胫骨多段骨折髓内钉固定骨折不愈合不同翻修方法疗效的对比分析

发布时间：2018-04-13 01:35

本文选题：钢板 + 髓内钉　；参考：《郑州大学》2017年硕士论文

【摘要】：研究背景目前,髓内钉技术已经广泛应用在临床的骨科手术中,效果也很确切,但是用来治疗胫骨多段骨折仍存在失败的几率。国内外的学者已经就固定失败的原因做了比较全面的阐释,但对二次手术的指导性却鲜有报道。有学者认为,既然髓内钉内固定手术失败,那么二次手术换用钢板固定应该是最佳选择,然而,分析种种髓内钉固定失败的原因,很多的骨折不愈合并不是髓内钉造成的,而且髓腔在扩髓之后髓内钉是否依然有效存在争议【1】。因此,在髓内钉固定失败后,需要对补救治疗方式进行指导,才能完善整个髓内钉的内固定体系,给患者带来福音。目的探讨胫骨多端骨折髓内钉固定后骨折不愈合的治疗方式,并对不同类型的骨折不愈合翻修方式的疗效进行对比分析,为该疾病的诊治提供更好的诊疗基础及术前指导依据。方法对郑州大学第一附属医院骨外科2004年1月至2017年3月治疗的25例胫骨多段骨折髓内钉固定后骨折不愈合的患者资料进行回顾性分析。所选患者均在骨折髓内钉固定失败后接受后续治疗,平均既往手术次数1.5次,其中男性14例,女性11例,年龄20-50岁,平均年龄36.5岁,左侧13例,右侧12例,均为胫骨多端或粉碎骨折髓内钉术后。入院患者完善术前准备,手术时机成熟后进行手术治疗。将接受二次手术治疗的病人分为2组,A组15人,二次手术前有3人存在膝关节畸形,接受了取出原有髓内钉,采用双钢板固定的手术;B组10人,二次手术前有3人存在膝关节畸形,接受了更换新的髓内钉的手术。两组患者均在术中视情况适当植骨,以促进骨折愈合。术后长期进行随访,观察并记录骨折愈合患者的人数,在骨折不愈合的病理分型、形态分型和部位等方面对A、B两组患者骨折的愈合率进行统计学分析,从而对二次手术方式疗效进行评价。结果患者住院时间14.3±3.5天,平均12.5天。术后所有患者均获得6-12个月(平均8.3个月)的随访,随访期间患者均无其余外伤或者死亡之情况。患者定期复查的X光片均可见有明显的骨痂形成,骨折存在愈合迹象。对于肥大型骨折不愈合两种手术方式愈合率无明显差异(P0.05),而萎缩性骨折不愈合时A组的愈合率要高于B组(P0.05);当骨折不愈合发生胫骨上半段时,A组的愈合率高于B组(P0.05),发生在胫骨下半段时A组的愈合率要低于B组(P0.05);对于简单的横断、斜形骨折不愈合,A、B两组的骨折愈合率没有明显的差异(P0.05),而对于存在旋转、多部分的复杂骨折不愈合,A组的愈合率要高于B组(P0.05)。结论胫骨多段骨折髓内钉固定不愈合时,双钢板固定在萎缩性骨不愈合、上半段骨折不愈合及复杂骨折不愈合等方面具有显著优势;而胫骨下半段的简单肥大骨折不愈合时,更换髓内钉具有显著优势。可以在临床上作为术前指导依据。
[Abstract]:Background at present, intramedullary nail technology has been widely used in clinical orthopedic surgery, the effect is also very accurate, but there is still a probability of failure in the treatment of tibial fractures.Scholars at home and abroad have made a comprehensive explanation of the reasons for the failure of fixation, but there are few reports on the guidance of secondary surgery.Some scholars believe that, since intramedullary nail internal fixation failed, then secondary surgery should be the best choice for plate fixation. However, by analyzing the causes of various failure of intramedullary nail fixation, many nonunion fractures are not caused by intramedullary nail.And whether intramedullary nail is still effective after reaming is controversial [1].Therefore, after the failure of intramedullary nail fixation, it is necessary to guide the remedial treatment to improve the internal fixation system of the whole intramedullary nail and bring good news to the patients.Objective to explore the treatment methods of nonunion of tibial fractures after fixation with intramedullary nail, and to compare and analyze the curative effect of different types of revision methods of fracture nonunion, so as to provide a better basis for diagnosis and treatment and guidance before operation for the diagnosis and treatment of this disease.Methods from January 2004 to March 2017, 25 cases of nonunion of tibial fractures treated with intramedullary nail fixation in the first affiliated Hospital of Zhengzhou University were retrospectively analyzed.All the patients received follow-up treatment after the failure of intramedullary nail fixation. The average number of previous operations was 1.5, including 14 males and 11 females, aged 20-50 years, with an average age of 36.5 years, left 13 cases and right 12 cases.All of them were treated with multiple tibia or comminuted intramedullary nail.The preoperative preparation was improved and the operative time was ripe for surgical treatment.The patients were divided into two groups: group A (n = 15) and group A (n = 15). There were 3 patients with knee joint malformation before the second operation, and 10 patients in group B were treated with intramedullary nail removal and double plate fixation.Three people had knee deformities prior to secondary surgery and underwent surgery to replace new intramedullary nails.The patients in both groups received proper bone grafting during operation to promote fracture healing.After long-term follow-up, the number of fracture healing patients was observed and recorded. The rate of fracture healing in group A B was statistically analyzed in terms of pathological classification, morphological classification and site of nonunion.Therefore, the curative effect of secondary operation was evaluated.Results the hospitalization time was 14.3 卤3.5 days, with an average of 12.5 days.All patients were followed up for 6 to 12 months (average 8.3 months).The X-ray films showed obvious callus formation and fracture healing.There was no significant difference in the healing rate between the two surgical methods for the nonunion of fat large fractures, but the healing rate of group A was higher than that of group B when the nonunion of atrophic fractures occurred, and the healing rate of group A was higher than that of group B when the nonunion of fracture occurred in the upper half of tibia.The healing rate of group A was lower than that of group B at the lower half of tibia.There was no significant difference in fracture healing rate between group A and group A, but the rate of union in group A was higher than that in group B for complex nonunion with rotation.Conclusion double plate fixation has significant advantages in atrophic bone nonunion, upper half fracture nonunion and complex fracture nonunion, while in simple hypertrophic fracture of the lower half of the tibia, it has significant advantages in nonunion of multiple tibial fractures with intramedullary nail fixation.Replacement of intramedullary nails has significant advantages.It can be used as the basis of preoperative guidance in clinic.
【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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