微型钢板与张力带内固定治疗髌骨骨折的对比研究

发布时间：2018-03-23 18:27

本文选题：微型钢板　切入点：钢丝张力带　出处：《河北医科大学》2015年硕士论文

【摘要】：目的:近年来随着交通业、建筑业的进步,髌骨骨折发生率尤其是粉碎性骨折的发生率呈上升趋势,人们对髌骨骨折治疗经历了一个漫长的历史,在1877年之前,多采用保守治疗,即采用膝关节支架,卧床休息,使骨折达到二期愈合,即通过骨痂形成方式,造成严重的膝关节功能障碍。1877年,Cameron第一次在国际上打破常规地提出髌骨骨折切开复位的发法。随后的100多年里,各种内固定材料出现在髌骨治疗之中。最经典的内固定是克氏针张力带固定,但是对于一些粉碎性的骨折,AO张力带固定常出现较高失败率和并发症,人们开始了对髌骨骨折手术各种类型内固定物的探索与研究。本课题探讨微型钢板内固定治疗髌骨骨折的临床疗效和可行性,为临床治疗髌骨骨折手术方式的提供新的内固定方法。方法:回顾性分析我科2012年9月-2014年9月接受手术治疗的23例髌骨骨折患者的临床资料,患者术前CT,均为闭合性新鲜骨折,受伤时间至手术时间为2小时-3天,平均1.2天,所有病例按髌骨Saunders分型分类:非粉碎骨折(横行骨折)8例,粉碎型骨折15折例。分为实验组和对照组,二者均采用髌前正中纵行切口。实验组:患者均采用微型钢板固定髌骨12例,其中,非粉碎骨折(横行骨折)4例,粉碎型(3块及以上)骨折8例;对照组:患者均采用克氏针张力固定11例,其中,非粉碎骨折4例,粉碎骨折(3块及以上)7例。手术方法:①微型钢板组:采用椎管内麻醉后,判断患者麻醉效果满意,术者用碘酒、酒精消毒,铺无菌巾、单,屈曲患膝,止血带充气至300mm Hg,取髌骨前正中纵行切口,逐层切开皮肤、皮下组织,切开髌骨前深筋膜再两侧分离,显露髌前腱膜及骨折断端,清理凝血块及微小骨折块,点状复位钳结合克氏针复位骨折断端,C型臂机下透视关节面和骨折复位均满意后将钢板覆盖骨面之上,再相应孔内钻孔、测深、在相应螺孔内拧入螺钉。必要时穿克氏针加强固定强度,确保主要骨折块均被微型钢板和螺钉覆盖并坚强固定,再次C型臂透视,微型钢板、螺钉和髌骨关节面位置均满意,术中被动活动膝关节,无异常后松止血带,彻底止血后逐层缝合伤口。②克氏针张力带组(由直径2.0mm克氏针和0.8mm钢丝组成):患肢采用椎管内麻醉,术者用碘酒、酒精消毒,铺无菌巾、单,屈曲患肢,止血带充气至300mm Hg,取髌骨前正中纵行切口,逐层切开皮肤、皮下组织,切开髌骨前深筋膜再两侧分离,显露髌前腱膜及骨折断端,点状复位钳结合克氏针复位骨折断端,尖嘴复位钳复位骨折断端,分别以2.0mm克氏针固将小的骨折块固定到主要骨折块上,再利用将钢丝绕克氏针头、尾部建立张力带,与在髌骨下极钢丝交叉打结,钢丝拧锁紧,剪去多余的钢丝,残端光滑处理,将克氏针尾端弯曲,凸向外,尽可能术中减少对局部软组织尤其是前侧软组织的刺激。同样的方法将不同的小骨块固定到主要骨块上。如为粉碎骨折,利用多个张力带,反复将钢丝缠绕克氏针。术后被动活动关节,无异常后松止血带,彻底止血后逐层缝合伤口。术后处理:所有患者都接受相同的用药、功能指导和康复锻炼。统计学分析:所有患者数据均被观察并记录,包括患者手术切口的愈合时间、骨折愈合时间、骨折愈合后膝关节功能。应用统计软件SPSS16.0进行统计学分析,采用样本t检验评价两组患者的手术切口愈合时间,采用样本卡方检验两种内固定术后3个月髌骨的骨折愈合率,采用样本秩和检验检验膝关节功能优良率,选取P0.05作为有统计学差异的标准。结果:1 23位患者均获随访,所有随访时间7-16个月,平均时间为12个月,所有的手术切口经观察并统计均甲级愈合。两种手术方式的术中手术切口愈合时间被比较后,两者无统计学意义(P0.05)。(Table 1)2对两种手术方式的骨折愈合进行比较,两者无统计学意义(P0.05)。(Table 1)3骨折愈合后,采用Bostman膝关节功能评分,微型钢板组患者骨折愈合后总体膝关节功能优良率高于克氏针张力带组总体优良率(P0.05)。横行骨折组膝关节功能优良率和克氏针张力带组总体优良率无统计学差异(P0.05)。粉碎骨折组膝关节功能优良率和克氏针张力带组总体优良率有统计学差异(P0.05)。结论:1两种手术方式都能较好复位固定简单横行髌骨骨折,骨折愈合率相当;2微型钢板大小、尺寸等不会妨碍伤口愈合;3微型钢板在固定粉碎性髌骨骨折方面较多枚克氏针钢丝张力带固定具有优势,术后复查有较好的膝关节功能。
[Abstract]:Objective: in recent years, along with the transportation industry, construction progress, especially the incidence of fracture of patella comminuted fracture incidence is rising, people in treatment of patellar fracture has a long history, before 1877, the use of conservative treatment, with a knee brace, bed rest, the fracture reached two healing by callus formation, causing serious knee joint dysfunction in.1877, Cameron for the first time in the world to put forward the break the normal procedure of open reduction method of patella fracture. For the next 100 years, a variety of internal fixation materials in treatment of patella. The classic internal fixation of Kirschner wire tension belt however, for some comminuted fracture fixation, often high failure rate and complications of AO tension band, people began to explore the operation of various types of internal fixation of fracture of patella and Research on this topic. The clinical efficacy and feasibility of mini plate internal fixation for treatment of patellar fractures, internal fixation methods provide new surgical methods for the clinical treatment of patellar fractures. Methods: a retrospective analysis in September 2012 September -2014 accepted surgical treatment of 23 cases of patients with patella fracture clinical data, preoperative CT, were closed fresh fractures the time of injury to the operation time is 2 hours -3 days, average 1.2 days, according to the classification of all cases of patellar Saunders: non comminuted fracture (transverse fracture) in 8 cases, 85% off cases of comminuted fractures. Divided into experimental group and control group, two patients with patellar anterior median longitudinal incision. Experimental group: patients were treated by mini plate fixation of patella in 12 cases, among them, the non comminuted fracture (transverse fracture) in 4 cases, crush type (3 and above) fracture in 8 cases; control group: patients were treated with Kirschner wire fixation in 11 cases, among them, 4 cases of non comminuted fracture, comminuted fracture (3 blocks and to On 7 cases of surgery). Methods: the mini plate group: after spinal anesthesia, patients satisfactory anesthesia, patients with iodine, alcohol disinfection, sterile towel, single, knee flexion, tourniquet to 300mm Hg, patella anterior median incision, incision of skin and subcutaneous tissue layer open, deep fascia and patella before separation on both sides, reveal the prepatellar aponeurosis and fracture, clean blood clot and micro fracture, point reduction forceps combined with Kirschner wire reduction and fracture under the C-arm fluoroscopy C articular surface and fracture reduction were satisfied after the cover plate on the bone surface, and the corresponding hole in drilling, sounding, in the corresponding holes in the screw. When necessary, wear Kirschner wire fixation strength to strengthen, to ensure that the main fracture fragments were micro plates and screws covered and strong fixation, again C arm fluoroscopy, mini plate and screw, and the articular surface of the patella position were satisfactory, passive activities in operation Knee joint, no abnormal after tourniquet release, thorough hemostasis after sutured wounds. The Kirschner wire tension band group (consisting of 2.0mm diameter Kirschner wire and 0.8mm): limb by spinal anesthesia, patients with iodine, alcohol disinfection, sterile towel, single limb, buckling, hemostatic belt inflatable to 300mm Hg, patella anterior median longitudinal incision, cut the skin, subcutaneous tissue layer, deep fascia and patellar incision before separation on both sides, revealing the prepatellar aponeurosis and fracture point reduction forceps combined with Kirschner wire reduction and fracture reduction forceps beak fracture, Kirschner wires respectively by 2.0mm the small solid fracture block fixed to the main fracture block, then use the wire around the Kirschner needle, a tail tension band in the lower pole of the patella and wire cross tie wire, screw locking, cut off the excess wire, stump smooth processing, Kirschner wire end bending, convex outward, as far as possible surgery may reduce Few of the local soft tissue especially the anterior soft tissue stimulation. The same method will be different bone block fixed to the main bone. As for comminuted fracture, using multiple tension band Kirschner wire winding will be repeated. After passive joint, no abnormal after tourniquet release, complete bleeding gradually after suture wound. Postoperative postprocessing: all patients received the same medication, the function of guidance and rehabilitation exercise. Statistical analysis: all the patients were observed and recorded data, including incision healing time, fracture healing time, the function of knee joint after fracture healing. The application of statistical software SPSS16.0 statistical analysis, healing time of surgery incision of the sample t test was evaluated in two groups, using the chi square test sample of two kinds of internal fixation after 3 months of patella fracture healing rate, the excellent rate of sample rank and inspection of knee joint function, select P0 There were significant differences in.05 as the standard. Results: 123 patients were followed up, all patients were followed up for 7-16 months, the average time was 12 months, all the incision healed after observation and statistics were compared. A healing time of incision surgical operation in two, the two was not statistically significant (P0.05 (Table). 1) 2 of the two surgical methods of fracture healing were compared, there was no statistical significance (P0.05). (Table 1) 3 after fracture healing, the Bostman knee function score, the excellent rate of patients with fracture of mini plate group total knee joint function after healing compared with Kirschner wire tension band group overall the excellent rate (P0.05). With the excellent and good rate of knee joint function group and Kirschner wire tension band group overall excellent rate showed no significant difference (P0.05). The fracture crushing group excellent rate of knee joint function and Kirschner wire tension band group overall rate had statistical difference between fracture (P0.05) Conclusion: 1. Two kinds of surgical methods can better fixation and simple transverse patellar fracture, fracture healing rate is 2; mini plate size, size does not interfere with wound healing; 3 mini plate in treatment of comminuted patella fracture with more Kirschner wire tension band fixation has advantages, postoperative knee joint good function.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

【共引文献】