Pilon骨折的外科治療醫(yī)學(xué)課件

Received:19July;accepted5October

DOI:10.1111/j.1757-7861..00113.x

Pilon骨折的外科治療第17頁MaterialsandMethods

Patientdata

FromApriltoJuly,28patientswithopentibialpilonfracturesweretreatedinourhospital.

Pilon骨折的外科治療第18頁Therewere21menand7womenwithanaverageageof36.5years(range,19–61years).Tenpatientswereinjuredontheleftside,17ontherightand1bilaterally(aclosedfractureoftherightmalleolus（踝）wasnotcounted).Pilon骨折的外科治療第19頁Theintervalbetweeninjuryandpresentationtoourclinicrangedfrom1to14hours(average,5.1hours).Themechanismsofinjurywerehigh-energyfallsin10cases,motorvehicleaccidentsin12,crushinginjury（擠壓傷）in4cases,andsportsinjuriesin2.

Pilon骨折的外科治療第20頁ThefractureswereclassifiedaccordingtotheAO/ASIFsystem:7wereclassifiedastypeC1,17typeC2,and4typeC3.

Pilon骨折的外科治療第21頁OpensofttissuedamagewasgradedaccordingtotheGustilosystem:4caseswereclassifiedasGustiloI,21GustiloII,2GustiloIIIA,and1GustiloIIIB.

Pilon骨折的外科治療第22頁acetabular?s?'t?bjul?]髖臼fibular腓骨;fibula腓骨femoral股骨Calcaneal[k?l'keini?l跟骨craniocerebral[,kreini?usi'ri:br?l顱腦protocol方法、協(xié)議presentingwith伴隨restoration恢復(fù)tibia脛骨Pilon骨折的外科治療第23頁cancellous

['k?ns(?)l?s]松質(zhì)骨insertion插入modified改善cloverleaf三葉草形Anteromedial前內(nèi)側(cè)medial內(nèi)側(cè)posterolateral后外側(cè)lateral外側(cè)constraint約束、限制keepinginmind切記anteroposterior前后;正位（影像）Pilon骨折的外科治療第24頁Combinedinjuriesincludedfibularfracturesin25cases,spinalfracturesin2,upper-armfracturesin2,ribfracturesin2,femoralfracturein1,acetabularfracturein1,calcanealfracturein1,andcraniocerebraltraumain1.

Pilon骨折的外科治療第25頁demonstrating顯示Calcaneus（口Ki尼爾斯）:跟骨metatarsal跖骨anklemortise踝關(guān)節(jié)Kirschner克氏pin克氏針Pilon骨折的外科治療第26頁Methods

Oneofthreedifferentsurgicalprotocolswasperformedinallpatients,thechoicebeingbasedontheconditionofsofttissue,typeoffractureandlengthofintervalbetween

injuryandpresentationfortreatment.

Pilon骨折的外科治療第27頁Debridement,open

reductionand

internalfixation(ORIF)

ThismethodwasappliedintypeC1fracturespresentingwithlow-gradesofttissueinjury(GustiloI,II)andintervalbetweeninjuryandpresentationfortreatmentoflessthan6hours.

Pilon骨折的外科治療第28頁Sevenpatients(fourtypeC1GustiloIandthreetypeC1GustiloII)weretreatedbythismethod.

Pilon骨折的外科治療第29頁Surgicaltreatmentofthepilonfractureswasinfoursteps:(a)restorationofthecorrectlengthand

stabilizationofthefibula;Pilon骨折的外科治療第30頁(b)reconstructionofthearticularsurfaceofthetibia;(c)insertionofcancellousautografts;and(d)stabilizationofthemedialaspectofthetibiawiththeuseofamodifiedcloverleafplate.

Pilon骨折的外科治療第31頁Ananteromedialincisionwasemployedtotreatthetibialcomponentandalateralorposterolateralincisiontotreatthefibularfracture.

Pilon骨折的外科治療第32頁Thesurgicalincisionswereplannedbasedontherequirementsofthefracturepattern,keepinginmindthesoft-tissueconstraintsoftheindividualinjury.Pilon骨折的外科治療第33頁Skinclosurewasachievedwithnotension.Thetibialincisionswereclosedfirst.Ifnecessary,thefibularincisionswereleftfordelayedclosure.

Pilon骨折的外科治療第34頁Oneofthesevenpatientsachievedprimaryclosureofthemedialincision,followedbydelayedclosureofthelateralone.AtypicalcaseisshowninFig.1.Pilon骨折的外科治療第35頁Figure1

A49year-oldmanwithalow-energyopenpilonfracture(GustiloI&C1)(a)Photographshowingopensofttissueinjury(GustiloI).(b)PreoperativeanteroposteriorandlateralradiographsshowingPilonfractureoftypeC1.(c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithplates.(d)Anteroposteriorandlateralradiographsdemonstratingfractureshavehealed1yearaftersurgery.

Pilon骨折的外科治療第36頁Pilon骨折的外科治療第37頁Figure2A22year-oldmanwithahigh-energyopenpilonfracture(GustiloII&C2)(a)Photographshowingopensofttissueinjury(GustiloII).(b)PreoperativeradiographsshowingPilonfractureoftypeC2.

Pilon骨折的外科治療第38頁(c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithexternalfixation,andthetibialfracturefixedwithlimitedinternalfixation.(d)Anteroposteriorandlateralradiographs

demonstratingthefractureshavehealed1.5yearaftersurgery.

Pilon骨折的外科治療第39頁Debridement,limited

ORIF

and

externalfixation

ThismethodwasappliedintypeC2andtypeC3fracturespresentingwithhigh-gradesofttissueinjury(GustiloII,III)andintervalbetweeninjuryandpresentationfortreatmentoflessthan8hours.

Pilon骨折的外科治療第40頁Nineteenpatients(16typeC2GustiloII,1typeC2GustiloIIIA,and2typeC3GustiloII)weretreatedbythismethod.

Pilon骨折的外科治療第41頁Thepatientsweremanagedbyimmediate（直接）debridementofthewound.Fibularfractureswerealwaysinternallyfixed,eitherwitha1/3tubular（管狀）plateor3.5mmcompressionplate.

Pilon骨折的外科治療第42頁Externalfixationwasappliedacrosstheankle

jointwithpinsinthecalcaneus,metatarsalbone,andtibia,reconstructionoftheanklemortise（踝關(guān)節(jié)）,andstabilizationwithscrewsorKirschnerpins.

Pilon骨折的外科治療第43頁split-thicknessskingrafting厚皮瓣轉(zhuǎn)移splint夾板edema（水腫）antibiotic（抗生素）extent（范圍）contamination（污染）Theaffectedextremity（下肢）elevate抬高;提升subtalar（距下）Pilon骨折的外科治療第44頁proscribe（嚴(yán)禁）supervise（指導(dǎo)）physicaltherapyprogram（康復(fù)鍛煉）Roll-A-Boutwalker（助行器）outpatients(門診就診)Staphylococcusepidermidis（表皮葡萄球菌）Acinetobacterbaumannii（鮑氏不動桿菌）Pilon骨折的外科治療第45頁Fiveofthe19patientsrequiredbonegraftingbecauseoflargedefectsofmetaphysealbone.Onecaseunderwentdelayedclosureofthelateralincision,anddelayedsplit-thicknessskingraftingwasappliedinanothercase.AtypicalcaseisshowninFig.2.

Pilon骨折的外科治療第46頁posttraumaticarthritis.（創(chuàng)傷后關(guān)節(jié)炎）

ankle-hind（后踝）Pilon骨折的外科治療第47頁Debridement

and

calcaneal

traction,delayedsurgeryThismethodwasappliedintypeC3fracturesaccompaniedbyhigh-gradesofttissueinjury(GustiloIII)and

intervalbetweeninjuryandpresentationfortreatmentof

morethan8hours.Pilon骨折的外科治療第48頁Intwopatients(onetypeC3Gustilo

IIIA,onetypeC3GustiloIIIB),thesurgeonchoseatwo

stageprocedure（步驟）.Pilon骨折的外科治療第49頁Thepatientswereputoncalcanealpin

skeletaltractionwithelevationofthelowerlimbovera

Bohler–Braunsplint（勃朗支架）,andmeasuresweretakentoavoid

edema（水腫）.Pilon骨折的外科治療第50頁Wounddrainage（引流管）wasremovedwhentherewasno

furtherevidenceofinfection,andasecondstageoperationwasperformedwhentheedemahadalmostcompletelyresolved.Pilon骨折的外科治療第51頁ThepatientsweretreatedwithlimitedORIFandexternalfixation.Thetimeintervalbetweenthetwosurgerieswas15and19days,respectively.Atypical

caseisshowninFig.3Pilon骨折的外科治療第52頁Pilon骨折的外科治療第53頁Figure3A37year-oldmanwithasuperhigh-energyopenpilonfracture(GustiloIIIB&C3)(a)Photographshowingopensofttissueinjury(GustiloIIIB)(b)PreoperativeradiographsshowingPilonfractureoftypeC3.Pilon骨折的外科治療第54頁(c)Postoperativeradiographsshowingthefractureshave

beenanatomicallyreducedandfixedwithexternalfixation,thetibialfixedwithlimitedinternalfixation,andthefibulawithaplate.(d)Anteroposteriorandlateralradiographsdemonstratingthefractureshavehealed1.5yearaftersurgery.Pilon骨折的外科治療第55頁PostoperativecareAppropriatecultures（培養(yǎng)）wereobtainedduringsurgery,andbroad-spectrumantibiotics（廣譜抗生素）wereadministered.（實施,使用）Thechoiceofantibiotic（抗生素）wasbasedontheextent（范圍）anddegreeofcontamination（污染）.Pilon骨折的外科治療第56頁Activeankleandsubtalar（距下）jointrange-of-motionexerciseswerebegunassoonasthewoundwasdry,usuallybetween2and5daysaftersurgery.Weight-bearingexercisewasproscribed（嚴(yán)禁）inthefirst12weeksaftersurgery.Pilon骨折的外科治療第57頁Asupervised（指導(dǎo)）physicaltherapy

program（康復(fù)鍛煉）encouragingactiveanklerange-of-motionexerciseswasemployedforthefirst6weeks.Thiswasprogressedtoincludepassiveexercisesbetween6and12

weeks.ARoll-A-Boutwalker（助行器）wasusedwhennecessary.Pilon骨折的外科治療第58頁Theaffectedextremity（下肢）waselevated（提升）continuouslyforthefirst48hoursandthen,asmuchaspossible,forthenext7days.Pilon骨折的外科治療第59頁procedure（步驟）broad-spectrumantibiotics（廣譜抗生素）extremity手足outpatients(門診就診)medial（內(nèi)側(cè)）originally(最初）dissection（解剖,切開）stripping（剝離）Pilon骨折的外科治療第60頁posttraumaticarthritis.（創(chuàng)傷后關(guān)節(jié)炎）ankle-hind（后踝）originally(最初)dissection（解剖,切開）stripping（剝離）ligamentotaxis（韌帶修復(fù)術(shù)）neutralization（中和）inregardto（相關(guān)）Pilon骨折的外科治療第61頁Radiographs

wereobtainedandevaluatedaccordingtotheBurwell

Charnleysystem:anatomicreductionwasachieved

in12cases,functionalreductionin15cases,andpoorreductionin1case.Pilon骨折的外科治療第62頁Thehealingtimeofthefracturewasfrom2.5to11months,withanaverageof4.7months.Pilon骨折的外科治療第63頁Results

All28patientswerefollowedupfrom6to48months

withanaverageof24months,andunderwentclinicaland

radiologicalexaminationasoutpatients(門診就診).Pilon骨折的外科治療第64頁Delayedunionwasfoundintwocases;inbothitwas

associatedwithbonedefectsofthemedial（內(nèi)側(cè)）tibia.Onestage

woundclosurewasperformedin18patients,twounderwentdelayedclosureoftheirlateralincisions,andone

underwentdelayedsplit-thicknessskingrafting.Pilon骨折的外科治療第65頁There

werefourcasesofsuperficialsloughingoftheskin.Two

patientsdevelopedsurfaceinfectionwithStaphylococcus

epidermidis（表皮葡萄球菌）andAcinetobacterbaumannii（鮑氏不動桿菌）andonedevelopeddeepinfectionwithAcinetobacterbaumannii;the

infectionratewas10.7%(3/28).Pilon骨折的外科治療第66頁Tenpatients(35.7%)showedevidenceofposttraumaticarthritis.（創(chuàng)傷后關(guān)節(jié)炎）AccordingtotheAOFASankle-hind（后踝）footfunctionevaluation（評定）,theaveragescorewas85.2(range,66to98):excellentin8patients,goodin14,fairin5,andpoorin1.Pilon骨折的外科治療第67頁DiscussionChoiceofsurgicalmethodsInpatientswithtypeC1fractureandGustiloIsoft

tissueinjuryduetolow-energyforces,pilonfracturewas

anatomicallyreducedandtreatedwithdebridementandinternalplatefixationfollowingAO/ASIFprinciples.Pilon骨折的外科治療第68頁Openreductionandinternalfixationwereoriginally(最初)used,butitisnowknownthatopenreductionincreasestherisk

ofcomplicationsafterhigh-energytrauma.Pilon骨折的外科治療第69頁Thisisprobablyrelatedtotheamountofdissection（解剖,切開）andstripping（剝離）ofsofttissueswhichisneededtoachievereductionandplatefixation.Pilon骨折的外科治療第70頁Therefore,whenperformingORIFprocedures,thesurgeonstriedtolimitsofttissuedamageandchoose

suitableinternalfixation.Pilon骨折的外科治療第71頁Thetibiawasreducedwitha

cloverleafplate,dynamiccompressionplateorlocking

compressionplate,dependingonthelevelofthefracture

anddegreeofstabilityrequired.Pilon骨折的外科治療第72頁Linetal.reportedan

83.3%goodratein30casestreatedwithORIFfollowed

upfor17~39months5.Kalendereretal.alsoreporteda

similarresult6.Pilon骨折的外科治療第73頁ExternalfixationandlimitedinternalfixationwereperformedinallpatientswithtypeC2andtypeC3fractures

presentingwithhigh-gradesofttissueinjury(GustiloII

andIII)andintervalbetweeninjuryandpresentationat

theauthors’clinicoflessthan8hours.

Pilon骨折的外科治療第74頁Useofexternalfixationduringthesurgicalprocedureenables（使能夠）thesurgeontoassess（評定）thelengthandhelpsstabilizethelimb（肢）forreconstructionoftheintra-articular（關(guān)節(jié)內(nèi)）component.Pilon骨折的外科治療第75頁Placement（放置）of

theexternalfixatorwithacalcanealpinandahalf-pinin

thetibiaallowsligamentotaxis（韌帶修復(fù)術(shù)）tooccurthroughtraction

onthecalcanealpin.Pilon骨折的外科治療第76頁Pilon骨折的外科治療第77頁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(對線不良)stiffness（僵硬）['st?fn?s]Pilon骨折的外科治療第78頁preclude（排除）Pre-existing（已存在）inviewof（鑒于,考慮到）ischemia（缺血）[?s'kim??]precarious（不確定）[pr?'ke?r??s]Pilon骨折的外科治療第79頁Thisishelpfulinreductionofthe

fractureandallowseasieraccessto（入路）theanklejointfor

joint

reconstruction.Pilon骨折的外科治療第80頁Usedasaneutralization（中和）device,thereisno

needforlargeplateswiththeassociated（相關(guān)）increasedriskof

skinsloughing7.Pilon骨折的外科治療第81頁Minimizing（將...減到最少）internalfixationanddamage

tosofttissuesandbloodsupplydecreasestherateofskin

sloughingandinfection.Pilon骨折的外科治療第82頁Wewereabletocorrectpostoperativelossofreduction（再移位）byadjustingexternalfixation.It

isalsoanexcellentdeviceinthoseseverelycomminuted

fracturesthatdonotallowstablefixationwiththeuseofa

plate.Pilon骨折的外科治療第83頁Severalresearchershavereportedsimilarfindingsinregardto（相關(guān)）externalfixation8–11.Pilon骨折的外科治療第84頁Ourresultsleadustorecommend(提議,推薦)thatTypeC3tibialpilonfracturespresentingwithhigh-gradesofttissueinjury(GustiloIII)andintervalbetweeninjuryandpresentationfortreatmentofmorethan8hoursshouldbetreatedwithatwo-stageprocedure.Pilon骨折的外科治療第85頁Atinitial(首先)presentation,anexternalfixatorisapplied.Afterthesofttissueshave

recovered,thesecondstageisperformed.Pilon骨折的外科治療第86頁Thegoalofthe

firststageistore-establishthelength,alignmentandrotation

oftheextremityandprovideanenvironmentfor

soft-tissuerecovery.Pilon骨折的外科治療第87頁Theearlyapplicationofadistraction（牽引）forcemayhelptolimitanysecondaryinjuryandeliminate（清除）additionalsofttissuecompromise（妥協(xié)、折衷、讓步）duringsurgicalexposure（顯露,暴露）12.Pilon骨折的外科治療第88頁Severalreportshaveshownthatthetwo-stageprocedure

canreducetherateofcomplicationssuchas

infection,skinsloughing,andpost-traumaticarthritis13–15.Pilon骨折的外科治療第89頁Preventionofpostoperativecomplications.Ithasbeenreportedthattheincidence（發(fā)生率）ofcomplications,includingwoundproblems,skinsloughing,infection,nonunion,malalignment(對線不良),jointstiffness（僵硬）andposttraumaticarthritis,ishigh(45.1%)inpatientswithsevere

pilonfractures16.Pilon骨折的外科治療第90頁Skinsloughingandinfectionarethemostimportant

earlypostoperativecomplications17.Pre-existing（已存在）severe

softtissueinjuryprecludes（不能）openreductioninviewof（考慮到）the

potentialwoundproblemsduetoischemia（缺血）orinfectionof

thesofttissues.Pilon骨折的外科治療第91頁Theprecarious（不確定）bloodsupplyinthisregionofthetibiacancontributeto（有利于）theproblemsofbothnonunionandinfection18.Pilon骨折的外科治療第92頁Intensive（加強）outweigh（勝過,強過）lateralcolumn(外側(cè)柱)ligament（韌帶）taxis（整復(fù)）circularframes（圓形框架）hybridsystems（混合系統(tǒng)）['ha?br?d]Pilon骨折的外科治療第93頁hingeaxis（鉸鏈軸）[h?nd?]plastercast（石膏）optimal（最好）manuscript（手稿,文章）Pilon骨折的外科治療第94頁Inthepresentstudy,therewerefour

casesofskinsloughing,twoofsuperficialinfections,and

onlyoneofdeepboneinfection.Pilon骨折的外科治療第95頁Surgicalapproachesare

nowplannedbasedonthe

requirementsofthefracture

pattern,keepinginmindthesoft-tissueconstraintsofthe

individualinjury.Pilon骨折的外科治療第96頁Theincisionsarekeptatleast7cmapart

topreventsoft-tissueischemiaandsecondarywoundbreakdown.Pilon骨折的外科治療第97頁Intensive（加強）debridement,minimizationofsofttissuestrippingandproperuseofantibioticsareusefulforpreventinginfection.Pilon骨折的外科治療第98頁Delayedunion,especiallyinthemetaphysealportion,is

alsoaproblemwithpilonfractures.Wenoteda7.1%

delayedunionrateinthisseries.Pilon骨折的外科治療第99頁Theseverityoftheinjuryandpoorbloodsupplytothedistaltibiamayoutweigh（勝過,強過）theaffectsofanyparticularapproachwhenitcomestononunionordelayedunion,anditisalsoprobablycausedbytibialbonedefectafterfixationofthefibula.Butthereisnotdecidedforthefibulafixation19,20.Pilon骨折的外科治療第100頁Wethinkthat

fibularfractureshouldbefixedtorestorethelengthofthe

lateralcolumn(柱)ofthet