Department of Orthopaedics, Stony Brook University Hospital, Stony Brook, NY.
Department of Orthopaedic Surgery, St. Louis University School of Medicine, Saint Louis University, St. Louis, MO.
J Orthop Trauma. 2018 Apr;32(4):e117-e122. doi: 10.1097/BOT.0000000000001109.
We present a surgical strategy to manage multicolumnar tibial plateau fracture variants by addressing the predominant posterior fragment employing a Lobenhoffer approach in the prone position followed by supine patient repositioning for anterolateral column access.
Multicenter retrospective analysis.
Three academic Level 1 trauma centers.
PATIENTS/METHODS: Twenty-eight cases (28 patients/28 knees) met inclusion criteria between 2003 and 2014. Patient demographic information was retrospectively reviewed with a mean follow-up time of 16.6 months (range 12-34 months). Postoperative radiographic analysis, physical examination findings, and patient outcome scores from the Knee Injury and Osteoarthritis Outcome Score questionnaire were recorded.
The average time to union was 3.6 months (range 3-9 months). Eighty-two percent of patients had satisfactory articular reduction (less than 2 mm articular step off). All patients demonstrated satisfactory coronal (medial proximal tibia angle 87 ± 5 degrees) and sagittal alignment (posterior proximal tibia angle 9 ± 4 degrees). Condylar width averaged 2.2 mm. Twenty percent of cases required posterior lateral columnar plating (in addition to posterior medial columnar plating), with none of these cases requiring an extensile exposure modification (medial gastrocnemius origin detachment) to expose posterior laterally. In 12 cases, the posterior approach was staged to allow for anterior soft tissue recovery before subsequent staged supine positioning and lateral column fixation. The knee range of motion averaged 123 degrees (ranged from 2 degrees of extension to 125 degrees flexion). The average Knee Injury and Osteoarthritis Outcome Score was 78/100 (range 29-95). Eleven percent of the patients in the series developed a surgical site infection (n = 3) with 2 requiring formal irrigation and debridement. The most common aseptic complication was radiographic posttraumatic arthrosis (18%). Clinically, 1 patient eventually required a total knee arthroplasty.
High-energy multicolumnar tibial plateau fractures with significant posterior articular surface involvement may be predictably addressed with prone positioning, exposure, and fixation followed by supine repositioning and the inclusion of an anterior approach. This study demonstrates excellent postoperative radiographic results and acceptable clinical outcomes resulting from the described staged protocol.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
我们提出了一种通过处理主要后骨折块的手术策略来治疗多柱胫骨平台骨折变体，该策略采用俯卧位下的 Lobenhoffer 入路，然后重新仰卧位以进入前外侧柱。
多中心回顾性分析。
三家学术一级创伤中心。
患者/方法：2003 年至 2014 年间，28 例（28 例患者/28 例膝关节）符合纳入标准。回顾性分析患者的人口统计学信息，平均随访时间为 16.6 个月（范围 12-34 个月）。记录术后影像学分析、体格检查结果和膝关节损伤和骨关节炎结果评分（Knee Injury and Osteoarthritis Outcome Score questionnaire）的患者结果评分。
平均愈合时间为 3.6 个月（范围 3-9 个月）。82%的患者关节面复位满意（关节面台阶小于 2mm）。所有患者的冠状面（胫骨近端内侧角 87±5°）和矢状面（胫骨近端后角 9±4°）均达到满意的对线。髁间宽度平均为 2.2mm。20%的病例需要后外侧柱钢板固定（除了后内侧柱钢板固定外），这些病例中没有一例需要广泛的外侧暴露修改（腓肠肌内侧起点切开）来暴露后外侧。在 12 例中，后入路分期进行，以便在随后分期仰卧位和外侧柱固定前恢复前软组织。膝关节活动度平均为 123°（范围为 2°伸展至 125°屈曲）。平均膝关节损伤和骨关节炎结果评分为 78/100（范围 29-95）。该系列中有 11%的患者（n=3）发生手术部位感染，其中 2 例需要进行冲洗和清创。最常见的无菌并发症是放射学创伤后关节炎（18%）。临床方面，1 例患者最终需要全膝关节置换术。
对于有明显后关节面受累的高能多柱胫骨平台骨折，可以通过俯卧位、暴露和固定来进行可预测的处理，然后重新仰卧位并纳入前入路。该研究表明，描述的分期方案可获得出色的术后影像学结果和可接受的临床结果。
治疗 IV 级。有关证据水平的完整描述，请参阅作者指南。
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