Lebailly Frédéric, Zemirline Ahmed, Facca Sybille, Gouzou Stéphanie, Liverneaux Philippe
Hand Surgery Department, Strasbourg University Hospitals, 10 Avenue Baumann, 67403, Illkirch Cedex, France.
Eur J Orthop Surg Traumatol. 2014 Aug;24(6):877-90. doi: 10.1007/s00590-013-1363-2. Epub 2013 Nov 21.
The volar Henry approach is becoming the gold standard for distal radius fracture fixation. It decreases the incidence of nonunion, limits complications especially complex regional pain syndrome (CRPS) type I, and allows early mobilization of the wrist. Nonetheless, it has some disadvantages such as the size of the incision, which is not esthetically pleasing, and the loss of ligamentotaxis. This is why some authors have developed a mini-invasive approach. The aim of this work was to evaluate the feasibility of the anterior mini-invasive approach of 15 mm in a clinical series of 144 cases of distal radius fracture. All patients were operated under regional anesthesia using the same techniques by five surgeons of the same team. According to the AO classification, there were 83 type A fractures, 2 type B, and 59 type C. A volar plate (Step One(®), Newclip Technics™, Haute-Goulaine, France) was used in all cases. The 2 proximal metaphyseal screws and the 2 distal central epiphyseal screws were monoaxial locking. The 2 distal ulnar and radial epiphyseal screws were placed in polyaxial locking at 20° angulation maximum. Skin closure without drainage was performed. No postoperative immobilization was prescribed, and patients were encouraged to use their upper limb immediately postoperative. No postoperative physiotherapy was prescribed. The mean follow-up was 4.1 months. The final size of the incision was on average 16.1 mm. Mean pain score was 1.8. The Quick DASH score was average 25. Average range of motion was more than 85 %, and global force of the hand was 67 % compared with contralateral side. On X-ray, the mean radial slope was 22°, the mean radial tilt was 8.3°, and the mean radioulnar variance/index was -0.4 mm. There were nine cases of CRPS type I, which all resolved. Specific complications included two secondary displacements and nine tenosynovitis cases. No tendon rupture was noted. Two intra-articular distal radioulnar joint screws had to be removed at 3 months. One epiphyseal screw required removal 1 month postoperative due to loosening. There were no intra-articular radiocarpal screws. Distal radius fracture fixation using a mini-invasive approach is a reliable and reproducible procedure with few complications. It allows anatomical reduction in the distal radius fractures including intra-articular ones. It can be associated with arthroscopy, scaphoid screw fixation or even percutaneous pinning. Thus, most traumatic lesions of the wrist bony or soft tissue can be treated through this mini-invasive approach.
掌侧亨利入路正成为桡骨远端骨折固定的金标准。它降低了骨不连的发生率，限制了并发症尤其是Ⅰ型复杂性区域疼痛综合征（CRPS）的发生，并允许早期进行腕关节活动。尽管如此，它也有一些缺点，比如切口大小，在美观上不尽人意，以及失去了韧带整复作用。这就是为什么一些作者开发了一种微创入路。本研究的目的是在144例桡骨远端骨折的临床系列病例中评估15mm前侧微创入路的可行性。所有患者均在区域麻醉下由同一团队的五名外科医生采用相同技术进行手术。根据AO分类，有83例A型骨折、2例B型骨折和59例C型骨折。所有病例均使用掌侧钢板（Step One(®)，Newclip Technics™，法国上古兰）。2枚近端干骺端螺钉和2枚远端中央骨骺螺钉为单轴锁定。2枚远端尺侧和桡侧骨骺螺钉以最大20°的角度进行多轴锁定。进行了不放置引流管的皮肤缝合。未规定术后制动，鼓励患者术后立即使用上肢。未规定术后物理治疗。平均随访时间为4.1个月。切口最终平均大小为16.1mm。平均疼痛评分为1.8分。Quick DASH评分为平均25分。平均活动范围超过85%，患侧手部总体力量为对侧的67%。X线检查显示，平均桡骨倾斜度为22°，平均桡骨倾角为8.3°，平均桡尺骨长度差/指数为-0.4mm。有9例Ⅰ型CRPS，均已痊愈。具体并发症包括2例二次移位和9例腱鞘炎。未发现肌腱断裂。2枚关节内远端桡尺关节螺钉在3个月时必须取出。1枚骨骺螺钉因松动在术后1个月需要取出。没有关节内桡腕螺钉。采用微创入路进行桡骨远端骨折固定是一种可靠且可重复的手术，并发症较少。它能实现包括关节内骨折在内的桡骨远端骨折的解剖复位。它可与关节镜检查、舟骨螺钉固定甚至经皮穿针固定相结合。因此，大多数腕部骨或软组织的创伤性损伤都可通过这种微创入路进行治疗。
