Dickson K F, Montgomery S, Field J
Department of Orthopaedics, Tulane University Health Science Center, 1430 Tulane Avenue, SL32, New Orleans, LA 70112, USA.
Injury. 2001 Dec;32 Suppl 4:SD92-8. doi: 10.1016/s0020-1383(01)00163-2.
Early open reduction and internal fixation (ORIF) with plates and screws for plafond injuries caused by skiing initially reported by Ruedi and Allgower proved inadequate for the treatment of high-energy motor vehicle accident type injuries. The purpose of our study was to review our treatment protocol using a spanning external fixator placed semi-emergently medially across the joint and a later staged ORIF of just the articular surface to achieve and maintain anatomic reduction.
We preformed a retrospective study of 35 patients with 37 highly comminuted severe (OTA 43-B3 and -C3 or Ruedi type II or III) tibial plafond fractures treated by a single surgeon. All patients were treated with an initial spanning unilateral external fixator and subsequent ORIF. Radiographs were examined for: classification, number of pieces of the tibial dome, evidence of ground-glass comminution (more than three pieces <2mm in size on CT), anatomic reduction, alignment, and presence/absence of arthritis.
Evidence of ground glass comminution existed in 26/37 patients (70%). Following ORIF, articular reduction was perfect (0-1mm displacement) in 29/36 (81%), imperfect (1-3mm) in 6/36 (17%) and poor (>3mm) in 1/36 (3%) cases. Joint alignment was anatomical in 35/37 (96%), with 15 degree anterior angulation in one patient and 5 degree valgus angulation in another patient. Radiographic arthritis was present in 10/36 patients (28%) at latest follow-up. Joint distraction at time of reduction was present in 27/37 patients (73%). A total of 25/37 patients (65%) had no post-operative complications, while 3/37 (8%) had a joint infection requiring one patient to have hardware removed. A total of 4/37 (11%) showed loss of reduction at latest follow-up. A total of 3/37 (8%) had a secondary arthrodesis; A total of 1 (3%) had a primary arthrodesis; 1 (3%) diabetic man had a below-knee amputation after a failed arthrodesis.
We treat severe tibial plafond fractures with a spanning external fixator at the time of injury, wait between 10 and 21 days to allow for soft tissue healing, and then perform a limited ORIF of the articular surface with canulated screws. In a group of high-energy plafond fractures, we achieved 81% good to excellent results with this protocol. We conclude that use of a spanning external fixator with delayed ORIF compares favorably with the literature.
鲁迪（Ruedi）和阿尔高厄（Allgower）最初报道的用于治疗滑雪所致胫骨平台骨折的早期钢板螺钉切开复位内固定术（ORIF），已证明不足以治疗高能机动车事故类型的损伤。我们研究的目的是回顾我们的治疗方案，即使用半紧急置于关节内侧的跨越外固定器以及随后仅对关节面进行二期切开复位内固定术，以实现并维持解剖复位。
我们对由一名外科医生治疗的35例患者的37例高度粉碎性严重（OTA 43 - B3和 - C3或鲁迪II型或III型）胫骨平台骨折进行了回顾性研究。所有患者均首先接受跨越单侧外固定器治疗，随后进行切开复位内固定术。对X线片进行检查，内容包括：分类、胫骨穹窿的碎骨片数量、磨玻璃样粉碎的证据（CT上超过三块尺寸小于2mm的碎骨片）、解剖复位、对线情况以及是否存在关节炎。
26/37例患者（70%）存在磨玻璃样粉碎的证据。切开复位内固定术后，29/36例（81%）关节复位完美（移位0 - 1mm），6/36例（17%）复位不完美（1 - 3mm），1/36例（3%）复位差（>3mm）。35/37例（96%）关节对线呈解剖位，1例患者有15度前倾角，另1例患者有5度外翻角。在最新随访时，10/36例患者（28%）存在影像学关节炎。37例患者中有27例（73%）在复位时有关节牵开。37例患者中有25例（65%）无术后并发症，而3/37例（8%）发生关节感染，其中1例患者需要取出内固定物。在最新随访时，共有4/37例（11%）出现复位丢失。共有3/37例（8%）进行了二期关节融合术；共有1例（3%）进行了一期关节融合术；1例（3%）糖尿病男性在关节融合术失败后进行了膝下截肢。
我们在损伤时用跨越外固定器治疗严重胫骨平台骨折，等待10至21天以便软组织愈合，然后用空心螺钉对关节面进行有限切开复位内固定术。在一组高能胫骨平台骨折中，我们通过该方案取得了81%的优良效果。我们得出结论，使用跨越外固定器并延迟切开复位内固定术与文献报道相比具有优势。
