本文關鍵詞：改良Carlson膝關節(jié)后外側入路治療脛骨平臺單純后外側柱骨折的解剖學研究及其應用　出處：《蘇州大學》2016年碩士論文　論文類型：學位論文

  更多相關文章： 脛骨平臺 后外側入路 骨折 鋼板 臨床解剖學

【摘要】：脛骨髁骨折,因常影響脛骨平臺關節(jié)面,臨床上亦被稱為脛骨平臺骨折,在致傷過程中還可合并半月板,甚至交叉韌帶或/和側副韌帶,因而易造成不良結果,如關節(jié)疼痛、僵硬、不穩(wěn)定或畸形。由于有生理性膝外翻角的存在,外側平臺骨折最為多見。脛骨平臺后外側柱骨折是外側平臺骨折中較為特殊的類型,是脛骨平臺骨折在冠狀面上單純累及后外側髁的骨折,通常表現(xiàn)為單純后外側關節(jié)面的塌陷、單純后外側皮質的劈裂、后外側皮質的劈裂合并關節(jié)面塌陷。切開復位結合鋼板內固定技術(open reduction and internal fixation,ORIF)已成為通過手術治療脛骨平臺骨折的主要治療方式,目的是將其關節(jié)面恢復平整。由于此種類型骨折的骨折塊位置偏后外側,普通X片對其診斷有局限性,有一定的漏診率。通過CT及MRI進一步檢查,不僅容易發(fā)現(xiàn)此類骨折,而且對于確定骨折類型、損傷范圍及指導治療優(yōu)勢明顯。目前對于這種骨折的手術治療方法沒有統(tǒng)一的標準,但任何手術入路及方式均應以創(chuàng)傷小、暴露充分和堅強內固定為目的。通過標準外側入路或前外側入路及后側入路均難以同時滿足此目的。從生物力學角度講,對骨折塊進行支撐鋼板直接加壓固定最為可靠。Carlson在1998年報道了涉及內外側平臺關節(jié)面的脛骨髁后側骨折,通過膝關節(jié)后內及后外雙側切口來進行暴露,并予以鋼板固定治療。但Carlson運用的后外側切口因不是專門針對治療單純的后外側柱骨折,切口偏外,其切口與膝關節(jié)后外側重要神經走行相交叉,術中容易造成神經損傷,術后切口疤痕亦容易卡壓神經,造成神經麻痹。另外,對于后外側柱骨折中涉及后交叉止點的部位,暴露不充分,對于治療后交叉止點骨折固定造成一定難度。由于膝關節(jié)后外側入路所涉及的解剖結構較為復雜,手術操作存在難度,熟悉和掌握膝關節(jié)后外側入路相關的骨性結構、韌帶結構、肌腱肌肉位置、血管及神經行徑及其支配,對于減少該部位手術創(chuàng)傷、保留骨折塊血運和提高療效具有重要意義。目的:通過對膝關節(jié)后外側入路所涉及的主要血管、神經等結構的解剖學觀察、測量和分析,確定通過此入路能暴露并安全操作的范圍及是否有足夠空間放置內固定。在解剖學研究的基礎上,結合臨床實際,探討改良carlson膝關節(jié)后外側入路治療脛骨平臺后外側骨折的手術方法及臨床療效。方法:(1)解剖學觀察及測量:取20例成尸下肢標本,男10例,女10例。取膝關節(jié)后側正中切口,起自大腿中下1/3,向遠側延伸到小腿中段,逐層剝離皮膚、皮下組織和筋膜,對腓腸外側皮神經及腓總神經的發(fā)出點、走向及相關距離進行測量,確定手術切口的安全范圍,逐層分離,觀察膝關節(jié)后外側主要韌帶、肌肉位置及附著特點、附著范圍,明確手術入路的間隙;完整剝離腓腸肌和比目魚肌,暴露乆血管神經束,對影響切口暴露的乆血管神經束、脛前動脈和膝下外側動脈進行觀察和解剖學測量,以確定該入路暴露范圍的可實施性。所得數(shù)據進行統(tǒng)計學處理。(2)臨床實踐:自2010年1月至2013年12月,按不同治療方案分為對照組及觀察組,分別采用前外側入路(對照組)及改良carlson后外側切口(觀察組)顯露脛骨平臺后外側,分別對隨機抽取的各48例脛骨平臺后外側骨折進行手術治療,男56例,女40例,年齡19-65歲,平均41歲。術后采用hss及rasmussen等評分標準評定關節(jié)功能,通過觀察患膝有無疼痛、關節(jié)活動度、有無感染、下肢深靜脈血栓、tpa及pa角度及并發(fā)癥等指標,評估此改良手術的療效。結果:(1)解剖學觀察和測量:腓腸外側皮神經距腓骨頭內側緣的水平距離1.696±0.396cm;腓腸外側皮神經從腓總神經發(fā)出點距腓骨頭上緣的垂直距離5.755±1.607cm;膝下外側動脈起點距腓骨頭上緣的垂直距離1.839±0.364cm,距腓骨頭內側緣的水平距離1.707±0.272cm;脛前動脈起點到小腿骨間膜裂孔的距離2.397±0.304cm;小腿骨間膜裂孔至腓骨頭上緣的垂直距離4.794±0.354cm,至腓骨頭內側緣的水平距離0.947±0.217cm。改良carlson膝關節(jié)后外側入路需要暴露脛骨后外側平臺,應將比目魚肌及乆肌在脛骨后方的止點適度剝離;膝下外側動脈會對外側平臺的顯露及乆血管神經束向內側牽開有一定限制,術中可予以結扎;由于脛前動脈的阻礙,小腿骨間膜裂孔平面以下的脛骨骨面顯露受到限制,乆動脈向內側牽拉也會受到一定限制,可通過擴大骨間膜裂孔,適當增加血管牽拉范圍。(2)臨床實踐:所有患者術后獲12-18個月(平均15.7個月)隨訪,術后3-4個月x片示所有骨折均獲愈合。觀察組膝關節(jié)功能hss評分為90.0-100.0分,平均94.3分。觀察組患者骨折愈合時間及術后完全負重時間、術后引流等明顯少于對照組,隨訪過程中未見平臺關節(jié)面高度丟失,膝關節(jié)伸0°屈曲度105.0°~135.0°,平均128.8°。無手術切口相關并發(fā)癥發(fā)生,無腓總神經損傷癥狀、感染、內固定失效及螺釘斷裂等并發(fā)癥發(fā)生。觀察組病例膝關節(jié)功能恢復優(yōu)良率為95.83%,對照組優(yōu)良率為83.34%,兩組比較差異有統(tǒng)計學意義(P0.05)。結論:(1)在熟悉解剖結構的前提下,用改良Carlson膝關節(jié)后外側入路治療單純后外側柱骨折是一種良好的選擇,其具有創(chuàng)傷小、顯露充分、復位良好和固定堅強的優(yōu)點,因脛前血管束在骨筋膜裂孔處較為固定,對于損傷力度較大,骨折線在骨間膜裂孔水平線以下的病例要慎用。(2)改良Carlson膝關節(jié)后外側入路能夠充分顯露手術區(qū)域,最大限度提供平臺后外側內固定的生物力學強度,術后出血少,骨愈合快,早期負重,較傳統(tǒng)的平臺截骨內固定治療更有優(yōu)勢,是治療脛骨平臺后外側骨折的優(yōu)先選擇入路,值得臨床推廣。對于合并內側平臺骨折,此入路及固定方法需結合其他方式運用。
[Abstract]:Fracture of tibial condyle, because often affect the articular surface of tibial platform, also known as the clinical fracture of tibial plateau in the injury process can also merge the meniscus, cruciate ligament and / or even the lateral collateral ligament, thus easy to cause adverse outcomes, such as joint pain, stiffness, instability or deformity. Due to physiological knee the valgus angle, lateral platform fracture is the most common. Posterolateral tibial plateau fracture is a special type of column lateral tibial plateau fracture, fracture of the lateral condyle in the coronal plane only involving the posterior tibial plateau fractures, usually for posterolateral articular surface and posterolateral cortical splitting after the lateral cortex splitting with articular surface collapse. Open reduction combined with internal fixation technique (open reduction and internal fixation, ORIF) has become the main treatment for surgical treatment of tibial plateau fractures, to be locked up The nodal plane healing. Due to the fracture of this type of fracture block position after partial lateral, ordinary X sheets have limitations on the diagnosis, there is a certain rate of misdiagnosis. Further examination by CT and MRI, not only easy to find such fractures, and to determine the type of fracture, injury and guide the treatment of the operation have obvious advantages. The treatment method of this kind of fracture is no uniform standard, but any surgical approaches and methods should be fully exposed to trauma, and internal fixation for the purpose. Through the standard lateral approach or the anterolateral and posterior approach are difficult to meet this objective. From the perspective of Biomechanics, fracture block support steel plate directly pressure fixed the most reliable.Carlson reported in 1998 involving the articular surface of the tibial platform and lateral posterior fractures, through the knee joint after and after bilateral incisions were exposed, and steel plate The use of Carlson fixation. But the posterior lateral incision because not specifically for the treatment of simple lateral posterior column fracture, partial incision, the incision and lateral knee joint important nerves cross, likely to cause nerve injury during operation, postoperative incision scar is easy to nerve entrapment, causing paralysis. In addition, for posterolateral fractures involving posterior cruciate insertion sites are not fully exposed, for the treatment of posterior cruciate check point fixed fracture caused certain difficulty. Because of very complicated posterolateral approach to the surgical operation is difficult, familiar with and master the posterolateral knee into the bone structure, related to the road the structure of muscle tendon ligament, position, blood vessels and nerves and acts of domination, to reduce the position of surgical trauma and retention is important fracture block blood supply and improve curative effect. Objective: to knee joint posterolateral approach The main vascular road to the anatomical observation of neural structures, measurement and analysis, determined by the scope of this approach can expose and safe operation and whether there is enough space for internal fixation. Based on anatomical studies, combined with clinical practice, to explore the operative method and clinical effect of modified Carlson knee joint posterolateral approach the treatment of posterolateral tibial plateau fractures. Methods: (1) the anatomical observation and measurement: 20 cases of adult cadaver lower limb specimens, 10 cases were male, 10 were female. The knee joint posterior median incision, since lower thigh 1/3 extends distally to the small middle leg, peeling off the skin and subcutaneous tissue. The fascia, the lateral sural cutaneous nerve and common peroneal nerve were measured to a point, and the correlation distance, the safety range of surgical incision, layer separation, observation of posterolateral knee ligaments, muscles attached position and characteristics of attachment, Ming The gap is the surgical approach; the complete separation of the gastrocnemius muscle and soleus muscle, exposure of people to people the neurovascular bundle, neurovascular bundle incision of anterior tibial artery and inferior lateral genicular artery were observed and anatomic measurement to determine the exposure range approach can be implemented. The data were analyzed statistically. (2) clinical practice: from January 2010 to December 2013, according to the different treatment plan is divided into control group and observation group, respectively, using the anterolateral approach (control group) and improved Carlson posterolateral incision (observation group) revealed posterolateral tibial plateau, respectively, 48 cases of tibial plateau were randomly selected for posterolateral fracture surgery the treatment, 56 cases were male, 40 were female, age 19-65 years, average 41 years old. The HSS and Rasmussen standard for evaluation evaluation of joint function after operation, through the observation of the knee with no pain, joint activity, there is no infection, deep vein thrombosis, and TPA PA index angle and complications, evaluating the curative effect of the improved operation. Results: (1) the anatomical observation and measurement: the horizontal distance of the lateral sural nerve from the medial margin of the fibular head was 1.696 + 0.396cm; lateral sural cutaneous nerve from the peroneal nerve from the upper edge of the vertical distance of fibular head distance 5.755 + 1.607cm; vertical distance 1.839 + 0.364cm lateral inferior genicular artery fibular head from the upper edge of the starting point, from the medial edge of the fibular head horizontal distance was 1.707 0.272cm; the anterior tibial artery to the starting point of leg interosseous membrane hole distance was 2.397 0.304cm; interosseous membrane split vertical distance 4.794 + 0.354cm hole to the fibular head of the upper edge of the horizontal distance to the medial margin of the fibular head 0.947 + 0.217cm. modified Carlson knee posterolateral to expose lateral tibial plateau, soleus muscle and muscle of people should be in a moderate stop stripping the posterior tibial; inferior lateral genicular artery will outside platform significantly Dew and kind of the neurovascular bundle medially to a certain limit, may be due to ligation; anterior tibial artery obstruction, crural interosseous membrane of tibial bone surface crack hole below the level of exposure is limited to the medial artery, people pull will be subject to certain restrictions, by expanding the interosseous membrane hole. Appropriate increase in vascular stretch range. (2) clinical practice: all patients for 12-18 months (average 15.7 months) follow-up, 3-4 months after operation X-ray showed that all fractures were healed. The observation group HSS score of knee joint function was 90.0-100.0, an average of 94.3 points. The fracture healing time and postoperative full weight-bearing time groups of patients, postoperative drainage was significantly less than the control group during the follow-up, no articular height loss, knee extension and flexion of 0 degrees 105 degrees ~135.0 degrees, with an average of 128.8 degrees. No incision complications, no symptoms of common peroneal nerve injury infection, internal fixation Failure and screw fracture and other complications. Observation group cases of knee joint function recovery rate is 95.83%, the control group was 83.34%, there was significant difference between two groups (P0.05). Conclusion: (1) in the familiar with the anatomy of the premise, using the improved Carlson posterolateral approach in the treatment of posterolateral column fracture is a good choice, it has less trauma, good exposure, good reduction and fixation advantages because of anterior tibial artery in osteofascial hole at the beam is fixed, the larger the damage strength, the fracture line in the interosseous membrane following Kong Shui split flat line cases (2) improved should be used with caution. Carlson knee posterolateral approach can expose the operation area, to maximize the platform for posterolateral fixation: a biomechanical strength, less postoperative bleeding, bone healing, early weight-bearing, platform osteotomy and internal fixation for the treatment of more than the traditional advantages, is the treatment of The preferred approach for posterolateral fractures of tibial plateau is worthy of clinical promotion. For the patients with medial platform fractures, this approach and fixation method should be combined with other ways.

【學位授予單位】：蘇州大學
【學位級別】：碩士
【學位授予年份】：2016
【分類號】：R687.3

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