Pilon骨折的外科治療(英文PPT加翻譯).ppt

Objective:Todiscussthemethods,timingandclinicaloutcomesofsurgicaltreatmentforopenpilonfractures.Methods:FromApril2003toJuly2008,28patientswithopenpilonfracturesweretreated.AllhadtypeCfracturesaccordingtotheArbeitsgemeinschaftfrosteosynthesefragenAssociationfortheStudyofInternalFixation(AO/ASIF)classification.Threeoperativemethodswereapplied,themethodsbeingdeterminedbythetypesoffracture,softtissuedamageandtimeintervalafterinjury.,trauma創(chuàng)傷classification分類；分級(jí)debridement清創(chuàng)術(shù)、擴(kuò)創(chuàng)術(shù)anatomicreduction解剖復(fù)位theArbeitsgemeinschaftfrosteosynthesefragen瑞士骨折內(nèi)固定協(xié)會(huì)/AOBurwell-Charnleyscore骨折復(fù)位放射學(xué)評(píng)價(jià)標(biāo)準(zhǔn)1965Orthopaedic骨科的；整形外科的,Complication并發(fā)癥sloughing蛻皮；脫落post-traumaticarthritisrats創(chuàng)傷后關(guān)節(jié)炎Thorough徹底地ranti-infectivemedication抗感染藥物occurrencekr()ns發(fā)生tibialtbl脛骨的talustels距骨softtissuedegloving(套袖狀的)軟組織撕裂,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創(chuàng)傷classification分類；分級(jí)debridement清創(chuàng)術(shù)、擴(kuò)創(chuàng)術(shù)anatomicreduction解剖復(fù)位Complication并發(fā)癥sloughing蛻皮；脫落post-traumaticarthritisrats創(chuàng)傷后關(guān)節(jié)炎Thorough徹底地r,anti-infectivemedication抗感染藥物occurrencekr()ns發(fā)生tibialtbl脛骨的；tibiatb脛骨talustels距骨softtissuedegloving軟組織撕裂lowerlimbfractures下肢骨折degloving套袖狀撕裂metaphyseal干骺端的articulardepression關(guān)節(jié)壓縮weightbearingarea負(fù)重區(qū),implant內(nèi)植物approach方法correspondencen.通信；一致；相當(dāng)DOI：數(shù)字對(duì)象唯一標(biāo)識(shí)符bilaterallybailtrli雙邊地malleolusmlils踝clinic臨床；診所motor發(fā)動(dòng)機(jī)vehiclevikl（車輛）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（擠壓傷）in4cases,andsportsinjuriesin2.,ThefractureswereclassifiedaccordingtotheAO/ASIFsystem:7wereclassifiedastypeC1,17typeC2,and4typeC3.,OpensofttissuedamagewasgradedaccordingtotheGustilosystem:4caseswereclassifiedasGustiloI,21GustiloII,2GustiloIIIA,and1GustiloIIIB.,acetabularstbjul髖臼的fibular腓骨的;fibula腓骨femoral股骨的Calcanealklkeinil跟骨的craniocerebral,kreiniusiri:brl顱腦的protocol方法、協(xié)議presentingwith伴隨restoration恢復(fù)tibia脛骨,cancellouskns()ls松質(zhì)骨insertion插入modified改進(jìn)的cloverleaf三葉草形Anteromedial前內(nèi)側(cè)的medial內(nèi)側(cè)的posterolateral后外側(cè)的lateral外側(cè)的constraint約束、限制keepinginmind牢記anteroposterior前后的；正位（影像）,Combinedinjuriesincludedfibularfracturesin25cases,spinalfracturesin2,upper-armfracturesin2,ribfracturesin2,femoralfracturein1,acetabularfracturein1,calcanealfracturein1,andcraniocerebraltraumain1.,demonstrating顯示Calcaneus（口Ki尼爾斯）：跟骨metatarsal跖骨的anklemortise踝關(guān)節(jié)Kirschner克氏pin克氏針,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（內(nèi)側(cè)）tibia.Onestagewoundclosurewasperformedin18patients,twounderwentdelayedclosureoftheirlateralincisions,andoneunderwentdelayedsplit-thicknessskingrafting.,Therewerefourcasesofsuperficialsloughingoftheskin.TwopatientsdevelopedsurfaceinfectionwithStaphylococcusepidermidis（表皮葡萄球菌）andAcinetobacterbaumannii（鮑氏不動(dòng)桿菌）andonedevelopeddeepinfectionwithAcinetobacterbaumannii;theinfectionratewas10.7%(3/28).,Tenpatients(35.7%)showedevidenceofposttraumaticarthritis.（創(chuàng)傷后關(guān)節(jié)炎）AccordingtotheAOFASankle-hind（后踝）footfunctionevaluation（評(píng)估）,theaveragescorewas85.2(range,66to98):excellentin8patients,goodin14,fairin5,andpoorin1.,DiscussionChoiceofsurgicalmethodsInpatientswithtypeC1fractureandGustiloIsofttissueinjuryduetolow-energyforces,pilonfracturewasanatomicallyreducedandtreatedwithdebridementandinternalplatefixationfollowingAO/ASIFprinciples.,Openreductionandinternalfixationwereoriginally(最初)used,butitisnowknownthatopenreductionincreasestheriskofcomplicationsafterhigh-energytrauma.,Thisisprobablyrelatedtotheamountofdissection（解剖，切開）andstripping（剝離）ofsofttissueswhichisneededtoachievereductionandplatefixation.,Therefore,whenperformingORIFprocedures,thesurgeonstriedtolimitsofttissuedamageandchoosesuitableinternalfixation.,Thetibiawasreducedwithacloverleafplate,dynamiccompressionplateorlockingcompressionplate,dependingonthelevelofthefractureanddegreeofstabilityrequired.,Linetal.reportedan83.3%goodratein30casestreatedwithORIFfollowedupfor1739months5.Kalendereretal.alsoreportedasimilarresult6.,ExternalfixationandlimitedinternalfixationwereperformedinallpatientswithtypeC2andtypeC3fracturespresentingwithhigh-gradesofttissueinjury(GustiloIIandIII)andintervalbetweeninjuryandpresentationattheauthorsclinicoflessthan8hours.,Useofexternalfixationduringthesurgicalprocedureenables（使能夠）thesurgeontoassess（評(píng)估）thelengthandhelpsstabilizethelimb（肢）forreconstructionoftheintra-articular（關(guān)節(jié)內(nèi)）component.,Placement（放置）oftheexternalfixatorwithacalcanealpinandahalf-pininthetibiaallowsligamentotaxis（韌帶修復(fù)術(shù)）tooccurthroughtractiononthecalcanealpin.,initial(首先)distraction（牽引）eliminate（清除）compromise（妥協(xié)、折衷、讓步）exposure（顯露，暴露）incidence（發(fā)生率）malalignment(對(duì)線不良)stiffness（僵硬）stfns,preclude（排除）Pre-existing（已存在）inviewof（鑒于，考慮到）ischemia（缺血）skimprecarious（不確定的）prkers,Thisishelpfulinreductionofthefractureandallowseasieraccessto（入路）theanklejointforjointreconstruction.,Usedasaneutralization（中和）device,thereisnoneedforlargeplateswiththeassociated（相關(guān)）increasedriskofskinsloughing7.,Minimizing（將.減到最少）internalfixationanddamagetosofttissuesandbloodsupplydecreasestherateofskinsloughingandinfection.,Wewereabletocorrectpostoperativelossofreduction（再移位）byadjustingexternalfixation.Itisalsoanexcellentdeviceinthoseseverelycomminutedfracturesthatdonotallowstablefixationwiththeuseofaplate.,Severalresearchershavereportedsimilarfindingsinregardto（關(guān)于）externalfixation811.,Ourresultsleadustorecommend(建議，推薦)thatTypeC3tibialpilonfracturespresentingwithhigh-gradesofttissueinjury(GustiloIII)andintervalbetweeninjuryandpresentationfortreatmentofmorethan8hoursshouldbetreatedwithatwo-stageprocedure.,Atinitial(首先)presentation,anexternalfixatorisapplied.Afterthesofttissueshaverecovered,thesecondstageisperformed.,Thegoalofthefirststageistore-establishthelength,alignmentandrotationoftheextremityandprovideanenvironmentforsoft-tissuerecovery.,Theearlyapplicationofadistraction（牽引）forcemayhelptolimitanysecondaryinjuryandeliminate（清除）additionalsofttissuecompromise（妥協(xié)、折衷、讓步）duringsurgicalexposure（顯露，暴露）12.,Severalreportshaveshownthatthetwo-stageprocedurecanreducetherateofcomplicationssuchasinfection,skinsloughing,andpost-traumaticarthritis1315.,Preventionofpostoperativecomplications.Ithasbeenreportedthattheincidence（發(fā)生率）ofcomplications,includingwoundproblems,skinsloughing,infection,nonunion,malalignment(對(duì)線不良),jointstiffness（僵硬）andposttraumaticarthritis,ishigh(45.1%)inpatientswithseverepilonfractures16.,Skinsloughingandinfectionarethemostimportantearlypostoperativecomplications17.Pre-existing（已存在）severesofttissueinjuryprecludes（不能）openreductioninviewof（考慮到）thepotentialwoundproblemsduetoischemia（缺血）orinfectionofthesofttissues.,Theprecarious（不確定的）bloodsupplyinthisregionofthetibiacancontributeto（有助于）theproblemsofbothnonunionandinfection18.,Intensive（加強(qiáng)的）outweigh（勝過，強(qiáng)過）lateralcolumn(外側(cè)柱)ligament（韌帶）taxis（整復(fù)）circularframes（圓形框架）hybridsystems（混合系統(tǒng)）habrd,hingeaxis（鉸鏈軸）hndplastercast（石膏）optimal（最佳的）manuscript（手稿，文章）,Inthepresentstudy,therewerefourcasesofskinsloughing,twoofsuperficialinfections,andonlyoneofdeepboneinfection.,Surgicalapproachesarenowplannedbasedontherequirementsofthefracturepattern,keepinginmindthesoft-tissueconstraintsoftheindividualinjury.,Theincisionsarekeptatleast7cmaparttopreventsoft-tissueischemiaandsecondarywoundbreakdown.,Intensive（加強(qiáng)的）debridement,minimizationofsofttissuestrippingandproperuseofantibioticsareusefulforpreventinginfection.,Delayedunion,especiallyinthemetaphysealportion,isalsoaproblemwithpilonfractures.Wenoteda7.1%delayedunionrateinthisseries.,Theseverityoftheinjuryandpoorbloodsupplytothedistaltibiamayoutweigh（勝過，強(qiáng)過）theaffectsofanyparticularapproachwhenitcomestononunionordelayedunion,anditisalsoprobablycausedbytibialbonedefectafterfixationofthefibula.Butthereisnotdecidedforthefibulafixation19,20.,Wethinkthatfibularfractureshouldbefixedtorestorethelengthofthelateralcolumn(柱)ofthetibiaindirectlyvialigament（韌帶）taxis（整復(fù)）.Megasetal.havereportedthatthenonunionrateindistaltibialfractureishigherthaninotherlongbonefractures.,Itcanlikelybepreventedbyminimizingsoft-tissuestrippingandusingstableinternalfixationinassociationwithsuitablebonegraft.,Post-traumaticarthritisisaseriouscomplication.Wyrschetal.believethatarthritisispossiblycausedbydamagetoarticularcartilage(軟骨)andlong-termimmobilizationwithex