Pilon骨折的外科治疗课件.ppt

Pilon骨折的外科治疗,trauma创伤,classification分类；分级,debridement清创术、扩创术,anatomic reduction,解剖复位,the Arbeitsgemeinschaft fr 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,Seven 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 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 Foot 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-traumatic 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-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 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 depression.,Introduction,Pilon 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 for 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 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,MDDepartment of Trauma,Tianjin Hospital,Tianjin,China 300211 Tel:[phone];Fax:[phone];Email:zengxiantieReceived:19 July 2010;accepted 5 October 2010DOI:10.1111/j.1757-7861.2010.00113.x,Materials and Methods,Patient data,From 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 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）,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 were 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 Gustilo 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,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,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 fracture 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 s,One 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.,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 presentation 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 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 fibular 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 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&C1),(a)Photograph showing open soft tissue injury(GustiloI).,(b)Preoperative anteroposterior and lateral radiographs showing Pilon fracture of type C1.,(c)Postoperative radiographs showing the fractures have been anatomically reduced and fixed with plates.,(d)Anteroposterior and lateral radiographs demonstrating fractures have healed 1 year after surgery.,Figure 2,A 22 year-old man with a high-energy open pilon fracture(Gustilo II&C2),(a)Photograph showing open soft tissue injury(GustiloII).,(b)Preoperative radiographs showing Pilon fracture of type C2.,(c)Postoperative radiographs showing the fractures have been anatomically reduced and fixed with external fixation,and the tibial fracture fixed with limited internal fixation.,(d)Anteroposterior and lateral radiographs,demonstrating the fractures have healed 1.5 year after surgery.,D 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 n,This method was applied in type C2 and type C3 fractures presenting with high-grade soft tissue injury(Gustilo II,III)and interval between injury and presentation for treatment of less than 8 hours.,Nineteen patients(16 type C2 Gustilo II,1 type C2 Gustilo IIIA,and 2 type C3 Gustilo II)were treated by this method.,The patients were managed by immediate,（直接的）,debridement of the wound.,Fibular fractures were always internally fixed,either with a 1/3 tubular,（管状的）,plate or 3.5 mm compression plate.,External fixation was applied across the ankle,joint with pins in the calcaneus,metatarsal bone,and tibia,reconstruction of the ankle mortise,（踝关节）,and stabilization with screws or Kirschner pins.,split-thickness skin grafting,厚皮瓣转移,splint,夹板,edema,（水肿）,antibiotic,（抗生素）,extent,（范围）,contamination,（污染）,The affected extremity,（下肢）,elevate,抬高；提高,subtalar,（距下）proscribe,（禁止）,supervise,（指导）,physical therapy,program,（康复锻炼）,Roll-A-Bout walker,（助行器）,outpatients,(门诊就诊),Staphylococcus,epidermidis,（表皮葡萄球菌）,Acinetobacter baumannii,（鲍氏不动杆菌）,Five of the 19 patients required bone grafting because of large defects of metaphyseal bone.,One case underwent delayed closure of the lateral incision,and delayed split-thickness skin grafting was applied in another case.,A typical case is shown in Fig.2.,posttraumatic arthritis.,（创伤后关节炎）,ankle-hind,（后踝）,D e b r i d e m e n t,a n d,calcane al,traction,delayed surgery,This method was applied in type C3 fractures accompanied by high-grade soft tissue injury(Gustilo III)and,interval between injury and presentation for treatment of,more than 8 hours.,In two patients(one type C3 Gustilo,IIIA,one type C3 Gustilo IIIB),the surgeon chose a two,stage procedure,（步骤）,.,The patients were put on calcaneal pin,skeletal traction with elevation of the lower limb over a,BohlerBraun splint,（勃朗支架）,and measures were taken to avoid,edema,（水肿）,.,Wound drainage,（引流管）,was removed when there was no,further evidence of infection,and a second stage operation was performed when the edema had almost completely resolved.,The patients were treated with limited,ORIF and external fixation.,The time interval between the,two surgeries was 15 and 19 days,respectively.,A typical,case is shown in Fig.3,Figure 3 A 37 year-old man with a super high-energy open pilon fracture(Gustilo IIIB&C3),(a)Photograph showing open soft tissue injury(Gustilo IIIB),(b)Preoperative radiographs showing Pilon fracture of type C3.,(c)Postoperative radiographs showing the fractures have,been anatomically reduced and fixed with external fixation,the tibial fixed with limited internal fixation,and the fibula with a plate.,(d)Anteroposterior and lateral radiographs demonstrating the fractures have healed 1.5 year after surgery.,Postoperative care,Appropriate cultures,（培养）,were obtained during surgery,and,broad-spectrum antibiotics,（广谱抗生素）,were administered.,（执行，使用）,The,choice of antibiotic,（抗生素）,was based on the extent,（范围）,and degree of,contamination,污染）,.,Active ankle and subtalar,（距下）,joint range-of-motion exercises were begun as soon as the,wound was dry,usually between 2 and 5 days after surgery.,Weight-bearing exercise was proscribed,（禁止）,in the first 12,weeks after surgery.,A supervised,（指导）,physical therapy,program,（康复锻炼）,encouraging active ankle range-of-motion exercises was employed for the first 6 weeks.,This was progressed to include passive exercises between 6 and 12,weeks.,A Roll-A-Bout walker,（助行器）,was used when necessary.,The affected extremity,（下肢）,was elevated,（提高）,continuously for the first 48 hours and then,as much as,possible,for the next 7 days.,procedure,（步骤）,broad-spectrum antibiotics,（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）,posttraumatic arthritis.,（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,regard to,（关于）,Radiographs,were obtained and evaluated according to the Burwell,Charnley system:anatomic reduction was achieved,in 12 cases,functional reduction in 15 cases,and poor,reduction in 1 case.,The healing time of the fracture was,from 2.5 to 11 months,with an average of 4.7 months,.,Results,All 28 patients were followed up from 6 to 48 months,with an average of 24 months,and underwent clinical and,radiological examination as outpatients,(门诊就诊),.,Delayed union was found in two cases;in both it was,associated with bone defects of 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 Staphylococcus,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 evaluation,（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 treated 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）,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 locking,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 were 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,to 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),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）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,joint,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 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 results lead us to recommend,(建议，推荐),that T