Tibiaplataeu frakturer - ortopaedi.dk · Open reduction and internal fixation compared with...
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Tibiaplataeu frakturer Behandling med ringfiksation Juozas Petruskevicius Overlæge, Fagområde for traumatologi Aalborg Sygehus
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Hvorfor ringe?
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Hvorfor ringe?
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Introduktion
Definition - frakturer sv.t. proximal tibia med involvering af knæled
Traumemekanismen – aksial overbelastning af tibiaplateau Etiologi:
Lav energi (valgustraume ved alm.fald, tackling, etc) Høj energi (trafik, fald fra stor højde)
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Klassifikation: AO 41-B og C type
• Intraartikulære • Ekstraartikulære
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Schatzker Schatzker J, McBroom R, Bruce D (1979) The tibial plateau fracture: the Toronto experience
1968–1975. Clin Orthop Rel Res 138:94–104
Schatzker I! Schatzker II! Schatzker III!
Schatzker IV! Schatzker V! Schatzker VI!
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Schatzker V
Begge kondyler er fraktureret Typisk høj-energi brud
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Schatzker VI
Begge kondyler og metafysær/diafysær overgang er fraktureret
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Frakturtype - ?
• Behandlingsstrategi • Risici & komplikationer • Prognose
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
The Canadian Orthopaedic Trauma Society Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Results of a multicenter, prospective, randomized clinical trial. J Bone JointSurg Am. 2006; 88: 2613-2623
Cole, Peter A. MD*; Zlowodzki, Michael MD†; Kregor, Philip J. MD. Treatment of Proximal Tibia Fractures Using the Less Invasive Stabilization System: Surgical Experience and Early Clinical Results in 77 Fractures. Journal of Orthopaedic Trauma. 2004; Volume 18(8): 528-535
Ryan J. Krupp, MD; Arthur L. Malkani, MD; Craig S. Roberts, MD; David Seligson, MD; Charles H. Crawford, MD; Langan Smith, BS Treatment of Bicondylar Tibia Plateau Fractures Using Locked Plating Versus External Fixation Trauma Orthopedics 2009;32(8):559. pii: orthosupersite.com/view.asp?rID=41916.
Litteratur
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Undersøgelser
Vurder bløddele og det neurovaskulære forhold: Hud (røde bullae –skidt) Compartment syndrom (åben fraktur) N. peroneus udfald (collum fibulae fraktur) A. poplitea læsion
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Planlægning
Rø. i 2 projektioner Altid CT-skanning med 3D rekonstruktion Frakturtype bestemmes og behandlingsstrategi lægges
Tegn frakturen op Kend din patient – informer tidligt om behandlings forløb,
realistiske forventninger
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Primær behandling
Imobilisering Høj bagre gipsskinne eller Don-Joy Schatzker I – IV(V) Temporær ekstern fiksation (PreFix, Hofmann, Orthofix) med
spanning over knæeet for alle dislocerede frakturer især med diafysær involvering
Efter reponering - altid røntgen/CT kontrolleres
Smertestillende Tromboseprofylakse
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Behandlings strategi – Vurder bløddele !!!
Fraktur distraction ved hjælp af basis ramme på tibia + ring på femur Ligamentotaksis (hjælper at genskabe kondylhøjden)
Lukket/åben reponering af medial og herefter lateral tibia kondyl Osteosyntese af tibias epifyse (skruefiksering af kondylparti) Ringfiksering af den samlede proksimale tibia fragment til diafysen
Defenitiv behandling med ringfiksation
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Ilizarov teknik
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Behandlingens mål
Genetablere Tibiaakse og ledlinje Ledstabillitet Leddets kongruens
At forhindre sekundær kollaps af ossøse strukturer Ingen evidens for bedre klinisk outcome ved akut ligament/
menisk rekonstruktion*
* The Canadian Orthopaedic Trauma Society. Multicenter, Prospective, Randomized Clinical TrialApplication for Bicondylar Tibial Plateau Fractures. Results of a Open Reduction and Internal Fixation Compared with Circular Fixator. J Bone Joint Surg Am. 2006;88:2613-2623.
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Ilizarov ekstern fiksation
Fordele: Minimal forstyrrelse af bløddele i frakturområdet Mulighed at reponere frakturen i flere planer samtidig Mulighed at stabilisere knæet ved ligamentærløshed Aktiv knæ bevægelighed umiddelbart postoperativt
Ulemper:
Lukket reponering af den mediale tibiakondyl er tit ikke mulig Udvendig fiksator, kræver pleje; fjernes først når frakturen er helet Hyppige pin-hul infektioner - hyppige ambulante kontroller hos
problempatienter Forhindrer fuld fleksion
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Case – Schatzker VI 24- årig ung kvinde falder ned fra en hest
Åben fraktur
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Primær behandling
Midlertidig fiksering med Hofmann II
Fraktur distraktion og
stabillisering Bløddelsskade mindskes Smertelindring
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Definitiv osteosyntese- Ilizarov metoden
1. Basis rammen og
femurring • Distraktion og aksekontrol
2. Åben fraktureponering, fiksering med K-tråde, kanyllerede skruer, optransplantering
3. Ringfiksering af den samlede proximal fragment til basisrammen
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Postoperativ aksekontrol
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Ambulant opfølgning hver 4-6 uge
Specialiseret genoptræning
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Status efter 1 år
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
Take-home messages
Intraartikulære proximal tibia frakturer kræver nøje
præoperativ planlægning Operationens mål: tibia-akse, ledstabillitet, leddets kongruitet Følg dine patienter – specialiseret fys. tidligt i forløbet
(fleksions kontraktur, gangtræning) Når andre osteosynteser fejler – redning er Ilizarov/TSF
ekstern fiksation
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Hoved-Orto-Hjertecenter
Ortopædkirurgisk Afdeling
TAK! Spørgsmål?