Saragaglia Dominique, Rubens-Duval Brice, Pailhé Régis
Service de chirurgie de l'arthrose et du sport, urgences traumatiques des membres, CHU de Grenoble-Alpes, hôpital Sud, Avenue de Kimberley, BP 338, 38434 Échirolles Cedex, France.
Service de chirurgie de l'arthrose et du sport, urgences traumatiques des membres, CHU de Grenoble-Alpes, hôpital Sud, Avenue de Kimberley, BP 338, 38434 Échirolles Cedex, France.
Orthop Traumatol Surg Res. 2020 Feb;106(1S):S63-S77. doi: 10.1016/j.otsr.2019.03.018. Epub 2019 Jun 14.
Extra- and intra-articular proximal tibia malunion is not uncommon. Functional impact is variable but may lead to almost total impotence. The present study aimed to provide a review on malunion, answering 5 questions: (1) How should malunion be classified, and with what pathogenicity? Malunion results from reduction defect and/or secondary displacement in tibial plateau fracture (A2, A3, B, C on the AO classification), but also from previous epiphysiodesis or osteotomy (valgization or varization). (2) How should malunion be assessed? Pre-treatment work-up comprises standard X-ray (AP, lateral, full-length), but also 2D and 3D CT-scan to assess the severity and type of residual depression in old fracture. (3) What conservative treatments are available, and for whom? In under-50 year-olds, correction osteotomy is recommended: intra- or extra-articular or combined. In extra-articular malunion, especially in the absence of osteoarthritis, realignment osteotomy may be indicated even in elderly subjects. (4) What implants are suited to what malunion, and for whom? In over-50 year-olds with intra-or extra-articular or combined malunion, partial or total replacement is recommended, isolated or associated to realignment osteotomy. The open questions concern material removal, surgical approach and type of implant, bearing in mind that these implants raise technical difficulties. (5) What are the complications, and the results? Results with osteotomy and partial prostheses are generally satisfactory. Results in total replacement are poorer than for primary implants in osteoarthritis of the knee, with much more frequent complications. LEVEL OF EVIDENCE: V, expert opinion.
胫骨近端关节内外侧畸形愈合并不少见。其功能影响因人而异，但可能导致几乎完全丧失功能。本研究旨在对畸形愈合进行综述，回答5个问题：（1）畸形愈合应如何分类，其发病机制是什么？畸形愈合源于胫骨平台骨折（AO分类中的A2、A3、B、C型）复位不良和/或继发移位，也可源于既往骨骺阻滞术或截骨术（外翻或内翻）。（2）应如何评估畸形愈合？治疗前检查包括标准X线片（前后位、侧位、全长），还包括二维和三维CT扫描，以评估陈旧性骨折残留凹陷的严重程度和类型。（3）有哪些保守治疗方法，适用于哪些人？对于50岁以下患者，建议行矫正截骨术：关节内或关节外或联合截骨。对于关节外畸形愈合，尤其是在无骨关节炎的情况下，即使是老年患者也可能需要行重新排列截骨术。（4）哪些植入物适合哪种畸形愈合，适用于哪些人？对于50岁以上的关节内或关节外或联合畸形愈合患者，建议行部分或全关节置换，可单独进行或与重新排列截骨术联合进行。未解决的问题涉及材料取出、手术入路和植入物类型，要记住这些植入物会带来技术难题。（5）有哪些并发症及治疗结果？截骨术和部分假体置换的结果通常令人满意。全关节置换的结果比膝关节骨关节炎初次植入假体的结果差，并发症更常见。证据级别：V，专家意见。
