髓内钉治疗胫骨骨折髌上入路和髌下入路的临床疗效比较

发布时间：2018-05-23 20:39

本文选题：胫骨骨折 + 髓内钉　；参考：《大连医科大学》2015年硕士论文

【摘要】：背景:髓内钉治疗胫骨近端骨折有成角畸形的问题,1996年Tornetta和Collins发明了一个新的入路,在膝关节半伸直位,切开膝关节囊,最初是在髌骨两侧的髌旁入路插入髓内钉,作为改良术式中的一种,髌上入路切口具有避免过多分离髌腱旁软组织的优点。反对者认为该点进针增加了髌股关节间压力,损伤髌股关节面引发髌股关节炎以及术后髌前疼痛的问题。但是关于髌上入路和髌下入路疗效差别尚缺乏足够的数据统计分析。目的:比较髓内钉内固定治疗胫骨骨折髌上入路和髌下入路的临床疗效比较。方法:回顾大连医科大学附属第一医院2012年9月至2014年9月收治的应用胫骨髓内钉治疗的42例胫骨骨折病例,男24例,女18例;年龄18-50岁,平均(33.7±7.7)岁。新鲜骨折40例,陈旧骨折2例。骨折类型:根据A0的Muller分类法:42A1型8例,42A2型22例,42B1型7例,42B2型例,42C1型1例。两组性别、年龄、骨折部位、骨折类型比较差异无统计学意义(PO.05),具有可比性。分为两组,A组是采用的髌上入路髓内钉内固定的病例,B组是采用的髌下入路髓内钉固定的病例。结果:获随访6个月一2.5年,术中出血量比较髌上入路组术中出血60~260 mL,平均112.6 mL;髌下入路组术中出血80~240 mL,平均121.7 mL。两组出血量比较无显著性差异(P0.05)。手术时间比较髌上组手术时间65-110分钟,平均81分钟;对照髌下组手术时间60-120分钟,平均89分钟。两组手术时间比较无显著性差(P0.05)。髌前痛发生率髌上组1例,髌下组6例,发生率分别为5%和27%,共7例术后出现膝关节疼痛,主要为膝前切口浅层疼痛。还有2例出现踝关节内侧疼痛。两组患者髌前痛发生率比较有显著性差异(P0.05)。骨折愈合时间:髌上入路组18例骨性愈合,2例骨延迟愈合,行动力化3个月后达到骨性愈合。至末次随访无骨折再次移位;内固定物无松动、移位或断裂;也未发现内固定周围骨折现象。髌下入路组19例骨性愈合,2例骨折延迟愈合,1例动力化3个月后达骨折愈合。另1例骨折不愈合,二期行自体骨植骨内固定后愈合。骨折I期愈合率髌上组和髌下组分别为90%和86.4%,两组骨折临床愈合率比较无显著性差(P0.05)。X线投照次数,髌上入路手术投照次数13-32次,平均17次,髌下入路锁钉投照次数18-52次,平均31次。两组投照次数比较有显著性差异(P0.05)手术操作人员:髌上入路组4--8人,平均6.2人。髌下入路组5--9人平均6.7人,两组手术操作人员配备比较无显著性差异(P0.05)。治疗结果两组术后均得到随访,随访时间术后0.5年至2.5年,平均1.4年,术后12月Johner-Wuchs评分78-100分,优30例,良8例,中2例,差2例,优良率达90%。其中髌上组优为14例,良为4例,中为1例,差为1例。优良率达分别为90%。而髌下组优为16例,良4例,中为1例,差为1例,优良率91%,两组术后优良率比较无显著性差(P0.05)。结论:胫骨骨折应用髓内钉治疗,在膝前痛发生率和放射线曝光次数方面髌上入路比髌下入路有明显的优势。
[Abstract]:Background: in 1996, Tornetta and Collins invented a new approach for the treatment of angular deformities of proximal tibial fractures with intramedullary nailing. In 1996, a new approach was developed, in which the knee joint capsule was cut open at the half extension of the knee joint, and the intramedullary nail was initially inserted into the parrapatellar approach on both sides of the patella. As one of the improved surgical procedures, the suprapatellar approach has the advantage of avoiding excessive separation of the peripatellar soft tissue. Opponents said the needle added to the pressure between the patellofemoral joint, patellofemoral joint surface injury caused patellofemoral arthritis and postoperative prepatellar pain problems. However, the difference between the suprapatellar approach and the subpatellar approach is not statistically significant. Objective: to compare the clinical efficacy of intramedullary nail fixation in the treatment of tibial fracture via superior patellar approach and subpatellar approach. Methods: 42 cases of tibial fractures treated with tibial intramedullary nail from September 2012 to September 2014 in the first affiliated Hospital of Dalian Medical University were retrospectively reviewed, including 24 males and 18 females, aged 18-50 years with an average age of 33.7 卤7.7 years. Fresh fracture 40 cases, old fracture 2 cases. Fracture types: according to the Muller classification of A0, 8 cases of type 42A2 were classified as type 42A2, 7 cases of type 42B1 were classified as type 42B2, and 1 case of type 42C1. There was no significant difference in sex, age, fracture site and fracture type between the two groups. Two groups were divided into two groups: group A was treated with suprapatellar intramedullary nail fixation and group B was treated with infrapatellar intramedullary nail fixation. Results: during the follow-up period from 6 months to 2.5 years, the amount of intraoperative bleeding was compared with that in the suprapatellar approach group with a mean of 112.6 mL (60 ~ 260mL), while in the infrapatellar approach group, the intrapatellar hemorrhage was 80 ~ 240mL (mean 121.7 mL). There was no significant difference in blood loss between the two groups (P 0.05). The operative time was 65-110 minutes (mean 81 minutes) in the suprapatellar group and 89 minutes (60-120 min) in the control group. There was no significant difference in operation time between the two groups (P 0.05). The incidence of prepatellar pain was 1 in the suprapatellar group and 6 in the subpatellar group. The incidence was 5% and 27% respectively. There were 7 cases of postoperative knee pain, mainly superficial pain in the anterior genicular incision. There were also 2 cases of medial ankle pain. There was significant difference in the incidence of prepatellar pain between the two groups (P 0.05). Fracture healing time: 18 cases of bony union and 2 cases of delayed union of bone in suprapatellar approach group. No redisplacement of fracture, no loosening, displacement or rupture of internal fixator, and no fracture around internal fixation were found at the last follow-up. In the subpatellar approach group, 19 cases of bone healing and 2 cases of delayed fracture healing were achieved after 3 months of dynamic healing. Another case of nonunion was treated with autogenous bone grafting and internal fixation. The rate of fracture healing was 90% in the suprapatellar group and 86.4% in the subpatellar group, respectively. There was no significant difference in the clinical healing rate between the two groups. The number of radiographs taken in the suprapatellar approach was 13-32, with an average of 17, and the number of the locking nails in the subpatellar approach was 18-52. The average is 31. There was a significant difference between the two groups in the number of radiographs (P 0.05): the supracrapatellar approach group consisted of 4-8 patients with an average of 6.2 people. The average number of 5 to 9 patients in the subpatellar approach group was 6.7, and there was no significant difference between the two groups in operating personnel. Results the two groups were followed up for 0.5 to 2.5 years (mean 1.4 years). Johner-Wuchs score was 78-100 points in 12 months after operation. Excellent 30 cases, good 8 cases, medium 2 cases, poor 2 cases, the excellent and good rate was 90%. In the suprapatellar group, 14 cases were excellent, 4 cases were good, 1 case was middle, and 1 case was poor. The excellent and good rate was 90% respectively. In the subpatellar group, 16 cases were excellent, 4 cases were good, 1 case was moderate, and 1 case was poor. The excellent and good rate was 91. There was no significant difference in the excellent and good rate between the two groups. Conclusion: the treatment of tibial fracture with intramedullary nail has obvious advantages over infrapatellar approach in the incidence of anterior knee pain and the times of radiation exposure.
【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

【相似文献】