锁定钢板在骨科创伤中应用的新进展

Abstract摘要

Locked plating for fracture fixation has enjoyed widespread popularity despite a paucity of published data on outcomes. Anatomically precontoured locked plates that allow fixation in various anatomic regions are widely available. New technologies incorporate subchondral support locking pegs, polyaxial bushings, and locking washers to improve intraoperative versatility. However, limited data are available on the efficacy of these new implants. The clinical performance of locked plates generally has been good. However, several unique complications have been noted, such as difficulty with implant removal, malalignment, fracture distraction, and loss of diaphyseal fixation, especially with percutaneous techniques and unicortical screws. The expense of locked plate constructs is a concern. This technology typically costs three times more than similar unlocked constructs. Locked constructs should be reserved for problematic fractures that have demonstrated poor outcomes with unlocked constructs.

尽管相关临床结果的出版资料比较匮乏，但锁定钢板已经被广泛接受。解剖预塑形锁定钢板允许在多个不同的解剖部位进行固定，因此适应性很广。软骨下支撑锁定针、多轴衬垫以及锁紧垫圈这些新技术的应用使得术中的灵活适应性进一步提高。不过目前有关这些新技术有效性的资料还不够充分。锁定钢板的临床疗效通常是很好的，但是也有其固有的并发症，例如内固定物取出困难、排列不齐、骨折块分散以及骨干固定不牢固，特别是对于预塑形锁定钢板和单皮质螺钉。锁定钢板价格昂贵也是一个问题，这项技术的花费超过同类非锁定钢板的3倍。锁定钢板应该被应用于非锁定钢板治疗效果不好的难治性骨折病人。Innovations in Locked Plate Design and Surgical Techniques锁定钢板设计及外科技术的进展The first commercially available locked plate designed for periar-ticular fracture fixation, the Less In?vasive Stabilization System (LISS; Synthes, Paoli, PA), has been in use in the United States for nearly a decade. This titanium alloy, fixed-trajectory locking plate with instru?mentation optimized for percutane?ous insertion demonstrated a clear advantage over traditional plates with regard to union rates without secondary surgery and improved end-segment fixation.1 The LISS sys?tem relies on unicortical shaft fix?ation and self-drilling, self-tapping screws. Published data have been encouraging. However, malalignment is not infrequent, even when used by experienced surgeons2-9 (Figure 1).

第一个应用于关节外骨折的商品化锁定钢板LISS系统在美国已经使用了有10年时间了。这种通过仪器精确定位经皮插入的钛合金固定轨道锁定钢板相比传统钢板在有关骨不连发生率方面显示出明显的优越性，减少了二次手术并强化了骨折远端固定强度【1】。LISS系统采用自钻自攻螺钉进行骨干单皮质固定。文献资料报告了其优越性。但是骨排列不齐也并非一个可以忽略的问题，甚至对有经验的外科医生也是如此【2~9】。图1

Many locked plating designs are now available. In general, the designs fit into two broad categories—those with fixed-trajectory locking screws and those that allow variable axis screw locking. Most locking plate systems provide instrumentation to facilitate percutaneous insertion, al?low traditional open techniques, pro?vide the option of inserting either unlocked or locked screws through the same plate hole, and allow uni-cortical or bicortical screw place?ment. Because many surgeons prefer to use these plates in conjunction with traditional open exposures, most, if not all, newer designs allow the optional use of a targeting jig.

Unicortical screw fixation for the diaphyseal portion of periarticular plating, popular in first-generation locked plates, has been an area of concern, primarily because such constructs