Pilon骨折的外科治疗(英文PPT加翻译).ppt 110页

Objective:Todiscussthemethods,timingandclinicaloutcomesofsurgicaltreatmentforopenpilonfractures.Methods:FromApril2003toJuly2008,28patientswithopenpilonfracturesweretreated.AllhadtypeCfracturesaccordingtotheArbeitsgemeinschaftfürosteosynthesefragen–AssociationfortheStudyofInternalFixation(AO/ASIF)classification.Threeoperativemethodswereapplied,themethodsbeingdeterminedbythetypesoffracture,softtissuedamageandtimeintervalafterinjury. trauma创伤classification分类；分级debridement清创术、扩创术anatomicreduction解剖复位theArbeitsgemeinschaftfürosteosynthesefragen瑞士骨折内固定协会/AOBurwell-Charnleyscore骨折复位放射学评价标准1965Orthopaedic骨科的；整形外科的 Complication并发症sloughing蜕皮；脱落post-traumaticarthritis[ɑː"θraɪtɪs]创伤后关节炎Thorough彻底地"θʌrəanti-infectivemedication抗感染药物occurrence[ə"kʌr(ə)ns}发生tibial["tɪbɪəl]胫骨的talus["teɪləs]距骨softtissuedegloving(套袖状的)软组织撕裂 metaphyseal干骺端的 Sevencasesweretreatedbydebridementandinternalfixationwithplate;19bylimitedinternalfixationcombinedwithexternalfixation;and2bydelayedsurgery.TheclinicaloutcomeswereevaluatedbytheBurwell-Charnleyscore.Results:Allcaseswerefollowedupforfrom6to48months(average24months).TheBurwell-Charnleyscoreofclinicaloutcomes:anatomicreductionachievedin12cases,functionalreductionin15,andunsatisfactoryreductionin1. Thehealingtimewasfrom2.5to11months(average4.7months).Twocaseshaddelayedunion.AccordingtotheAmericanOrthopaedicFootandAnkleSociety(AOFAS)scalefortheanklejoint,therewereexcellentresultsin8cases,goodin14,fairin5andpoorin1.Complicationsincludedfourcasesofskinsuperficialsloughing,twoofsuperficialinfection,oneofdeepinfection,twoofdelayedfractureunionandtenofpost-traumaticarthritis. Thoroughdebridement,properuseofanti-infectivemedication,appropriatebonegrafting,andpostoperativeanklefunctionexercisecanreducetheoccurrenceofcomplications. trauma创伤classification分类；分级debridement清创术、扩创术anatomicreduction解剖复位Complication并发症sloughing蜕皮；脱落post-traumaticarthritis[ɑː"θraɪtɪs]创伤后关节炎Thorough彻底地"θʌrə anti-infectivemedication抗感染药物occurrence[ə"kʌr(ə)ns}发生tibial["tɪbɪəl]胫骨的；tibia["tɪbɪə]胫骨talus["teɪləs]距骨softtissuedegloving软组织撕裂lowerlimbfractures下肢骨折degloving套袖状撕裂metaphyseal干骺端的articulardepression关节压缩weightbearingarea负重区 implant内植物approach方法correspondencen.通信；一致；相当DOI：数字对象唯一标识符bilaterally[bai"lætərəli]双边地malleolus[mæ"liːələs]踝clinic临床；诊所motor发动机vehicle[ˈviːəkl]（车辆）accident Openfracturescomprisesabout10%to30%ofallpilonfractures3.Thesefracturesareoftenassociatedwithsignificantsofttissuedegloving,metaphysealbonedefectsandarticulardepression. IntroductionPilonfractureconstitutes1%ofalllowerlimbfracturesandabout3%to10%oftibialfractures1,2.Itisusuallytheresultofhighenergyinjurytotheweightbearingareaofthelowerendofthetibiabythetalus. Conclusion:Itisimportanttoperformappropriatesurgeriesforopenpilonfractureaccordingtofractureclassification,differentdamagetoskinandtissueandtimeintervalafterinjury. Keywords:Delayedoperation;Externalfixators;Fracturesopen;Internalfixators Inspiteofimprovementsinsurgicalapproachesandimplants,treatmentoftibialpilonfracturesremainschallenging4. Inthepresentstudy,wediscussthemethods,timingandclinicaloutcomesofsurgicaltreatmentforopenpilonfractures. AddressforcorrespondenceXian-tieZeng,MD,DepartmentofTrauma,TianjinHospital,Tianjin,China300211Tel:0086-022-24151288;Fax:008602224151288;Email:zengxiantie@163.comReceived:19July2010;accepted5October2010DOI:10.1111/j.1757-7861.2010.00113.x MaterialsandMethodsPatientdataFromApril2003toJuly2008,28patientswithopentibialpilonfracturesweretreatedinourhospital. Therewere21menand7womenwithanaverageageof36.5years(range,19–61years).Tenpatientswereinjuredontheleftside,17ontherightand1bilaterally(aclosedfractureoftherightmalleolus（踝）wasnotcounted). Theintervalbetweeninjuryandpresentationtoourclinicrangedfrom1to14hours(average,5.1hours).Themechanismsofinjurywerehigh-energyfallsin10cases,motorvehicleaccidentsin12,crushinginjury（挤压伤）in4cases,andsportsinjuriesin2. ThefractureswereclassifiedaccordingtotheAO/ASIFsystem:7wereclassifiedastypeC1,17typeC2,and4typeC3. OpensofttissuedamagewasgradedaccordingtotheGustilosystem:4caseswereclassifiedasGustiloI,21GustiloII,2GustiloIIIA,and1GustiloIIIB. acetabularæsə"tæbjulə]髋臼的fibular腓骨的;fibula腓骨femoral股骨的Calcaneal[kæl"keiniəl跟骨的craniocerebral[,kreiniəusi"ri:brəl颅脑的protocol方法、协议presentingwith伴随restoration恢复tibia胫骨 cancellous ["kæns(ə)ləs]松质骨insertion插入modified改进的cloverleaf三叶草形Anteromedial前内侧的medial内侧的posterolateral后外侧的lateral外侧的constraint约束、限制keepinginmind牢记anteroposterior前后的；正位（影像） Combinedinjuriesincludedfibularfracturesin25cases,spinalfracturesin2,upper-armfracturesin2,ribfracturesin2,femoralfracturein1,acetabularfracturein1,calcanealfracturein1,andcraniocerebraltraumain1. demonstrating显示Calcaneus（口Ki尼尔斯）：跟骨metatarsal跖骨的anklemortise踝关节Kirschner克氏pin克氏针 MethodsOneofthreedifferentsurgicalprotocolswasperformedinallpatients,thechoicebeingbasedontheconditionofsofttissue,typeoffractureandlengthofintervalbetweeninjuryandpresentationfortreatment. Debridement,openreductionandinternalfixation(ORIF)ThismethodwasappliedintypeC1fracturespresentingwithlow-gradesofttissueinjury(GustiloI,II)andintervalbetweeninjuryandpresentationfortreatmentoflessthan6hours. Sevenpatients(fourtypeC1GustiloIandthreetypeC1GustiloII)weretreatedbythismethod. Surgicaltreatmentofthepilonfractureswasinfoursteps:(a)restorationofthecorrectlengthandstabilizationofthefibula; (b)reconstructionofthearticularsurfaceofthetibia;(c)insertionofcancellousautografts;and(d)stabilizationofthemedialaspectofthetibiawiththeuseofamodifiedcloverleafplate. Ananteromedialincisionwasemployedtotreatthetibialcomponentandalateralorposterolateralincisiontotreatthefibularfracture. Thesurgicalincisionswereplannedbasedontherequirementsofthefracturepattern,keepinginmindthesoft-tissueconstraintsoftheindividualinjury. Skinclosurewasachievedwithnotension.Thetibialincisionswereclosedfirst.Ifnecessary,thefibularincisionswereleftfordelayedclosure. Oneofthesevenpatientsachievedprimaryclosureofthemedialincision,followedbydelayedclosureofthelateralone.AtypicalcaseisshowninFig.1. Figure1A49year-oldmanwithalow-energyopenpilonfracture(GustiloI&C1)(a)Photographshowingopensofttissueinjury(GustiloI).(b)PreoperativeanteroposteriorandlateralradiographsshowingPilonfractureoftypeC1.(c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithplates.(d)Anteroposteriorandlateralradiographsdemonstratingfractureshavehealed1yearaftersurgery. Figure2A22year-oldmanwithahigh-energyopenpilonfracture(GustiloII&C2)(a)Photographshowingopensofttissueinjury(GustiloII).(b)PreoperativeradiographsshowingPilonfractureoftypeC2. (c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithexternalfixation,andthetibialfracturefixedwithlimitedinternalfixation.(d)Anteroposteriorandlateralradiographsdemonstratingthefractureshavehealed1.5yearaftersurgery. Debridement,limitedORIFandexternalfixationThismethodwasappliedintypeC2andtypeC3fracturespresentingwithhigh-gradesofttissueinjury(GustiloII,III)andintervalbetweeninjuryandpresentationfortreatmentoflessthan8hours. Nineteenpatients(16typeC2GustiloII,1typeC2GustiloIIIA,and2typeC3GustiloII)weretreatedbythismethod. Thepatientsweremanagedbyimmediate（直接的）debridementofthewound.Fibularfractureswerealwaysinternallyfixed,eitherwitha1/3tubular（管状的）plateor3.5mmcompressionplate. Externalfixationwasappliedacrosstheanklejointwithpinsinthecalcaneus,metatarsalbone,andtibia,reconstructionoftheanklemortise（踝关节）,andstabilizationwithscrewsorKirschnerpins. split-thicknessskingrafting厚皮瓣转移splint夹板edema（水肿）antibiotic（抗生素）extent（范围）contamination（污染）Theaffectedextremity（下肢）elevate抬高；提高subtalar（距下） proscribe（禁止）supervise（指导）physicaltherapyprogram（康复锻炼）Roll-A-Boutwalker（助行器）outpatients(门诊就诊)Staphylococcusepidermidis（表皮葡萄球菌）Acinetobacterbaumannii（鲍氏不动杆菌） Fiveofthe19patientsrequiredbonegraftingbecauseoflargedefectsofmetaphysealbone.Onecaseunderwentdelayedclosureofthelateralincision,anddelayedsplit-thicknessskingraftingwasappliedinanothercase.AtypicalcaseisshowninFig.2. posttraumaticarthritis.（创伤后关节炎）ankle-hind（后踝） Debridementandcalcanealtraction,delayedsurgeryThismethodwasappliedintypeC3fracturesaccompaniedbyhigh-gradesofttissueinjury(GustiloIII)andintervalbetweeninjuryandpresentationfortreatmentofmorethan8hours. Intwopatients(onetypeC3GustiloIIIA,onetypeC3GustiloIIIB),thesurgeonchoseatwostageprocedure（步骤）. ThepatientswereputoncalcanealpinskeletaltractionwithelevationofthelowerlimboveraBohler–Braunsplint（勃朗支架）,andmeasuresweretakentoavoidedema（水肿）. Wounddrainage（引流管）wasremovedwhentherewasnofurtherevidenceofinfection,andasecondstageoperationwasperformedwhentheedemahadalmostcompletelyresolved. ThepatientsweretreatedwithlimitedORIFandexternalfixation.Thetimeintervalbetweenthetwosurgerieswas15and19days,respectively.AtypicalcaseisshowninFig.3 Figure3A37year-oldmanwithasuperhigh-energyopenpilonfracture(GustiloIIIB&C3)(a)Photographshowingopensofttissueinjury(GustiloIIIB)(b)PreoperativeradiographsshowingPilonfractureoftypeC3. (c)Postoperativeradiographsshowingthefractureshavebeenanatomicallyreducedandfixedwithexternalfixation,thetibialfixedwithlimitedinternalfixation,andthefibulawithaplate.(d)Anteroposteriorandlateralradiographsdemonstratingthefractureshavehealed1.5yearaftersurgery. PostoperativecareAppropriatecultures（培养）wereobtainedduringsurgery,andbroad-spectrumantibiotics（广谱抗生素）wereadministered.（执行，使用）Thechoiceofantibiotic（抗生素）wasbasedontheextent（范围）anddegreeofcontamination（污染）. Activeankleandsubtalar（距下）jointrange-of-motionexerciseswerebegunassoonasthewoundwasdry,usuallybetween2and5daysaftersurgery.Weight-bearingexercisewasproscribed（禁止）inthefirst12weeksaftersurgery. Asupervised（指导）physicaltherapyprogram（康复锻炼）encouragingactiveanklerange-of-motionexerciseswasemployedforthefirst6weeks.Thiswasprogressedtoincludepassiveexercisesbetween6and12weeks.ARoll-A-Boutwalker（助行器）wasusedwhennecessary. Theaffectedextremity（下肢）waselevated（提高）continuouslyforthefirst48hoursandthen,asmuchaspossible,forthenext7days. procedure（步骤）broad-spectrumantibiotics（广谱抗生素）extremity手足outpatients(门诊就诊)medial（内侧）originally(最初）dissection（解剖，切开）stripping（剥离） posttraumaticarthritis.（创伤后关节炎）ankle-hind（后踝）originally(最初)dissection（解剖，切开）stripping（剥离）ligamentotaxis（韧带修复术）neutralization（中和）inregardto（关于） RadiographswereobtainedandevaluatedaccordingtotheBurwellCharnleysystem:anatomicreductionwasachievedin12cases,functionalreductionin15cases,andpoorreductionin1case. Thehealingtimeofthefracturewasfrom2.5to11months,withanaverageof4.7months. ResultsAll28patientswerefollowedupfrom6to48monthswithanaverageof24months,andunderwentclinicalandradiologicalexaminationasoutpatients(门诊就诊). Delayedunionwasfoundintwocases;inbothitwasassociatedwithbonedefectsofthemedial（内侧）tibia.Onestagewoundclosurewasperformedin18patients,twounderwentdelayedclosureoftheirlateralincisions,andoneunderwentdelayedsplit-thicknessskingrafting. Therewerefourcasesofsuperficialsloughingoftheskin.TwopatientsdevelopedsurfaceinfectionwithStaphylococcusepidermidis（表皮葡萄球菌）andAcinetobacterbaumannii（鲍氏不动杆菌）andonedevelopeddeepinfectionwithAcinetobacterbaumannii;theinfectionratewas10.7%(3/28). Tenpatients(35.7%)showedevidenceofposttraumaticarthritis.（创伤后关节炎）AccordingtotheAOFASankle-hind（后踝）footfunctionevaluation（评估）,theaveragescorewas85.2(range,66to98):excellentin8patients,goodin14,fairin5,andpoorin1. DiscussionChoiceofsurgicalmethodsInpatientswithtypeC1fractureandGustiloIsofttissueinjuryduetolow-energyforces,pilonfracturewasanatomicallyreducedandtreatedwithdebridementandinternalplatefixationfollowingAO/ASIFprinciples. Openreductionandinternalfixationwereoriginally(最初)used,butitisnowknownthatopenreductionincreasestheriskofcomplicationsafterhigh-energytrauma. Thisisprobablyrelatedtotheamountofdissection（解剖，切开）andstripping（剥离）ofsofttissueswhichisneededtoachievereductionandplatefixation. Therefore,whenperformingORIFprocedures,thesurgeonstriedtolimitsofttissuedamageandchoosesuitableinternalfixation. Thetibiawasreducedwithacloverleafplate,dynamiccompressionplateorlockingcompressionplate,dependingonthelevelofthefractureanddegreeofstabilityrequired. Linetal.reportedan83.3%goodratein30casestreatedwithORIFfollowedupfor17~39months5.Kalendereretal.alsoreportedasimilarresult6. ExternalfixationandlimitedinternalfixationwereperformedinallpatientswithtypeC2andtypeC3fracturespresentingwithhigh-gradesofttissueinjury(GustiloIIandIII)andintervalbetweeninjuryandpresentationattheauthors’clinicoflessthan8hours. Useofexternalfixationduringthesurgicalprocedureenables（使能够）thesurgeontoassess（评估）thelengthandhelpsstabilizethelimb（肢）forreconstructionoftheintra-articular（关节内）component. Placement（放置）oftheexternalfixatorwithacalcanealpinandahalf-pininthetibiaallowsligamentotaxis（韧带修复术）tooccurthroughtractiononthecalcanealpin. initial(首先)distraction（牵引）eliminate（清除）compromise（妥协、折衷、让步）exposure（显露，暴露）incidence（发生率）malalignment(对线不良)stiffness（僵硬）["stɪfnɪs] preclude（排除）Pre-existing（已存在）inviewof（鉴于，考虑到）ischemia（缺血）[ɪs"kimɪə]precarious（不确定的）[prɪ"keərɪəs] Thisishelpfulinreductionofthefractureandallowseasieraccessto（入路）theanklejointforjointreconstruction. Usedasaneutralization（中和）device,thereisnoneedforlargeplateswiththeassociated（相关）increasedriskofskinsloughing7. Minimizing（将...减到最少）internalfixationanddamagetosofttissuesandbloodsupplydecreasestherateofskinsloughingandinfection. Wewereabletocorrectpostoperativelossofreduction（再移位）byadjustingexternalfixation.Itisalsoanexcellentdeviceinthoseseverelycomminutedfracturesthatdonotallowstablefixationwiththeuseofaplate. Severalresearchershavereportedsimilarfindingsinregardto（关于）externalfixation8–11. Ourresultsleadustorecommend(建议，推荐)thatTypeC3tibialpilonfracturespresentingwithhigh-gradesofttissueinjury(GustiloIII)andintervalbetweeninjuryandpresentationfortreatmentofmorethan8hoursshouldbetreatedwithatwo-stageprocedure. Atinitial(首先)presentation,anexternalfixatorisapplied.Afterthesofttissueshaverecovered,thesecondstageisperformed. Thegoalofthefirststageistore-establishthelength,alignmentandrotationoftheextremityandprovideanenvironmentforsoft-tissuerecovery. Theearlyapplicationofadistraction（牵引）forcemayhelptolimitanysecondaryinjuryandeliminate（清除）additionalsofttissuecompromise（妥协、折衷、让步）duringsurgicalexposure（显露，暴露）12. Severalreportshaveshownthatthetwo-stageprocedurecanreducetherateofcomplicationssuchasinfection,skinsloughing,andpost-traumaticarthritis13–15. Preventionofpostoperativecomplications.Ithasbeenreportedthattheincidence（发生率）ofcomplications,includingwoundproblems,skinsloughing,infection,nonunion,malalignment(对线不良),jointstiffness（僵硬）andposttraumaticarthritis,ishigh(45.1%)inpatientswithseverepilonfractures16. Skinsloughingandinfectionarethemostimportantearlypostoperativecomplications17.Pre-existing（已存在）severesofttissueinjuryprecludes（不能）openreductioninviewof（考虑到）thepotentialwoundproblemsduetoischemia（缺血）orinfectionofthesofttissues. Theprecarious（不确定的）bloodsupplyinthisregionofthetibiacancontributeto（有助于）theproblemsofbothnonunionandinfection18. Intensive（加强的）outweigh（胜过，强过）lateralcolumn(外侧柱)ligament（韧带）taxis（整复）circularframes（圆形框架）hybridsystems（混合系统）["haɪbrɪd] hingeaxis（铰链轴）[hɪndʒ]plastercast（石膏）optimal（最佳的）manuscript（手稿，文章） Inthepresentstudy,therewerefourcasesofskinsloughing,twoofsuperficialinfections,andonlyoneofdeepboneinfection. Surgicalapproachesarenowplannedbasedontherequirementsofthefracturepattern,keepinginmindthesoft-tissueconstraintsoftheindividualinjury. Theincisionsarekeptatleast7cmaparttopreventsoft-tissueischemiaandsecondarywoundbreakdown. Intensive（加强的）debridement,minimizationofsofttissuestrippingandproperuseofantibioticsareusefulforpreventinginfection. Delayedunion,especiallyinthemetaphysealportion,isalsoaproblemwithpilonfractures.Wenoteda7.1%delayedunionrateinthisseries. Theseverityoftheinjuryandpoorbloodsupplytothedistaltibiamayoutweigh（胜过，强过）theaffectsofanyparticularapproachwhenitcomestononunionordelayedunion,anditisalsoprobablycausedbytibialbonedefectafterfixationofthefibula.Butthereisnotdecidedforthefibulafixation19,20. Wethinkthatfibularfractureshouldbefixedtorestorethelengthofthelateralcolumn(柱)ofthetibiaindirectlyvialigament（韧带）taxis（整复）.Megasetal.havereportedthatthenonunionrateindistaltibialfractureishigherthaninotherlongbonefractures. Itcanlikelybepreventedbyminimizingsoft-tissuestrippingandusingstableinternalfixationinassociationwithsuitablebonegraft. Post-traumaticarthritisisaseriouscomplication.Wyrschetal.believethatarthritisispossiblycausedbydamagetoarticularcartilage(软骨)andlong-termimmobilizationwithexternalfixatorsandplastercasts（石膏）22. Wefoundthat9of10casesofpost-traumaticarthritisdevelopedaftertypeC2ortypeC3fractures.Rosereportedthatcircularframes（圆形框架）orhybridsystems（混合系统）,whichmaybeappliedwithahingeaxis（铰链轴）movementattheleveloftheanklejoint,maybecomeusefulalternativesforimprovingtherangeofmotionoftheankle11. Arthrodesis（关节融合）isindicatedfor(被认为是)themostseverearthriticchanges. However,themostimportanttoolremainsexperiencedoperativeassessmentofthespecificcharacteristicsoftheinjury,leadingtotheselectionoftheoptimal（最佳的）treatmentplanforanygivenpatient. Itisimportanttomaketherightchoiceinregardtothetimingofsurgeryandcorrectmethodoffixationaccordingtofractureclassification,extentandtypeofdamagetoskinandtissue,andintervalbetweeninjuryandreachingthehospital. Itisthekeythatthecorrectevaluationofskinandtissueandthegoodprotectionofthebloodsupplytothebone.Intensivedebridement,properuseofantibiotics,appropriatebonegrafting,andpostoperativeanklefunctionexercisecanreducetheoccurrenceofcomplications DisclosureThismanuscript（手稿，文章）doesnotcontaininformationaboutmedicaldevice(s)/drug(s).Nobenefitsinanyformhavebeen,orwillbe,receivedfromacommercialpartyrelateddirectlyorindirectlytothesubjectofthismanuscript Pilon骨折的外科治疗本文为英文文献翻译PPT译者：麻仓叶简介：本文介绍开放性Pilon骨折的分型和相应的治疗方案，围手术期进行影像学的随访，预后的情况及注意事项。