两种手术入路治疗累及后外侧Schatzker Ⅳ型胫骨平台骨折的临床效果比较

Comparison of two combined approaches in treating Schatzker type Ⅳ tibial plateau fracture involving the posterolateral plateau

关键词:  胫骨平台骨折  Schatzker Ⅳ型  内侧联合后外侧入路  后内侧联合前外侧入路

Key words:  tibial plateau fracture  schatzker type Ⅳ  medial combined posterolateral approach  posteromedial combined anterolateral approach

摘要:

目的比较内侧联合后外侧入路和后内侧倒L切口联合前外侧入路治疗累及后外侧Schatzker Ⅳ型胫骨平台骨折的安全性及中期临床效果。方法回顾性研究复旦大学附属中山医院青浦分院自2016—2020年收治的累及后外侧的Schatzker Ⅳ型胫骨平台骨折、符合入组条件的患者共57例，按不同手术入路进行分组，其中采用内侧联合后外侧入路治疗的患者30例，采用后内侧倒L切口联合前外侧入路治疗的患者27例。收集患者性别、年龄等一般资料，记录受伤至内固定时间、手术时间、术中失血量等，术后随访评估骨折复位情况、下肢力线、膝关节活动范围及手术并发症，根据HSS、SF36量表进行膝关节功能评分。将两组资料进行比较。结果两组患者一般资料差异无统计学意义，具有可比性。内侧联合后外侧入路组，13例采用内侧单钢板固定，17例内侧双钢板固定，后外侧平台均采用支撑钢板固定。手术时间平均为(133.7±23.2)min，术中出血量平均(318.3±111.0)mL，末次随访时膝关节平均活动范围为127.2°(0~5°；115~140°)，平均HSS评分为93.9±3.2，平均SF36评分为91.5±3.3，1例患者术后出现内侧切口浅表感染，8例患者已行内固定取出术。后内侧倒L切口联合前外侧入路组，均采用后内侧钢板、前外侧钢板固定，有11例采用后外侧平台支撑钢板固定，手术时间平均为(157.0±31.3)min，术中出血量平均(403.7±142.1)mL。末次随访时膝关节平均活动范围为128.3°(0~10°；110~140°)，平均HSS评分为94.2±3.3，平均SF36评分为91.6±3.6。2例患者出现前外侧切口浅表感染，7例患者已行内固定取出术。所有患者下肢力线均正常，未见其他并发症。两组相比，手术时间和术中出血量存在显著性差异，其他数据均差异无统计学意义。结论内侧联合后外侧入路、后内侧倒L切口联合前外侧入路治疗胫骨平台内侧伴后外侧骨折都是安全有效的，手术医生应根据骨折的形态特征来推导损伤机制、结合客观器械条件制定完善的术前计划，从而获得满意的临床效果。

Abstract:

ObjectiveTo compare the safety and clinical outcomes of two combined approaches in treating Schatzker type Ⅳ tibial plateau fracture involving the posterolateral plateau. MethodsFifty seven patients with medial tibial plateau fractures involving posterolateral plateau treated in Qingpu Campus of Zhongshan Hospital, Fudan University from January 2016 to December 2020 were enrolled, including 30 cases treated with medial combined posterolateral approach(M+PL) and 27 cases treated with posteromedial combined anterolateral approach(PM+AL). The gender, age, interval between injury and surgery, operation time, intraoperative blood loss and surgical complications were recorded. Patients were follow-up for ≥12 months, knee range of motion was measured. HSS and SF-36 were applied for functional and radiological evaluation. ResultsThe basic data of two groups were comparable. In the M+PL group, the posterolateral plateau was all fixed with supporting plate, the medial plateau were fixed with single plate in 13 cases, and fixed with double plates in 17 cases. The mean operative time was (133.7±23.2)min, mean intraoperative bleeding was (318.3±111.0)mL, mean range of knee motion was 127.2°(0-5°; 115-140°), mean HSS score was 93.9±3.2 and mean SF36 score was 91.5±3.3. One patient had superficial infection at medial incision, and 8 patients had hardware removal. In the PM+AL group, the anterolateral and medial plateau was all fixed with plate, and 11 cases had posterolateral supporting plate. The mean operative time was (157.0±31.3)min, mean intraoperative bleeding was (403.7±142.1)mL, mean range of knee motion was 128.3°(0-10°; 110-140°), mean HSS score was 94.2±3.3 and mean SF36 score was 91.6±3.6. Two patients had superficial infection at anterolateral incision and 7 patients had hardware removal. All patients had correct lower limb alignment and no other complications. There were significant differences in the operation time and intraoperative bleeding volume, and no difference in the other indicators between two groups. ConclusionThe M+PL and PM+AL approaches are both safe and effective in treatment of Schatzker type Ⅳ tibial plateau fracture involving the posterolateral plateau. The surgeon should deduce the injury mechanism according to the morphological characteristics of the fracture and make surgical plan accordingly to achieve satisfactory clinical outcomes.