Klammer III型后侧Pilon骨折的改良入路手术

Modified combined approaches for Klammer type Ⅲ posterior Pilon fracture

摘要:

[目的]介绍 Klammer III 型后侧 Pilon 骨折的改良入路固定的手术技术和初步临床效果。[方法]2018 年 1 月—2021 年 4 月，采用后外侧联合改良后内侧入路切开复位内固定治疗 Klammer Ⅲ型后 Pilon 骨折 21 例。后外侧切口位于腓骨远端后缘与跟腱之间中线，在腓骨肌与母长屈肌腱之间分离，显露后侧柱；将切口前外侧分离全层筋膜皮瓣向前外侧牵拉，可显露腓骨远端。改良后内侧切口沿胫骨远端内侧后缘，在胫后肌腱与胫骨之间分离，肌腱血管神经束全部向外侧牵拉，显露内侧柱。 [结果]所有患者均顺利完成手术，随访（15.2±1.5）个月。1 例患者术后出现伤口浅表感染，通过换药后顺利愈合。末次随访 VAS 评分 （1.9±0.2） 分；AOFAS 踝-后足评分 （86.0±1.4） 分。影像方面，18 例骨折获得解剖复位，3 例关节面移位 1~2 mm。 至末次随访时，所有患者骨折均愈合，无内固定物松动断裂。[结论]俯卧位下后外侧联合改良后内侧入路治疗 Klammer Ⅲ型后 Pilon 骨折，具有显露充分、复位率高、并发症少等优点，是一种安全有效的手术方式。

Abstract:

[Objective] To introduce the surgical technique and preliminary clinical results of modified combined approaches for Klam- mer type Ⅲ posterior Pilon fracture. [Methods] A total of 21 patients received open reduction and internal fixation through posterolateral combined with modified posteromedial approaches for Klammer type III posterior Pilon fracture from January 2018 to April 2021. The pos- terolateral incision was made in the middle line between the posterior edge of the distal fibula and the Achilles tendon, then separate be- tween the peroneus and the flexor hallux longus tendons to expose the posterior column of the distal tibia; while to expose the distal fibula if the full-thickness fasciocutaneous flap was retracted anterolaterally. In addition, the modified posteromedial approach was made along the posteromedial edge of the distal tibia, and separate between the posterior tibialis and the bone with pulling all the tendon, blood vessels and nerve bundles posteriorly to expose the medial column of the distal tibia. [Results] All patients had operation performed successfully, and followed up for (15.2±1.5) months on an average. One patient developed superficial wound infection after operation and healed smoothly af- ter dressing change. At the last follow-up the VAS score for pain was of (1.9±0.2), while the AOFAS ankle hind foot score was of (86.0± 1.4). Radiographically, 18 patients obtained anatomical reduction and 3 patients had articular surface displacement of 1mm to 2mm postop- eratively, all the patients got bony healing of the fracture without loosening or breaking of the implants by the time of the latest follow up. [Conclusion] The posterolateral combined with modified posteromedial approaches for open reduction and internal fixation of Klammer type Ⅲ posterior Pilon fracture in prone position with the advantages of full exposure, high reduction rate and few complications, are safe and effective surgical approaches.