CAJ | 학술논문

目的探讨Topliss分型下前外侧入路与后内侧入路内固定治疗闭合矢状面Pilon骨折的指导意义,并比较二者疗效.方法选择2007年-2010年采用切开复位内固定治疗的闭合矢状面Pilon骨折患者57例,其中采用前外侧入路(A组)29例；采用后内侧入路(B组)28例,均为闭合性骨折,伤后手术时间窗均在10～19d之间.比较两组患者性别、年龄、骨折类型、软组织分度、致伤因素、合并腓骨骨折情况、手术时间窗、手术时间、术中出血量、下地时间、皮肤及软组织的感染及坏死率、住院时间、内固定置入后踝关节功能恢复情况及术中X线复位程度.结果术后随访12～26个月,平均20个月.全部患者中仅A组1例失访,总随访率为98％.两组间性别、年龄、骨折类型、软组织分度、致伤因素、合并腓骨骨折情况、手术时间窗选择、手术时间及术中出血量、下地时间差异无统计学意义(P＞0.05).与B组比较,内固定术后A组皮肤软组织感染及坏死发生率更低,住院时间明显缩短(P＜0.05).其中A组中2例术后出现趾伸肌腱粘连,内固定取出术中予以松解.15例患者住院期间发生切口感染,其中A组3例,B组12例,均通过换药等处理后治愈.15例患者术中Ⅰ期同种异体骨充填,11例自体髂骨植骨,均无骨不愈合发生.结论 Topliss分型对闭合矢状面Pilon骨折的手术方案选择及手术操作具有明确的临床指导意义.虽然前外侧入路与后内侧入路治疗闭合矢状面Pilon骨折最终均能取得良好的疗效,但前外侧入路治疗高能量损伤所致闭合矢状面Pilon骨折皮肤软组织感染及坏死率低、住院时间短,是一种较为理想的手术人路选择.
목적 탐토Topliss분형하전외측입로여후내측입로내고정치료폐합시상면Pilon골절적지도의의,병비교이자료효.방법 선택2007년-2010년채용절개복위내고정치료적폐합시상면Pilon골절환자57례,기중채용전외측입로(A조)29례；채용후내측입로(B조)28례,균위폐합성골절,상후수술시간창균재10～19d지간.비교량조환자성별、년령、골절류형、연조직분도、치상인소、합병비골골절정황、수술시간창、수술시간、술중출혈량、하지시간、피부급연조직적감염급배사솔、주원시간、내고정치입후과관절공능회복정황급술중X선복위정도.결과 술후수방12～26개월,평균20개월.전부환자중부A조1례실방,총수방솔위98％.량조간성별、년령、골절류형、연조직분도、치상인소、합병비골골절정황、수술시간창선택、수술시간급술중출혈량、하지시간차이무통계학의의(P＞0.05).여B조비교,내고정술후A조피부연조직감염급배사발생솔경저,주원시간명현축단(P＜0.05).기중A조중2례술후출현지신기건점련,내고정취출술중여이송해.15례환자주원기간발생절구감염,기중A조3례,B조12례,균통과환약등처리후치유.15례환자술중Ⅰ기동충이체골충전,11례자체가골식골,균무골불유합발생.결론 Topliss분형대폐합시상면Pilon골절적수술방안선택급수술조작구유명학적림상지도의의.수연전외측입로여후내측입로치료폐합시상면Pilon골절최종균능취득량호적료효,단전외측입로치료고능량손상소치폐합시상면Pilon골절피부연조직감염급배사솔저、주원시간단,시일충교위이상적수술인로선택.
Objective To discuss the clinical significance of internal fixation through anterolaterel and posteromedial approaches in the treatment of closed sagittal Pilon fractures of Topliss classification and compare the effects of the two approaches.Methods The study involved 57 patients with closed sagittal Pilon fractures treated with open reduction and internal fixation from 2007 to 2010,including 29 patients treated through anterolateral approach (Group A) and 28 through posteromedial approach (Group B).All patients were with closed fractures,and all surgery time windows were 10-19 days.The two groups were compared in aspects of gender,age,type of fractures,soft tissue graduation,injury factors,condition of combined fibula fracture,surgery time window,operation time,intra-operative blood loss,ambulation time,infection and necrosis rate of skin and soft tissue,length of stay,ankle joint function recovery after internal fixation,and intra-operative X-ray reduction.Results All patients were followed up for 12-26 months (mean,20 months) except for one patient in the Group A,with total follow-up rate of 98％.The two groups showed no significant differences regarding the gender,age,type of fractures,soft tissue graduation,injury factors,condition of combined fibula fracture,surgery time window selection,operation time,intra-operative blood loss,and ambulation time (P ＞0.05).While,the infection and necrosis incidence of skin and soft tissue,and the hospital stay we re significantly lower and shorter in the Group A than that in the Group B (P ＜ 0.05 ).Two patients in the Group A were complicated with toe extensor tendon adhesion,which was released by removing the fixation.Fifteen patients had wound infection during hospitalization,including three patients in the Group A and 12 in the Group B,but they were all cured after treatments like dressing.Fifteen patients were treated with stage Ⅰ allogeneic bone graft and 11 with autologous iliac bone graft.All the patients obtained bone union.Conclusions Topliss classification of closed sagittal Pilon fractures has clear clinical significance in surgical plan selection and operative procedures.Both of the anterolateral and posteromedial approaches can achieve good effects in the treatment of closed sagittal Pilon fractures due to high energy injury.However,the anterolateral approach is relatively a better choice,for it brings in a lower incidence of infection and necrosis of skin and soft tissue and a shorter length of hospital stay.