經(jīng)內(nèi)側(cè)入路利用解剖鋼板治療股骨髁間骨折病例報告

姬文晨，李新友，邱裕生，焦 帥，張小衛(wèi).西安交通大學醫(yī)學院第一附屬醫(yī)院骨科，西安 7006；.河南洛陽市伊川縣醫(yī)院骨科，洛陽 47300

經(jīng)內(nèi)側(cè)入路利用解剖鋼板治療股骨髁間骨折病例報告

姬文晨1，李新友1，邱裕生1，焦 帥2，張小衛(wèi)1
1.西安交通大學醫(yī)學院第一附屬醫(yī)院骨科，西安 710061；
2.河南洛陽市伊川縣醫(yī)院骨科，洛陽 471300

股骨髁間骨折是一種常見的骨科疾病，通常由高能量暴力所致，如何選擇合適的治療方法是臨床討論的熱點。經(jīng)外側(cè)入路利用解剖鋼板治療股骨髁間骨折是最常用的方案，經(jīng)內(nèi)側(cè)入路治療的報道較為罕見。股骨髁間骨折的內(nèi)固定一般包括：微創(chuàng)內(nèi)固定系統(tǒng)，動力髁間螺釘固定、克氏針固定、髁間鋼板固定。該文報道的病例采用了脛骨近端解剖鋼板經(jīng)內(nèi)側(cè)入路治療股骨髁間骨折，成功的固定了骨折，為治療股骨髁間骨折提供了新思路。

解剖鋼板；內(nèi)側(cè)入路；股骨髁間骨折

1 Introduction

Femoral condylar fracture is a common intraarticular fracture caused by ahigh-energy violence[1].Inappropriate treatment w ill lead to complications which is difficult to be tackled，surgery is considered as the most suitable choice to treat this disease，the types of surgeryhave many options which require small trauma，accurate reduction and solid fixation which means reduction of the damage of soft tissue existed around the knee joints and guaranteeing that fracture accurately resets in the coronal，sagittal and transverse section，patient can do functional exercise in the early time after operation and achieve an ideal effect at last[2].As the development of surgical techniques and internal fixation of equipment，many researchers think supracondylar comm inuted fracture of the femur needs to be operated as soon as possible if there is no surgical contraindications，which can improve the cure rate and reduce the complications[3].Clinically，most of doctors usually choose lateral operative approach for the operation，but in this casereport we choose anatom ical plate which is usually used in proximal tibia fracture to treat femoral condylar fracture and successfully fix the avulse fragment，especially we choose medial operative approach for thisoperation.

Fig.1 X-ray detection before surgery.A：frontal film；B：lateral film圖1 術(shù)前X線（A：正位片；B：側(cè)位片）

Fig.2 CT scanning and three-dimensional reconstruction before surgery.A：frontalview of three-dim ensional reconstruction；B：back view of three-dimensional reconstruction；C：CT scanning in coronalsection；D：CT scanning in transverse section圖2 術(shù)前CT掃描和三維重建.A：三維重建正位片；B：三維重建背面片；C：CT掃描冠狀面；D：CT掃描橫斷面

Fig.3 X-ray detection onew eek after surgery.A：frontal film；B：lateral film圖3 術(shù)后1周X線（A：正位片；B：側(cè)位片）

Fig.4 X-ray detection threem onthsafter surgery.A：frontal film；B：lateral film圖4 術(shù)后3月X線（A：正位片；B：側(cè)位片）

2 Clinicalm aterial

A 49-year-old female was adm itted to the department of orthopedics at the First A ffiliatedhospital of School of Medicine of Xi’an Jiaotong University.A electric bicycle riding fifteenhours ago causedher craniometrical and right leg injuries.The X-ray film，CT scanning and three-dimensional reconstruction were performed on the right knee.X-ray frontal and lateral film results reveal（Fig1-A，B）the fracture line is clearly visible from upper left to lower right through the femoral condyle which was demonstrated by three-dimensional reconstruction in frontal and back views（Fig2-A，B），the result of which is consistent w ith CT scanning that could see the medial femoral condyle avulsion fracture and fractured several parts in coronal and transverse section（Fig2-C，D），so we diagnosed the patient as the right femoral condyle fracture and operation was needed to fully recover it.Before the operation，bloodtest，hepatic function，renal function，electrolytes-test，five items ofhepatitis B and cardiogram were done，all the results revealed there was not obvious abnorm ity.Under the epidural anesthesia，open reduction and internal fixation of femoral intercondylar fracture were done through the medial operative way w ith anatom ical plate（A.O Sm ith Company）that is usually used in proximal tibia fracture during surgery，traction and reposition of the fracture end，boneholding forcepswas used to fix it，tenholes pressure locking of the anatom ical platewas used to attach themedial femoral condyle which was fixed by eight screws，on twoholes located in the fracture line the screw was notused，at last the avulse fragmentwas fixed successfully.After the operation，the patient was advised to do limb exercises in the bed to prevent deep vein from thrombosis.One week later，the X-ray frontal and lateral filmswere done to observe operational effect（Fig3-A，B）and anatom ical plate was found adhered to the bonesurface closely and the effect of reduction was good.Threemonths later，the fracture line couldn’t be seen in the X-ray frontal and lateral film（Fig4-A，B）.A w ritten patients com firmation was obtained during this studyhe remains in follow-up.

3 Discussion

Femoral condylar fracture belongs to violence and intra-articular fracture which is a shift fracture in the most of time，the purpose and principle to cure this disease are the reduction of the fracture pieces，recovery of joint surface smoothness，reduction of the occurrence rate of knee joint conglutination，anchylosis and traumatic arthritis[4].The traditional manipulatian reduction couldn't correct the displacementof internal and external condyle，couldn't restore the articular surface and the original anatom ical position，the most important thing is to fix the knee for a long time（more than 4 weeks）which is the key to the irreversibility of degeneration，the severity of which is consistent w ith time[5].The purpose of open reduction is to achieve fully anatom ical reduction which can benefit the knee early activity and prevent conglutination and anchylosis[6].

Up to now，there aremany types ofmethods to cure the femoral condylar fracture，such as less invasive stabilization system （LISS）which is suitable to the distal femoral and proximal tibia comm inuted fracture fixation，especially in patients w ith osteoporosis and fracture around the prosthesis，the use of external screwhole visible could reduce soft tissue damage to the lowest degree in surgery，but the disadvantage of which m ight lead to malreduction and fracture shift again[7].Dynam ic condyle screw fixation（DCS）has advantages：low technical requirements，simple operation，anatom ic reduction and reliable fixation，but the problem for this technique is：screw is easy to be loose and pulled out，because drilling removes massive bone which decreases the bonding ability of screw[8].Kischner w ire fixation is suitable for open fractures，this method can reduce internal fixation exposure to outside and fracture infection from the exposure is easy to be covered，the other merits of this method are：operation is simple，operating time is short and fewer complications，the most important is this method can cost patient lessmonye[9].Condylar plate is designed according to the anatom ical characteristics of the femoral condyle，coincide w ith the shape of lateral femoral condyle and no reshaping broad during surgery，but the distal of condylar plate needed which may damage important structure of the lateral condyle of femur and the attachment of anterior cruciate ligament and could even affect patellofemoral joint activities[10]were itpoorly positioned.

Our case report is about femoral condyle fracture，the lateral operative approach is usually chosen to cure this disease，but we could see the fracture line is clearly visible from upper left to lower right from X-ray film，so if we still choose the lateral operative approach and want to solidly fix the bone fragment the lateral incision is needed to be enlarged and cutting of the vastus intermedius which may damagemost of the vastus intermediusmuscle fibers leading to form scar tissue which is less elastic，easy to adhere the bone callus and prohibit the contraction of the quadriceps muscle activity.So during the surgery，we choose themedial operative approach for treating the patient who want to resolve the above problems.Except the choice of operative approach，how to select proper internal fixation is very important，compared to othermethods，the anatom ical plate is the best，for it，easy operation，early activities after operation，but if using anatom ical plate used in distal femur fracture through lateral operative approach we couldn't closely adhere it on the bone surface for the internal and external femoral condyle angle is not the same.So we choose A.O sm ith company anatom ical plate which usually used in proximal tibia fracture，the angle of the anatom ical plate is founded to almost coincides w ith the internal femoral condyle angle and thus the ussually bone fragmentcan reach anatom ical reduction.

4 Conclusion

In conclusion，femoral condylar fracture is acommon disease the lateral operative approach is used to cure it and ithas many options of internal fixation.We present the case of 49 old female patients w ith femoral condylar fractures in them anatom ical plates（A.O Sm ith Company）were used，which usually used in proximal tibia fracture through the medial operative approach to cure the fracture which rarely reported in the previous literature，the result reveals that this type of plate and operative approach can solidly fix the bone fragment and reach anatom ical reduction successfully after surgery.However，long-term follow-up is needed to evaluate the recovery of the fracture and knee function.

5 Acknow ledgem ents

We are very grateful to associate professor Xinyou Liwho put forward the operation scheme and completed theoperation togetherw ith XiaoweiZhang.

Reference

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R683.42

A

2095-378X（2015）01-0036-04

10.3969/j.issn.2095-378X.2015.01.012

姬文晨（1985—），男，陜西西安人，博士，研究運用組織工程技術(shù)修復脊髓損傷

張小衛(wèi)，電子信箱：xiaoweizhang1962@163.com