经内侧入路利用解剖钢板治疗股骨髁间骨折病例报告

姬文晨，李新友，邱裕生，焦 帅，张小卫.西安交通大学医学院第一附属医院骨科，西安 7006；.河南洛阳市伊川县医院骨科，洛阳 47300

经内侧入路利用解剖钢板治疗股骨髁间骨折病例报告

姬文晨1，李新友1，邱裕生1，焦 帅2，张小卫1
1.西安交通大学医学院第一附属医院骨科，西安 710061；
2.河南洛阳市伊川县医院骨科，洛阳 471300

股骨髁间骨折是一种常见的骨科疾病，通常由高能量暴力所致，如何选择合适的治疗方法是临床讨论的热点。经外侧入路利用解剖钢板治疗股骨髁间骨折是最常用的方案，经内侧入路治疗的报道较为罕见。股骨髁间骨折的内固定一般包括：微创内固定系统，动力髁间螺钉固定、克氏针固定、髁间钢板固定。该文报道的病例采用了胫骨近端解剖钢板经内侧入路治疗股骨髁间骨折，成功的固定了骨折，为治疗股骨髁间骨折提供了新思路。

解剖钢板；内侧入路；股骨髁间骨折

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图1 术前X线（A：正位片；B：侧位片）

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图2 术前CT扫描和三维重建.A：三维重建正位片；B：三维重建背面片；C：CT扫描冠状面；D：CT扫描横断面

Fig.3 X-ray detection onew eek after surgery.A：frontal film；B：lateral film图3 术后1周X线（A：正位片；B：侧位片）

Fig.4 X-ray detection threem onthsafter surgery.A：frontal film；B：lateral film图4 术后3月X线（A：正位片；B：侧位片）

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

[1] Nikolopoulos DD，Polyzois IG，Magnissalis EA，et al.Fracture at the stem-condylar junction of amodular femoral prosthesis in a varus-valgus constrained total knee arthroplasty [J].Knee Surg Sports TraumatolArthrosc，2012，20（6）：1071-1074.

[2] Narsaria N，Singh AK，RastogiA，etal.Biomechanical analysis of distal femoral fracture fixation：dynam ic condylar screw versus locked compression plate[J].JOrthop Sci，2014，19（5）：770-775.

[3] LamhY，Lo CK，Cheung KY.The use of tibia Less Invasive Stabilization System（LISS）plate[AO-ASIF]for the treatment of pediatric supracondylar fracture of femur：a case report[J].J Orthop Surg Res，2010，18（5）：10.

[4] Julien TP，Ramappa AJ，Rodriguez EK.Femoral condylar fracture through a femoral tunnel eleven years after anterior cruciate ligament reconstruction：a case report[J].JBone Joint Surg Am，2010，92（4）：963-967.

[5] Sun KH，X ia SP，Chen C，et al.M anipulative reduction and traction for treatment of backward supracondylar fractures ofhumerus in children[J].Zhongguo Gu Shang，2009，22（5）：345.

[6] Nagaoka T，M izuno J，Ino K，et al.Femoral and sciatic nerve blocks for open reduction and internal fixation of a femoral condylar fracture in a patient w ith post-polio syndrome[J].Masui，2011，60（8）：964-967.

[7] Devkota P，ManandharhK，Khadka PB，et al.Less invasive stabilization system for the management of proximal tibia fractures[J].Eur JOrthop Surg Traumatol，2014，24（6）：993-998.

[8] Freitas A，M aciel RA，Lima Rde A，et al.Mechanical analysis of femoral neck fracture fixation w ith dynam ic condylar screw in synthetic bone[J].ActaOrtop Bras，2014，22（5）：264-268.

[9] Harrison MR，Ham ilton S，Johnstone AJ.Pseudo-rupture of Extensor Pollicis Longus follow ing Kischner w ire fixation of distal radius fractures[J].Acta Ortop Bras，2004，70（5）：492-494.

[10] Liang B，Ding Z，Shen J，et al.A distal femoral supra-condylar plate：biomechanical comparison w ith condylar plate and first clinical application for treatment of supracondylar fracture[J].IntOrthop，2012，36（8）：1673-1679.

R683.42

A

2095-378X（2015）01-0036-04

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

姬文晨（1985—），男，陕西西安人，博士，研究运用组织工程技术修复脊髓损伤

张小卫，电子信箱：xiaoweizhang1962@163.com