锁定钢板在骨科创伤中应用的新进展
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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 exhibit weakness in tor?sion, especially in patients with very thin cortices10 (Figure 2). Kregor et
al6 demonstrated proximal fixation problems in 5% of patients when unicortical screws were used
to manage distal femur fracture. Prox?imal fixation failure was extremely rare with traditional
plates, but dis?tal fixation failure was common. In?terestingly, there were no distal fix?ation
failures in the series by Kregor et al.6 This unique complication of first-generation locked plates
has driven the development of plates with screw holes that accept a vari?ety of screw types.
Currently, lock?ing screws typically are inserted after predrilling holes. This allows tactile
confirmation of bicortical purchase, which may assist the sur?geon in confirming plate position on
the diaphysis. No shaft fixation fail?ure has been reported with the use of bicortical fixation.11
多数锁定钢板的设计都是合理的。通常设计应适合于两个大的分类—有固定轨道的锁定螺钉和允许轴向螺钉锁定。多数锁定钢板系统为了使经皮钢板插入变得简便而配备了仪器辅助，允许传统的开放技术，对同一钢板孔可以选择锁定或非锁定螺钉，也可以选择双皮质或单皮质固定。因为很多外科医生喜欢在传统开放切开的基础上使用锁定钢板，所以目前多数（但不是全部）新设计的锁定钢板采用了标靶模具。用于关节周围钢板的骨干部分的单皮质螺钉，特别是第一代锁定钢板，已经引起了人们对于其安全性的担忧，因为这种螺钉的抗旋转性很差，特别是对于骨皮质很薄的病人【10】。图2
Kregor【6】发现当单皮质螺钉用于处理远端股骨骨折时，其中5%的病例近端会出现固定问题。而采用传统钢板近端固定失败的非常少，远端失败却常见。有趣的是，在Kregor的研究中没有发现远端失败的病例。第一代锁定钢板的这个设计缺陷使钢板设计得以改进，其钢板孔可以适合不同类型的螺钉。一般锁定螺钉要待丝攻后在拧入，这有助于外科医生了解两侧的骨皮质是否都被穿透，并进一步确定钢板相当于骨干的位置。未见采用双皮质固定出现骨干固定失败的报道【11】。
Fixed-trajectory locked plates of?fer the advantages of excellent mid?term results as well as a
reproducible surgical technique.8,12-14 However, obstacles to screw placement can oc?cur, such
