复杂胫骨平台骨折手术治疗的病例对照研究

摘要

目的:探讨闭合性复杂胫骨平台骨折最佳手术时机与手术入路的选择及其影响因素.方法:2003年1月至2011年1月,分别采用膝前外侧单切口单钢板法(A组,22例)、膝内外侧双切口双钢板法(B组,36例)、膝前正中直切口双钢板法(C组,37例)治疗SchatzkerV、Ⅵ型胫骨平台骨折95例,其中男56例,女39例；年龄19～57岁,平均36.3岁.左侧50例,右侧45例.按Schatzker分型:V型51例,Ⅵ型44例.观察手术时间,术中失血量,术后并发症发生情况(包括伤口深浅部感染、切口坏死、切口愈合不良、骨折塌陷、内固定松动、断裂失效等)、骨折愈合情况(连续骨痂形成时间)及术后下肢关节功能恢复情况.结果:3组患者骨折愈合时间差异无统计学意义(P＞0.05)；膝前外侧单切口单钢板组手术出血量明显少于其他两组(P＜0.05)；膝前外侧单切口单钢板组关节面再塌陷发生率及内固定失效率明显高于其他两组(P＜0.05).3组术后1年Merchant评分:膝内外侧双切口双钢板组与膝前正中直切口双钢板组在日常活动功能、步态、活动范围及总分方面均明显优于膝前外侧单切口单钢板组(P＜0.05).下肢功能评定结果:膝前外侧单切口单钢板纽,优10例,良5例,可4例,差3例；膝内外侧双切口双钢板组:优21例,良11例,可3例,差1例；膝前正中直切口双钢板组,优23例,良11例,可2例,差1例.结论:膝前外侧单切口单钢板法术中出血量最少,但无法满意显露骨折断端与关节面,无法提供坚强的固定效果,远期疗效差；对于累及双髁及移位明显的复杂胫骨平台骨折仍建议行双切口或膝前单切口双钢板法治疗,有利于关节面的复位及骨折的坚强固定、早期锻炼.%Objective:To explore optimal choice of surgical treatment and operative approach for closed complex tibial plateau fractures and its influencing factors. Methods;From January 2003 to January 2011,95 patients with closed complex tibial plateau fractures were estimated Schatzker Ⅴ and Ⅳ, and treated with three different surgical methods. The methods included single plate through anterolateral incision (Group A,22 cases) ,double plates through inside and outside incisions (Group B,36 cases) ,and double plates through antero-midline incisions (Group C,37 cases). There were 56 males and 39 females,ranged the age from 19 to 57 years (averaged,36.3 years),50 cases in left,45 cases in right. According to Schatzker classification,51 cases were type Ⅴ ,44 cases were Ⅳ. The data of operation time,intraoperative blood loss,complications(infectious of wound,necrosis,bad incision,collapse fracture,loosen of internal fixation,fracture failure)and recovery of function of lower limb joint were collected. Results: There were no significant difference among three groups in operation time (P> 0.05); blood loss in goup A was obvious better than other groups (P<0.05); collapse of joint surface and failure rate of internal fixation in group A was higher than other groups(P>0.05) ;Merchant score after 1 year were higher in group B,C than group A. For lower limb function, 10 cases got excellent results,5 good,4 fair and 3 poor in group A;21 cases got excellent results, 11 good,3 fair and 1 poor in group B;23 cases got excellent results, 11 good,2 fair and 1 poor in group C. Conclusion:The blood loss in group A was least,but fracture exposure and joint surface was not satisfactory,and stable fixation could not be achieved, the long-term result was not good. For fractures with double condyles and dislocated involved, double plates through inside and outside incisions or double plates through antero-midline incisions was suggested,which benefit good reduction of joint surface , stable fixation, and erlier exercise.