【摘要】：背景介紹:復(fù)雜脛骨平臺(tái)骨折通常為年輕患者遭受高能量創(chuàng)傷或骨質(zhì)疏松的年老患者遭受低能量創(chuàng)傷后造成。治療目的需達(dá)到解剖復(fù)位,穩(wěn)定的內(nèi)固定與早期活動(dòng)并盡量減少并發(fā)癥�；颊甙l(fā)生復(fù)雜脛骨平臺(tái)骨折后的圍手術(shù)期管理在于防止神經(jīng)與血管損傷,穩(wěn)定患者生命體征直到手術(shù)。復(fù)雜脛骨平臺(tái)骨折的傳統(tǒng)治療為切開復(fù)位內(nèi)固定,主要在于能夠達(dá)到良好的解剖復(fù)位和對(duì)齊,但術(shù)中對(duì)軟組織的廣泛剝離與損傷干擾骨的血運(yùn)重建。MIPO(Minimally invasive percutaneous plate osteosynthesis,微創(chuàng)經(jīng)皮鋼板固定術(shù))最初用來(lái)治療股骨近端與遠(yuǎn)端骨折,最近開始用于治療復(fù)雜脛骨近端骨折。MIPO技術(shù)在于達(dá)到對(duì)關(guān)節(jié)及關(guān)節(jié)周圍骨折既定的治療目標(biāo)的同事,保護(hù)軟組織,減少剝離骨膜。目的:多數(shù)骨科醫(yī)生在對(duì)于復(fù)雜脛骨平臺(tái)骨折的切開復(fù)位內(nèi)固定(ORIF)治療時(shí)傾向于選擇關(guān)節(jié)切開術(shù),便于直觀關(guān)節(jié)面,達(dá)到良好的關(guān)節(jié)復(fù)位。雖然有半月板下關(guān)節(jié)切開術(shù)中,遭切割的半月板及周圍軟組織術(shù)后得到了愈合的報(bào)道,但我們不禁疑惑:關(guān)節(jié)切開術(shù)的必要性有多大?或是否能不行關(guān)節(jié)切開術(shù)但實(shí)現(xiàn)相同甚至更好的結(jié)果?本研究即評(píng)估了在治療復(fù)雜脛骨平臺(tái)骨折時(shí),較傳統(tǒng)的切開復(fù)位內(nèi)固定術(shù),雙側(cè)牽引快速?gòu)?fù)位裝置是否能夠增加微創(chuàng)經(jīng)皮鋼板內(nèi)固定術(shù)的使用,從而在恢復(fù)關(guān)節(jié)穩(wěn)定,對(duì)齊及固定關(guān)節(jié)的同時(shí)減少軟組織損傷。方法:收集2014年9月到2016年6月期間于我院住院的脛骨平臺(tái)骨折患者共31例。所有31例患者均有手術(shù)治療指正。將病例分為2組,A組(對(duì)照組)共17人、B組14人。A組患者為10名女性與7名男性,B組患者為5名女性與9名男性。本研究使用Schatzker系統(tǒng)對(duì)患者進(jìn)行分類。A組骨折分類如下:II型4例,III型2例,IV型3例,V型4例,另4例為Ⅵ型。B組骨折分類如下:II型3例,III型2例,IV型1例,V型5例和VI型3例。A組作為對(duì)照組,大多使用傳統(tǒng)手術(shù)治療,術(shù)者為了取得更好的手術(shù)視野在助手手動(dòng)牽引下行關(guān)節(jié)切開術(shù)。B組,通過使用雙側(cè)牽引快速?gòu)?fù)位裝置實(shí)現(xiàn)MIPO,不需要助手人為牽拉分離患肢同時(shí)保持穩(wěn)定。雙側(cè)牽引快速?gòu)?fù)位裝置主要由復(fù)位支架、牽引弓、牽引銷、連桿、復(fù)位輔助銷(尚茨銷或柯式線)和近端連接裝置構(gòu)成�？焖�?gòu)?fù)位器通過兩個(gè)牽引弓一頭連接到遠(yuǎn)端股骨,另一頭脛骨遠(yuǎn)端或跟骨。兩個(gè)牽引弓通過連桿連接形成一個(gè)機(jī)械閉環(huán)系統(tǒng),產(chǎn)生強(qiáng)大的力量來(lái)復(fù)位并穩(wěn)定骨折部位。骨折復(fù)位、手術(shù)、透視操作與術(shù)中失血量的數(shù)據(jù)均詳細(xì)收集記錄。同時(shí)此研究評(píng)估了關(guān)節(jié)切開術(shù)的必要性。研究中記錄了兩組患者的平均住院時(shí)間。使用HSS評(píng)分系統(tǒng)評(píng)價(jià)功能恢復(fù)與臨床療效。A組平均隨訪14.06個(gè)月,B組評(píng)價(jià)隨訪12.5個(gè)月。結(jié)果:未見雙側(cè)牽引快速?gòu)?fù)位裝置導(dǎo)致的直接或間接相關(guān)并發(fā)癥。兩組患者無(wú)術(shù)后感染、皮膚壞死或不愈合。手術(shù)時(shí)間主要用于暴露術(shù)野,對(duì)脛骨平臺(tái)的復(fù)位和固定,以及透視。A組患者的平均手術(shù)時(shí)間為180.9分鐘,平均術(shù)中失血量為249.4ml,平均隨訪時(shí)間為14.06個(gè)月。相比較B組患者平均手術(shù)時(shí)間為135分鐘,平均術(shù)中失血量為121.8ml,平均隨訪時(shí)間為12.5個(gè)月。A組患者的平均住院日為7天,B組的平均住院日為4天。骨愈合的平均時(shí)間A組為12.2周,B組為10.5周,其中A組有3例患者出現(xiàn)骨折延遲愈合,B組無(wú)此現(xiàn)象。A組和B組平均HSS評(píng)分分別為89.3和94.9。結(jié)論:MIPO對(duì)于骨折處軟組織有良好的保護(hù)作用。治療復(fù)雜脛骨平臺(tái)骨折時(shí)對(duì)相關(guān)軟組織的保護(hù)已成為主要目標(biāo)之一。雙側(cè)牽引快速?gòu)?fù)位裝置作為一個(gè)良好的設(shè)計(jì),成為提高治療復(fù)雜脛骨平臺(tái)骨折時(shí)使用MIPO技術(shù)使用率的有效手段。雙側(cè)牽引快速?gòu)?fù)位裝置能減少軟組織剝離與骨血管損傷。從而使減少了手術(shù)時(shí)間,減少患者術(shù)中失血量,取得了滿意的臨床療效。雙側(cè)牽引快速?gòu)?fù)位裝置可穩(wěn)定骨折處處于解剖位,無(wú)需人工助手術(shù)中持續(xù)人手牽引控制。B組患者較對(duì)照組骨折愈合好,并取得了良好的功能恢復(fù)。雙側(cè)牽引快速?gòu)?fù)位裝置方便使用的特性為復(fù)雜脛骨平臺(tái)骨折臨床治療提供了合理的解決方案。
[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.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3

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