Pilon骨折的外科治疗(英文PPT加翻译).ppt

1、Objective: To discuss the methods, timing and clinical outcomes of surgical treatment for open pilon fractures. Methods: From April 2003 to July 2008, 28 patients with open pilon fractures were treated. All had type C fractures according to the Arbeitsgemeins chaft fr osteosynthesefragenAssociation

2、for the Study of Internal Fixation (AO/ASIF)classification. Three operative methods were applied, the methods being determined by the types of fracture, soft tissue damage and time interval after injury.,trauma创伤 classification分类；分级 debridement清创术、扩创术 anatomic reduction解剖复位 the Arbeitsgemeinschaft f

3、r osteosynthesefragen瑞士骨折内固定协会/AO Burwell-Charnley score骨折复位放射学评价标准1965 Orthopaedic骨科的；整形外科的,Complication并发症 sloughing蜕皮；脱落 post-traumatic arthritisrats创伤后关节炎 Thorough彻底地r anti-infective medication抗感染药物 occurrence kr()ns发生 tibial tbl胫骨的 talustels距骨 soft tissue degloving(套袖状的) 软组织撕裂,metaphyseal干骺端的,S

4、even cases were treated by debridement and internal fixation with plate; 19 by limited internal fixation combined with external fixation; and 2 by delayed surgery. The clinical outcomes were evaluated by the Burwell-Charnley score. Results: All cases were followed up for from 6 to 48 months (average

5、 24 months). The Burwell-Charnley score of clinical outcomes: anatomic reduction achieved in 12 cases, functional reduction in 15, and unsatisfactory reduction in 1.,The healing time was from 2.5 to 11 months (average 4.7 months). Two cases had delayed union. According to theAmerican Orthopaedic Foo

6、t and Ankle Society (AOFAS) scale for the ankle joint, there were excellent results in 8 cases,good in 14, fair in 5 and poor in 1. Complications included four cases of skin superficial sloughing, two of superficial infection, one of deep infection, two of delayed fracture union and ten of post-trau

7、matic arthritis.,Thorough debridement, proper use of anti-infective medication, appropriate bone grafting, and postoperative ankle function exercise can reduce the occurrence of complications.,trauma创伤 classification分类；分级 debridement清创术、扩创术 anatomic reduction解剖复位 Complication并发症 sloughing蜕皮；脱落 post-

8、traumatic arthritisrats创伤后关节炎 Thorough彻底地r,anti-infective medication抗感染药物 occurrence kr()ns发生 tibial tbl胫骨的；tibiatb胫骨 talustels距骨 soft tissue degloving 软组织撕裂 lower limb fractures 下肢骨折 degloving套袖状撕裂 metaphyseal干骺端的 articular depression关节压缩 weight bearing area负重区,implant内植物 approach方法 correspondence

9、n. 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vehicle vikl（车辆）accident,Open fractures comprises about 10% to 30% of all pilon fractures3. These fractures are often associated with significant soft tissue degloving, metaphyseal bone defects and articular depres

10、sion.,IntroductionPilon fracture constitutes 1% of all lower limb fractures and about 3% to 10% of tibial fractures1,2. It is usually the result of high energy injury to the weight bearing area of the lower end of the tibia by the talus.,Conclusion: It is important to perform appropriate surgeries f

11、or open pilon fracture according to fracture classification, different damage to skin and tissue and time interval after injury.,Key words: Delayed operation; External fixators; Fractures open; Internal fixators,In spite of improvements in surgical approaches and implants, treatment of tibial pilon

12、fractures remains challenging4.,In the present study, we discuss the methods,timing and clinical outcomes of surgical treatment for open pilon fractures.,Address f or correspondence Xian-tie Zeng, MD, Department of Trauma, Tianjin Hospital, Tianjin, China 300211 Tel: 0086 Fax: 0086 022

13、 24151288; Email: Received: 19 July 2010; accepted 5 October 2010DOI: 10.1111/j.1757-7861.2010.00113.x,Materials and MethodsPatient dataFrom April 2003 to July 2008, 28 patients with open tibial pilon fractures were treated in our hospital.,There were 21 men and 7 women with an average age of 36.5 y

14、ears (range, 1961 years). Ten patients were injured on the left side, 17 on the right and 1 bilaterally (a closed fracture of the right malleolus（踝） was not counted).,The interval between injury and presentation to our clinic ranged from 1 to 14 hours (average, 5.1 hours). The mechanisms of injury w

15、ere high-energy falls in 10 cases,motor vehicle accidents in 12, crushing injury （挤压伤）in 4 cases,and sports injuries in 2.,The fractures were classified according to the AO/ASIF system: 7 were classified as type C1, 17 type C2, and 4 type C3.,Open soft tissue damage was graded according to the Gusti

16、lo system: 4 cases were classified as Gustilo I, 21 Gustilo II, 2 Gustilo IIIA, and 1 Gustilo IIIB.,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 presenting with伴随 restoration恢复 tibia胫骨,cancellous kns()ls松质骨 insertion 插入 modi

17、fied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 keeping in mind牢记 anteroposterior前后的；正位（影像）,Combined injuries included fibular fractures in 25 cases, spinal fractures in 2, upper-arm fractures in 2, rib fractures in 2, femoral fracture in 1,acetabular fr

18、acture in 1, calcaneal fracture in 1, and craniocerebral trauma in 1.,demonstrating 显示 Calcaneus（口Ki尼尔斯）：跟骨 metatarsal 跖骨的 ankle mortise踝关节 Kirschner克氏pin克氏针,Me t h o d sOne of three different surgical protocols was performed in all patients, the choice being based on the condition of soft tissue, t

19、ype of fracture and length of interval between injury and presentation for treatment.,D e b r i d e m e n t , o p e n reduction and internal fix at ion (ORIF)This method was applied in type C1 fractures presenting with low-grade soft tissue injury (Gustilo I, II) and interval between injury and pres

20、entation for treatment of less than 6 hours.,Seven patients (four type C1 Gustilo I and three type C1 Gustilo II) were treated by this method.,Surgical treatment of the pilon fractures was in four steps: (a) restoration of the correct length and stabilization of the fibula;,(b) reconstruction of the

21、 articular surface of the tibia; (c) insertion of cancellous autografts; and (d) stabilization of the medial aspect of the tibia with the use of a modified cloverleaf plate.,An anteromedial incision was employed to treat the tibial component and a lateral or posterolateral incision to treat the fibu

22、lar fracture.,The surgical incisions were planned based on the requirements of the fracture pattern, keeping in mind the soft-tissue constraints of the individual injury.,Skin closure was achieved with no tension. The tibial incisions were closed first. If necessary, the fibular incisions were left

23、for delayed closure.,One of the seven patients achieved primary closure of the medial incision, followed by delayed closure of the lateral one. A typical case is shown in Fig. 1.,Figure 1 A 49 year-old man with a low-energy open pilon fracture (Gustilo I in both it was associated with bone defects o

24、f the medial （内侧）tibia. One stage wound closure was performed in 18 patients, two underwent delayed closure of their lateral incisions, and one underwent delayed split-thickness skin grafting.,There were four cases of superficial sloughing of the skin. Two patients developed surface infection with S

25、taphylococcus epidermidis（表皮葡萄球菌） and Acinetobacter baumannii （鲍氏不动杆菌）and one developed deep infection with Acinetobacter baumannii; the infection rate was 10.7% (3/28).,Ten patients (35.7%) showed evidence of posttraumatic arthritis.（创伤后关节炎） According to the AOFAS ankle-hind（后踝） foot function evalu

26、ation（评估）, the average score was 85.2 (range, 66 to 98): excellent in 8 patients, good in 14, fair in 5, and poor in 1.,Discussion Choice of surgical methods In patients with type C1 fracture and Gustilo I soft tissue injury due to low-energy forces, pilon fracture was anatomically reduced and treat

27、ed with debridement and internal plate fixation following AO/ASIF principles.,Open reduction and internal fixation were originally (最初)used,but it is now known that open reduction increases the risk of complications after high-energy trauma.,This is probably related to the amount of dissection（解剖，切开

28、） and stripping （剥离）of soft tissues which is needed to achieve reduction and plate fixation.,Therefore, when performing ORIF procedures,the surgeons tried to limit soft tissue damage and choose suitable internal fixation.,The tibia was reduced with a cloverleaf plate, dynamic compression plate or lo

29、cking compression plate, depending on the level of the fracture and degree of stability required.,Lin et al. reported an 83.3% good rate in 30 cases treated with ORIF followed up for 17 39 months5. Kalenderer et al. also reported a similar result6.,External fixation and limited internal fixation wer

30、e performed in all patients with type C2 and type C3 fractures presenting with high-grade soft tissue injury (Gustilo II and III) and interval between injury and presentation at the authors clinic of less than 8 hours.,Use of external fixation during the surgical procedure enables （使能够）the surgeon t

31、o assess（评估） the length and helps stabilize the limb（肢） for reconstruction of the intra-articular（关节内） component.,Placement （放置）of the external fixator with a calcaneal pin and a half-pin in the tibia allows ligamentotaxis （韧带修复术）to occur through traction on the calcaneal pin.,initial(首先) distractio

32、n（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） in view of（鉴于，考虑到） ischemia（缺血）skim precarious（不确定的）prkers,This is helpful in reduction of the fracture and allows easier access to（入路） the ankle joint for j

33、oint reconstruction.,Used as a neutralization（中和） device, there is no need for large plates with the associated （相关）increased risk of skin sloughing7.,Minimizing（将.减到最少） internal fixation and damage to soft tissues and blood supply decreases the rate of skin sloughing and infection.,We were able to

34、correct postoperative loss of reduction（再移位） by adjusting external fixation. It is also an excellent device in those severely comminuted fractures that do not allow stable fixation with the use of a plate.,Several researchers have reported similar findings in regard to （关于）external fixation811.,Our

35、results lead us to recommend (建议，推荐)that Type C3 tibial pilon fractures presenting with high-grade soft tissue injury (Gustilo III) and interval between injury and presentation for treatment of more than 8 hours should be treated with a two-stage procedure.,At initial(首先) presentation,an external fi

36、xator is applied. After the soft tissues have recovered, the second stage is performed.,The goal of the first stage is to re-establish the length, alignment and rotation of the extremity and provide an environment for soft-tissue recovery.,The early application of a distraction（牵引） force may help to

37、 limit any secondary injury and eliminate（清除） additional soft tissue compromise（妥协、折衷、让步） during surgical exposure（显露，暴露）12.,Several reports have shown that the two-stage procedure can reduce the rate of complications such as infection, skin sloughing, and post-traumatic arthritis1315.,Prevention of

38、 postoperative complications. It has been reported that the incidence （发生率）of complications,including wound problems, skin sloughing, infection,nonunion, malalignment(对线不良), joint stiffness（僵硬） and posttraumatic arthritis, is high (45.1%) in patients with severe pilon fractures16.,Skin sloughing and

39、 infection are the most important early postoperative complications17. Pre-existing（已存在） severe soft tissue injury precludes（不能） open reduction in view of（考虑到） the potential wound problems due to ischemia（缺血） or infection of the soft tissues.,The precarious（不确定的） blood supply in this region of the t

40、ibia can contribute to（有助于） the problems of both nonunion and infection18.,Intensive（加强的） outweigh（胜过，强过） lateral column (外侧柱) ligament （韧带）taxis（整复） circular frames（圆形框架） hybrid systems（混合系统）habrd,hinge axis （铰链轴）hnd plaster cast（石膏） optimal（最佳的） manuscript（手稿，文章）,In the present study, there were f

41、our cases of skin sloughing, two of superficial infections, and only one of deep bone infection.,Surgical approaches are now planned based on the requirements of the fracture pattern, keeping in mind the soft-tissue constraints of the individual injury.,The incisions are kept at least 7 cm apart to

42、prevent soft-tissue ischemia and secondary wound breakdown.,Intensive（加强的） debridement,minimization of softtissue stripping and proper use of antibiotics are useful for preventing infection.,Delayed union, especially in the metaphyseal portion, is also a problem with pilon fractures. We noted a 7.1%

43、 delayed union rate in this series.,The severity of the injury and poor blood supply to the distal tibia may outweigh（胜过，强过） the affects of any particular approach when it comes to nonunion or delayed union, and it is also probably caused by tibial bone defect after fixation of the fibula. But there

44、 is not decided for the fibula fixation19,20.,We think that fibular fracture should be fixed to restore the length of the lateral column (柱)of the tibia indirectly via ligament （韧带）taxis（整复）. Megas et al. have reported that the nonunion rate in distal tibial fracture is higher than in other long bon

45、e fractures.,It can likely be prevented by minimizing soft-tissue stripping and using stable internal fixation in association with suitable bone graft.,Post-traumatic arthritis is a serious complication. Wyrsch et al. believe that arthritis is possibly caused by damage to articular cartilage(软骨) and long-term immobilization with extern