Pilon骨折的外科治疗(英文PPT加翻译).ppt

Objective:Todiscussthemethods,timingandclinicaloutcomesofsurgicaltreatmentforopenpilonfractures.Methods:FromApril2003toJuly2008,28patientswithopenpilonfracturesweretreated.AllhadtypeCfracturesaccordingtotheArbeitsgemeinschaftfrosteosynthesefragenAssociationfortheStudyofInternalFixation(AO/ASIF)classification.Threeoperativemethodswereapplied,themethodsbeingdeterminedbythetypesoffracture,softtissuedamageandtimeintervalafterinjury.,trauma创伤classification分类；分级debridement清创术、扩创术anatomicreduction解剖复位theArbeitsgemeinschaftfrosteosynthesefragen瑞士骨折内固定协会/AOBurwell-Charnleyscore骨折复位放射学评价标准1965Orthopaedic骨科的；整形外科的,Complication并发症sloughing蜕皮；脱落post-traumaticarthritisrats创伤后关节炎Thorough彻底地ranti-infectivemedication抗感染药物occurrencekr()ns发生tibialtbl胫骨的talustels距骨softtissuedegloving(套袖状的)软组织撕裂,metaphyseal干骺端的,Sevencasesweretreatedbydebridementandinternalfixationwithplate;19bylimitedinternalfixationcombinedwithexternalfixation;and2bydelayedsurgery.TheclinicaloutcomeswereevaluatedbytheBurwell-Charnleyscore.Results:Allcaseswerefollowedupforfrom6to48months(average24months).TheBurwell-Charnleyscoreofclinicaloutcomes:anatomicreductionachievedin12cases,functionalreductionin15,andunsatisfactoryreductionin1.,Thehealingtimewasfrom2.5to11months(average4.7months).Twocaseshaddelayedunion.AccordingtotheAmericanOrthopaedicFootandAnkleSociety(AOFAS)scalefortheanklejoint,therewereexcellentresultsin8cases,goodin14,fairin5andpoorin1.Complicationsincludedfourcasesofskinsuperficialsloughing,twoofsuperficialinfection,oneofdeepinfection,twoofdelayedfractureunionandtenofpost-traumaticarthritis.,Thoroughdebridement,properuseofanti-infectivemedication,appropriatebonegrafting,andpostoperativeanklefunctionexercisecanreducetheoccurrenceofcomplications.,trauma创伤classification分类；分级debridement清创术、扩创术anatomicreduction解剖复位Complication并发症sloughing蜕皮；脱落post-traumaticarthritisrats创伤后关节炎Thorough彻底地r,anti-infectivemedication抗感染药物occurrencekr()ns发生tibialtbl胫骨的；tibiatb胫骨talustels距骨softtissuedegloving软组织撕裂lowerlimbfractures下肢骨折degloving套袖状撕裂metaphyseal干骺端的articulardepression关节压缩weightbearingarea负重区,implant内植物approach方法correspondencen.通信；一致；相当DOI：数字对象唯一标识符bilaterallybailtrli双边地malleolusmlils踝clinic临床；诊所motor发动机vehiclevikl（车辆）accident,Openfracturescomprisesabout10%to30%ofallpilonfractures3.Thesefracturesareoftenassociatedwithsignificantsofttissuedegloving,metaphysealbonedefectsandarticulardepression.,IntroductionPilonfractureconstitutes1%ofalllowerlimbfracturesandabout3%to10%oftibialfractures1,2.Itisusuallytheresultofhighenergyinjurytotheweightbearingareaofthelowerendofthetibiabythetalus.,Conclusion:Itisimportanttoperformappropriatesurgeriesforopenpilonfractureaccordingtofractureclassification,differentdamagetoskinandtissueandtimeintervalafterinjury.,Keywords:Delayedoperation;Externalfixators;Fracturesopen;Internalfixators,Inspiteofimprovementsinsurgicalapproachesandimplants,treatmentoftibialpilonfracturesremainschallenging4.,Inthepresentstudy,wediscussthemethods,timingandclinicaloutcomesofsurgicaltreatmentforopenpilonfractures.,AddressforcorrespondenceXian-tieZeng,MD,DepartmentofTrauma,TianjinHospital,Tianjin,China300211Tel:0086Fax:008602224151288;Email:zengxiantieReceived:19July2010;accepted5October2010DOI:10.1111/j.1757-7861.2010.00113.x,MaterialsandMethodsPatientdataFromApril2003toJuly2008,28patientswithopentibialpilonfracturesweretreatedinourhospital.,Therewere21menand7womenwithanaverageageof36.5years(range,1961years).Tenpatientswereinjuredontheleftside,17ontherightand1bilaterally(aclosedfractureoftherightmalleolus（踝）wasnotcounted).,Theintervalbetweeninjuryandpresentationtoourclinicrangedfrom1to14hours(average,5.1hours).Themechanismsofinjurywerehigh-energyfallsin10cases,motorvehicleaccidentsin12,crushinginjury（挤压伤）in4cases,andsportsinjuriesin2.,ThefractureswereclassifiedaccordingtotheAO/ASIFsystem:7wereclassifiedastypeC1,17typeC2,and4typeC3.,OpensofttissuedamagewasgradedaccordingtotheGustilosystem:4caseswereclassifiedasGustiloI,21GustiloII,2GustiloIIIA,and1GustiloIIIB.,acetabularstbjul髋臼的fibular腓骨的;fibula腓骨femoral股骨的Calcanealklkeinil跟骨的craniocerebral,kreiniusiri:brl颅脑的protocol方法、协议presentingwith伴随restoration恢复tibia胫骨,cancellouskns()ls松质骨insertion插入modified改进的cloverleaf三叶草形Anteromedial前内侧的medial内侧的posterolateral后外侧的lateral外侧的constraint约束、限制keepinginmind牢记anteroposterior前后的；正位（影像）,Combinedinjuriesincludedfibularfracturesin25cases,spinalfracturesin2,upper-armfracturesin2,ribfracturesin2,femoralfracturein1,acetabularfracturein1,calcanealfracturein1,andcraniocerebraltraumain1.,demonstrating显示Calcaneus（口Ki尼尔斯）：跟骨metatarsal跖骨的anklemortise踝关节Kirschner克氏pin克氏针,MethodsOneofthreedifferentsurgicalprotocolswasperformedinallpatients,thechoicebeingbasedontheconditionofsofttissue,typeoffractureandlengthofintervalbetweeninjuryandpresentationfortreatment.,Debridement,openreductionandinternalfixation(ORIF)ThismethodwasappliedintypeC1fracturespresentingwithlow-gradesofttissueinjury(GustiloI,II)andintervalbetweeninjuryandpresentationfortreatmentoflessthan6hours.,Sevenpatients(fourtypeC1GustiloIandthreetypeC1GustiloII)weretreatedbythismethod.,Surgicaltreatmentofthepilonfractureswasinfoursteps:(a)restorationofthecorrectlengthandstabilizationofthefibula;,(b)reconstructionofthearticularsurfaceofthetibia;(c)insertionofcancellousautografts;and(d)stabilizationofthemedialaspectofthetibiawiththeuseofamodifiedcloverleafplate.,Ananteromedialincisionwasemployedtotreatthetibialcomponentandalateralorposterolateralincisiontotreatthefibularfracture.,Thesurgicalincisionswereplannedbasedontherequirementsofthefracturepattern,keepinginmindthesoft-tissueconstraintsoftheindividualinjury.,Skinclosurewasachievedwithnotension.Thetibialincisionswereclosedfirst.Ifnecessary,thefibularincisionswereleftfordelayedclosure.,Oneofthesevenpatientsachievedprimaryclosureofthemedialincision,followedbydelayedclosureofthelateralone.AtypicalcaseisshowninFig.1.,Figure1A49year-oldmanwithalow-energyopenpilonfracture(GustiloIinbothitwasassociatedwithbonedefectsofthemedial（内侧）tibia.Onestagewoundclosurewasperformedin18patients,twounderwentdelayedclosureoftheirlateralincisions,andoneunderwentdelayedsplit-thicknessskingrafting.,Therewerefourcasesofsuperficialsloughingoftheskin.TwopatientsdevelopedsurfaceinfectionwithStaphylococcusepidermidis（表皮葡萄球菌）andAcinetobacterbaumannii（鲍氏不动杆菌）andonedevelopeddeepinfectionwithAcinetobacterbaumannii;theinfectionratewas10.7%(3/28).,Tenpatients(35.7%)showedevidenceofposttraumaticarthritis.（创伤后关节炎）AccordingtotheAOFASankle-hind（后踝）footfunctionevaluation（评估）,theaveragescorewas85.2(range,66to98):excellentin8patients,goodin14,fairin5,andpoorin1.,DiscussionChoiceofsurgicalmethodsInpatientswithtypeC1fractureandGustiloIsofttissueinjuryduetolow-energyforces,pilonfracturewasanatomicallyreducedandtreatedwithdebridementandinternalplatefixationfollowingAO/ASIFprinciples.,Openreductionandinternalfixationwereoriginally(最初)used,butitisnowknownthatopenreductionincreasestheriskofcomplicationsafterhigh-energytrauma.,Thisisprobablyrelatedtotheamountofdissection（解剖，切开）andstripping（剥离）ofsofttissueswhichisneededtoachievereductionandplatefixation.,Therefore,whenperformingORIFprocedures,thesurgeonstriedtolimitsofttissuedamageandchoosesuitableinternalfixation.,Thetibiawasreducedwithacloverleafplate,dynamiccompressionplateorlockingcompressionplate,dependingonthelevelofthefractureanddegreeofstabilityrequired.,Linetal.reportedan83.3%goodratein30casestreatedwithORIFfollowedupfor1739months5.Kalendereretal.alsoreportedasimilarresult6.,ExternalfixationandlimitedinternalfixationwereperformedinallpatientswithtypeC2andtypeC3fracturespresentingwithhigh-gradesofttissueinjury(GustiloIIandIII)andintervalbetweeninjuryandpresentationattheauthorsclinicoflessthan8hours.,Useofexternalfixationduringthesurgicalprocedureenables（使能够）thesurgeontoassess（评估）thelengthandhelpsstabilizethelimb（肢）forreconstructionoftheintra-articular（关节内）component.,Placement（放置）oftheexternalfixatorwithacalcanealpinandahalf-pininthetibiaallowsligamentotaxis（韧带修复术）tooccurthroughtractiononthecalcanealpin.,initial(首先)distraction（牵引）eliminate（清除）compromise（妥协、折衷、让步）exposure（显露，暴露）incidence（发生率）malalignment(对线不良)stiffness（僵硬）stfns,preclude（排除）Pre-existing（已存在）inviewof（鉴于，考虑到）ischemia（缺血）skimprecarious（不确定的）prkers,Thisishelpfulinreductionofthefractureandallowseasieraccessto（入路）theanklejointforjointreconstruction.,Usedasaneutralization（中和）device,thereisnoneedforlargeplateswiththeassociated（相关）increasedriskofskinsloughing7.,Minimizing（将.减到最少）internalfixationanddamagetosofttissuesandbloodsupplydecreasestherateofskinsloughingandinfection.,Wewereabletocorrectpostoperativelossofreduction（再移位）byadjustingexternalfixation.Itisalsoanexcellentdeviceinthoseseverelycomminutedfracturesthatdonotallowstablefixationwiththeuseofaplate.,Severalresearchershavereportedsimilarfindingsinregardto（关于）externalfixation811.,Ourresultsleadustorecommend(建议，推荐)thatTypeC3tibialpilonfracturespresentingwithhigh-gradesofttissueinjury(GustiloIII)andintervalbetweeninjuryandpresentationfortreatmentofmorethan8hoursshouldbetreatedwithatwo-stageprocedure.,Atinitial(首先)presentation,anexternalfixatorisapplied.Afterthesofttissueshaverecovered,thesecondstageisperformed.,Thegoalofthefirststageistore-establishthelength,alignmentandrotationoftheextremityandprovideanenvironmentforsoft-tissuerecovery.,Theearlyapplicationofadistraction（牵引）forcemayhelptolimitanysecondaryinjuryandeliminate（清除）additionalsofttissuecompromise（妥协、折衷、让步）duringsurgicalexposure（显露，暴露）12.,Severalreportshaveshownthatthetwo-stageprocedurecanreducetherateofcomplicationssuchasinfection,skinsloughing,andpost-traumaticarthritis1315.,Preventionofpostoperativecomplications.Ithasbeenreportedthattheincidence（发生率）ofcomplications,includingwoundproblems,skinsloughing,infection,nonunion,malalignment(对线不良),jointstiffness（僵硬）andposttraumaticarthritis,ishigh(45.1%)inpatientswithseverepilonfractures16.,Skinsloughingandinfectionarethemostimportantearlypostoperativecomplications17.Pre-existing（已存在）severesofttissueinjuryprecludes（不能）openreductioninviewof（考虑到）thepotentialwoundproblemsduetoischemia（缺血）orinfectionofthesofttissues.,Theprecarious（不确定的）bloodsupplyinthisregionofthetibiacancontributeto（有助于）theproblemsofbothnonunionandinfection18.,Intensive（加强的）outweigh（胜过，强过）lateralcolumn(外侧柱)ligament（韧带）taxis（整复）circularframes（圆形框架）hybridsystems（混合系统）habrd,hingeaxis（铰链轴）hndplastercast（石膏）optimal（最佳的）manuscript（手稿，文章）,Inthepresentstudy,therewerefourcasesofskinsloughing,twoofsuperficialinfections,andonlyoneofdeepboneinfection.,Surgicalapproachesarenowplannedbasedontherequirementsofthefracturepattern,keepinginmindthesoft-tissueconstraintsoftheindividualinjury.,Theincisionsarekeptatleast7cmaparttopreventsoft-tissueischemiaandsecondarywoundbreakdown.,Intensive（加强的）debridement,minimizationofsofttissuestrippingandproperuseofantibioticsareusefulforpreventinginfection.,Delayedunion,especiallyinthemetaphysealportion,isalsoaproblemwithpilonfractures.Wenoteda7.1%delayedunionrateinthisseries.,Theseverityoftheinjuryandpoorbloodsupplytothedistaltibiamayoutweigh（胜过，强过）theaffectsofanyparticularapproachwhenitcomestononunionordelayedunion,anditisalsoprobablycausedbytibialbonedefectafterfixationofthefibula.Butthereisnotdecidedforthefibulafixation19,20.,Wethinkthatfibularfractureshouldbefixedtorestorethelengthofthelateralcolumn(柱)ofthetibiaindirectlyvialigament（韧带）taxis（整复）.Megasetal.havereportedthatthenonunionrateindistaltibialfractureishigherthaninotherlongbonefractures.,Itcanlikelybepreventedbyminimizingsoft-tissuestrippingandusingstableinternalfixationinassociationwithsuitablebonegraft.,Post-traumaticarthritisisaseriouscomplication.Wyrschetal.believethatarthritisispossiblycausedbydamagetoarticularcartilage(软骨)andlong-termimmobilizationwithex