合并干骺端粉碎的胫骨平台双髁骨折通常合并严重的软组织损伤，手术目的是恢复关节面平整，恢复骨折的对位对线。前外侧与后内侧双入路较为常用，但双切口存在较高的软组织并发症发生率，有报道并发症约8%-12%。对此，有学者研究通过外侧插入钢板，联合小切口髓内钉置入，通过更小的软组织创伤，达到骨折固定的目的。
胫骨平台双髁伴干骺端粉碎骨折通常伴有严重软组织损伤。联合钢板-髓内钉固定是一种新兴技术，它利用有限前外侧入路进行钢板应用，并通过经皮切口置入髓内钉。这项技术减少了对胫骨近端单独内侧入路的需求。
我们报告了一系列用这种方法治疗的患者，并概述了实施步骤。
[Introduction: Bicondylar tibial plateau fractures with meta-diaphyseal comminution commonly have a compromised soft tissue envelope. Combined plate-nail fixation is an emerging technique that utilizes a limited anterolateral approach for plate application and percutaneous incisions for placement of an intramedullary nail. This technique alleviates the need for a separate medial approach to the proximal tibia. We report a series of patients treated with this approach and outline the steps for implementation.]
我们对2016年至2019年在同一机构连续接受联合外侧锁定钢板和髓内钉治疗的18名患者进行了回顾性研究。其中，16名患者符合纳入标准被纳入本研究。所有患者均为AO/OTA型41C2/C3骨折。主要结果包括最近一次随访时冠状面和矢状面对线情况、最近一次随访时关节面下沉率和术后感染率。
[Methods: We performed a retrospective review of 18 consecutive patients treated with combination lateral locked plating and intramedullary nailing at a single academic institution from 2016 to 2019. Of these, 16 patients met inclusion criteria and were included in this study. All patients had AO/OTA type 41C2/C3 fractures. Primary outcomes included coronal plane and sagittal plane alignment at latest follow up, rate of articular subsidence at latest follow up, and rate of postoperative infection.]图1 1例41岁男性患者，车祸伤，可见干骺端粉碎骨折，合并外侧平台塌陷的双髁骨折。
图2 大体照可见内侧软组织的脱套伤。
图3 术前CT横断（A）、矢状位（B）和冠状位（C）可见外侧平台塌陷的双髁骨折，干骺端粉碎。
纳入16名患者，平均随访8.2个月(范围0.1-29.7个月)。在最近的随访中，平均冠状位内翻0.8±1.2度(最大4.0度)到外翻1.4±1.7度(最大4.0度)不等。平均矢状面成角范围从前弯0.8±1.1度(最大3.0度)到后弯0.6±1.2度(最大4.0度)。在最近的随访中，没有任何患者出现关节塌陷的影像学证据。一名患者(5.9%)在术后141天出现伤口引流和感染。[Results: Of the 16 patients included, average followup was 8.2 months (range 0.1-29.7 months). At latest follow-up, average coronal alignment ranged from 0.8±1.2 degrees of varus (maximum 4.0 degrees) to 1.4±1.7 degrees of valgus (maximum 4.0 degrees). Average sagittal alignment ranged from 0.8±1.1 degrees of procurvatum (maximum 3.0 degrees) to 0.6±1.2 degrees of recurvatum (maximum 4.0 degrees). There was no radiographic evidence of articular subsidence at latest follow up for any patient. One patient (5.9%) presented at 141 days postoperatively with a draining wound and infection.]
图4 通过顶棒恢复关节面塌陷，克氏针进行软骨下支撑，置入外侧接骨板，近端横排3枚螺钉锁定，远端单皮质螺钉锁定。
图5 置入髓内钉，钢板远端采用双皮质螺钉，置入髓内钉前方骨质内。
图6 术后影像片及大体照。
图7 术后1年随访，可见骨折愈合。
对于合并干骺端粉碎的胫骨平台双髁骨折患者，联合钢板-髓内钉固定是一种可行的选择。这一系列短期随访的病例显示了可接受的影像学和临床结果，以及术后感染率和植入物移除率，类似于目前文献中报道的用于治疗这些骨折的其他技术。
[Conclusion: Combination plate-nail fixation is a viable option for treating patients with select bicondylar tibial plateau fractures with meta-diaphyseal comminution. This case series with short-term followup demonstrates acceptable radiographic and clinical outcomes, as well as rates of postoperative infection and implant removal similar to those currently reported in the literature for other techniques used to treat these fractures.]图8 手术具体操作步骤。
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