微创与切开复位接骨板内固定治疗膝关节内骨折的比较 MIPO

2008-8-2 chenmo 骨科专业

【摘要】  比较研究微创接骨板内固定和切开复位接骨板内固定对膝关节内骨折的治疗效果,探讨生物学内固定在膝关节内骨折中的使用价值。[方法]总结近年来根据生物学固定原则,以微创接骨板固定术(MIPO)治疗的膝关节内骨折共21例。以创伤类型及年龄等因素进行配对,选择切开复位内固定(ORIF)治疗的病例资料比较手术及术后恢复情况。采用HSS评分评价结果。[结果]MIPO组随访10~16月(平均14.2个月),有2例进行骨移植术,平均手术时间60.0 min,术中失血量45.0 ml,平均骨折愈合时间10.0周,3例有5°以上膝内、外翻畸形,HSS功能评分平均86.67分;ORIF组经过12~48个月(平均21.2个月)随访,有18例进行骨移植术,平均手术时间79.52 min,平均术中失血量117.1 ml,平均骨折愈合时间12.24周,2例发生5°以上膝关节内、外翻畸形,HSS功能评分平均82.14分。两组均获得骨愈合,没有感染和内固定断裂等并发症发生。比较发现两组在手术时间、术中失血量、骨折愈合时间和功能恢复方面差异有统计学意义。[结论]对于合适的膝关节内骨折病例以微创接骨板内固定治疗可以降低植骨需求和术中失血,在手术过程和术后恢复方面有明显优势。
【关键词】  膝关节 骨折固定术 间接复位 生物学固定
    Minimally invasive plate osteosynthesis versus ORIF in treatment of intra-articular fracture of knee joint∥SUN Wenjian,WANG Liming,YANG Wengui,et al.Department of Orthopedics,the Nanjing First Hospital Affiliated to Nanjing Medical University,Nanjing 210006,China
    Abstract:[Objective]To comparatively analyze the clinical results of minimally invasive plate osteosynthesis (MIPO) and ORIF in treatment of intra-articular fracture of knee joint and to investigate the utilization value of biological fixation.[Method]According to the principles of conservation of the vascularity,21 cases of intra-articular fractures of knee joint underwent surgical treatment of MIPO in recent years.In accordance with the type of fracture and other anticipated factors influenced bony healing,paired-samples treated of ORIF were selected.The two groups were compared following: operation time,intra-operative blood loss,bone union time,axial malalignment radiologically of knee joint,and the ROM of knee.HSS criteria were used to evaluate the results.[Result]In MIPO group,all 21 fractures were followed up for averagely 14.2 months (range 10~16 months).The mean duration of surgery was 60.0 min (range 50~70 min) and bone grafting underwent in 2 cases.Complete fracture healing was achieved with the average time of 10.0 weeks and assessment of vallgus/varus alignment showed a deviation more than 5 degrees in 3 cases.The average HSS score was 86.67.In ORIF group,all 21 fractures were followed up for averagely 21.2months (range 12~48 months).The mean duration of surgery was 79.52 min (range 65-95 min) and bone grafting underwent in 18 cases.Complete fracture healing was achieved with the average time of 12.24 weeks and assessment of valgus/varus alignment showed a deviation more than 5 degrees in 2 cases.The average HSS score was 82.14.All patients got bony union and no patient developed infection,implant failure in both groups.There was significant difference in operation time,union time and function of knee between the two groups.[Conclusion]To the suitable cases,MIPO appears to stabilize fractures with a low intraoperative blood loss and a low incidence of bone grafting; on the other hand it offers many advantages in the aspects of operation procedures and functional recovery postoperatively.
    Key words:knee joint;  internal fixator;  indirect reduction;  biological fixation
    涉及股骨远端、胫骨近端关节面的膝关节内骨折是容易产生膝关节功能障碍的严重骨折。传统AO原则通过广泛显露进行复位固定治疗,手术操作复杂,术后制动时间长,容易引起膝关节僵硬和创伤性关节炎等并发症。本文总结了近年来根据生物学固定原则,以微创接骨板固定术(MIPO,minimally invasive plate osteosynthesis)治疗的膝关节内骨折21例,以创伤类型及能够预知的影响骨折愈合的因素进行配对,选择以AO原则切开复位内固定治疗(ORIF,open reduction and internal fixation)的病例资料比较手术过程及术后恢复情况,介绍如下。
1  资料与方法
    1.1  一般资料
    MIPO组:本组21例,男15例,女6例。年龄28~62岁,平均44.2岁。其中15例交通事故伤,4例高空坠落伤,2例重物砸伤。骨折AO分型:33B1有2例;33C1有3例;33C2有5例;41B1有3例;41B3有2例;41C1有5例;41C2有1例。其中开放性骨折5例(Tscherne分类OⅠ有2例,OⅡ有3例),7例合并颅脑、胸部复合伤。所有合并伤无须手术,均在病情平稳后进行膝部手术。有开放性伤口者常规处理至感染控制,手术前时间6~16 d,平均9.6 d。
    ORIF组:选择与MIPO组病例骨折分型一致,软组织损伤相同,年龄接近的病人为对照组(表1)。手术时机及术前准备情况基本相同。表1  MIPO组与ORIF组患者资料比较分组性别(例)男女平均年龄两组病例以往均无膝关节疼痛史及手术外伤史。术前常规进行X线片及CT检查,部分病例行3D重建和MRI检查。
    1.2  手术方法
    MIPO组:患者仰卧位,安装气囊止血带,采用连续硬膜外麻醉。胫骨平台骨折取前外侧切口,股骨远端骨折取髌旁外侧切口,根据关节面复位需要,长度一般4~6 cm。切开关节囊后探察关节骨折情况,通过撬拨恢复关节面平整性,克氏针临时固定。借助牵引和软组织铰链手法整复干骺端骨折,经关节股骨或胫骨骨膜外插入接骨板,克氏针临时固定,C型臂X线机确认骨折复位和接骨板位置后以螺钉固定。大量生理盐水冲洗关节腔,清除骨折产生的碎骨屑和软骨碎片。通过关节切口检查交叉韧带和半月板有无损伤,行前后抽屉试验、Lanchman试验检查。本文所有病例均无需要处理的交叉韧带、半月板损伤和侧副韧带损伤。除2例合并有关节面塌陷的胫骨平台骨折行平台下植骨外,均未行骨移植手术。
    ORIF组:根据骨折情况,常规切口入路,直接显露骨折部位进行复位,骨折块间加压固定。其余同MIPO组。共有18例进行自体或异体骨移植。
    1.3  术后处理
    术后行下肢肌肉舒张收束练习,足趾屈伸锻炼。3~4周后逐渐行膝关节不负重主动锻炼恢复关节活动度,至X线片有连续骨痂通过,骨折线模糊后拄拐下地,逐渐开始患肢承重,骨折线消失后弃拐行走。
    1.4  观察指标
    两组资料手术情况包括:手术时间,术中出血量,骨移植病例数;术后恢复情况包括:骨痂出现时间,骨折愈合时间,膝关节活动度(ROM),膝关节5°以上内外翻畸形数。采用HSS膝关节评分标准记录最终膝关节功能恢复情况。应用SPSS 11.0统计软件包进行统计学分析,以P

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