Department of Orthopaedics, Changhai Hospital, Shanghai 200433, China.
Int Orthop. 2012 Apr;36(4):833-7. doi: 10.1007/s00264-011-1434-0. Epub 2011 Dec 20.
Here we introduce a two-stage procedure protocol for minimally invasive plate osteosynthesis (MIPO) to treat complex pilon fractures and evaluate surgical wound healing and infection rates after this method was applied in clinical practice.
This is a retrospective study design. The protocol consisted of immediate (within eight to 24 hours) open reduction and internal fixation of the fibula, using a fibular plate or one third tubular plate and application of an external fixator spanning the ankle joint. Patients were discharged after initial stabilisation and revaluated approximately ten to 14 days after discharge. Formal open reconstruction of the articular surface using MIPO depended on whether soft tissue swelling had lessened. Artificial bone was then injected into the defect rather than open surgery. Objective evaluation criteria were wound infection rates. Objective criteria (amount of post-traumatic arthritis, range of ankle movement, number of arthrodeses) and subjective criteria (pain, swelling, restriction of work or leisure activities) were identified via chart and radiograph reviews, patient interviews and physical examination.
Twenty-nine patients, each with one pilon fracture were included. First-stage operations were performed from eight hours to seven days after injury, depending on whether the fracture was open or not. Average time from external fixation to open reduction and revision was one month (range 24-38 days); average time for the second-stage operation was 58 (range 45-110) minutes; average amount of haemorrhage was 400 (range 150-560) ml; average time of follow-up was 24 months and average time of healing was 6.7 (range five to 11.5) months after the second stage. There was no superficial or deep infection or wound-healing problem. All patients had normal functioning ankle joints.
Application of the two-stage procedure protocol with MIPO seems to play a key role in reducing infection rates associated with open reduction and internal fixation of pilon fractures. Its effectiveness in closed and open fractures will be further tested by a late randomised controlled study.
本研究旨在介绍一种微创钢板接骨术（MIPO）的两阶段手术方案，用于治疗复杂的PILON 骨折，并评估该方法应用于临床实践后的手术切口愈合和感染率。
这是一项回顾性研究设计。方案包括腓骨即刻（伤后 8-24 小时内）切开复位内固定，使用腓骨板或三分之一管状钢板，并应用外固定架横跨踝关节。患者在初次稳定后出院，并在出院后约 10-14 天进行再次评估。是否进行关节面的正式微创切开复位取决于软组织肿胀是否减轻。然后将人工骨注入缺损部位，而不是进行开放性手术。客观评估标准为伤口感染率。通过图表和 X 线复查、患者访谈和体格检查确定客观标准（创伤后关节炎的程度、踝关节活动范围、融合数量）和主观标准（疼痛、肿胀、工作或休闲活动受限）。
共纳入 29 例 PILON 骨折患者，每位患者均有 1 处骨折。一期手术根据骨折是否为开放性在伤后 8 小时至 7 天进行。从外固定架到切开复位和修正的平均时间为 1 个月（24-38 天）；二期手术的平均时间为 58 分钟（45-110 分钟）；平均出血量为 400ml（150-560ml）；平均随访时间为 24 个月，二期手术后平均愈合时间为 6.7 个月（5-11.5 个月）。无浅表或深部感染或伤口愈合问题。所有患者的踝关节功能均正常。
应用 MIPO 的两阶段手术方案似乎在降低 PILON 骨折切开复位内固定相关感染率方面发挥了关键作用。其在闭合性和开放性骨折中的有效性将通过后期的随机对照研究进一步验证。
