内侧入路治疗胫骨平台骨折时对鹅足不同处理方法的预后分析
发布时间：2018-08-03 10:32
【摘要】：目的:膝关节作为人体下肢三大负重关节之一,是全身关节中滑膜面积最大的关节,滑膜反应也最明显。膝关节是人体较大且复杂的屈曲关节。它所受到的应力大,结构稳定而又灵活。由于膝关节负重大,运动多,且由于膝关节滑膜广泛位于肢体较表浅的部位,最易受到损伤和感染。所有膝关节损伤当中,胫骨平台骨折严重影响了膝关节的功能及其稳定性。近年来,高能量损伤所致的胫骨平台骨折呈日益增加的趋势,且随着我国社会步入迈入老龄化,患病人数逐年增多,但往往处理中等能量所致的胫骨平台骨折时,多采用手术治疗。因此,为了患者术后更好的日常生活,保护膝关节伤后周围软组织及患者术后肢体功能恢复情况的重要性越来越受到人们的关注。一般来说,因为Schatzker I型、II型及III型骨折仅涉及胫骨平台外侧关节面,仅需外侧入路手术即可对其进行良好固定,治疗较简单。而对于高能量损伤所致的Schatzker IV型损伤,临床上多采用内侧手术入路,至于更加复杂的Schatzker V型,甚至VI型骨折,常常需要使用内侧入路合并外侧入路手术治疗,以达到良好的治疗效果。但胫骨平台骨折内侧入路手术切口多平行于胫骨近端的后内侧缘,作为膝关节重要组成部分的鹅足,位于缝匠肌、股薄肌及半腱肌的联合腱止点与胫骨内侧副韧带之间,恰好位于切口处。因此,在手术过程中,术者不可避免的需要面对处理鹅足的问题。骨折复位之后,鹅足多被切断、牵开或直接放置内固定物钢板,但并没有相关研究或文献明确指出,术中如何处理鹅足,对病人术后患肢功能恢复效果最佳。有鉴于此,本研究通过应用三种不同的处理鹅足方法,根据患者术后3个月,6个月及1年的HSS膝关节功能评分互相比较,以评估那种处理方法其临床疗效最佳。方法:取河北医科大学第三医院从2012年9月至2014年3月收治的45例存在胫骨平台内侧骨折的患者。纳入标准:1)患者年龄25岁-55岁之间;2)所有患者均为新鲜闭合性骨折,并且其受伤后2周内接受手术治疗;3)术前检查均未发现患有糖尿病、甲状腺功能亢进以及严重的心、肺、肝、肾功能不全等内科疾病及血栓患者。男31例,其中1例为双侧胫骨平台骨折,另一患肢诊断为Schatzker II型骨折;女14例。平均40.3岁。左侧26例,右侧19例。按Schatzker分类:IV型32例,V型11例,VI型2例。致伤原因:高处坠落伤31例,交通伤11例,其他3例。所有患者治疗内侧胫骨平台骨折时,均选择切开复位,采用锁定钢板内固定手术治疗,取仰卧位,患膝屈曲20°左右,应用气囊止血带加压止血。取内侧切口,自膝关节内侧间隙上方5cm起,沿胫骨干纵轴向远侧延伸至关节间隙下8~10cm。沿皮肤切口切开浅筋膜,充分暴露鹅足肌腱.其中A组15例术中切断鹅足,骨折解剖复位,放置内固定物后,予以鹅足7#手术线缝合,重建修复;B组15例术中予以骨膜起子及弯钳细心分离鹅足,充分牵拉保护,在不影响骨折固定复位的情况下,将钢板置于鹅足下方。最后C组15例术中不分离切断鹅足,直接将钢板放置于鹅足上方,予以复位固定。待内侧骨折被纠正后,Schatzker V型及VI型骨折再以外侧手术入路处理外侧合并骨折。检测下肢力线和膝关节稳定性,逐层缝合切口并放置引流。所有患者于术后第2~3天均拔除引流,开始在不负重状态下的适当膝关节功能锻炼。术后8~10周开始部分负重锻炼,定期复查膝关节正侧位X线。待其局部无疼痛及叩痛并且X线提示骨折愈合后,开始完全负重锻炼。患者术后3个月、6个月、12个月随访复查,评估骨折愈合情况、并发症发生情况及膝关节关节功能恢复情况,以HSS膝关节功能评分为标准。住院期间及随访资料通过统计学分析进行比较。结果:住院期间患者身体情况指标无明显差异,都为健康成人。随机分为A、B、C三组,其中A组患者为鹅足修复重建组,B组为分离鹅足,牵拉保护组,C组为直接安放钢板,压迫鹅足组。以患者术后3个月、6个月、12个月HSS膝关节功能评分为标准来评估膝关节的功能恢复情况,根据患者对疼痛、功能、活动度、肌力、屈曲畸形、稳定性和减分项目等方面进行评分,根据患者术后1年复查得到的HSS评分确定术后恢复效果。术后三个月复查结果,A组平均HSS评分为69.96,B组平均HSS评分为75.00,C组平均HSS评分为68.33,两两比较,A组与B组及B组与C组均数标准差对比有统计学意义,P0.05。证明术后短期3个月复查,B组处理鹅足的方式优于A组与C组,而A组与C组间无明显差异。术后六个月复查结果,A组平均HSS评分为81.92,B组平均HSS评分为86.06,C组平均HSS评分为79.00,两两比较,B组与C组均数标准差对比有统计学意义,P0.05;而A组与C组之间无统计学意义,P0.05。证明术后6个月复查,B组处理鹅足的方式优于C组,而A组与C组及A组与B组间互相比较,无明显区别。术后1年患者复查,A组平均HSS评分为85.42,B组平均HSS评分为87.20,C组平均HSS评分为81.13,两两比较,B组与C组均数标准差对比,P=0.05;而A组与C组之间无统计学意义,P0.05。证明术后12个月复查,三组处理方式对患者膝关节功能恢复则无明显区别。所有45例患者,除A组一例患者于六个月复查时脱漏,其他患者都获得了12个月以上的随访,随访期间骨折均得到愈合,C组1例患者出现鹅足滑膜炎。经统计学分析,患者术后1年复查,A组患者HSS评分,总14例,优11良2可1差0。B组患者总15例,优12良2可1差0,C组患者总15例,优10良1可3差1,根据统计学卡方检验,P0.99,无明显统计学差异。因此,根据术后长期效果,三组处理方式对于患者的术后功能恢复并未有明显区别。但就本组研究来看,B组相对于A组与C组预后优良率明显稍高(93.33%92.86%73.33%)。结论:本研究通过分析在以内侧手术入路治疗胫骨平台内侧骨折时,比较三种不同的术中处理鹅足方式,根据其术后3个月,6个月及1年的HSS膝关节功能评分可以发现,术中予以患者分离鹅足,牵拉保护,术后短期内可有效促进患者膝关节功能恢复,减少疼痛,提高了患者术后生活质量。所以我们可以认为,对于Schatzker IV、V型及VI型胫骨平台的治疗,充分保护鹅足,是最合适的选择,为患者术后功能恢复创造了有利条件。
[Abstract]:Objective: as one of the three heavy joints of the lower limbs of the lower limbs of the human body, the knee joint is the largest joint in the synovial membrane and the most obvious synovial reaction. The knee joint is the large and complex flexion joint of the human body. It is subjected to large stress, stable and flexible structure. Because of the large knee joint, many movements, and wide position of the knee joint synovium. The fracture of the tibial plateau seriously affects the function and stability of the knee joint in all knee joint injuries. In recent years, the fracture of the tibial plateau caused by high energy damage is increasing, and the number of diseases is increasing year by year as our society enters the aging process, but the number of patients is increasing year by year. Surgical treatment is often used when treating fractures of the tibial plateau caused by moderate energy. Therefore, the importance of protecting the soft tissue and the recovery of limb function after the injury of the knee joint is becoming more and more important for the better daily life of the patients. Generally speaking, the Schatzker I, II and III fractures are only the only ones. The lateral articular surface of the tibial plateau involves a good fixation and simple treatment with the lateral approach. For the Schatzker IV type injury caused by high energy damage, the medial approach is often used clinically. As for the more complex Schatzker V, or even the VI type fracture, the medial approach is often required to be used with the lateral approach. The medial approach of the tibial plateau fracture is mostly parallel to the posterior medial edge of the proximal tibia. As an important part of the knee joint, the surgical incision is located between the sartorius muscle, the combined tendon of the gracilis and the semitendinosus and the medial tibial collateral ligament, which happens to be located at the incision. Therefore, the operation is over. In the course, the operator inevitably needs to face the problem of treating goose foot. After the reduction of fracture, the goose foot is cut off, and the internal fixation plate is placed directly or directly, but there is no related research or the literature clearly points out that how to deal with goose foot in the operation is the best for the patient's limb function recovery after operation. In view of this, three kinds of methods are applied in this study. Different methods of handling the goose foot were compared to each other according to the HSS knee joint function score of the 3 months, 6 months and 1 years after the operation to assess the best clinical effect of the treatment. Methods: 45 patients with the medial tibial plateau fracture from September 2012 to March 2014 were treated by the third Hospital of Hebei Medical University. 1) All patients were 25 years old -55 years old and 2) all patients were fresh closed fracture and underwent surgical treatment within 2 weeks after injury; 3) no diabetes, hyperthyroidism and severe heart, lung, liver, renal dysfunction and other internal medical diseases and thrombus patients were found before operation. 31 cases were male and 1 of them were bilateral tibial plateau fractures. One limb was diagnosed as Schatzker II type fracture, 14 female cases, average 40.3 years old, left 26 cases and right 19 cases. According to Schatzker classification: IV type 32 cases, V type 11 cases, VI type 2 cases. The cause of injury: high falling injury 31 cases, traffic injury 11 cases, other 3 cases. All patients were treated with open reduction and locking plate internal fixation operation when treating medial tibial plateau fracture. Treatment, take the supine position, the knee flexion 20 degrees about 20 degrees, use the airbag tourniquet pressure hemostasis. Take the medial incision, from the medial space of the knee joint above the medial space of the knee joint, extending the longitudinal axis of the tibia shaft to the distal part to the joint space and opening the superficial fascia along the skin incision and exposing the tendon of the goose foot fully. Among them, 15 cases of A group cut off the goose foot and dissection the fracture anatomic reduction. After placing the internal fixator, the goose foot was sutured and repaired by 7# operation line. In group B, 15 cases were treated with periosteum and bending forceps to separate the goose foot carefully. The plate was placed under the goose foot without affecting the fixed reduction. In the final group, 15 cases in group C were not separated from the goose foot, and the steel plate was placed directly above the goose foot. Reposition and fixation. After the medial fracture was corrected, Schatzker V and VI type fractures were treated with lateral surgical approach to treat the lateral combined fracture. The stability of the lower limb force line and knee joint was detected, the incision was sutured and the drainage was placed by layer. All patients removed the drainage on day 2~3 after the operation and began to exercise appropriate knee joint function under the condition of no weight negative. 3 months, 6 months and 12 months after 3 months, 6 months, and 12 months follow-up examination, the patients were followed up to evaluate the fracture healing, complications and knee joint function recovery, HSS The score of knee joint function was the standard. During the period of hospitalization and follow-up data, the results were compared by statistical analysis. Results: there were no significant differences in physical condition between patients during hospitalization and healthy adults. They were randomly divided into three groups: A, B, C, of which group A patients were goose foot repair and reconstruction group, B group was separated goose foot, traction protection group, and C group was directly placed steel plate, The functional recovery of the knee joint was evaluated by the 3 months, 6 months and 12 months HSS knee joint function score of the patients. The patients were scored according to the patients' pain, function, activity, muscle strength, flexion deformity, stability and subtraction, and the HSS score of the patients after 1 years' reexamination was determined after the operation. The results were three months after the operation, the average HSS score in group A was 69.96, the average HSS score in group B was 75, the average HSS score in group C was 68.33, and 22 was compared. The comparison of the standard difference between the A group and B group and B group and C group was statistically significant. The average HSS score in group A was 81.92, the average HSS score in group B was 86.06, the average HSS score in group C was 79, and the comparison of the standard difference between the B group and C group was statistically significant, but there was no statistical significance between the B group and the C group, while the A group and the C group were not statistically significant, and the P0.05. proved 6 months after the operation, and the way to deal with goose feet was better than that of the group. There was no significant difference between group A and group C and group A and group B. The average HSS score in group A after 1 years of operation was 85.42, the average HSS score in group B was 87.20, the average HSS score of group C was 81.13, 22 was compared, and there was no statistical difference between the B group and the C group, but there was no statistical significance between the group and the group, three after 12 months of review, three, three. There was no significant difference between the group treatment and the recovery of the knee joint function. All 45 cases, except one case in group A, were missed at six months, and all the other patients were followed up for more than 12 months. All the fractures were healed during the follow-up period, and 1 patients in group C had the synovitis of goose foot. After statistical analysis, the patients were rechecked for 1 years after 1 years and the patients in group A were reexamined. HSS score, total 14 cases, excellent 11 good 2 1 poor 0.B patients total 15 cases, excellent 12 good 2 to 1 difference 0, C group of 15 patients, excellent 10 good 1 can be 3 difference 1, according to statistical chi square test, P0.99, no significant statistical difference. The good prognosis of group B was slightly higher than that of group A and C (93.33%92.86%73.33%). Conclusion: in this study, three different methods of handling goose foot were compared in the treatment of medial tibial plateau fracture by medial surgical approach. The HSS knee function score of 6 months and 1 years after the operation was found to be found during the operation. It can effectively promote the recovery of the knee joint function, reduce the pain and improve the quality of life after operation, so we can think that it is the most suitable choice for the treatment of Schatzker IV, V type and VI type tibial plateau to fully protect the goose foot, which creates a favorable article for the postoperative recovery of the patients' function. Pieces.
【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
本文编号：2161470
[Abstract]:Objective: as one of the three heavy joints of the lower limbs of the lower limbs of the human body, the knee joint is the largest joint in the synovial membrane and the most obvious synovial reaction. The knee joint is the large and complex flexion joint of the human body. It is subjected to large stress, stable and flexible structure. Because of the large knee joint, many movements, and wide position of the knee joint synovium. The fracture of the tibial plateau seriously affects the function and stability of the knee joint in all knee joint injuries. In recent years, the fracture of the tibial plateau caused by high energy damage is increasing, and the number of diseases is increasing year by year as our society enters the aging process, but the number of patients is increasing year by year. Surgical treatment is often used when treating fractures of the tibial plateau caused by moderate energy. Therefore, the importance of protecting the soft tissue and the recovery of limb function after the injury of the knee joint is becoming more and more important for the better daily life of the patients. Generally speaking, the Schatzker I, II and III fractures are only the only ones. The lateral articular surface of the tibial plateau involves a good fixation and simple treatment with the lateral approach. For the Schatzker IV type injury caused by high energy damage, the medial approach is often used clinically. As for the more complex Schatzker V, or even the VI type fracture, the medial approach is often required to be used with the lateral approach. The medial approach of the tibial plateau fracture is mostly parallel to the posterior medial edge of the proximal tibia. As an important part of the knee joint, the surgical incision is located between the sartorius muscle, the combined tendon of the gracilis and the semitendinosus and the medial tibial collateral ligament, which happens to be located at the incision. Therefore, the operation is over. In the course, the operator inevitably needs to face the problem of treating goose foot. After the reduction of fracture, the goose foot is cut off, and the internal fixation plate is placed directly or directly, but there is no related research or the literature clearly points out that how to deal with goose foot in the operation is the best for the patient's limb function recovery after operation. In view of this, three kinds of methods are applied in this study. Different methods of handling the goose foot were compared to each other according to the HSS knee joint function score of the 3 months, 6 months and 1 years after the operation to assess the best clinical effect of the treatment. Methods: 45 patients with the medial tibial plateau fracture from September 2012 to March 2014 were treated by the third Hospital of Hebei Medical University. 1) All patients were 25 years old -55 years old and 2) all patients were fresh closed fracture and underwent surgical treatment within 2 weeks after injury; 3) no diabetes, hyperthyroidism and severe heart, lung, liver, renal dysfunction and other internal medical diseases and thrombus patients were found before operation. 31 cases were male and 1 of them were bilateral tibial plateau fractures. One limb was diagnosed as Schatzker II type fracture, 14 female cases, average 40.3 years old, left 26 cases and right 19 cases. According to Schatzker classification: IV type 32 cases, V type 11 cases, VI type 2 cases. The cause of injury: high falling injury 31 cases, traffic injury 11 cases, other 3 cases. All patients were treated with open reduction and locking plate internal fixation operation when treating medial tibial plateau fracture. Treatment, take the supine position, the knee flexion 20 degrees about 20 degrees, use the airbag tourniquet pressure hemostasis. Take the medial incision, from the medial space of the knee joint above the medial space of the knee joint, extending the longitudinal axis of the tibia shaft to the distal part to the joint space and opening the superficial fascia along the skin incision and exposing the tendon of the goose foot fully. Among them, 15 cases of A group cut off the goose foot and dissection the fracture anatomic reduction. After placing the internal fixator, the goose foot was sutured and repaired by 7# operation line. In group B, 15 cases were treated with periosteum and bending forceps to separate the goose foot carefully. The plate was placed under the goose foot without affecting the fixed reduction. In the final group, 15 cases in group C were not separated from the goose foot, and the steel plate was placed directly above the goose foot. Reposition and fixation. After the medial fracture was corrected, Schatzker V and VI type fractures were treated with lateral surgical approach to treat the lateral combined fracture. The stability of the lower limb force line and knee joint was detected, the incision was sutured and the drainage was placed by layer. All patients removed the drainage on day 2~3 after the operation and began to exercise appropriate knee joint function under the condition of no weight negative. 3 months, 6 months and 12 months after 3 months, 6 months, and 12 months follow-up examination, the patients were followed up to evaluate the fracture healing, complications and knee joint function recovery, HSS The score of knee joint function was the standard. During the period of hospitalization and follow-up data, the results were compared by statistical analysis. Results: there were no significant differences in physical condition between patients during hospitalization and healthy adults. They were randomly divided into three groups: A, B, C, of which group A patients were goose foot repair and reconstruction group, B group was separated goose foot, traction protection group, and C group was directly placed steel plate, The functional recovery of the knee joint was evaluated by the 3 months, 6 months and 12 months HSS knee joint function score of the patients. The patients were scored according to the patients' pain, function, activity, muscle strength, flexion deformity, stability and subtraction, and the HSS score of the patients after 1 years' reexamination was determined after the operation. The results were three months after the operation, the average HSS score in group A was 69.96, the average HSS score in group B was 75, the average HSS score in group C was 68.33, and 22 was compared. The comparison of the standard difference between the A group and B group and B group and C group was statistically significant. The average HSS score in group A was 81.92, the average HSS score in group B was 86.06, the average HSS score in group C was 79, and the comparison of the standard difference between the B group and C group was statistically significant, but there was no statistical significance between the B group and the C group, while the A group and the C group were not statistically significant, and the P0.05. proved 6 months after the operation, and the way to deal with goose feet was better than that of the group. There was no significant difference between group A and group C and group A and group B. The average HSS score in group A after 1 years of operation was 85.42, the average HSS score in group B was 87.20, the average HSS score of group C was 81.13, 22 was compared, and there was no statistical difference between the B group and the C group, but there was no statistical significance between the group and the group, three after 12 months of review, three, three. There was no significant difference between the group treatment and the recovery of the knee joint function. All 45 cases, except one case in group A, were missed at six months, and all the other patients were followed up for more than 12 months. All the fractures were healed during the follow-up period, and 1 patients in group C had the synovitis of goose foot. After statistical analysis, the patients were rechecked for 1 years after 1 years and the patients in group A were reexamined. HSS score, total 14 cases, excellent 11 good 2 1 poor 0.B patients total 15 cases, excellent 12 good 2 to 1 difference 0, C group of 15 patients, excellent 10 good 1 can be 3 difference 1, according to statistical chi square test, P0.99, no significant statistical difference. The good prognosis of group B was slightly higher than that of group A and C (93.33%92.86%73.33%). Conclusion: in this study, three different methods of handling goose foot were compared in the treatment of medial tibial plateau fracture by medial surgical approach. The HSS knee function score of 6 months and 1 years after the operation was found to be found during the operation. It can effectively promote the recovery of the knee joint function, reduce the pain and improve the quality of life after operation, so we can think that it is the most suitable choice for the treatment of Schatzker IV, V type and VI type tibial plateau to fully protect the goose foot, which creates a favorable article for the postoperative recovery of the patients' function. Pieces.
【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
【引证文献】
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1 梅永良;;AO-BO理念及MO概念在骨折中的应用[A];2007年贵州省医学会骨科学分会学术年会论文汇编[C];2007年
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