Pilon骨折的外科治疗英文PPT加翻译

1、Pilon骨折的外科治疗英文PPT加翻译trauma创伤classification分类；分级debridement清创术、扩创术anatomic reduction解剖复位the Arbeitsgemeinschaft fr osteosynthesefragen瑞士骨折内固定协会/AOBurwell-Charnley score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-traumatic arthritisrats创伤后关节炎Thorough彻底地ranti-infective medicati

2、on抗感染药物occurrence kr()ns发生tibial tbl胫骨的talustels距骨soft tissue degloving(套袖状的) 软组织撕裂metaphyseal干骺端的Seven cases were treated by debridement and internal fixation with plate; 19 by limited internal fixation combined with external fixation; and 2 by delayed surgery. The clinical outcomes were evaluated

3、by the Burwell-Charnley score.Results: All cases were followed up for from 6 to 48 months (average 24 months). The Burwell-Charnley score of clinical outcomes: anatomic reduction achieved in 12 cases, functional reduction in 15, and unsatisfactory reduction in 1.The healing time was from 2.5 to 11 m

4、onths (average 4.7 months). Two cases had delayed union. According to theAmerican Orthopaedic Foot and Ankle Society (AOFAS) scale for the ankle joint, there were excellent results in 8 cases,good in 14, fair in 5 and poor in 1. Complications included four cases of skin superficial sloughing, two of

5、 superficial infection, one of deep infection, two of delayed fracture union and ten of post-traumatic arthritis.Thorough debridement, proper use of anti-infective medication, appropriate bone grafting, and postoperative ankle function exercise can reduce the occurrence of complications.trauma创伤clas

6、sification分类；分级debridement清创术、扩创术anatomic reduction解剖复位Complication并发症sloughing蜕皮；脱落post-traumatic arthritisrats创伤后关节炎Thorough彻底地ranti-infective medication抗感染药物occurrence kr()ns发生tibial tbl胫骨的；tibiatb胫骨talustels距骨soft tissue degloving 软组织撕裂lower limb fractures 下肢骨折degloving套袖状撕裂metaphyseal干骺端的 artic

7、ular depression关节压缩weight bearing area负重区implant内植物approach方法correspondence n. 通信；一致；相当DOI：数字对象唯一标识符bilaterallybailtrli双边地malleolusmlils踝踝clinic临床；诊所临床；诊所motor 发动机发动机vehicle vikl（车辆）（车辆）accidentOpen fractures comprises about 10% to 30% of all pilon fractures3. These fractures are often associated wi

8、th significant soft tissue degloving, metaphyseal bone defects and articular depression.IntroductionPilon fracture constitutes 1% of all lower limb fractures and about 3% to 10% of tibial fractures1,2. It is usually the result of high energy injury to the weight bearing area of the lower end of the

9、tibia by the talus. Conclusion: It is important to perform appropriate surgeries for open pilon fracture according to fracture classification, different damage to skin and tissue and time interval after injury. Key words: Delayed operation; External fixators; Fractures open; Internal fixators In spi

10、te of improvements in surgical approaches and implants, treatment of tibial pilon fractures remains challenging4. In the present study, we discuss the methods,timing and clinical outcomes of surgical treatment for open pilon fractures.Address f or correspondence Xian-tie Zeng, MD, Department of Trau

11、ma, Tianjin Hospital, Tianjin, China 300211 Tel: 0086 Fax: 0086 022 24151288; Email: Received: 19 July 2010; accepted 5 October 2010DOI: 10.1111/j.1757-7861.2010.00113.xMaterials and MethodsPatient dataFrom April 2003 to July 2008, 28 patients with open tibial pilon fractures were trea

12、ted in our hospital. There were 21 men and 7 women with an average age of 36.5 years (range, 1961 years). Ten patients were injured on the left side, 17 on the right and 1 bilaterally (a closed fracture of the right malleolus（踝）（踝） was not counted). The interval between injury and presentation to ou

13、r clinic ranged from 1 to 14 hours (average, 5.1 hours). The mechanisms of injury were high-energy falls in 10 cases,motor vehicle accidents in 12, crushing injury （挤压伤）in 4 cases,and sports injuries in 2. The fractures were classified according to the AO/ASIF system: 7 were classified as type C1, 1

14、7 type C2, and 4 type C3. Open soft tissue damage was graded according to the Gustilo system: 4 cases were classified as Gustilo I, 21 Gustilo II, 2 Gustilo IIIA, and 1 Gustilo IIIB. acetabularstbjul髋臼的fibular腓骨的;fibula腓骨femoral股骨的Calcanealklkeinil跟骨的craniocerebral ,kreiniusiri:brl颅脑的protocol方法、协议pr

15、esenting with伴随restoration恢复 tibia胫骨cancellous kns()ls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 keeping in mind牢记anteroposterior前后的；正位（影像）Combined injuries included fibular fractures in 25 cases, spinal fractures in 2, upper-arm fra

16、ctures in 2, rib fractures in 2, femoral fracture in 1,acetabular fracture in 1, calcaneal fracture in 1, and craniocerebral trauma in 1.demonstrating 显示 Calcaneus（口Ki尼尔斯）：跟骨metatarsal 跖骨的ankle mortise踝关节Kirschner克氏pin克氏针Me t h o d sOne of three different surgical protocols was performed in all pati

17、ents, the choice being based on the condition of soft tissue, type of fracture and length of interval between injury and presentation for treatment.D e b r i d e m e n t , o p e n reduction and internal fix at ion (ORIF)This method was applied in type C1 fractures presenting with low-grade soft tiss

18、ue injury (Gustilo I, II) and interval between injury and presentation for treatment of less than 6 hours. Seven patients (four type C1 Gustilo I and three type C1 Gustilo II) were treated by this method. Surgical treatment of the pilon fractures was in four steps: (a) restoration of the correct len

19、gth and stabilization of the fibula; (b) reconstruction of the articular surface of the tibia; (c) insertion of cancellous autografts; and (d) stabilization of the medial aspect of the tibia with the use of a modified cloverleaf plate. An anteromedial incision was employed to treat the tibial compon

20、ent and a lateral or posterolateral incision to treat the fibular fracture. The surgical incisions were planned based on the requirements of the fracture pattern, keeping in mind the soft-tissue constraints of the individual injury. Skin closure was achieved with no tension. The tibial incisions wer

21、e closed first. If necessary, the fibular incisions were left for delayed closure.One of the seven patients achieved primary closure of the medial incision, followed by delayed closure of the lateral one. A typical case is shown in Fig. 1.Figure 1 A 49 year-old man with a low-energy open pilon fract

22、ure (Gustilo I & C1) (a) Photograph showing open soft tissue injury (GustiloI). (b) Preoperative anteroposterior and lateral radiographs showing Pilon fracture of type C1. (c) Postoperative radiographs showing the fractures have been anatomically reduced and fixed with plates. (d) Anteroposterio

23、r and lateral radiographs demonstrating fractures have healed 1 year after surgery.Figure 2 A 22 year-old man with a high-energy open pilon fracture (Gustilo II & C2) (a) Photograph showing open soft tissue injury (GustiloII). (b) Preoperative radiographs showing Pilon fracture of type C2. (c) P

24、ostoperative radiographs showing the fractures have been anatomically reduced and fixed with external fixation, and the tibial fracture fixed with limited internal fixation. (d) Anteroposterior and lateral radiographs demonstrating the fractures have healed 1.5 year after surgery.D e b r i d e m e n

25、 t , l i m i t e d O R I F a n d e x t e r n a l fi x a t i o nThis method was applied in type C2 and type C3 fractures presenting with high-grade soft tissue injury (Gustilo II, III) and interval between injury and presentation for treatment of less than 8 hours. Nineteen patients (16 type C2 Gusti

26、lo II, 1 type C2 Gustilo IIIA,and 2 type C3 Gustilo II) were treated by this method.The patients were managed by immediate（直接的） debridement of the wound. Fibular fractures were always internally fixed, either with a 1/3 tubular（管状的） plate or 3.5 mm compression plate. External fixation was applied ac

27、ross the ankle joint with pins in the calcaneus, metatarsal bone, and tibia, reconstruction of the ankle mortise（踝关节）, and stabilization with screws or Kirschner pins.split-thickness skin grafting厚皮瓣转移splint夹板edema（水肿） antibiotic（抗生素）extent（范围）contamination（污染）The affected extremity （下肢）elevate抬高；提高

28、subtalar （距下）proscribe（禁止）supervise（指导）physical therapy program （康复锻炼）Roll-A-Bout walker（助行器）outpatients(门诊就诊)Staphylococcus epidermidis（表皮葡萄球菌） Acinetobacter baumannii （鲍氏不动杆菌）Five of the 19 patients required bone grafting because of large defects of metaphyseal bone. One case underwent delayed clo

29、sure of the lateral incision, and delayed split-thickness skin grafting was applied in another case. A typical case is shown in Fig. 2.posttraumatic arthritis.（创伤后关节炎） ankle-hind（后踝）D e b r i d e m e n t a n d calcane al traction ,delayed surgeryThis method was applied in type C3 fractures accompani

30、ed by high-grade soft tissue injury (Gustilo III) and interval between injury and presentation for treatment of more than 8 hours. In two patients (one type C3 Gustilo IIIA, one type C3 Gustilo IIIB), the surgeon chose a two stage procedure（步骤）. The patients were put on calcaneal pin skeletal tracti

31、on with elevation of the lower limb over a BohlerBraun splint（勃朗支架）, and measures were taken to avoid edema（水肿）. Wound drainage（引流管） was removed when there was no further evidence of infection, and a second stage operation was performed when the edema had almost completely resolved.The patients were

32、 treated with limited ORIF and external fixation. The time interval between the two surgeries was 15 and 19 days, respectively. A typical case is shown in Fig. 3Figure 3 A 37 year-old man with a super high-energy open pilon fracture (Gustilo IIIB &C3) (a) Photograph showing open soft tissue inju

33、ry(Gustilo IIIB) (b) Preoperative radiographs showing Pilon fracture of type C3. (c) Postoperative radiographs showing the fractures have been anatomically reduced and fixed with external fixation, the tibial fixed with limited internal fixation, and the fibula with a plate.(d) Anteroposterior and l

34、ateral radiographs demonstrating the fractures have healed 1.5 year after surgery.Postoperative careAppropriate cultures （培养）were obtained during surgery, and broad-spectrum antibiotics（广谱抗生素） were administered.（执行，使用） The choice of antibiotic（抗生素）was based on the extent（范围）and degree of contaminati

35、on（污染）. Active ankle and subtalar （距下）joint range-of-motion exercises were begun as soon as the wound was dry, usually between 2 and 5 days after surgery.Weight-bearing exercise was proscribed（禁止） in the first 12 weeks after surgery. A supervised（指导） physical therapy program （康复锻炼）encouraging active

36、 ankle range-of-motion exercises was employed for the first 6 weeks. This was progressed to include passive exercises between 6 and 12 weeks. A Roll-A-Bout walker（助行器） was used when necessary.The affected extremity （下肢）was elevated （提高）continuously for the first 48 hours and then, as much as possibl

37、e, for the next 7 days. procedure（步骤）broad-spectrum antibiotics（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）posttraumatic arthritis.（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）in regard t

38、o （关于）Radiographs were obtained and evaluated according to the Burwell Charnley system: anatomic reduction was achieved in 12 cases, functional reduction in 15 cases, and poor reduction in 1 case. The healing time of the fracture was from 2.5 to 11 months, with an average of 4.7 months.Results All 2

39、8 patients were followed up from 6 to 48 months with an average of 24 months, and underwent clinical and radiological examination as outpatients(门诊就诊). Delayed union was found in two cases; in both it was associated with bone defects of the medial （内侧）tibia. One stage wound closure was performed in

40、18 patients, two underwent delayed closure of their lateral incisions, and one underwent delayed split-thickness skin grafting. There were four cases of superficial sloughing of the skin. Two patients developed surface infection with Staphylococcus epidermidis（表皮葡萄球菌） and Acinetobacter baumannii （鲍氏

41、不动杆菌）and one developed deep infection with Acinetobacter baumannii; the infection rate was 10.7% (3/28). Ten patients (35.7%) showed evidence of posttraumatic arthritis.（创伤后关节炎） According to the AOFAS ankle-hind（后踝） foot function evaluation（评估）, the average score was 85.2 (range, 66 to 98): excellen

42、t in 8 patients, good in 14, fair in 5, and poor in 1.DiscussionChoice of surgical methodsIn patients with type C1 fracture and Gustilo I soft tissue injury due to low-energy forces, pilon fracture was anatomically reduced and treated with debridement andinternal plate fixation following AO/ASIF pri

43、nciples.Open reduction and internal fixation were originally (最初)used,but it is now known that open reduction increases the risk of complications after high-energy trauma. This is probably related to the amount of dissection（解剖，切开） and stripping （剥离）of soft tissues which is needed to achieve reducti

44、on and plate fixation. Therefore, when performing ORIF procedures,the surgeons tried to limit soft tissue damage and choose suitable internal fixation. The tibia was reduced with a cloverleaf plate, dynamic compression plate or locking compression plate, depending on the level of the fracture and de

45、gree of stability required. Lin et al. reported an 83.3% good rate in 30 cases treated with ORIF followed up for 17 39 months5. Kalenderer et al. also reported a similar result6.External fixation and limited internal fixation were performed in all patients with type C2 and type C3 fractures presenti

46、ng with high-grade soft tissue injury (Gustilo II and III) and interval between injury and presentation at the authors clinic of less than 8 hours. Use of external fixation during the surgical procedure enables （使能够）the surgeon to assess（评估） the length and helps stabilize the limb（肢） for reconstruct

47、ion of the intra-articular（关节内） component. Placement （放置）of the external fixator with a calcaneal pin and a half-pin in the tibia allows ligamentotaxis （韧带修复术）to occur through traction on the calcaneal pin. 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）mala

48、lignment(对线不良)stiffness（僵硬） stfnspreclude（排除）Pre-existing（已存在）in view of（鉴于，考虑到） ischemia（缺血）skimprecarious（不确定的）prkersThis is helpful in reduction of the fracture and allows easier access to（入路） the ankle joint for joint reconstruction. Used as a neutralization（中和） device, there is no need for larg

49、e plates with the associated （相关）increased risk of skin sloughing7. Minimizing（将.减到最少） internal fixation and damage to soft tissues and blood supply decreases the rate of skin sloughing and infection. We were able to correct postoperative loss of reduction（再移位） by adjusting external fixation. It is

50、also an excellent device in those severely comminuted fractures that do not allow stable fixation with the use of a plate. Several researchers have reported similar findings in regard to （关于）external fixation811.Our results lead us to recommend (建议，推荐)that Type C3 tibial pilon fractures presenting w

51、ith high-grade soft tissue injury (Gustilo III) and interval between injury and presentation for treatment of more than 8 hours should be treated with a two-stage procedure.At initial(首先) presentation,an external fixator is applied. After the soft tissues have recovered, the second stage is performe

52、d. The goal of the first stage is to re-establish the length, alignment and rotation of the extremity and provide an environment for soft-tissue recovery.The early application of a distraction（牵引） force may help to limit any secondary injury and eliminate（清除） additional soft tissue compromise（妥协、折衷、

53、让步） during surgical exposure（显露，暴露）12.Several reports have shown that the two-stage procedure can reduce the rate of complications such as infection, skin sloughing, and post-traumatic arthritis1315.Prevention of postoperative complications.It has been reported that the incidence （发生率）of complicatio

54、ns,including wound problems, skin sloughing, infection,nonunion, malalignment(对线不良), joint stiffness（僵硬） and posttraumaticarthritis, is high (45.1%) in patients with severe pilon fractures16.Skin sloughing and infection are the most important early postoperative complications17. Pre-existing（已存在） se

55、vere soft tissue injury precludes（不能） open reduction in view of（考虑到） the potential wound problems due to ischemia（缺血） or infection of the soft tissues.The precarious（不确定的） blood supply in this region of the tibia can contribute to（有助于） the problems of both nonunion and infection18.Intensive（加强的）outw

56、eigh（胜过，强过） lateral column (外侧柱) ligament （韧带）taxis（整复）circular frames（圆形框架） hybrid systems（混合系统）habrdhinge axis （铰链轴）hndplaster cast（石膏）optimal（最佳的）manuscript（手稿，文章） In the present study, there were four cases of skin sloughing, two of superficial infections, and only one of deep bone infection. Su

57、rgical approaches are now planned based on the requirements of the fracture pattern, keeping in mind the soft-tissue constraints of the individual injury.The incisions are kept at least 7 cm apart to prevent soft-tissue ischemia and secondary woundbreakdown. Intensive（加强的） debridement,minimization o

58、f softtissue stripping and proper use of antibiotics are useful for preventing infection.Delayed union, especially in the metaphyseal portion, is also a problem with pilon fractures. We noted a 7.1% delayed union rate in this series. The severity of the injury and poor blood supply to the distal tibia may outweigh（胜过，强过） the affects of any particular approach when it comes to nonunion or delayed union, and it is also probably caused by tibial bone defect after fixation of the fibula. But there is not decided for the fibula fixation19,20.We think that fibular fracture shou