《Pilon骨折的外科治疗(英文PPT加翻译).ppt》由会员分享，可在线阅读，更多相关《Pilon骨折的外科治疗(英文PPT加翻译).ppt（110页珍藏版）》请在三一办公上搜索。
1、Objective:To discuss the methods,timing and clinical outcomes of surgical treatment for open pilon fractures.Methods:From April 2003 to July 2008,28 patients with open pilon fractures were treated.All had type C fractures according to the Arbeitsgemeins chaft fr osteosynthesefragenAssociation for th
2、e Study of Internal Fixation(AO/ASIF)classification.Three operative methods were applied,the methods being determined by the types of fracture,soft tissue damage and time interval after injury.,trauma创伤classification分类；分级debridement清创术、扩创术anatomic reduction解剖复位the Arbeitsgemeinschaft fr osteosynthes
3、efragen瑞士骨折内固定协会/AOBurwell-Charnley score骨折复位放射学评价标准1965Orthopaedic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ranti-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 b
4、y 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-Charnle
5、y 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 th
6、e 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 u
7、se 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-infectiv
8、e 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
9、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.,IntroductionPilon fracture constitutes 1%of all lower limb fractures a
10、nd 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 s
11、kin 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
12、clinical outcomes of surgical treatment for open pilon fractures.,Address f or correspondence,Materials and MethodsPatient dataFrom 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
13、,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 fal
14、ls 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 c
15、lassified 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
16、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 cranio
17、cerebral 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 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
18、 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
19、(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 autog
20、rafts;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 requir
21、ements 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 o
22、f 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
23、 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(Gu
24、stilo 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 f
25、ixation.(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 nThis method was applied in type C2 and type C3 fractures presenting with high-grade soft tissue injury(Gu
26、stilo 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 wer
27、e 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-thickne
28、ss 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
29、 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
30、 r i d e m e n t a n d calcane al traction,delayed surgeryThis 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 Gustil
31、o 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,an
32、d 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 sup
33、er 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 f
34、ixed 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 careAppropriate cultures（培养）were obtained during surgery,and broad-spectrum antibiotics（广谱抗生素）were administered.（执行
35、，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
36、 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
37、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
38、，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 fr
39、om 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 t
40、he 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 Staphyloc
41、occus 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 av
42、erage score was 85.2(range,66 to 98):excellent in 8 patients,good in 14,fair in 5,and poor in 1.,DiscussionChoice of surgical methodsIn 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 andint
43、ernal 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 ti
44、ssues 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,dependin
45、g 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
46、 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 stabili
47、ze 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
48、（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）skimprecarious（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,the
49、re 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 extern
50、al 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 Type C3 tibial pilon fract
