Pilon骨折的外科治疗(英文PPT加翻译).ppt

lObjective:Todiscussthemethods,timingandclinicaloutcomesofsurgicaltreatmentforopenpilonfractures.lMethods:FromApril2003toJuly2008,28patientswithopenpilonfracturesweretreated.lAllhadtypeCfracturesaccordingtotheArbeitsgemeinschaftfrosteosynthesefragenAssociationfortheStudyofInternalFixation(AO/ASIF)classification.lThreeoperativemethodswereapplied,themethodsbeingdeterminedbythetypesoffracture,softtissuedamageandtimeintervalafterinjury.ltrauma创伤lclassification分类；分级ldebridement清创术、扩创术lanatomicreduction解剖复位ltheArbeitsgemeinschaftfrosteosynthesefragen瑞士骨折内固定协会/AOlBurwell-Charnleyscore骨折复位放射学评价标准1965lOrthopaedic骨科的；整形外科的lComplication并发症lsloughing蜕皮；脱落lpost-traumaticarthritisrats创伤后关节炎lThorough彻底地rlanti-infectivemedication抗感染药物loccurrencekr()ns发生ltibialtbl胫骨的ltalustels距骨lsofttissuedegloving(套袖状的)软组织撕裂lmetaphyseal干骺端的lSevencasesweretreatedbydebridementandinternalfixationwithplate;19bylimitedinternalfixationcombinedwithexternalfixation;and2bydelayedsurgery.lTheclinicaloutcomeswereevaluatedbytheBurwell-Charnleyscore.lResults:Allcaseswerefollowedupforfrom6to48months(average24months).lTheBurwell-Charnleyscoreofclinicaloutcomes:anatomicreductionachievedin12cases,functionalreductionin15,andunsatisfactoryreductionin1.lThehealingtimewasfrom2.5to11months(average4.7months).lTwocaseshaddelayedunion.AccordingtotheAmericanOrthopaedicFootandAnkleSociety(AOFAS)scalefortheanklejoint,therewereexcellentresultsin8cases,goodin14,fairin5andpoorin1.lComplicationsincludedfourcasesofskinsuperficialsloughing,twoofsuperficialinfection,oneofdeepinfection,twoofdelayedfractureunionandtenofpost-traumaticarthritis.lThoroughdebridement,properuseofanti-infectivemedication,appropriatebonegrafting,andpostoperativeanklefunctionexercisecanreducetheoccurrenceofcomplications.ltrauma创伤lclassification分类；分级ldebridement清创术、扩创术lanatomicreduction解剖复位lComplication并发症lsloughing蜕皮；脱落lpost-traumaticarthritisrats创伤后关节炎lThorough彻底地rlanti-infectivemedication抗感染药物loccurrencekr()ns发生ltibialtbl胫骨的；tibiatb胫骨ltalustels距骨lsofttissuedegloving软组织撕裂llowerlimbfractures下肢骨折ldegloving套袖状撕裂lmetaphyseal干骺端的larticulardepression关节压缩lweightbearingarea负重区limplant内植物lapproach方法lcorrespondencen.通信；一致；相当lDOI：数字对象唯一标识符lbilaterallybailtrli双边地lmalleolusmlils踝踝lclinic临床；诊所临床；诊所lmotor 发动机发动机vehicle vikl（车辆）（车辆）accidentlOpenfracturescomprisesabout10%to30%ofallpilonfractures3.lThesefracturesareoftenassociatedwithsignificantsofttissuedegloving,metaphysealbonedefectsandarticulardepression.lIntroductionPilonfractureconstitutes1%ofalllowerlimbfracturesandabout3%to10%oftibialfractures1,2.lItisusuallytheresultofhighenergyinjurytotheweightbearingareaofthelowerendofthetibiabythetalus.lConclusion:l Itisimportanttoperformappropriatesurgeriesforopenpilonfractureaccordingtofractureclassification,differentdamagetoskinandtissueandtimeintervalafterinjury.lKey words:Delayedoperation;Externalfixators;Fracturesopen;InternalfixatorsllInspiteofimprovementsinsurgicalapproachesandimplants,treatmentoftibialpilonfracturesremainschallenging4.lInthepresentstudy,wediscussthemethods,timingandclinicaloutcomesofsurgicaltreatmentforopenpilonfractures.lAddress f or correspondence lXian-tieZeng,MD,DepartmentofTrauma,TianjinHospital,Tianjin,China300211Tel:[phone];Fax:[phone];Email:Received:19July2010;accepted5October2010DOI:10.1111/j.1757-7861.2010.00113.xlMaterials and MethodsPatient dataFrom April 2003 to July 2008,28 patients with open tibial pilon fractures were treated in our hospital.lThere were 21 men and 7 women with an average age of 36.5 years(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）（踝）was not counted).lTheintervalbetweeninjuryandpresentationtoourclinicrangedfrom1to14hours(average,5.1hours).Themechanismsofinjurywerehigh-energyfallsin10cases,motorvehicleaccidentsin12,crushinginjury（挤压伤）in4cases,andsportsinjuriesin2.llThefractureswereclassifiedaccordingtotheAO/ASIFsystem:7wereclassifiedastypeC1,17typeC2,and4typeC3.lOpensofttissuedamagewasgradedaccordingtotheGustilosystem:4caseswereclassifiedasGustiloI,21GustiloII,2GustiloIIIA,and1GustiloIIIB.llacetabularstbjul髋臼的lfibular腓骨的;fibula腓骨lfemoral股骨的lCalcanealklkeinil跟骨的lcraniocerebral,kreiniusiri:brl颅脑的lprotocol方法、协议lpresentingwith伴随lrestoration恢复ltibia胫骨lcancellouskns()ls松质骨linsertion插入lmodified改进的cloverleaf三叶草形lAnteromedial前内侧的medial内侧的lposterolateral后外侧的lateral外侧的lconstraint约束、限制keepinginmind牢记lanteroposterior前后的；正位（影像）lCombinedinjuriesincludedfibularfracturesin25cases,spinalfracturesin2,upper-armfracturesin2,ribfracturesin2,femoralfracturein1,acetabularfracturein1,calcanealfracturein1,andcraniocerebraltraumain1.ldemonstrating显示Calcaneus（口Ki尼尔斯）：跟骨lmetatarsal跖骨的lanklemortise踝关节lKirschner克氏pin克氏针lMe 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,type of fracture and length of interval between injury and presentation for treatment.lD 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 presentation for treatment of less than 6 hours.lSevenpatients(fourtypeC1GustiloIandthreetypeC1GustiloII)weretreatedbythismethod.llSurgicaltreatmentofthepilonfractureswasinfoursteps:(a)restorationofthecorrectlengthandstabilizationofthefibula;l(b)reconstructionofthearticularsurfaceofthetibia;(c)insertionofcancellousautografts;and(d)stabilizationofthemedialaspectofthetibiawiththeuseofamodifiedcloverleafplate.lAnanteromedialincisionwasemployedtotreatthetibialcomponentandalateralorposterolateralincisiontotreatthefibularfracture.llThesurgicalincisionswereplannedbasedontherequirementsofthefracturepattern,keepinginmindthesoft-tissueconstraintsoftheindividualinjury.lSkinclosurewasachievedwithnotension.lThetibialincisionswereclosedfirst.lIfnecessary,thefibularincisionswereleftfordelayedclosure.lOneofthesevenpatientsachievedprimaryclosureofthemedialincision,followedbydelayedclosureofthelateralone.lAtypicalcaseisshowninFig.1.lFigure 1 A49year-oldmanwithalow-energyopenpilonfracture(GustiloI&C1)l(a)Photographshowingopensofttissueinjury(GustiloI).l(b)PreoperativeanteroposteriorandlateralradiographsshowingPilonfractureoftypeC1.l(c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithplates.l(d)Anteroposteriorandlateralradiographsdemonstratingfractureshavehealed1yearaftersurgery.lFigure 2 A22year-oldmanwithahigh-energyopenpilonfracture(GustiloII&C2)l(a)Photographshowingopensofttissueinjury(GustiloII).l(b)PreoperativeradiographsshowingPilonfractureoftypeC2.ll(c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithexternalfixation,andthetibialfracturefixedwithlimitedinternalfixation.l(d)Anteroposteriorandlateralradiographsdemonstratingthefractureshavehealed1.5yearaftersurgery.lD e b r i d e m e n t,l i m i t e d O R I F a n d e x t e r n a l fi x a t i o nThismethodwasappliedintypeC2andtypeC3fracturespresentingwithhigh-gradesofttissueinjury(GustiloII,III)andintervalbetweeninjuryandpresentationfortreatmentoflessthan8hours.lNineteenpatients(16typeC2GustiloII,1typeC2GustiloIIIA,and2typeC3GustiloII)weretreatedbythismethod.lThepatientsweremanagedbyimmediate（直接的）debridementofthewound.lFibularfractureswerealwaysinternallyfixed,eitherwitha1/3tubular（管状的）plateor3.5mmcompressionplate.llExternalfixationwasappliedacrosstheanklejointwithpinsinthecalcaneus,metatarsalbone,andtibia,reconstructionoftheanklemortise（踝关节）,andstabilizationwithscrewsorKirschnerpins.lsplit-thicknessskingrafting厚皮瓣转移lsplint夹板ledema（水肿）lantibiotic（抗生素）lextent（范围）lcontamination（污染）lTheaffectedextremity（下肢）lelevate抬高；提高lsubtalar（距下）lproscribe（禁止）lsupervise（指导）lphysicaltherapyprogram（康复锻炼）lRoll-A-Boutwalker（助行器）loutpatients(门诊就诊)lStaphylococcusepidermidis（表皮葡萄球菌）Acinetobacterbaumannii（鲍氏不动杆菌）lFiveofthe19patientsrequiredbonegraftingbecauseoflargedefectsofmetaphysealbone.Onecaseunderwentdelayedclosureofthelateralincision,anddelayedsplit-thicknessskingraftingwasappliedinanothercase.AtypicalcaseisshowninFig.2.lposttraumaticarthritis.（创伤后关节炎）lankle-hind（后踝）lDebridementandcalcanealtraction,delayedsurgerylThismethodwasappliedintypeC3fracturesaccompaniedbyhigh-gradesofttissueinjury(GustiloIII)andintervalbetweeninjuryandpresentationfortreatmentofmorethan8hours.lIntwopatients(onetypeC3GustiloIIIA,onetypeC3GustiloIIIB),thesurgeonchoseatwostageprocedure（步骤）.lThepatientswereputoncalcanealpinskeletaltractionwithelevationofthelowerlimboveraBohlerBraunsplint（勃朗支架）,andmeasuresweretakentoavoidedema（水肿）.lWounddrainage（引流管）wasremovedwhentherewasnofurtherevidenceofinfection,andasecondstageoperationwasperformedwhentheedemahadalmostcompletelyresolved.lThepatientsweretreatedwithlimitedORIFandexternalfixation.lThetimeintervalbetweenthetwosurgerieswas15and19days,respectively.lAtypicalcaseisshowninFig.3lFigure3A37year-oldmanwithasuperhigh-energyopenpilonfracture(GustiloIIIB&C3)l(a)Photographshowingopensofttissueinjury(GustiloIIIB)l(b)PreoperativeradiographsshowingPilonfractureoftypeC3.l(c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithexternalfixation,thetibialfixedwithlimitedinternalfixation,andthefibulawithaplate.l(d)Anteroposteriorandlateralradiographsdemonstratingthefractureshavehealed1.5yearaftersurgery.lPostoperative carelAppropriatecultures（培养）wereobtainedduringsurgery,andbroad-spectrumantibiotics（广谱抗生素）wereadministered.（执行，使用）lThechoiceofantibiotic（抗生素）wasbasedontheextent（范围）anddegreeofcontamination（污染）.lActiveankleandsubtalar（距下）jointrange-of-motionexerciseswerebegunassoonasthewoundwasdry,usuallybetween2and5daysaftersurgery.lWeight-bearingexercisewasproscribed（禁止）inthefirst12weeksaftersurgery.lAsupervised（指导）physicaltherapyprogram（康复锻炼）encouragingactiveanklerange-of-motionexerciseswasemployedforthefirst6weeks.lThiswasprogressedtoincludepassiveexercisesbetween6and12weeks.lARoll-A-Boutwalker（助行器）wasusedwhennecessary.lTheaffectedextremity（下肢）waselevated（提高）continuouslyforthefirst48hoursandthen,asmuchaspossible,forthenext7days.lprocedure（步骤）lbroad-spectrumantibiotics（广谱抗生素）lextremity手足loutpatients(门诊就诊)lmedial（内侧）loriginally(最初）ldissection（解剖，切开）lstripping（剥离）lposttraumaticarthritis.（创伤后关节炎）lankle-hind（后踝）loriginally(最初)ldissection（解剖，切开）lstripping（剥离）lligamentotaxis（韧带修复术）lneutralization（中和）linregardto（关于）lRadiographswereobtainedandevaluatedaccordingtotheBurwellCharnleysystem:anatomicreductionwasachievedin12cases,functionalreductionin15cases,andpoorreductionin1case.lThehealingtimeofthefracturewasfrom2.5to11months,withanaverageof4.7months.lResultsAll28patientswerefollowedupfrom6to48monthswithanaverageof24months,andunderwentclinicalandradiologicalexaminationasoutpatients(门诊就诊).lDelayedunionwasfoundintwocases;inbothitwasassociatedwithbonedefectsofthemedial（内侧）tibia.lOnestagewoundclosurewasperformedin18patients,twounderwentdelayedclosureoftheirlateralincisions,andoneunderwentdelayedsplit-thicknessskingrafting.lTherewerefourcasesofsuperficialsloughingoftheskin.lTwopatientsdevelopedsurfaceinfectionwithStaphylococcusepidermidis（表皮葡萄球菌）andAcinetobacterbaumannii（鲍氏不动杆菌）andonedevelopeddeepinfectionwithAcinetobacterbaumannii;theinfectionratewas10.7%(3/28).lTenpatients(35.7%)showedevidenceofposttraumaticarthritis.（创伤后关节炎）lAccordingtotheAOFASankle-hind（后踝）footfunctionevaluation（评估）,theaveragescorewas85.2(range,66to98):excellentin8patients,goodin14,fairin5,andpoorin1.lDiscussionlChoice of surgical methodslInpatientswithtypeC1fractureandGustiloIsofttissueinjuryduetolow-energyforces,pilonfracturewasanatomicallyreducedandtreatedwithdebridementandlinternalplatefixationfollowingAO/ASIFprinciples.lOpenreductionandinternalfixationwereoriginally(最初)used,butitisnowknownthatopenreductionincreasestheriskofcomplicationsafterhigh-energytrauma.lThisisprobablyrelatedtotheamountofdissection（解剖，切开）andstripping（剥离）ofsofttissueswhichisneededtoachievereductionandplatefixation.lTherefore,whenperformingORIFprocedures,thesurgeonstriedtolimitsofttissuedamageandchoosesuitableinternalfixation.lThetibiawasreducedwithacloverleafplate,dynamiccompressionplateorlockingcompressionplate,dependingonthelevelofthefractureanddegreeofstabilityrequired.lLinetal.reportedan83.3%goodratein30casestreatedwithORIFfollowedupfor1739months5.Kalendereretal.alsoreportedasimilarresult6.lExternalfixationandlimitedinternalfixationwereperformedinallpatientswithtypeC2andtypeC3fracturespresentingwithhigh-gradesofttissueinjury(GustiloIIandIII)andintervalbetweeninjuryandpresentationattheauthorsclinicoflessthan8hours.lUseofexternalfixationduringthesurgicalprocedureenables（使能够）thesurgeontoassess（评估）thelengthandhelpsstabilizethelimb（肢）forreconstructionoftheintra-articular（关节内）component.lPlacement（放置）oftheexternalfixatorwithacalcanealpinandahalf-pininthetibiaallowsligamentotaxis（韧带修复术）tooccurthroughtractiononthecalcanealpin.linitial(首先)ldistraction（牵引）leliminate（清除）lcompromise（妥协、折衷、让步）lexposure（显露，暴露）lincidence（发生率）lmalalignment(对线不良)lstiffness（僵硬）stfnslpreclude（排除）lPre-existing（已存在）linviewof（鉴于，考虑到）lischemia（缺血）skimlprecarious（不确定的）prkerslThisishelpfulinreductionofthefractureandallowseasieraccessto（入路）theanklejointforjointreconstruction.lUsedasaneutralization（中和）device,thereisnoneedforlargeplateswiththeassociated（相关）increasedriskofskinsloughing7.lMinimizing（将.减到最少）internalfixationanddamagetosofttissuesandbloodsupplydecreasestherateofskinsloughingandinfection.lWewereabletocorrectpostoperativelossofreduction（再移位）byadjustingexternalfixation.lItisalsoanexcellentdeviceinthoseseverelycomminutedfracturesthatdonotallowstablefixationwiththeuseofaplate.lSeveralresearchershavereportedsimilarfindingsinregardto（关于）externalfixation811.lOurresultsleadustorecommend(建议，推荐)thatTypeC3tibialpilonfracturespresentingwithhigh-gradesofttissueinjury(GustiloIII)andintervalbetweeninjuryandpresentationfortreatmentofmorethan8hoursshouldbetreatedwithatwo-stageprocedure.lAtinitial(首先)presentation,anexternalfixatorisapplied.lAfterthesofttissueshaverecovered,thesecondstageisperformed.lThegoalofthefirststageistore-establishthelength,alignmentandrotationoftheextremityandprovideanenvironmentforsoft-tissuerecovery.lTheearlyapplicationofadistraction（牵引）forcemayhelptolimitanysecondaryinjuryandeliminate（清除）additionalsofttissuecompromise（妥协、折衷、让步）duringsurgicalexposure（显露，暴露）12.lSeveralreportshaveshownthatthetwo-stageprocedurecanreducetherateofcomplicationssuchasinfection,skinsloughing,andpost-traumaticarthritis1315.Prevention of postoperative complications.Ithasbeenreportedthattheincidence（发生率）ofcomplications,includingwoundproblems,skinsloughing,infection,nonunion,malalignment(对线不良),jointstiffness（僵硬）andposttraumaticarthritis,ishigh(45.1%)inpatientswithseverepilonfractures16.lSkinsloughingandinfectionarethemostimportantearlypostoperativecomplications17.lPre-existing（已存在）severesofttissueinjuryprecludes（不能）openreductioninviewof（考虑到）thepotentialwoundproblemsduetoischemia（缺血）orinfectionofthesofttissues.lTheprecarious（不确定的）bloodsupplyinthisregionofthetibiacan