镜下避开骺板固定儿童胫骨髁间棘骨折△

Arthroscopic fixation of tibial intercondylar spine fractures without involving the epiphyseal plate in children

摘要:

[目的] 介绍镜下避开骺板固定儿童胫骨髁间棘骨折的手术方法和初步临床结果。[方法] 取膝关节前内、前外入路，置入关节镜及刨刀清理阻挡滑膜、骨折端内血凝块，予缝合钩横穿前交叉韧带下止点处，引入PDS 线，利用PDS 线引入高强线，将高强线引出前内侧切口，牵引高强线复位骨折端，并于胫骨近端前内侧骨骺处寻找安装外排钉最佳位置，予2.0 mm克氏针钻孔，C 形臂X 线机透视确认位置，于克氏针入针点处作0.3 cm 切口，拔除定位克氏针，于该切口处将高强线引出并将尾线穿入外排钉，将其打入钻好的骺内隧道，再次镜下检查骨折复位情况及前交叉韧带松紧度。[结果] 所有患者均顺利完成手术，手术时间平均（59.4±1.7） min，术中出血量平均（44.2±2.0） ml，术后X 线片示骨折对位对线满意。随访时间平均（23.4±10.7） 个月。与术前相比，末次随访时，Lysholm 评分[(34.6±7.9), (94.4±3.5), P＜0.001]、IKDC 评分[(32.3±8.7), (93.2±4.5),P＜0.001] 显著增加。[结论] 镜下外排钉规避骺板固定治疗儿童新鲜胫骨髁间棘骨折是一种微创、安全、有效的术式；外排钉内固定可靠，规避骺板固定可避免损伤骺板，可以早期行功能锻炼。

Abstract:

[Objective] To introduce the surgical method and preliminary clinical results of arthroscopic fixation of tibial intercondylarspine fractures without involving the epiphyseal plate in children. [Methods] As the anteromedial (AM) and anterolateral (AL) portals weremade, the arthroscope and instruments were placed to debride the blocking synovium and the blood clot in the fracture fragments. Suturehooks were passed across the lower insertion of the anterior cruciate ligament, with a PDS suture introduced, followed by a high-strength su-ture introduced, and then the high-strength suture was led out of AM. The fracture fragments were reduced by traction. As optimal locationfor outer row anchors was determined at the anteromedial epiphysis of the proximal tibia, a 2.0 mm Kirschner wire was drilled, with the posi-tion confirmed by fluoroscopy. A 0.3 cm incision was made at the entry point of the Kirschner wire, and then the positioning Kirschner wirewas removed. The high-strength suture was transferred out the incision, and fixed in proper fracture reduction with a outer row anchor with-out involving the epiphyseal plate. The reduction of the fracture and the tightness of the anterior cruciate ligament were examined again.[Results] All patients successfully completed the operation, with the average operation time of (59.4±1.7) min, the average intraoperativeblood loss of (44.2±2.0) ml. The postoperative X-ray showed that the fracture reduction was satisfactory in all the patients. Compared withthose preoperatively, Lysholm scores [(34.6±7.9), (94.4±3.5), P＜0.001], IKDC scores [(32.3±8.7), (93.2±4.5), P＜0.001] increased signifi-cantly at the latest follow-up lasted for a mean of (23.4±10.7) months. [Conclusion] This technique is a minimally invasive, safe and effec-tive for fresh tibial intercondylar spine fractures in children. The outer row anchor fixation is reliable to avoid injury of epiphyseal plate, per-mits early functional exercise.