后外側(cè)脛骨平臺(tái)骨折（課堂PPT）

1、1后外側(cè)脛骨平臺(tái)骨折后外側(cè)脛骨平臺(tái)骨折潘德悅2定義脛骨平臺(tái)骨折脛骨平臺(tái)骨折-是指骨折線累及脛骨近端關(guān)節(jié)面的骨折后外側(cè)脛骨平臺(tái)的定義？后外側(cè)脛骨平臺(tái)的定義？3后外側(cè)4 后外側(cè)脛骨平臺(tái)5解剖6解剖7解剖A：46.39.0mmB：35.79.0mm后側(cè)血管后側(cè)血管脛前動(dòng)脈ATA腘動(dòng)脈不能結(jié)扎！8解剖后外側(cè)復(fù)合體！后外側(cè)復(fù)合體！ （PLC）維持膝關(guān)節(jié)后外側(cè)穩(wěn)定維持膝關(guān)節(jié)后外側(cè)穩(wěn)定外側(cè)副韌帶外側(cè)副韌帶腘肌腱復(fù)合體腘肌腱復(fù)合體腘腓韌帶腘腓韌帶弓狀韌帶弓狀韌帶后外側(cè)關(guān)節(jié)囊后外側(cè)關(guān)節(jié)囊9解剖外翻角：外翻角：87 （85-90） 后傾角：后傾角：0-10Cong-Feng Luo.Reference axes

2、for reconstruction of the knee. The Knee 2004, 11:253-25710損傷機(jī)制低能量損傷屈曲伸直外翻內(nèi)翻過伸11影像學(xué)檢查 X線 CT MRI CTA或動(dòng)脈血管造影12分型Schatzker 分型AO/OTA分型三柱分型Hohl-Moore分型13Schatzker 分型Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Torontoexperience 1968-1975. Clin Orthop Relat Res. 1979 Jan-Feb;(138):94-

3、104.14AO/OTA分型關(guān)節(jié)外骨折(Type A)單髁骨折(Type B)雙髁骨折(TyPe C)15三柱分型Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010 Nov;24(11):683-92.16這是幾型？AO ： 41-B3 Schatzker：型 三柱：外側(cè)+后側(cè)柱 17治療18 關(guān)節(jié)塌陷和分離3 mm 干骺端明顯移位或成角5 開放性骨折合并血管神經(jīng)損傷 出現(xiàn)骨筋膜間隔綜合征等 屈膝不穩(wěn)治療手術(shù)治療指征1

4、.Thomas C，Athanasiov A，Wullschleger M，et a1Current concepts in tibial plateau fracturesJActa Chir Orthop Traumatol Cech，2009，76(5)：3633732.Papagelopoulos PJ,Partsinevelos AA,Themistocleous GS,et al.Complications after tibia plateau fracture surgeryJ.Injury,2006,37(6)：47548419前外側(cè)入路前外側(cè)入路治療20后正中入路后正中入路

5、Hughston JC. A surgical approach to the medial and posterior ligaments of the knee. Clin Orthop Relat Res 1973;91(91):293321倒倒L入路入路Luo CF, Sun H, Zhang B, Zeng BF. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010 Nov;24(11):683-92.22擴(kuò)大擴(kuò)大 Tscherne-Johnson 入路入路治療Johnso

6、n EE, Timon S, Osuji C. Surgical technique: Tscherne-Johnson extensile approach for tibial plateau fractures. Clin Orthop Relat Res. 2013 Sep;471(9):2760-7.23后外側(cè)骨折后外側(cè)骨折-后外側(cè)切口入路后外側(cè)切口入路Chang SM, Zheng HP, Li HF, Jia YW, Huang YG, Wang X, Yu GR. Treatment ofisolated posterior coronal fracture of the la

7、teral tibial plateau throughposterolateral approach for direct exposure and buttress plate fixation. ArchOrthop Trauma Surg. 2009 Jul;129(7):955-6224Chang SM, Zheng HP, Li HF, Jia YW, Huang YG, Wang X, Yu GR. Treatment ofisolated posterior coronal fracture of the lateral tibial plateau throughposter

8、olateral approach for direct exposure and buttress plate fixation. ArchOrthop Trauma Surg. 2009 Jul;129(7):955-62后外側(cè)骨折后外側(cè)骨折-后外側(cè)切口入路后外側(cè)切口入路25后外側(cè)骨折后外側(cè)骨折-前外側(cè)擴(kuò)大切口入路前外側(cè)擴(kuò)大切口入路26后外側(cè)骨折后外側(cè)骨折-后正中切口入路后正中切口入路27后外側(cè)骨折后外側(cè)骨折-腓骨頭截骨入路腓骨頭截骨入路 Yu B, Han K, Zhan C, Zhang C, Ma H, Su J. Fibular head osteotomy: a new appr

9、oach for the treatment of lateral or posterolateral tibial plateau fractures.Knee. 2010 Oct;17(5):313-8.28后外側(cè)骨折后外側(cè)骨折-Carlson入路入路Carlson DA. Posterior bicondylar tibial plateau fractures. J Orthop Trauma.2005 Feb;19(2):73-829Frosch KH, Balcarek P, Walde T, Strmer KM. A new posterolateral approachwith

10、out fibula osteotomy for the treatment of tibial plateau fractures. J Orthop Trauma. 2010 Aug;24(8):515-20.后外側(cè)骨折后外側(cè)骨折-Frosch入路入路30經(jīng)腓骨頭上入路經(jīng)腓骨頭上入路31后（外）側(cè)入路問題n 暴露困難，易損傷血管神經(jīng)n 復(fù)位困難，無法直視關(guān)節(jié)面n 力線糾正不足32后（外）側(cè)入路優(yōu)點(diǎn)n 直接復(fù)位n 可以有效固定33常見治療方式34 拉力螺釘拉力螺釘 鎖定鋼板鎖定鋼板 普通鋼板普通鋼板 克氏針克氏針 空心加壓螺釘空心加壓螺釘 髓內(nèi)釘髓內(nèi)釘內(nèi)固定材料治療35 后外側(cè)骨折復(fù)位后外側(cè)

11、骨折復(fù)位 經(jīng)骨折線復(fù)位經(jīng)骨折線復(fù)位 開窗開窗 截骨截骨 后（外）側(cè)入路后（外）側(cè)入路36經(jīng)骨折線復(fù)位37 后外側(cè)骨折常見固定方式38 Zhang W, Luo CF, Putnis S, Sun H, Zeng ZM, Zeng BF. Biomechanical analysis of four different fixations for the posterolateral shearing tibial plateau fracture.Knee. 2012 Mar;19(2):94-8.3940內(nèi)固定技術(shù)Raft技術(shù)（竹筏或排釘技術(shù)） Cross WW 3rd, Levy BA,

12、Morgan JA, Armitage BM, Cole PA. Periarticular raft constructs and fracture stability in split-depression tibial plateau fractures.Injury. 2013 Jun;44(6):796-801.41JAIL（網(wǎng)格）技術(shù) Weimann A, Heinkele T, Herbort M, Schliemann B, Petersen W, Raschke MJ.Minimally invasive reconstruction of lateral tibial pl

13、ateau fractures using thejail technique: a biomechanical study. BMC Musculoskelet Disord. 2013 Apr4;14:120.內(nèi)固定技術(shù)42經(jīng)皮內(nèi)固定技術(shù)This new technique is recommended for fractures with cleavage and compression or only compression43球囊復(fù)位技術(shù)Heiney JP, Kursa K, Schmidt AH, Stannard JP. Reduction and Stabilization of Depressed Articular Tibial Plateau Fractures: Comparison of Inflatable and Conventional Bone Tamps: Study of a Cadaver Model. J Bone Joint Surg Am. 2014 Aug 6;96(15):1273-127944