Pilon骨折的外科治疗(英文加翻译)

Received:19July2010;accepted5October2010

DOI:10.1111/j.1757-7861.2010.00113.x

目前十六页\总数一百零九页\编于十五点MaterialsandMethods

Patientdata

FromApril2003toJuly2008,28patientswithopentibialpilonfracturesweretreatedinourhospital.

目前十七页\总数一百零九页\编于十五点Therewere21menand7womenwithanaverageageof36.5years(range,19–61years).Tenpatientswereinjuredontheleftside,17ontherightand1bilaterally(aclosedfractureoftherightmalleolus（踝）wasnotcounted).目前十八页\总数一百零九页\编于十五点Theintervalbetweeninjuryandpresentationtoourclinicrangedfrom1to14hours(average,5.1hours).Themechanismsofinjurywerehigh-energyfallsin10cases,motorvehicleaccidentsin12,crushinginjury（挤压伤）in4cases,andsportsinjuriesin2.

目前十九页\总数一百零九页\编于十五点ThefractureswereclassifiedaccordingtotheAO/ASIFsystem:7wereclassifiedastypeC1,17typeC2,and4typeC3.

目前二十页\总数一百零九页\编于十五点OpensofttissuedamagewasgradedaccordingtotheGustilosystem:4caseswereclassifiedasGustiloI,21GustiloII,2GustiloIIIA,and1GustiloIIIB.

目前二十一页\总数一百零九页\编于十五点acetabularæsə'tæbjulə]髋臼的fibular腓骨的;fibula腓骨femoral股骨的Calcaneal[kæl'keiniəl跟骨的craniocerebral[,kreiniəusi'ri:brəl颅脑的protocol方法、协议presentingwith伴随restoration恢复

tibia胫骨目前二十二页\总数一百零九页\编于十五点cancellous

['kæns(ə)ləs]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）目前二十三页\总数一百零九页\编于十五点Combinedinjuriesincludedfibularfracturesin25cases,spinalfracturesin2,upper-armfracturesin2,ribfracturesin2,femoralfracturein1,acetabularfracturein1,calcanealfracturein1,andcraniocerebraltraumain1.

目前二十四页\总数一百零九页\编于十五点demonstrating显示

Calcaneus（口Ki尼尔斯）：跟骨metatarsal跖骨的anklemortise踝关节Kirschner克氏pin克氏针目前二十五页\总数一百零九页\编于十五点Methods

Oneofthreedifferentsurgicalprotocolswasperformedinallpatients,thechoicebeingbasedontheconditionofsofttissue,typeoffractureandlengthofintervalbetween

injuryandpresentationfortreatment.

目前二十六页\总数一百零九页\编于十五点Debridement,open

reductionand

internalfixation(ORIF)

ThismethodwasappliedintypeC1fracturespresentingwithlow-gradesofttissueinjury(GustiloI,II)andintervalbetweeninjuryandpresentationfortreatmentoflessthan6hours.

目前二十七页\总数一百零九页\编于十五点Sevenpatients(fourtypeC1GustiloIandthreetypeC1GustiloII)weretreatedbythismethod.

目前二十八页\总数一百零九页\编于十五点Surgicaltreatmentofthepilonfractureswasinfoursteps:(a)restorationofthecorrectlengthandstabilizationofthefibula;目前二十九页\总数一百零九页\编于十五点

(b)reconstructionofthearticularsurfaceofthetibia;(c)insertionofcancellousautografts;and(d)stabilizationofthemedialaspectofthetibiawiththeuseofamodifiedcloverleafplate.

目前三十页\总数一百零九页\编于十五点Ananteromedialincisionwasemployedtotreatthetibialcomponentandalateralorposterolateralincisiontotreatthefibularfracture.

目前三十一页\总数一百零九页\编于十五点Thesurgicalincisionswereplannedbasedontherequirementsofthefracturepattern,keepinginmindthesoft-tissueconstraintsoftheindividualinjury.目前三十二页\总数一百零九页\编于十五点Skinclosurewasachievedwithnotension.Thetibialincisionswereclosedfirst.Ifnecessary,thefibularincisionswereleftfordelayedclosure.

目前三十三页\总数一百零九页\编于十五点Oneofthesevenpatientsachievedprimaryclosureofthemedialincision,followedbydelayedclosureofthelateralone.AtypicalcaseisshowninFig.1.目前三十四页\总数一百零九页\编于十五点Figure1

A49year-oldmanwithalow-energyopenpilonfracture(GustiloI&C1)(a)Photographshowingopensofttissueinjury(GustiloI).(b)PreoperativeanteroposteriorandlateralradiographsshowingPilonfractureoftypeC1.(c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithplates.(d)Anteroposteriorandlateralradiographsdemonstratingfractureshavehealed1yearaftersurgery.

目前三十五页\总数一百零九页\编于十五点目前三十六页\总数一百零九页\编于十五点Figure2A22year-oldmanwithahigh-energyopenpilonfracture(GustiloII&C2)(a)Photographshowingopensofttissueinjury(GustiloII).(b)PreoperativeradiographsshowingPilonfractureoftypeC2.

目前三十七页\总数一百零九页\编于十五点(c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithexternalfixation,andthetibialfracturefixedwithlimitedinternalfixation.(d)Anteroposteriorandlateralradiographsdemonstratingthefractureshavehealed1.5yearaftersurgery.

目前三十八页\总数一百零九页\编于十五点Debridement,limited

ORIF

and

externalfixation

ThismethodwasappliedintypeC2andtypeC3fracturespresentingwithhigh-gradesofttissueinjury(GustiloII,III)andintervalbetweeninjuryandpresentationfortreatmentoflessthan8hours.

目前三十九页\总数一百零九页\编于十五点Nineteenpatients(16typeC2GustiloII,1typeC2GustiloIIIA,and2typeC3GustiloII)weretreatedbythismethod.

目前四十页\总数一百零九页\编于十五点Thepatientsweremanagedbyimmediate（直接的）debridementofthewound.Fibularfractureswerealwaysinternallyfixed,eitherwitha1/3tubular（管状的）plateor3.5mmcompressionplate.

目前四十一页\总数一百零九页\编于十五点Externalfixationwasappliedacrosstheanklejointwithpinsinthecalcaneus,metatarsalbone,andtibia,reconstructionoftheanklemortise（踝关节）,andstabilizationwithscrewsorKirschnerpins.

目前四十二页\总数一百零九页\编于十五点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）目前四十三页\总数一百零九页\编于十五点proscribe（禁止）supervise（指导）physicaltherapy

program（康复锻炼）Roll-A-Boutwalker（助行器）outpatients(门诊就诊)Staphylococcus

epidermidis（表皮葡萄球菌）Acinetobacterbaumannii（鲍氏不动杆菌）目前四十四页\总数一百零九页\编于十五点Fiveofthe19patientsrequiredbonegraftingbecauseoflargedefectsofmetaphysealbone.Onecaseunderwentdelayedclosureofthelateralincision,anddelayedsplit-thicknessskingraftingwasappliedinanothercase.AtypicalcaseisshowninFig.2.

目前四十五页\总数一百零九页\编于十五点posttraumaticarthritis.（创伤后关节炎）

ankle-hind（后踝）目前四十六页\总数一百零九页\编于十五点Debridement

and

calcaneal

traction,delayedsurgeryThismethodwasappliedintypeC3fracturesaccompaniedbyhigh-gradesofttissueinjury(GustiloIII)and

intervalbetweeninjuryandpresentationfortreatmentof

morethan8hours.目前四十七页\总数一百零九页\编于十五点Intwopatients(onetypeC3Gustilo

IIIA,onetypeC3GustiloIIIB),thesurgeonchoseatwo

stageprocedure（步骤）.目前四十八页\总数一百零九页\编于十五点Thepatientswereputoncalcanealpin

skeletaltractionwithelevationofthelowerlimbovera

Bohler–Braunsplint（勃朗支架）,andmeasuresweretakentoavoid

edema（水肿）.目前四十九页\总数一百零九页\编于十五点Wounddrainage（引流管）wasremovedwhentherewasno

furtherevidenceofinfection,andasecondstageoperationwasperformedwhentheedemahadalmostcompletelyresolved.目前五十页\总数一百零九页\编于十五点ThepatientsweretreatedwithlimitedORIFandexternalfixation.Thetimeintervalbetweenthetwosurgerieswas15and19days,respectively.Atypical

caseisshowninFig.3目前五十一页\总数一百零九页\编于十五点目前五十二页\总数一百零九页\编于十五点Figure3A37year-oldmanwithasuperhigh-energyopenpilonfracture(GustiloIIIB&C3)(a)Photographshowingopensofttissueinjury(GustiloIIIB)(b)PreoperativeradiographsshowingPilonfractureoftypeC3.目前五十三页\总数一百零九页\编于十五点(c)Postoperativeradiographsshowingthefractureshave

beenanatomicallyreducedandfixedwithexternalfixation,thetibialfixedwithlimitedinternalfixation,andthefibulawithaplate.(d)Anteroposteriorandlateralradiographsdemonstratingthefractureshavehealed1.5yearaftersurgery.目前五十四页\总数一百零九页\编于十五点PostoperativecareAppropriatecultures（培养）wereobtainedduringsurgery,and

broad-spectrumantibiotics（广谱抗生素）wereadministered.（执行，使用）

The

choiceofantibiotic（抗生素）wasbasedontheextent（范围）anddegreeof

contamination（污染）.

目前五十五页\总数一百零九页\编于十五点Activeankleandsubtalar（距下）jointrange-of-motionexerciseswerebegunassoonasthe

woundwasdry,usuallybetween2and5daysaftersurgery.Weight-bearingexercisewasproscribed（禁止）inthefirst12

weeksaftersurgery.目前五十六页\总数一百零九页\编于十五点Asupervised（指导）physicaltherapy

program（康复锻炼）encouragingactiveanklerange-of-motionexerciseswasemployedforthefirst6weeks.Thiswasprogressedtoincludepassiveexercisesbetween6and12

weeks.ARoll-A-Boutwalker（助行器）wasusedwhennecessary.目前五十七页\总数一百零九页\编于十五点Theaffectedextremity（下肢）waselevated（提高）continuouslyforthefirst48hoursandthen,asmuchas

possible,forthenext7days.目前五十八页\总数一百零九页\编于十五点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）目前五十九页\总数一百零九页\编于十五点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）in

regardto（关于）目前六十页\总数一百零九页\编于十五点Radiographs

wereobtainedandevaluatedaccordingtotheBurwell

Charnleysystem:anatomicreductionwasachieved

in12cases,functionalreductionin15cases,andpoorreductionin1case.目前六十一页\总数一百零九页\编于十五点Thehealingtimeofthefracturewasfrom2.5to11months,withanaverageof4.7months.目前六十二页\总数一百零九页\编于十五点Results

All28patientswerefollowedupfrom6to48months

withanaverageof24months,andunderwentclinicaland

radiologicalexaminationasoutpatients(门诊就诊).目前六十三页\总数一百零九页\编于十五点Delayedunionwasfoundintwocases;inbothitwas

associatedwithbonedefectsofthemedial（内侧）tibia.Onestage

woundclosurewasperformedin18patients,twounderwentdelayedclosureoftheirlateralincisions,andone

underwentdelayedsplit-thicknessskingrafting.目前六十四页\总数一百零九页\编于十五点There

werefourcasesofsuperficialsloughingoftheskin.Two

patientsdevelopedsurfaceinfectionwithStaphylococcus

epidermidis（表皮葡萄球菌）andAcinetobacterbaumannii（鲍氏不动杆菌）andonedevelopeddeepinfectionwithAcinetobacterbaumannii;the

infectionratewas10.7%(3/28).目前六十五页\总数一百零九页\编于十五点Tenpatients(35.7%)

showedevidenceofposttraumaticarthritis.（创伤后关节炎）

Accordingto

theAOFASankle-hind（后踝）footfunctionevaluation（评估）,the

averagescorewas85.2(range,66to98):excellentin8

patients,goodin14,fairin5,andpoorin1.目前六十六页\总数一百零九页\编于十五点DiscussionChoiceofsurgicalmethodsInpatientswithtypeC1fractureandGustiloIsoft

tissueinjuryduetolow-energyforces,pilonfracturewas

anatomicallyreducedandtreatedwithdebridementandinternalplatefixationfollowingAO/ASIFprinciples.目前六十七页\总数一百零九页\编于十五点Openreductionandinternalfixationwereoriginally(最初)used,butitisnowknownthatopenreductionincreasestherisk

ofcomplicationsafterhigh-energytrauma.目前六十八页\总数一百零九页\编于十五点Thisisprobablyrelatedtotheamountofdissection（解剖，切开）andstripping（剥离）of

softtissueswhichisneededtoachievereductionandplate

fixation.目前六十九页\总数一百零九页\编于十五点Therefore,whenperformingORIFprocedures,thesurgeonstriedtolimitsofttissuedamageandchoose

suitableinternalfixation.目前七十页\总数一百零九页\编于十五点Thetibiawasreducedwitha

cloverleafplate,dynamiccompressionplateorlocking

compressionplate,dependingonthelevelofthefracture

anddegreeofstabilityrequired.目前七十一页\总数一百零九页\编于十五点Linetal.reportedan

83.3%goodratein30casestreatedwithORIFfollowed

upfor17~39months5.Kalendereretal.alsoreporteda

similarresult6.目前七十二页\总数一百零九页\编于十五点ExternalfixationandlimitedinternalfixationwereperformedinallpatientswithtypeC2andtypeC3fractures

presentingwithhigh-gradesofttissueinjury(GustiloII

andIII)andintervalbetweeninjuryandpresentationat

theauthors’clinicoflessthan8hours.

目前七十三页\总数一百零九页\编于十五点Useofexternal

fixationduringthesurgicalprocedureenables（使能够）thesurgeon

toassess（评估）thelengthandhelpsstabilizethelimb（肢）forreconstructionoftheintra-articular（关节内）component.目前七十四页\总数一百零九页\编于十五点Placement（放置）of

theexternalfixatorwithacalcanealpinandahalf-pinin

thetibiaallowsligamentotaxis（韧带修复术）tooccurthroughtraction

onthecalcanealpin.目前七十五页\总数一百零九页\编于十五点目前七十六页\总数一百零九页\编于十五点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）['stɪfnɪs]目前七十七页\总数一百零九页\编于十五点preclude（排除）Pre-existing（已存在）inviewof（鉴于，考虑到）

ischemia（缺血）[ɪs'kimɪə]precarious（不确定的）[prɪ'keərɪəs]目前七十八页\总数一百零九页\编于十五点Thisishelpfulinreductionofthe

fractureandallowseasieraccessto（入路）theanklejointfor

joint

reconstruction.目前七十九页\总数一百零九页\编于十五点Usedasaneutralization（中和）device,thereisno

needforlargeplateswiththeassociated（相关）increasedriskof

skinsloughing7.目前八十页\总数一百零九页\编于十五点Minimizing（将...减到最少）internalfixationanddamage

tosofttissuesandbloodsupplydecreasestherateofskin

sloughingandinfection.目前八十一页\总数一百零九页\编于十五点Wewereabletocorrectpostoperativelossofreduction（再移位）byadjustingexternalfixation.It

isalsoanexcellentdeviceinthoseseverelycomminuted

fracturesthatdonotallowstablefixationwiththeuseofa

plate.目前八十二页\总数一百零九页\编于十五点Severalresearchershavereportedsimilarfindingsin

regardto（关于）externalfixation8–11.目前八十三页\总数一百零九页\编于十五点Ourresultsleadustorecommend(建议，推荐)thatTypeC3tibial

pilonfracturespresentingwithhigh-gradesofttissue

injury(GustiloIII)andintervalbetweeninjuryandpresentation

fortreatmentofmorethan8hoursshouldbe

treatedwithatwo-stageprocedure.目前八十四页\总数一百零九页\编于十五点Atinitial(首先)presentation,anexternalfixatorisapplied.Afterthesofttissueshave

recovered,thesecondstageisperformed.目前八十五页\总数一百零九页\编于十五点Thegoalofthe

firststageistore-establishthelength,alignmentandrotation

oftheextremityandprovideanenvironmentfor

soft-tissuerecovery.目前八十六页\总数一百零九页\编于十五点Theearlyapplicationofadistraction（牵引）forcemayhelptolimitanysecondaryinjuryandeliminate（清除）additionalsofttissuecompromise（妥协、折衷、让步）duringsurgicalexposure（显露，暴露）12.目前八十七页\总数一百零九页\编于十五点Severalreportshaveshownthatthetwo-stageprocedure

canreducetherateofcomplicationssuchas

infection,skinsloughing,andpost-traumaticarthritis13–15.目前八十八页\总数一百零九页\编于十五点Preventionofpostoperativecomplications.Ithasbeenreportedthattheincidence（发生率）ofcomplications,includingwoundproblems,skinsloughing,infection,nonunion,malalignment(对线不良),jointstiffness（僵硬）andposttraumaticarthritis,ishigh(45.1%)inpatientswithsevere

pilonfractures16.目前八十九页\总数一百零九页\编于十五点Skinsloughingandinfectionarethemostimportant

earlypostoperativecomplications17.Pre-existing（已存在）severe

softtissueinjuryprecludes（不能）openreductioninviewof（考虑到）the

potentialwoundproblemsduetoischemia（缺血）orinfectionof

thesofttissues.目前九十页\总数一百零九页\编于十五点Theprecarious（不确定的）bloodsupplyinthisregion

ofthetibiacancontributeto（有助于）theproblemsofbothnonunion

andinfection18.目前九十一页\总数一百零九页\编于十五点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）['haɪbrɪd]目前九十二页\总数一百零九页\编于十五点hingeaxis（铰链轴）[hɪndʒ]plastercast（石膏）optimal（最佳的）manuscript（手稿，文章）

目前九十三页\总数一百零九页\编于十五点Inthepresentstudy,therewerefour

casesofskinsloughing,twoofsuperficialinfections,and

onlyoneofdeepboneinfection.目前九十四页\总数一百零九页\编于十五点Surgicalapproachesare

nowplannedbasedonthe

requirementsofthefracture

pattern,keepinginmindthesoft-tissueconstraintsofthe

individualinjury.目前九十五页\总数一百零九页\编于十五点Theincisionsarekeptatleast7cmapart

topreventsoft-tissueischemiaandsecondarywoundbreakdown.目前九十六页\总数一百零九页\编于十五点Intensive（加强的）debridement,minimizationofsofttissuestrippingandproperuseofantibioticsareusefulfor

preventinginfection.目前九十七页\总数一百零九页\编于十五点Delayedunion,especiallyinthemetaphysealportion,is

alsoaproblemwithpilonfractures.Wenoteda7.1%

delayedunionrateinthisseries.目前九十八页\总数一百零九页\编于十五点Theseverityoftheinjury

andpoorbloodsupplytothedistaltibiamayoutweigh（胜过，强过）the

affectsofanyparticularapproachwhenitcomestononunionordelayedunion,anditisalsoprobablycausedby

tibialbonedefectafterfixationofthefibula.Butthereis

notdecidedforthefibulafixation19,20.目前九十九页\总数一百零九页\编于十五点Wethinkthat

fibularfractureshouldbefixedtorestorethelengthofthe

lateralcolumn