双侧牵引快速复位装置协助下微创治疗复杂胫骨平台骨折

发布时间：2018-08-20 15:07

【摘要】：背景介绍:复杂胫骨平台骨折通常为年轻患者遭受高能量创伤或骨质疏松的年老患者遭受低能量创伤后造成。治疗目的需达到解剖复位,稳定的内固定与早期活动并尽量减少并发症。患者发生复杂胫骨平台骨折后的围手术期管理在于防止神经与血管损伤,稳定患者生命体征直到手术。复杂胫骨平台骨折的传统治疗为切开复位内固定,主要在于能够达到良好的解剖复位和对齐,但术中对软组织的广泛剥离与损伤干扰骨的血运重建。MIPO(Minimally invasive percutaneous plate osteosynthesis,微创经皮钢板固定术)最初用来治疗股骨近端与远端骨折,最近开始用于治疗复杂胫骨近端骨折。MIPO技术在于达到对关节及关节周围骨折既定的治疗目标的同事,保护软组织,减少剥离骨膜。目的:多数骨科医生在对于复杂胫骨平台骨折的切开复位内固定(ORIF)治疗时倾向于选择关节切开术,便于直观关节面,达到良好的关节复位。虽然有半月板下关节切开术中,遭切割的半月板及周围软组织术后得到了愈合的报道,但我们不禁疑惑:关节切开术的必要性有多大?或是否能不行关节切开术但实现相同甚至更好的结果?本研究即评估了在治疗复杂胫骨平台骨折时,较传统的切开复位内固定术,双侧牵引快速复位装置是否能够增加微创经皮钢板内固定术的使用,从而在恢复关节稳定,对齐及固定关节的同时减少软组织损伤。方法:收集2014年9月到2016年6月期间于我院住院的胫骨平台骨折患者共31例。所有31例患者均有手术治疗指正。将病例分为2组,A组(对照组)共17人、B组14人。A组患者为10名女性与7名男性,B组患者为5名女性与9名男性。本研究使用Schatzker系统对患者进行分类。A组骨折分类如下:II型4例,III型2例,IV型3例,V型4例,另4例为Ⅵ型。B组骨折分类如下:II型3例,III型2例,IV型1例,V型5例和VI型3例。A组作为对照组,大多使用传统手术治疗,术者为了取得更好的手术视野在助手手动牵引下行关节切开术。B组,通过使用双侧牵引快速复位装置实现MIPO,不需要助手人为牵拉分离患肢同时保持稳定。双侧牵引快速复位装置主要由复位支架、牵引弓、牵引销、连杆、复位辅助销(尚茨销或柯式线)和近端连接装置构成。快速复位器通过两个牵引弓一头连接到远端股骨,另一头胫骨远端或跟骨。两个牵引弓通过连杆连接形成一个机械闭环系统,产生强大的力量来复位并稳定骨折部位。骨折复位、手术、透视操作与术中失血量的数据均详细收集记录。同时此研究评估了关节切开术的必要性。研究中记录了两组患者的平均住院时间。使用HSS评分系统评价功能恢复与临床疗效。A组平均随访14.06个月,B组评价随访12.5个月。结果:未见双侧牵引快速复位装置导致的直接或间接相关并发症。两组患者无术后感染、皮肤坏死或不愈合。手术时间主要用于暴露术野,对胫骨平台的复位和固定,以及透视。A组患者的平均手术时间为180.9分钟,平均术中失血量为249.4ml,平均随访时间为14.06个月。相比较B组患者平均手术时间为135分钟,平均术中失血量为121.8ml,平均随访时间为12.5个月。A组患者的平均住院日为7天,B组的平均住院日为4天。骨愈合的平均时间A组为12.2周,B组为10.5周,其中A组有3例患者出现骨折延迟愈合,B组无此现象。A组和B组平均HSS评分分别为89.3和94.9。结论:MIPO对于骨折处软组织有良好的保护作用。治疗复杂胫骨平台骨折时对相关软组织的保护已成为主要目标之一。双侧牵引快速复位装置作为一个良好的设计,成为提高治疗复杂胫骨平台骨折时使用MIPO技术使用率的有效手段。双侧牵引快速复位装置能减少软组织剥离与骨血管损伤。从而使减少了手术时间,减少患者术中失血量,取得了满意的临床疗效。双侧牵引快速复位装置可稳定骨折处处于解剖位,无需人工助手术中持续人手牵引控制。B组患者较对照组骨折愈合好,并取得了良好的功能恢复。双侧牵引快速复位装置方便使用的特性为复杂胫骨平台骨折临床治疗提供了合理的解决方案。
[Abstract]:Background: Complex tibial plateau fractures are usually caused by low-energy trauma in young patients with high-energy trauma or osteoporosis. The objective of treatment is to achieve anatomical reduction, stable internal fixation and early mobilization, and minimize complications. The traditional treatment of complex tibial plateau fractures is open reduction and internal fixation, mainly because it can achieve good anatomical reduction and alignment, but extensive dissection of soft tissue and injury interfere with bone revascularization. Minimally invasive percutaneous plate fixation (MIPO) was originally used to treat proximal and distal femoral fractures, but has recently been used to treat complex proximal tibial fractures. Open reduction and internal fixation (ORIF) for plateau fractures tends to choose arthroplasty to facilitate intuitive articular surface and achieve good articular reduction. This study assesses whether bilateral traction rapid reduction devices can increase the use of minimally invasive percutaneous plate internal fixation in the treatment of complex tibial plateau fractures, thereby restoring joint stability, alignment, and Methods: 31 patients with tibial plateau fractures were enrolled in our hospital from September 2014 to June 2016. All 31 patients were corrected by surgery. The patients were divided into two groups, group A (control group) 17, group B 14. Group A consisted of 10 women and 7 men, group B consisted of 5 women and 9 men. Fractures in group A were classified as follows: type II in 4 cases, type III in 2 cases, type IV in 3 cases, type V in 4 cases, and type VI in 4 cases. Fractures in group B were classified as follows: type II in 3 cases, type III in 2 cases, type IV in 1 case, type V in 5 cases and type VI in 3 cases. In group B, MIPO was achieved by using a rapid reduction device with bilateral traction, without manual pulling to separate the affected limbs while maintaining stability. The rapid reduction device with bilateral traction was mainly connected by a reduction bracket, a traction arch, a traction pin, a connecting rod, a reset auxiliary pin (Shanz pin or an offset wire) and a proximal end. The rapid reductor connects one end of the distal femur to the other end of the tibia or the calcaneus through two traction bows. The two traction bows are connected by connecting rods to form a mechanical closed-loop system that produces powerful forces to reposition and stabilize the fracture site. Data on fracture reduction, surgery, fluoroscopy, and intraoperative blood loss are collected in detail. The study assessed the need for arthroplasty. The average length of hospital stay was recorded in both groups. The HSS scoring system was used to assess functional recovery and clinical outcomes. The mean follow-up period was 14.06 months in group A and 12.5 months in group B. Results: There was no direct or indirect correlation between rapid reduction with bilateral traction. There were no postoperative infection, skin necrosis or nonunion in the two groups. The operation time was mainly used to expose the surgical field, reset and fix the tibial plateau, and fluoroscopy. The average operation time in group A was 180.9 minutes, the average intraoperative blood loss was 249.4 ml, and the average follow-up time was 14.06 months. The average length of hospital stay was 7 days in group A and 4 days in group B. The average time of bone union was 12.2 weeks in group A and 10.5 weeks in group B. Three patients in group A had delayed union, but no such phenomenon in group B. The average HSS scores in group A and B were 89.3 and 89.3 respectively. Conclusion: MIPO has a good protective effect on the soft tissues of the fracture site. The protection of the related soft tissues in the treatment of complex tibial plateau fractures has become one of the main objectives. Bilateral traction rapid reduction device can reduce soft tissue dissection and bone vascular injury, thus reducing the operation time and blood loss during the operation, and achieved satisfactory clinical results. Bilateral traction quick reduction device provides a reasonable solution for the clinical treatment of complex tibial plateau fractures.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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