1、Surgical Management of Tibial Tubercle Fractures in Association With Tibial Plateau Fractures Fixed by Direct Wiring to a Locking Plate,Technical Trick,Chakraverty, Julian K MBChB, DO*; Weaver, Michael J MD; Smith, R Malcolm MD; Vrahas, Mark S MD From the *Frenchay Hospital, North Bristol NHS Trust,
2、 Bristol, United Kingdom; Harvard Combined Orthopaedic Program, Massachusetts General Hospital, Boston, MA; and Massachusetts General Hospital Orthopaedics and Partners Orthopaedics, Harvard School of Medicine, Massachusetts General Hospital, Boston, MA.,The authors did not receive grants or outside
3、 funding in support of their research or preparation of this article. One author (M.S.V.) has received an unrestricted educational grant from Synthes in support of his fellowship program.,All devices included in this article are Food Drug Administration approved. Presentation of Material: not applic
4、able. Reprints: Mark S. Vrahas, MD, Chief of Orthopaedic Trauma, Partners Orthopaedics, Associate Professor, Harvard School of Medicine, Massachusetts General Hospital, 55 Fruit St, YAW 3600-3C, Boston, MA 02114.,Summary,Tibial tubercle fractures disrupting the extensor mechanism of the knee can occ
5、ur in association with complex tibial plateau fractures (AO type 41A, B, C). The management of these fractures can be difficult; a stable repair of the tibial tubercle fragment is essential if the extensor mechanism is to be reconstituted. There are few reported techniques described to manage tibial
6、 tubercle fractures in conjunction with complex proximal tibial injuries. Traditionally, tibial tubercle fractures have been repaired by lagging the tubercle fragment to the posterior cortex of the tibia using 1 or more screws. However, the cortex of the posterior tibia does not always offer good pu
7、rchase for screw fixation, particularly in osteopenic bone. Additionally, in complex proximal tibial fractures, comminution often extends posteriorly, further complicating stable lag screw fixation. Placement of an anteroposterior lag screw can also be complicated by screw traffic if there are a lar
8、ge number of screws fixing the primary fracture. In this article, we report a novel surgical approach for the management of tibial tubercle fracture fragments occurring in association with complex proximal tibial fractures. Using this technique, the tibial tubercle fragment is stabilized by wiring i
9、t directly to the screws of a locking plate. It allows for reduction and fixation of the tibial tubercle fragment that is stable enough to allow immediate full active range of motion. Over the past 5 years, we have applied this technique in 16 patients. Our preliminary results using this new techniq
10、ue have demonstrated a high rate of clinical and radiographic union with near normal return of extensor mechanism function.,胫骨平台骨折合并胫骨结节骨折采用锁定钢板联合直接钢丝固定,综述,胫骨结节骨折导致伸膝装置破裂可以和复杂的胫骨平台骨折同时发生（AO分型）。这类骨折处理困难；胫骨结节骨块的稳定修复是需要的以利于伸膝装置的恢复。文献关于胫骨结节骨折合并复杂的胫骨平台骨折的处理鲜有报道。一般采用1到多枚螺钉将断裂的胫骨结节修复固定于胫骨的后侧皮质。但是胫骨后侧皮质并不总是
11、能用于螺钉的固定，特别是在骨质疏松骨。另外，在复杂的胫骨平台骨折，骨折粉碎可以延伸至后侧，不利于稳定螺钉的固定。如果对骨折进行大量前后位固定的话，螺钉的位置安置也是问题。,目的,一个新型的手术技术用于处理胫骨结节骨折合并复杂的胫骨平台骨折。使用这项技术，将其稳定作用的钢丝直接固定在锁定钢板的螺钉上。允许胫骨结节骨折块的复位固定，其固定牢固程度允许病人进行即刻的全关节活动。,结果,在过去5年中，我们采用这项治疗技术治疗了16个病人。采用新技术后的初步结果显示病例骨折获得了良好的临床和放射学愈合，且伸膝装置功能接近恢复至正常水平。,表1近端胫骨固定和结节钢丝捆绑后的病人特征,表2近端胫骨固定和结节
12、钢丝捆绑术后病人的随访结果,外科技术,外科技术,使用钢丝环绕胫骨结节骨块，再通过锁定钢板髓腔中的螺钉，当钢丝收紧的时候胫骨结节骨块就牢固固定于应有的位置。 示意图如下:,手术图例,（一） 利用侧切口暴露胫骨近端，骨折预备进行复位和固定。从侧方打开骨折部位，同时保留胫骨结节上的软组织附着。可见胫骨近端的骨髓腔。P：近端；L：侧方。,图2所示的是一例复杂的胫骨平台骨折，经历过失败的固定手术（见螺钉孔），合并大块的胫骨结节骨块撕脱。,（二） 用三根16尺寸的钢丝被环绕在胫骨结节骨块，注意避免过多的软组织剥离。P：近端；L：侧方。,（三） 将钢丝被分别绕过一根锁定螺钉，或者穿过锁定钢板上的某一空洞（没有上螺钉的孔）。P：近端；L：侧方,（四） 将胫骨结节骨块通过钢丝的不断扭曲缩紧复位，并紧紧固定于胫骨上保持复位状态。其稳定性通过膝关节的活动得以验证。P：近端；L：侧方。,图6 AD显示的是正位和侧位X线检查为C型胫骨平台骨折，CT检查显示胫骨结节骨块撕脱。,图7所示在LISS钢板固定和钢丝固定胫骨结节5个月后，正位和侧位X线片均显示骨折愈合。,
