目的:探讨经双切口采用骨缝合技术结合锁定钢板内固定治疗合并腓骨骨折的C型Pilon骨折的临床疗效。方法:回顾分析2018年01月至2022年01月我科运用骨缝合技术结合锁定钢板内固定治疗的13例合并腓骨骨折的C型Pilon骨折患者临床资料,其中男性患者8例,女性5例,平均年龄44.5岁。本组患者采用对部分破碎游离骨块进行骨缝合结合锁定钢板内固定治疗,术后定期复查并按医务人员指导进行功能锻炼,对患者治疗终末时骨折愈合及踝关节功能恢复情况进行分析。结果:13例患者骨折均实现临床愈合,愈合时间平均为6.54 ± 1.36月。1例患者出现创口局部坏死,部分钢板外露,经治疗后创口愈合,其余患者未出现皮肤坏死、骨折移位、严重感染、骨折不愈合并发症发生。治疗终末患者踝关节功能评定优6例,良6例,优良率92.31%。结论:经双切口采用骨缝合结合锁定钢板内固定治疗合并腓骨骨折的C型Pilon骨折,可简化手术过程,提高复位质量,可获得较好的治疗效果。 Objective: This paper aims to investigate the clinical effect by bone suture combined with locking plate internal fixation in the treatment of type C Pilon fracture complicated with fibula fracture. Methods: From January 2018 to January 2022, 13 patients (8 males, 5 females; mean age 44.5 years) with type C Pilon fracture complicated with fibula fracture treated by bone suture combined with locking plate internal fixation were retrospectively analyzed. Regular follow-up examinations and functional exercises were performed after surgery. The recovery of ankle joint function and fracture healing time were analyzed. Results: The mean time to fracture healing was 6.54 ± 1.36 months. One patient had skin necrosis and part of the plate was exposed, and the wound healed after careful treatment finally. The other patients did not have serious soft tissue infection, fracture displacement, osteomyelitis, fracture nonunion, or other complications. At the end of treatment, functional outcomes were excellent in 6, and good in 6. The excellent and good rate of functional results was 92.31%. Conclusion: Bone suture combined with locking plate internal fixation is a simple and effective method for the treatment of type C Pilon fracture with fibula fracture, and it could obtain better therapeutic effect.
目的:探讨经双切口采用骨缝合技术结合锁定钢板内固定治疗合并腓骨骨折的C型Pilon骨折的临床疗效。方法:回顾分析2018年01月至2022年01月我科运用骨缝合技术结合锁定钢板内固定治疗的13例合并腓骨骨折的C型Pilon骨折患者临床资料,其中男性患者8例,女性5例,平均年龄44.5岁。本组患者采用对部分破碎游离骨块进行骨缝合结合锁定钢板内固定治疗,术后定期复查并按医务人员指导进行功能锻炼,对患者治疗终末时骨折愈合及踝关节功能恢复情况进行分析。结果:13例患者骨折均实现临床愈合,愈合时间平均为6.54 ± 1.36月。1例患者出现创口局部坏死,部分钢板外露,经治疗后创口愈合,其余患者未出现皮肤坏死、骨折移位、严重感染、骨折不愈合并发症发生。治疗终末患者踝关节功能评定优6例,良6例,优良率92.31%。结论:经双切口采用骨缝合结合锁定钢板内固定治疗合并腓骨骨折的C型Pilon骨折,可简化手术过程,提高复位质量,可获得较好的治疗效果。
C型Pilon骨折,内固定术,切开复位,治疗
Xiangting Jin1, Xia Li2, Min Wan1, Jun Huang1, Rui Chen1
1Department of Traumatic Orthopedics, First Naval Hospital of Southern Theater Command, PLA, Zhanjiang Guangdong
2Department of Hyperbaric Oxygen, First Naval Hospital of Southern Theater Command, PLA, Zhanjiang Guangdong
Received: Jan. 2nd, 2024; accepted: Feb. 16th, 2024; published: Feb. 23rd, 2024
Objective: This paper aims to investigate the clinical effect by bone suture combined with locking plate internal fixation in the treatment of type C Pilon fracture complicated with fibula fracture. Methods: From January 2018 to January 2022, 13 patients (8 males, 5 females; mean age 44.5 years) with type C Pilon fracture complicated with fibula fracture treated by bone suture combined with locking plate internal fixation were retrospectively analyzed. Regular follow-up examinations and functional exercises were performed after surgery. The recovery of ankle joint function and fracture healing time were analyzed. Results: The mean time to fracture healing was 6.54 ± 1.36 months. One patient had skin necrosis and part of the plate was exposed, and the wound healed after careful treatment finally. The other patients did not have serious soft tissue infection, fracture displacement, osteomyelitis, fracture nonunion, or other complications. At the end of treatment, functional outcomes were excellent in 6, and good in 6. The excellent and good rate of functional results was 92.31%. Conclusion: Bone suture combined with locking plate internal fixation is a simple and effective method for the treatment of type C Pilon fracture with fibula fracture, and it could obtain better therapeutic effect.
Keywords:Type C Pilon Fracture, Internal Fixation, Open Reduction, Therapy
Copyright © 2024 by author(s) and beplay安卓登录
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
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Pilon骨折是累及胫距关节面的胫骨远端骨折,最早由Etienne Destot于1911年提出 [
2018年01月至2022年01月期间我科采用骨缝合技术结合锁定钢板内固定治疗合并腓骨骨折的C型Pilon骨折病人共13人,其中闭合性骨折9例,开放性骨折4例(Gustilo分型:I型2例,II型1例,IIIA型1例)。骨折均为高处坠落、车祸等暴力原因所致,其中患者男性8例,女性5例,年龄22~69岁,平均年龄44.5岁。AO/OTA分型:C2型8例,C3型5例。患者均予以X线及三维CT重建检查确定骨折损伤及移位情况(见图1、图2)。本组患者无主要神经、血管断裂伤。
开放性伤口先行急诊清创,予硬膜外麻醉后常规以生理盐水、3%过氧化氢溶液及碘伏反复冲洗伤处及周围皮肤,伤处泥土等污物较多者以无菌纱布覆盖创口后先以皂液刷洗并擦拭干净,之后再行常规冲洗、消毒。铺无菌单后,予以清创,修剪坏死失活组织,清除污染物,再以生理盐水、3%过氧化氢溶液及碘伏冲洗伤口三遍。本组2例Gustilo I型开放性骨折病人予以急诊清创及一期内固定治疗,其余2例因污染较重及软组织情况稍差清创冲洗后予以外固定架跨踝关节固定后二期行内固定手术(一期术后12天、14天)。闭合性骨折肿胀明显、软组织情况不佳者先行根骨牵引、消肿等对症支持治疗,待肿胀消退、皮纹明显后再行手术,以避免术后皮肤坏死、感染等并发症 [
内固定手术采用硬膜外麻醉或腰硬联合麻醉,麻醉成功后,患者先取俯卧位,在患者骨盆和胸部下放置长垫,并于患肢踝关节下放置软垫。患肢常规上气囊止血带,消毒并铺无菌手术铺单。抬高下肢驱血,止血带充气,压力75 KPa。
取踝关节外侧扩大入路切口 [
术后予患肢抬高、脱水消肿及抗血栓治疗,酌情应用抗生素预防感染,术后1~2天伤口已无明显引流物后予以引流管拔除,术后14天酌情拆除缝合线。一般于术后两周开始逐渐患肢非负重功能锻炼,2~3月后可拄拐部分负重,骨质达到临床愈合后逐渐完全负重训练,注意避免过早弃拐负重。患者定期门诊复查(间隔约1~2月),在医务人员指导下逐渐进行功能康复锻炼,并行胫腓骨正、侧位X线片检查评价骨折愈合情况(见图4)。
根据患者复查结果记录患者骨折愈合情况、功能恢复及并发症发生情况。患者术后随访时间为16~26个月,所有患者骨折均达到临床愈合,愈合时间为4.5~9.0个月,平均临床愈合时间为6.54 ± 1.36个月,未出现骨折移位、严重感染并发症,内固定效果良好,无固定物松脱情况。其中1例二期内固定患者出现原发创口局部坏死,部分钢板外露,经按时换药、抗感染治疗1月余创口愈合。患者终末复查采用美国足踝外科学会AOFAS踝–后足评分系统(American orthopedic foot and ankle society, AOFAS)进行功能评定,总分为100分,分值越高者说明踝关节功能恢复越好。结果为功能优6例,良6例,一般1例,优良率92.31%。
图1. 伴腓骨下端骨折C3型Pion骨折(X线片)
图2. 伴腓骨下端骨折C3型Pion骨折(CT三维重建)
图3. 将游离碎骨拼接复位整合,可吸收缝线缝合固定后
图4. 骨折内固定术后(X线片)
有研究指出对pilon骨折早期进行手术内固定治疗,出现感染等并发症的机率较高(约34%) [
近年来有学者提出分期治疗方案,对开放性及软组织条件不佳的pilon骨折采取一期骨折临时固定,二期再进行骨折切开复位内固定的治疗方式,该方法目前已逐渐得到了临床医生的认可 [
本组患者术中采用锁定钢板螺钉内固定系统,其较普通解剖钢板可获得更佳坚强的固定效果,患者可进行早期功能锻炼。该系统钢板采用解剖设计,且置入不要求完全贴附;钢板、螺钉可与骨折块一体锁定,系统置入过程中不易使复位的骨折块移位,植入后不易退钉;术中对因松质骨严重压缩造成的骺端缺损部位进行植骨,钢板远端“L形”转折、排钉设计,可对复位后的远端关节面进行有效支撑,防止关节面复位后再次塌陷、移位。因伴有腓骨骨折,本组患者手术采用踝前及踝后双切口,其中利用踝关节后外侧一个手术切口同时进行腓骨骨折复位固定及后踝骨折复位固定,在简化手术过程的同时避免了额外增加切口加重软组织损伤,降低了皮肤坏死几率,利于术后康复,但术中应注意避免损伤小隐静脉及深部血管。
综上所述,作者认为对于骨折粉碎及移位明显的合并腓骨骨折的C型Pilon骨折患者,可根据具体骨折损伤情况,采用踝关节前后双切口入路进行骨折块缝合复位并结合锁定钢板内固定的治疗方法,其在实际临床治疗中有较高的应用价值。但是本文为回顾性研究分析,所选用病例数量有限,具有一定局限性,需要进一步探讨及临床观察。
金相廷,李 霞,万 岷,黄 俊,陈 锐. 骨缝合结合锁定钢板内固定治疗合并腓骨骨折的C型Pilon骨折Treatment of Type C Pilon Fractures with Fibula Fracture by Bone Suture Combined with Locking Plate Internal Fixation[J]. 外科, 2024, 13(01): 1-7. https://doi.org/10.12677/HJS.2024.131001
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