摘要
目的通过回顾分析临床资料及生物力学检测，比较间接复位螺钉从前向后固定（screw anterior-posterior fixation，SAPF）、直接复位螺钉从后向前固定（screw posterior-anterior fixation，SPAF）和支撑钢板固定（buttress plate fixation，BPF）治疗后侧Pilon骨折的效果。 方法取15具新鲜冰冻小腿标本制备后侧Pilon骨折模型，分别行BPF、SAPF和SPAF内固定（n=5），置于电压伺服加载机，以1 cm/min速度垂直加载至内固定失败（骨折线出现2 mm台阶），记录出现1、2 mm台阶时载荷及内固定失败原因。回顾分析2008年5月－2011年12月符合选择标准的56例后侧Pilon骨折患者临床资料，根据内固定方法不同，将患者分为SAPF组（11例）、SPAF组（26例）和BPF组（19例）。3组患者性别、年龄、致伤原因、侧别、受伤至手术时间、合并症等一般资料比较，差异均无统计学意义（P 〉 0.05），具有可比性。随访时摄踝关节正侧位X线片，评估骨折复位及愈合情况。末次随访时，采用美国矫形足踝协会（AOFAS）踝与后足评分标准及疼痛视觉模拟评分（VAS）评价疗效。 结果加载后各组标本均未出现螺钉断裂或弯曲，内固定失败原因均为螺钉周围松质骨压缩。出现1 mm及2 mm台阶时BPF组载荷最大，SPAF组次之，SAPF组最小，组间比较差异均有统计学意义（P 〈 0.05）。术后47例获随访，其中SAPF组9例，SPAF组22例，BPF组16例；随访时间16～54个月，平均35.2个月。X线片检查示，除SAPF组2例复位不佳及骨折再移位行二次手术外，其余骨折均获骨性愈合，愈合时间为3～4 个月，平均3.2个月；均无内固定失败发生。末次随访时， SAPF组AOFAS评分显著低于SPAF组和BPF组，VAS评分显著高于SPAF组和BPF组，差异均有统计学意义（P 〈 0.05）；SPAF组和BPF组间比较差异均无统计学意义（P 〉 0.05）。 结论后侧Pilon骨折由于骨折线和胫骨干轴线的夹角较小，SAPF无法达到足够固定强度，内固定易失败；而SPAF和BPF均可达到牢固固定，临床疗效肯定；生物力学检测分析显示BPF内固定效果更佳。
ObjectiveTo investigate the effectiveness and biomechanical analysis of 3 fixation methods of screw anterior-posterior fixation （SAPF）, screw posterior-anterior fixation （SPAF）, and buttress plate fixation （BPF） in treatment of posterior Pilon fractures. MethodsFifteen fresh-frozen skeleto-ligamentous lower leg specimens were harvested to establish the models of posterior Pilon fracture, and then fracture was fixed with BPF （n=5）, SAPF （n=5）, and SPAF （n=5）. Vertical force was loaded to internal fixation failure in a speed of 1 cm/minute with servohydraulic testing machine. The instantaneous loads of 1 mm and 2 mm steps and the failure modes were recorded. Between May 2008 and December 2011, 56 patients with posterior Pilon fracture were treated with SAPF （SAPF group） in 11 cases, or SPAF （SPAF group） in 26 cases, or BPF （BPF group） in 19 cases. There was no significant difference in age, gender, injury cause, side, disease duration, and complications among groups （P 〉 0.05）. Clinical and radiographic examinations were used to assess the reduction and healing of fracture; the American Orthopaedic Foot and Ankle Society （AOFAS） ankle-hindfoot score and the visual analogue scale （VAS） were used to evaluate the functional outcomes. ResultsNo breaking or bending was observed in all specimens, fixation failure was caused by cancellous bone compression. The instantaneous loads of 1 mm and 2 mm steps were the largest in BPF group, larger in SPAF group, and smallest in SAPF group, showing significant differences among 3 groups （P 〈 0.05）. A total of 47 cases were followed up 16-54 months （9 in SAPF group, 22 in SPAF group, and 16 in BPF group）, with a mean time of 35.2 months. Fixation failure was found in 2 cases of SAPF group; the other cases obtain bony union within 3 to 4 months （mean, 3.2 months） with no fixation failure. The AOFAS score was significantly lower in SAPF group than in SPAF and BPF groups （P 〈 0.05）, but no significant difference was found between SPAF and BPF groups （P 〉 0.05）. The VAS score was significantly higher in SAPF group than in SPAF and BPF groups （P 〈 0.05）, but no significant difference was found between SPAF and BPF groups （P 〉 0.05）. Conclusion SAPF could not reach enough fixation strength for the posterior Pilon fracture; both SPAF and BPF could reach rigid fixation, and have good effectiveness. And from the biomechanical points, BPF could reach better fixation strength than screw fixations.
出处
《中国修复重建外科杂志》
CAS
CSCD
北大核心
2013年第10期1190-1195,共6页
Chinese Journal of Reparative and Reconstructive Surgery
基金
国家自然科学基金资助项目(81271992/H0605)~~
