly related to axial, bending and rotating forces or the combination of these forces. Surgical treatment of displaced and unstable fractures is becoming increasingly common. These fractures are often described by Schatzker and AO/OTA classification systems. For timing of surgical treatment, understand The degree of soft tissue damage around the knee joint is crucial unless a pure transdermal approach is used. Although the earlier the operation is performed, the simpler the reduction is technically, the later the operation is performed is meaningful in reducing the risk of wound complications. The use of implants can also minimize the risk of complications such as wound infection, nonunion, etc. Fine anatomy and procedures to prevent injuries to soft tissues are necessary to avoid nerve and vascular injuries or iatrogenic injuries to soft tissues. The choice of approach depends primarily on the type of fracture, taking into account the condition of soft tissue, patient's own factors and other injuries (such as revascularization or fasciotomy), and occasional changes in surgical procedures. The use of computed tomography (CT) greatly improves our understanding of the type of injury. Sagittal and coronal CT All proximal tibial fractures can be reconstructed by scanning. If external fixation is necessary according to the condition of injury, CT scan can be postponed until after external fixation and before closed reduction. Detailed analysis of fracture types, especially fracture section, displacement of joint surface, comminution, is necessary for fracture reduction and the application of fixed implants. Early treatment of proximal tibial fractures relies on a direct anterior median approach, requiring the removal of a large number of soft tissue flaps to expose the corresponding fracture. To deal with related lateral ligament and meniscus injuries, an inverted "L" incision was modified above the marked articular line. Since Tscherne and Lobenhoffer published their views 20 years ago, peripatellar incisions have been reduced in use, posteromedial and posterolateral approaches have been described and commonly used dual approaches have evolved. There is not much soft tissue between the upper tibia and the subcutaneous portion of the upper tibia. These injuries can cause significant soft tissue damage. Successful treatment of the surrounding soft tissue for high-energy knee injuries or tibial plateau fractures is a crucial good outcome. For most patients, the knee joint lacks soft tissue protection, especially This increases the risk of complications in the treatment of proximal tibial fractures due to high-energy injuries. The treatment of tibial plateau fractures is challenging and involves infection and deformities. Accurate diagnosis and early treatment can alleviate the impact of these complications. We classify tibial plateau fractures into unicondylar and bicondylar fractures to summarize the risk and complication management strategies for such injuries. Bicondylar injuries are treated by surgery as compared with unicondylar tibial plateau fractures. Complications are significantly higher after treatment. They are usually caused by high-energy trauma, such as severe comminuted fractures, open fractures, vascular injuries, and the risk of osteofascial compartment syndrome. Injury. Therefore, tibial plateau fractures, especially bicondylar fractures, now require a unique set of requirements. Good results require careful preoperative planning, reduction, and full protection of soft tissue, and early identification and treatment of postoperative acute complications. Common surgical approaches, related soft tissue injuries and postoperative complications of the treatment of such fractures to provide help for clinical treatment.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

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