Pilon骨折的外科治疗(英文PPT加翻译).ppt

Objective Todiscussthemethods timingandclinicaloutcomesofsurgicaltreatmentforopenpilonfractures Methods FromApril2003toJuly2008 28patientswithopenpilonfracturesweretreated AllhadtypeCfracturesaccordingtotheArbeitsgemeinschaftf rosteosynthesefragen AssociationfortheStudyofInternalFixation 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theArbeitsgemeinschaftf rosteosynthesefragen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 traumaticarthritis ra t s 创伤后关节炎Thorough彻底地 r anti infectivemedication抗感染药物occurrence k r ns 发生tibial t b l 胫骨的talus te l s 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 traumaticarthritis ra t s 创伤后关节炎Thorough彻底地 r anti infectivemedication抗感染药物occurrence k r ns 发生tibial t b l 胫骨的 tibia t b 胫骨talus te l s 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bilaterally bai l t r li 双边地malleolus m li l s 踝clinic临床 诊所motor发动机vehicle vi kl 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 0086 022 24151288 Fax 008602224151288 Email zengxiantie Received 19July2010 accepted5October2010DOI 10 1111 j 1757 7861 2010 00113 x MaterialsandMethodsPatientdataFromApril2003toJuly2008 28patientswithopentibialpilonfracturesweretreatedinourhospital Therewere21menand7womenwithanaverageageof36 5years range 19 61years 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 acetabular s t bjul 髋臼的fibular腓骨的 fibula腓骨femoral股骨的Calcaneal k l keini l跟骨的craniocerebral kreini usi ri br l颅脑的protocol方法 协议presentingwith伴随restoration恢复tibia胫骨 cancellous k ns l s 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 GustiloI C1 a Photographshowingopensofttissueinjury GustiloI b PreoperativeanteroposteriorandlateralradiographsshowingPilonfractureoftypeC1 c Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithplates d Anteroposteriorandlateralradiographsdemonstratingfractureshavehealed1yearaftersurgery Figure2A22year oldmanwithahigh energyopenpilonfracture GustiloII C2 a Photographshowingopensofttissueinjury GustiloII b PreoperativeradiographsshowingPilonfractureoftypeC2 c Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithexternalfixation andthetibialfracturefixedwithlimitedinternalfixation d Anteroposteriorandlateralradiographsdemonstratingthefractureshavehealed1 5yearaftersurgery Debridement limitedORIFandexternalfixationThismethodwasappliedintypeC2andtypeC3fracturespresentingwithhigh gradesofttissueinjury GustiloII III andintervalbetweeninjuryandpresentationfortreatmentoflessthan8hours Nineteenpatients 16typeC2GustiloII 1typeC2GustiloIIIA and2typeC3GustiloII weretreatedbythismethod Thepatientsweremanagedbyimmediate 直接的 debridementofthewound Fibularfractureswerealwaysinternallyfixed eitherwitha1 3tubular 管状的 plateor3 5mmcompressionplate Externalfixationwasappliedacrosstheanklejointwithpinsinthecalcaneus metatarsalbone andtibia reconstructionoftheanklemortise 踝关节 andstabilizationwithscrewsorKirschnerpins split thicknessskingrafting厚皮瓣转移splint夹板edema 水肿 antibiotic 抗生素 extent 范围 contamination 污染 Theaffectedextremity 下肢 elevate抬高 提高subtalar 距下 proscribe 禁止 supervise 指导 physicaltherapyprogram 康复锻炼 Roll A Boutwalker 助行器 outpatients 门诊就诊 Staphylococcusepidermidis 表皮葡萄球菌 Acinetobacterbaumannii 鲍氏不动杆菌 Fiveofthe19patientsrequiredbonegraftingbecauseoflargedefectsofmetaphysealbone Onecaseunderwentdelayedclosureofthelateralincision anddelayedsplit thicknessskingraftingwasappliedinanothercase AtypicalcaseisshowninFig 2 posttraumaticarthritis 创伤后关节炎 ankle hind 后踝 Debridementandcalcanealtraction delayedsurgeryThismethodwasappliedintypeC3fracturesaccompaniedbyhigh gradesofttissueinjury GustiloIII andintervalbetweeninjuryandpresentationfortreatmentofmorethan8hours Intwopatients onetypeC3GustiloIIIA onetypeC3GustiloIIIB thesurgeonchoseatwostageprocedure 步骤 ThepatientswereputoncalcanealpinskeletaltractionwithelevationofthelowerlimboveraBohler Braunsplint 勃朗支架 andmeasuresweretakentoavoidedema 水肿 Wounddrainage 引流管 wasremovedwhentherewasnofurtherevidenceofinfection andasecondstageoperationwasperformedwhentheedemahadalmostcompletelyresolved ThepatientsweretreatedwithlimitedORIFandexternalfixation Thetimeintervalbetweenthetwosurgerieswas15and19days respectively AtypicalcaseisshowninFig 3 Figure3A37year oldmanwithasuperhigh energyopenpilonfracture GustiloIIIB C3 a Photographshowingopensofttissueinjury GustiloIIIB b PreoperativeradiographsshowingPilonfractureoftypeC3 c Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithexternalfixation thetibialfixedwithlimitedinternalfixation andthefibulawithaplate d Anteroposteriorandlateralradiographsdemonstratingthefractureshavehealed1 5yearaftersurgery PostoperativecareAppropriatecultures 培养 wereobtainedduringsurgery andbroad spectrumantibiotics 广谱抗生素 wereadministered 执行 使用 Thechoiceofantibiotic 抗生素 wasbasedontheextent 范围 anddegreeofcontamination 污染 Activeankleandsubtalar 距下 jointrange of motionexerciseswerebegunassoonasthewoundwasdry usuallybetween2and5daysaftersurgery Weight bearingexercisewasproscribed 禁止 inthefirst12weeksaftersurgery Asupervised 指导 physicaltherapyprogram 康复锻炼 encouragingactiveanklerange of motionexerciseswasemployedforthefirst6weeks Thiswasprogressedtoincludepassiveexercisesbetween6and12weeks ARoll A Boutwalker 助行器 wasusedwhennecessary Theaffectedextremity 下肢 waselevated 提高 continuouslyforthefirst48hoursandthen asmuchaspossible forthenext7days procedure 步骤 broad spectrumantibiotics 广谱抗生素 extremity手足outpatients 门诊就诊 medial 内侧 originally 最初 dissection 解剖 切开 stripping 剥离 posttraumaticarthritis 创伤后关节炎 ankle hind 后踝 originally 最初 dissection 解剖 切开 stripping 剥离 ligamentotaxis 韧带修复术 neutralization 中和 inregardto 关于 RadiographswereobtainedandevaluatedaccordingtotheBurwellCharnleysystem anatomicreductionwasachievedin12cases functionalreductionin15cases andpoorreductionin1case Thehealingtimeofthefracturewasfrom2 5to11months withanaverageof4 7months ResultsAll28patientswerefollowedupfrom6to48monthswithanaverageof24months andunderwentclinicalandradiologicalexaminationasoutpatients 门诊就诊 Delayedunionwasfoundintwocases inbothitwasassociatedwithbonedefectsofthemedial 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 goodratein30casestreatedwithORIFfollowedupfor17 39months5 Kalendereretal alsoreportedasimilarresult6 ExternalfixationandlimitedinternalfixationwereperformedinallpatientswithtypeC2andtypeC3fracturespresentingwithhigh gradesofttissueinjury GustiloIIandIII andintervalbetweeninjuryandpresentationattheauthors clinicoflessthan8hours 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 st fn s preclude 排除 Pre existing 已存在 inviewof 鉴于 考虑到 ischemia 缺血 s kim precarious 不确定的 pr ke r s 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 externalfixation8 11 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 traumaticarthritis13 15 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 ha br d hingeaxis 铰链轴 h nd plastercast 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 Wethinkthatfibularfractureshouldbefixedt