三种交锁髓内钉近端入路治疗胫骨骨折的临床研究

发布时间：2018-06-06 18:03

本文选题：胫骨髓内钉 + 髌上入路　；参考：《吉林大学》2015年硕士论文

【摘要】：目的：探讨三种不同近端手术入路经交锁髓内钉(IMN)固定治疗胫骨的手术时间、出血量、愈合时间以及术后膝关节疼痛发生率及膝关节功能效果，并分析导致术后相关并发症的因素，为以后手术方式的选择及研究提供依据并分享一些手术技巧及功能锻炼方面的经验及体会。方法：回顾性研究2012年8月至2014年11月期间，我院骨科创伤学组诊治的胫骨骨折患者经筛选后得到58例。所有患者均为高能量损伤，包括车祸伤、砸伤、高空坠落伤)均采用国产或进口交锁髓内钉，直径8-10mm.长度280-360mm，男34例，女24例。年龄16—63周岁，平均年龄48.5岁。外伤原因：车祸伤32例，跌倒砸伤15例，高空坠落伤11例。将58例患者按手入路分为A、B、C三组，A组经髌韧带入路组患者28名，B组经髌韧带旁入路患者13名，C组经髌上入路组患者17名。每组都记录相应手术时间、出血量等，住院期间开始在医师指导下进行早期功能锻炼。术后根据复查、随访都记录愈合时间，有无感染、骨筋膜室综合症、骨不连等并发症，并应用相同的膝关节运动功能评价标准评估术后膝关节功能和相关并发症的发生率。平均随访18个月（最短12个月，最长20个月）。骨折1-7天内行手术治疗。排除标准:陈旧性骨折、病理性骨折、合并膝关节损伤或骨性关节炎。统计学方法:应用SPSS18.0软件进行数据处理，资料用均数加减标准（X±S）表示，数据比较采用方差分析，P＜0.05差异有统计学意义。结果：对手术中相关指标如手术时间，出血量等进行记录并分析，对患者定期复查、电话、二次手术取出内固定装置等方式随访，随访内容包括术后相关节间段的影像学资料以及是否存在膝前疼痛、膝关节活动范围、日常生活恢复水平。绝大多数骨折均达到临床愈合标准，愈合时间为75-85天，平均81天，有1例出现了骨不连，考虑原因为闭合复位不理想，锁钉位置偏移。有1例行“经髌韧带入路”的患者术后铜绿假单胞菌感染，经一期手术清创、氟喹诺酮类药物抗炎治疗一周后伤口愈合，未拔出髓内钉。经髌韧带入路组共10例出现术后膝关节轻中度疼痛；经髌韧带旁入路组共8例出现术后膝关节轻中度疼痛，经髌韧带入路组共4例出现术后膝关节轻中度疼痛。术后膝关节评分三组患者为83-95，平均91分，，1例开放性骨折的患者开放创口较小为皮肤擦伤，经清创控制感染后行髌上入路髓内钉固定，术后未出现了切口及创口的表面感染，在常规换药2周后切口愈合。根据术后膝关节同意功能评分标准评分，58例患者中优47例，良10例，中1例，差0例，总的优良率为98.2%。按照骨术中出血量B组与A、C组P＜0.05，差别有统计学意义，B组与A组P0.05，差别无统计学意义，即经髌韧带入路和经髌上入路比经髌旁入路髓内钉内固定治疗胫骨骨折书中出血量少。手术时间指标A组与B组、A组与C组间相较P0.05，差别无统计学意义，B组与C组P0.05，差别无统计学意义，即经髌韧带入路、经髌上入路和经髌旁入路髓内钉内固定治疗胫骨骨折手术时间无明显差异。愈合时间及术后感染、骨不连、骨筋膜室综合症发生率指标A、B、C三组P＞0.05，差别无统计学意义，即三组住院时间、骨折愈合时间及术后相关并发症无明显差别。术后疼痛等功能评分A组与B组、A组与C组间相较P＜0.05，差别具有统计学意义，B组与C组P0.05，差别无统计学意义，即经髌韧带入路比较经髌上入路和经髌旁入路髓内钉内固定治疗胫骨骨折术后膝前痛发生率高。经髌韧带组一例患者术中扩髓操作不当导致髌韧带撕裂，经韧带缝合线缝合后术后出现明显膝前疼痛及功能障碍。其余无明显手术意外出现。结论：随着理论的进步与科学的发展，使用髓内钉治疗胫骨或合并腓骨骨折逐渐成为大家的共识，并取得了良好的临床效果，对于相关手术入路及手术体位、术后相关并发症的研究仍有分歧。和经髌韧带途径相比，经髌韧带旁途径和髌上途径治疗胫骨骨折膝关节功能评分更高和膝关节疼痛发生率更低；和髌韧带途径和髌上途径相比，经髌韧带旁途径出血较多，除此外，三者在手术时间、愈合时间指标上无差异。术中精细的操作、软组织的保护及重建非常有利于预后。
[Abstract]:Objective: To explore the operative time, bleeding volume, healing time, the incidence of knee joint pain and the effect of knee joint function after three different proximal surgical approach interlocking intramedullary nail (IMN) fixation, and to analyze the factors leading to the postoperative complications and to provide the basis for the selection and study of the methods of hand operation and to share some of them. Experience and understanding of surgical skills and functional exercises.
Methods: from August 2012 to November 2014, 58 cases of tibial fractures in the Department of orthopedics of our hospital were screened. All patients were treated with high energy injury, including car accident injury, injury, high altitude falling injury, both domestic or oral interlocking intramedullary nail, diameter 8-10mm. length 280-360mm, male 34 cases, female 24 cases. Age 1. 6 to 63 years old, the average age of 48.5 years. The cause of trauma: accident injury 32 cases, fall and crush 15 cases, high altitude fall 11 cases. 58 patients were divided into A, B, C three, group A, 28 by patellar ligament entry group, 13 by patellar ligament approach in group B and 17 in group of patellar approach group in group C. Each group recorded the corresponding operation time, bleeding volume. In the period of hospitalization, early functional exercise was conducted under the guidance of the physician. After the reexamination, the healing time was recorded, the complications such as infection, osteofascial compartment syndrome, bone nonunion were recorded, and the incidence of postoperative knee function and related complications was evaluated with the same knee motion function evaluation criteria. The average follow-up was 18 months. The shortest 12 months, the longest 20 months). Surgical treatment within 1-7 days of fracture. Exclusion criteria: old fracture, pathological fracture, knee joint injury or osteoarthritis. Statistical method: data processing with SPSS18.0 software, data using mean number addition and subtraction standard (X + S), data comparison using variance analysis, P < 0.05 difference statistics Significance.
Results: the related indexes such as the operation time and the amount of bleeding were recorded and analyzed. The patients were reviewed regularly, the telephone and the internal fixation devices were taken out of the two operation. The follow-up contents included the imaging data of the inter articular segment after the operation, the existence of pain in the knee, the range of knee joint activity, and the level of daily life. Most fractures reached the standard of clinical healing, with a healing time of 75-85 days, an average of 81 days, and 1 cases of bone nonunion. Considering the reasons for closed reduction and locking position, 1 cases of Pseudomonas aeruginosa infection after the "patellar ligament approach" were treated after one stage operation debridement and fluoroquinolones for one week after anti-inflammatory treatment. The wound healing, unpulled intramedullary nail. 10 cases of mild and moderate pain in the knee joint after the patellar ligament approach group, 8 cases of mild and moderate pain in the knee joint after the patellar ligament approach group, and 4 cases of mild and moderate pain in the knee joint after the patellar ligament approach. The score of the knee joint was 83-95, 91 and 1 open after the operation. The patients with sexual fracture were less open wound and skin bruise, with intramedullary nail fixation after debridement control, and no surface infection of incision and wound after operation. The incision healed after 2 weeks of conventional change. According to the score of the knee joint agreement function score, 58 patients were excellent in 47 cases, good in 10 cases, 1 in 1 cases, and 0 cases in general. The good rate was 98.2%. in group B and A in bone operation, and P < 0.05 in group C. The difference was statistically significant. There was no statistical difference between group B and A group P0.05, that is, there was less bleeding in the treatment of tibial fracture by patellar ligament approach and patellar approach by intramellar intramedullary nail internal fixation. There was no significant difference in the difference between the B group and the C group P0.05. There was no significant difference between the patellar ligament approach, the patellar approach and the intramapellar intramedullary nail internal fixation for the treatment of tibial fracture. The healing time and postoperative infection, bone nonunion, and the incidence of osteofascial compartment syndrome were A, B, C three, P > 0.05, and there was no statistical difference. Meaning, there was no significant difference between the three groups of hospitalization time, fracture healing time and postoperative complications. Postoperative pain scores in group A and group B, group A and group C were P < 0.05, the difference was statistically significant. There was no statistical difference between group B and C group P0.05, that is, comparing the patellar approach to the patellar approach and the intramedullary intramedullary nail by patellar approach. There is a high incidence of anterior knee pain in the fixed treatment of tibial fracture. A patient with patellar ligament is unsuitable to tear the patellar ligament during the operation. After suture of the ligamentous suture, there is obvious anterior knee pain and dysfunction after the suture of the ligamentous suture.
Conclusion: with the progress of theory and the development of science, intramedullary nail is gradually becoming a common understanding in the treatment of tibia and fracture of the fibula, and good clinical results have been achieved. There are still differences in the study of related surgical approaches, surgical position and postoperative complications. The knee joint function score of the tibial fracture is higher and the incidence of knee joint pain is lower. Compared with the patellar approach and the patellar approach, there are more bleeding than the patellar approach. Besides, there are no differences in the time of the operation and the time of healing. The fine exercises in the operation, the protection and reconstruction of the soft tissue are very beneficial to the prognosis in the three cases.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R687.3

【参考文献】