The Different Prognostic Analysis Of Handling Methods Of Pes Anserinus In The Treatment Of Medial Tibial Plateau Fracture Through Medial Approach Incision

Objective: Knee joint is one of the 3 main weight-bearing joints ofhuman lower limbs, has the largest synovial membrane area among all thejoints in the body, and the most obvious synovial membrane response. Kneejoint is large and complicated flexional joint in the human body. It bearsstrong stress but its structure is still stable and flexible. Since the knee jointbears strong stress, moves a lot, and the synovial membrane is widely locatedin superficial part of the body, it’s easiest to be harmed and infected. Amongall the injuries of knee joints, tibial plateau fracture seriously affected thefunction and stability of the knee joint.In recent years, tibial plateau fracture caused by high energy damageaccompanied by dislocation has shown an increasing trend, Besides, as ourcountry has entered aging society period, there’re more and more patients aresuffering from lower limb fracture.and the majority of cases with a tibialplateau fracture caused by moderate energy are treated by surgery. Therefore,the importance of protecting the surrounding soft tissues after knee joint isinjured and the recovery conditions of limb functions after the surgery havedrawn more and more attention from people. Generally speaking, sinceSchatzker type I, II and III fractures only involve the lateral articular surfaceof the tibial plateau, and only requires lateral approach surgery to have goodfixation, and the treatment is simple. While for Schatzker type IV fracturecaused by high energy, medial approach surgery is usually adopted in theclinic. As for more complicated Schatzker type V fracture, or even type VIfracture, it usually requires the combination of both medial and lateralapproach surgeries for the treatment to achieve better treatment effect.But most of the incisions of medial approach tibial plateau fracturesurgery are parallel to the medial end of the proximal tibia, and the pesanserinus, as the most important component of the knee joint, is locatedexactly between the integrated tendon insertion of sartorius, gracilis andsemitendinosus and the medial accessory ligament.During the operation, it’sinevitable that the operator needs to take care of the pes anserinus. When thefracture is replaced, internal fixator will be placed under the pes anserinus.The pes anserinus is usually pulled, cut or the internal plate is placed directly,but no related papers or researches have clearly indicated how to handle thepes anserinus can make sure patients’ affected limbs have a best recoveryeffect. Therefore, this study uses 3 different methods to handle the pesanserinus, basing on the comparison of HSS knee joint function scores of 3months after surgery, 6 months after surgery and 1 year after surgery to assesswhich method has the best clinical effect.Methods: Totally 45 patients of proximal humeral fractures from Sep.2012 to Jan. 2014 in the Third Hospital of Hebei Medical University.Patients were included in this analysis based on the following criteria: 1) 25<age < 55; 2) All the patients were suffered from fresh closed fracture, andaccepted surgery in 2 weeks after injury; and none of the following diseases,i.e. diabetes, hyperthyroidism, serious heart, lung, liver and kidneydysfunction and thrombus, had been observed in preoperative examination forall the patients. 31 male cases, one of them was both side tibial plateaufracture. Another limb was diagnosed as Schatzker type II fracture; 14 femalecases. Average age is 40.3. Left side has 26 limbs, right side has 19 limbs.According to Schatzker classification: type II for 1 limb, type IV for 32 limbs,type V for 11 limbs and type VI for 2 limbs. Injury reasons: high falling injuryfor 31 limbs, traffic injury for 11 limbs, others for 3 limbs. All patientsaccepted open reduction by internal fixation surgery with fixed plates, supineposition, affected knees flexed for 20°, and pneumatic tourniquet was used tostop the bleeding. Medial approach incision was adopted, starting from 5cmabove the medial clear space of the knee joint, extending along the verticalaxis of the tibia distally to 8~10cm below clear space of the knee joint. Openthe superficial fascia following the skin incision, fully exposed the pesanserinus tendon, for the 15 cases in group A, cut the pes anserinus, replacedthe fracture, placed the internal fixator, then sutured the pes anserinus with #7suture line to established the restoration; for the 15 cases in group B, afterseparating the pes anserinus, pulled to protect, placed the plate in the innerside of the pes anserinus without affecting the fixation and replacement of thefracture; for the 15 cases in group C, without separating and cutting the pesanserinus, placed the plate under the pes anserinus for replacement andfixation. Then checked the alignment of the lower limb and the stability of theknee joint, sutured the incision layer by layer and placed the drainage tube.Results: There was no significant difference between Patients in hospitaland healthy adults in the physical condition index. The patients were dividedinto A, B, C three groups randomly, including A group defined as pesanserinus rehabilitation group, group B defined as the separation of the pesanserinus and force protection, group C designed as put steel directly, fullsetof oppression goose. The period of follow-up was postoperative 3 months, 6months and 12 months which HSS knee joint function score standard toevaluate the functional recovery of knee joint, according to the pain, function,mobility, strength, buckling deformation, stability and rating points program,etc, according to the postoperative patients with 1 year review of HSS scoredetermine the effect of postoperative recovery. Three months after the review,group A of average HSS score was 69.96, group B HSS average score of75.00, group C average HSS score was 68.33。Compared to each other, theconsequence provided that treatment B of three groups after 3 months hadstatistically significant difference in HSS score between overall mean, P<0.05. But there was no statistical significance between group A and group C,group B can be thought better than group A of group C for patients’ recovery in3 months. Six months after the review, A group of average HSS score was81.92, group B HSS score of 86.06 on average, group C average HSS scorewas 79.00. Compared to each other, he consequence provided that thisexample F = 8.735, P < 0.05, proving that treatment B of three groups after sixmonths had statistically significant difference for group C in HSS score, P<0.05. But there was no statistical significance between group A and group C, P>0.05。For the recovery of patients 6 months after surgery, group B is betterthan group C, there was no obvious difference between group A and group C,group A and group B. Within 1 year after the review, A group of HSS averagescore was 85.42, group B HSS average score was 87.20, group C averageHSS score was 81.13.Compared to each other, group B compared with groupC mean standard deviation, P = 0.05; and there was no statistical significancebetween group A and group C, P>0.05。The consequence in the 12 monthsresults after surgery, functional recovery of three groups after of surgery didnot have obvious difference. 45 case of patients were received follow-up aftersix months except 1 patient, others have been more than 12 months follow-up,fracture were healing during the follow-up period, 1 case of group C inpatients was received a goose synovitis. With statistics analysis, postoperativepatients after surgery 1 year, patients in group A of HSS score( total 14 cases),excellent 11 good 2 normal 10.A total of 15 patients in group B wereexcellent 12, good 2, normal 10, a total of 15 patients in group C, good 10 normal 3 1, according to the statistical chi-square test( P > 0.99).In thelong-term results after surgery, functional recovery of three groups after ofsurgery did not have obvious difference. But for this group of data, group Bhad little higher than in group A and group C prognosis was(93.33% >92.86% > 73.33%).Conclusion: Through comparison of 3 different handling methods of thepes anserinus in the treatment of medial tibial plateau fracture, depending onthe HSS knee joint function scores at 3 months after surgery, 6 months aftersurgery and 1 year after surgery, it can be found out that, separating the pesanserinus and pulling to protect for the patients can effectively stimulate theknee joint function recovery for the patients, and improve the patients’ postoperative life quality. It’s therefore suggested that for Schatzker IV、V andVI tibial plateau fracture, adequate protection of the pes anserinus in thetreatment by the fixed plate is the best option, which creates a favorablecondition for patients’ functional recovery after the surgery.